Is Theory Fading Away from Reality? Examining the Pathology Rather than the Technology to Understand Potential Personality Changes
Is Theory Fading Away from Reality? Examining the Pathology Rather than the Technology to Understand Potential Personality Changes
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理论正在脱离现实吗？
DOI：
10.1080/21507740.2022.2150712
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发表时间：
2022
影响因子：
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通讯作者：
Anya Daly
中科院分区：
文献类型：
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作者：
F. Gilbert;Joel Smith;Anya Daly
Haeusermann et al.（2023）从其关于难治性癫痫临床治疗中闭环神经调节和自我感知的研究中得出了三个总体结论。首先，闭环神经调节装置并没有实质上改变癫痫患者的个性或自我感知术后。第二，一些患者和护理人员将观察到的个性和自我感知的变化归因于癫痫本身，而不是DBS治疗。第三，这些设备为参与者提供了新的方式来理解他们的疾病。这些发现进一步证明了一些神经伦理学家对假定的术后人格变化的担忧与这种变化的经验证据之间的不一致。然而，Haeusermann等人承认，“针对持续性而不是偶发性临床现象的神经技术可能对人格或自我感知有更大的影响，因为它们更连续地运作，或者针对更稳定地整合到患者自我概念中的临床现象”（41）。我们承认，假设参与者没有报告变化，因为他们只是偶尔，而不是不断刺激提供了一个有趣的线为未来的调查。尽管如此，我们想提出，潜在的术后人格变化可能与病理生理学本身相关，而不是技术的刺激作用。总的来说，我们提出的观点是，不能排除技术本身引起的意外影响。无论如何，这一评论旨在强调伦理学家的出发点应该是，患有不同病理生理学的患者，或在不同脑区接受刺激和不同参数治疗的患者，可能不会以相同的方式对治疗作出反应。确定连续或间歇性DBS刺激是否会对患者的个性、身份、能动性、自主性、真实性和自我（PIAAAS）产生因果影响，是用户、家庭和临床医生面临的一个关键问题（吉尔伯特、Via~ na和Ineichen 2021 a、2021 b; Bluhm和Cabrera 2019; Pugh 2020）。尽管如此，在连续或间歇性脑刺激的背景下理解术语“原因”在医学上和科学上都很难实现，至少有六个原因，其中一些是由Haeusermann等人确定的。首先，如果DBS被认为是一个必要的原因，这将意味着效果（在我们的情况下，PIAAAS的变化）只与原因（DBS）共存。我们怀疑是否有许多伦理学家或临床医生支持这一观点，因为这将需要在DBS后始终看到PIAAAS的变化。我们不知道有证据表明所有DBS受试者都会发生非预期的PIAAAS变化。其次，正如Haeusermann等人的研究所示，患者的自我概念（理解为受试者将自己解释为具有病理学的代理人的不同方式）通常对其治疗轨迹结果至关重要，这意味着非DBS因素明显相关。第三，其他研究表明，患者术前因疾病而感到疏远的越多，DBS后他们经历的自我疏远就越多（吉尔伯特等人，2017）。第四，报告的患者术前自我形象问题与其病理学相关的经历导致了对植入式脑机接口的根本性心理排斥（吉尔伯特等人，2019）。第五，Haeusermann等人指出，患者的癫痫发作和非DBS治疗的副作用是“成为他们想要成为或想象自己成为的人的障碍”（39），这些“深刻影响了他们的感觉......自我”（39）。然而，上述实现目标的障碍，未能实现目标的挫折感，以及
Haeusermann et al. (2023) draw three overall conclusions from their study on closed loop neuromodulation and self-perception in clinical treatment of refractory epilepsy. The first is that closed-loop neuromodulation devices did not substantially change epileptic patient’s personalities or self-perception postoperatively. The second is that some patients and caregivers attributed observed changes in personality and self-perception to the epilepsy itself and not to the DBS treatments. The third is that the devices provided participants with novel ways to make sense of their illness. These findings further demonstrate a misalignment between some neuroethicists’ concerns about putative postoperative changes to personality, and the empirical evidence for such changes. Haeusermann et al. nonetheless concede that “neurotechnology directed at persisting rather than episodic clinical phenomena could have greater implications for personality or self-perception, either because they operate more continuously or are directed at clinical phenomena that are more stably integrated into patients’ self-concepts” (41). We acknowledge that the hypothesis that participants did not report changes because they were only episodically and not continually stimulated offers an interesting line for future investigation. Nonetheless, we would like to propose that potential postoperative personality changes might be correlated with the pathophysiology itself, rather than the stimulation effects of the technology. Generally, we advance the view that unintended effects solely induced by the technology cannot be excluded per se. Regardless, this comment aims to highlight that ethicists’ starting premise should be that patients suffering from diverse pathophysiology, or patients who are treated with stimulation in different brain regions and with differing parameters, would likely not react in the same way to treatment. Determining whether continuous or episodic DBS stimulation causally affects a patient’s personality, identity, agency, autonomy, authenticity, and self (PIAAAS) is a crucial question for users, families, and clinicians (Gilbert, Via~ na, and Ineichen 2021a, 2021b; Bluhm and Cabrera 2019; Pugh 2020). Nonetheless, understanding the term “cause” in the context of continuous or episodic brain stimulation is philosophically and scientifically difficult to achieve, for at least six reasons, some of which are identified by Haeusermann et al. First, if DBS is considered a necessary cause, it would imply that the effect (in our case, change in PIAAAS) only ever co-exists with the cause (DBS). We doubt there are many ethicists or clinicians advocating for this view because it would entail always seeing change in PIAAAS following DBS. We are not aware of evidence demonstrating that all DBS subjects experience unintended PIAAAS changes. Second, as the Haeusermann et al. study has shown, a patient’s self-concept (understood as the diverse ways a subject interprets themselves as an agent with a pathology) is often critical to their treatment trajectory outcomes, implying that non-DBS factors are conspicuously relevant. Third, other studies have shown that the more patients felt preoperatively alienated by their illness, the more they experienced self-estrangement following DBS (Gilbert et al. 2017). Fourth, reported patient experiences of preoperative self-image issues in relation to their pathology has contributed to radical psychological rejection of implanted brain-computer interfaces (Gilbert et al. 2019). Fifth, Haeusermann et al. note that patient’s seizures and side-effects of non-DBS treatments were “barriers to becoming who they wanted to be or imagined themselves to be” (39) and that these “profoundly affected their sense of... self” (39). However, the aforementioned barriers to achieving goals, frustration with failing to obtain goals, and the