Wednesday, February 25, 2009

In Practice: Fuhgeddaboudit

By Peter D. Kramer in In Practice

spiderIf we had a drug that could erase bad memories, should we use it? That was the question the press extracted from an arguably limited set of observations reported in an on-line article in Nature Neuroscience.

You've probably heard about the experiment. A trio of Dutch researchers showed normal subjects photos of spiders, accompanying one image with an electric shock. The next day, the scientiest re-presented the images, with or without pre-administering the subjects an anti-adrenalin drug, propranolol. Down the road, those who had taken propranolol were less likely to startle when exposed to a loud noise in the presence of an offending picture. The conclusion was that the drug interfered with the consolidation of the emotional memory, stripping it of its fear element.

This finding is a slim reed on which to rest a philosophical inquiry, but in truth the medical ethics field has been debating the broader question for the better part of a decade, based on earlier, similar suggestive research involving propranolol. In 2003, the President's Council on Bioethics weighed in, arguing that the modification of emotional memory was a worrisome alteration of personhood, one that risked trivializing signal forms of pain that compose a complex self. In 2007, the American Journal of Bioethics devoted most of an issue to discussions of an essay that argued in favor of choice in the matter of muting disabling fear.

Yesterday, for better or for worse, I represented the bioethics community when AirTalk with Larry Mantle, a public radio show, took up this issue, under the heading "The Spotless Mind." The broadcast does a fair job of presenting the issues — those who are interested should give a listen.

I want here only to clarify a single point - one that was at the heart of Listening to Prozac. When we wrestle with an ethics question in neuroscience, often it is important to ask what worries us: Is it that we disapprove of the goal of an intervention, or that we dislike the intervention itself.

Do we really, for the most part, worry about the attenuation of fearful memories? Let's say that a patient comes to a doctor and says, "I had a terrible experience yesterday, and I'm worried that it will haunt me. Can you help prevent the fear from lingering?" That's the set up.

Now imagine that the doctor prescribes "tincture of time," that is, she reassures the patient: "Don't worry. I know you. That memory will fade." No one, I would guess, has moral worries about that scenario. Yes, there will be a change in the self, but so what? The content in our library of memories shifts all the time. If the self is continuous, that's not because our emotions are always identical.

What if the doctor says, "You're adept at meditation. Tomorrow, when you recall the event, enter into a relaxed state. Later, the memory will upset you less." Do we object to that prescription? If not, then in truth we do not fret about the result, a muted emotional response to a real stimulus.

How about a more mechanical behavioral prescription? Let's say we believe in the efficacy of "Eye Movement Desensitization and Reprocessing," or EMDR, in its simplest form. The doctor trains the patient to recall the trauma while moving his eyes this back and forth. The memory loses its force. Are we alarmed? Well, perhaps this approach does seem a bit eerie.

Now think of an ingested substance, chocolate or green tea. The doctor has the patient call up the memory while enjoying a soothing snack. Do we object to that sort of interference with reconsolidation?

My point is a simple one. We only initiate an ethics debate when the intervention is a medication - here, one with a complex name, propanolol. (In truth, the consolidation of anxiety may be a fairly easy target; it looks as if steroids, opiates, benzodiazepines, and anesthetics might do the job, along with beta-blockers.) That category, medication, seems to bring into play technology, doctors, patient status, and drug companies, and therefore hierarchy, social coercion, and communal norms. Now we worry, if we do, about altering the self in ways that the culture favors.

There's much more to say on this topic, but for the moment, I think I'll stop with this question: Why is it that we debate the ethics of muting anxious memories now, in the years since it's seemed propranolol can do the trick, when we never argued over that capacity before? Like everyone else, I understand the dystopian science fiction scenario of "eternal sunshine," but to undertake a serious philosophical discussion we need to do better of specifying what's at issue. Why precisely do we worry over a drug's doing a job we are happy to see accomplished by any number of other means?

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