Faculty Bibliography

Parents of school-age children are increasingly claiming nonmedical exemptions to refuse vaccinations required for school entry. The resultant unvaccinated pockets in many areas of the country have been linked with outbreaks of vaccine-preventable diseases. Many states are now focused on reducing rates of nonmedical exemptions by making exemption processes more restrictive or burdensome for the exemptor. These strategies, however, pose ethical problems and may ultimately be inadequate. A shift to strategies that raise the financial liabilities of exemptors may lead to better success and prove ethically more sound. Potential areas of reform include tax law, health insurance, and private school funding programs. We advocate an approach that combines this type of incentive with more effective vaccination education.

Deep brain stimulation (DBS) is an efficacious surgical treatment for many conditions, including obsessive-compulsive disorder and treatment-resistant depression. DBS provides a unique opportunity to not only ameliorate disease but also to study mood, cognition, and behavioral effects in the brain. However, there are many ethical questions that must be fully addressed in designing clinical research trials. It is crucial to maintain sound ethical boundaries in this new era so as to permit the proper testing of the potential therapeutic role DBS may play in ameliorating these devastating and frequently treatment-refractory psychiatric disorders. In this review, we focus on the selection of patients for study, informed consent, clinical trial design, DBS in the pediatric population, concerns about intentionally or inadvertently altering an individual's personal identity, potential use of DBS for brain enhancement, direct modification of behavior through neuromodulation, and resource allocation.

Some argue that to be effective in healthcare settings autonomy needs to be strengthened. The author thinks autonomy is fundamentally inadequate in healthcare settings and requires supplementation by experience-based paternalism on the part of doctors and healthcare providers.

The success of deep brain stimulation (DBS) for movement disorders and the improved understanding of the neurobiologic and neuroanatomic bases of psychiatric diseases have led to proposals to expand current DBS applications. Recent preclinical and clinical work with Alzheimer's disease and obsessive-compulsive disorder, for example, supports the safety of stimulating regions in the hypothalamus and nucleus accumbens in humans. These regions are known to be involved in addiction and overeating associated with obesity. However, the use of DBS targeting these areas as a treatment modality raises common ethical considerations, which include informed consent, coercion, enhancement, threat to personhood, and manipulation of the reward center. Pilot studies for both of these conditions are currently investigational. If these studies show promise, then there is a need to address the ethical concerns related to the initiation of clinical trials including the reliability of preclinical evidence, patient selection, study design, compensation for participation and injury, cost-effectiveness, and the need for long-term follow-up. Multidisciplinary teams are necessary for the ethical execution of such studies. In addition to establishing safety and efficacy, the consideration of these ethical issues is vital to the adoption of DBS as a treatment for these conditions. We offer suggestions about the pursuit of future clinical trials of DBS for the treatment of addiction and overeating associated with obesity and provide a framework for addressing ethical concerns related to treatment.

One area in which money alone doesn't rule the day in America is transplantation. Since 1984, the nation's system for deciding who gets scarce organs for transplant has relied both on the ability to pay and a rule-based, physician-determined rationing system. It's about as close as the country has ever come to making tough decisions about who gets life-saving therapy. Here, Caplan shares the case of ten-year-old Sarah Murnaghan who recently put that system to its most severe test ever

Here, Caplan says if there is any silver lining in the ignorant, and grossly offensive statements offered about rape by the failed candidates for Senate in the recently concluded election, Missouri's Congressman Todd Akin and Indiana's Richard Mourdock, it is that they may have finally shown both the folly and the moral dodginess inherent in efforts by conservative fundamentalists to posit God's hand in every act, no matter how horrific or awful. They do this both in situations where misery besets an individual and where tragedy overwhelms a group and both are ethically disgusting. He adds he is inclined to think that the best explanation for hurricanes, floods, and other calamities is coincidence often compounded by poor human choices. To paraphrase Abraham Lincoln, there is a lot of prayer going on with mixed messages being sent, and God cannot satisfy everyone. Perhaps someday, fervent religious leaders will come to see that linking pregnancies resulting from rape and the destruction of a city to divine will and retribution is a very dicey and highly unethical thing to do

Caplan talks about Ariel Sharon's brain activity. Sharon was the eleventh prime minister of Israel, serving from 2001 to 2006. He has been diagnosed as being in a persistent vegetative state since suffering first a minor stroke and then another massive one on Jan 4, 2006. A respirator and a feeding tube have kept him alive for seven years at Sheba Hospital in Tel Hashomer, Israel. Last January, a team of doctors and neuroscientists from Israel's Soroka University Medical Center was hired to subject the now eighty-four-year-old Sharon to a series of sophisticated brain scans. The team showed the former prime minister pictures of random houses, which he would not be expected to be familiar with. Then they flashed a picture of his own house before his eyes. When the images of his own home were shown, areas of his brain "lit up" with activity. Similarly, his brain "fired up" in response to hearing family voices but not when nonsensical gibberish sounds were played for him