Are emotional states post psychiatic deep brain stimulation authentic?

Carolyn is a PhD student in the Department of Philosophy at the Graduate Center of the City University of New York. Her research focuses on ethics, with special emphasis on Bioethics and Neuroethics, as well as social and political philosophy. Her most recent work is on the authenticity of emotions, and considers authentic emotions as a normative ideal in the debate over neuromodification. Other work explores human rights, moral psychology, and democratic community. Carolyn received her BA in Philosophy at Georgetown University, and earned honors for her undergraduate thesis on personal identity. Below is a synopsis of the paper she presented recently at Brain Matters 3 in Cleveland, Ohio on the authenticity of emotions and deep brain stimulation.

Deep brain stimulation (DBS) of the ventral striatum region and the nucleus accumbens has proven effective in improving symptoms of treatment-refractory psychiatric disorders (PD) such as major depression, obsessive-compulsive disorder, and anxiety disorders, among others. DBS in this region induces smiles and laughter associated with mood elevation, and improves long-term symptoms of PD (Haq et al. 2011, Goodman et al. 2010). It has been celebrated among those who treat PD, those who suffer from PD, and families of PD. Look no further than YouTube for corroboration of this claim. While the positive effects of psychiatric DBS on quality of life are unquestionable for certain patients, though, I remain wary of widespread use of DBS among PD sufferers, and especially for enhancement purposes.

My worry is motivated by concern for the authenticity of emotions induced by DBS, which is a little off the beaten path of bioethical concerns. Lots of important work is being done on the informed consent process for psychiatric DBS (Lipsman, et. al. 2012), exploitation of treatment-refractory PD sufferers for research purposes (Copeland, 2012), and the gap between patient expectations and results of clinical trials (Racine & Bell, 2012). The conclusion of most, though, is that if the highest standards of informed consent are met, and patients are not exploited, then there are no convincing intrinsic objections against the use of DBS either for treatment of treatment-refractory psychiatric illness or enhancement purposes. If a patient will benefit from DBS, and the choice to undergo DBS is in line with his or her true values, then its use is ethically justifiable (see also Synofzik, et. al., 2012). In response, I argue that the questions raised by the authors leave out an important normative concern when considering neuromodification and neuroenhancement: authenticity of mental states, in particular of emotions.

In my recent paper at the Brain Matters 3 neuroethics conference, I adopt Michael Stocker’s account of emotions as having affective, non-affective, and motivational aspects. I then explain what it would mean for an emotion or emotional state to be authentic. Authentic emotions meet two requirements: sincerity and integrity (Salmela, 2011). Emotions are sincere when one is not deceived about his or her beliefs and feelings and motivations. The additional integrity requirement for authentic emotions requires that the emotion is consistent with and coherent with one’s internally justified beliefs and values. It involves a commitment to one’s own conception of the good.

I believe there is a distinction between facilitated or managed emotions and induced emotions. Facilitated emotions are when we regulate or manipulate one or more aspects of emotions such as to change the emotion felt and expressed. Can facilitated emotions be authentic? Well, yes. Whether spontaneous, facilitated by caffeine, surface acting, etc these emotions occur with various aspects of emotions (feelings, beliefs, actions) in concert with and committed to self and one’s conception of the good. Facilitated emotions neither preclude sincerity nor threaten necessarily integrity.

On the other hand, induced emotions include brainwashing or hypnosis. Induced emotions are one’s that could not be experienced unless a third party altered one’s beliefs, affect, or motivational structure. These emotions are also managed and manipulated, but not by the first person. Follow up question: can induced emotions be authentic? Well, no. Although may not violate condition of sincerity (you are not deceived about what you are feeling or beliefs; have an undistorted perception of psychological reality), the emotion is not consistent with one’s internally justified beliefs and values or conception of the good.

Armed with some vocabulary for talking about emotions, I turn to emotions and psychiatric DBS. Are the emotions experienced authentic or inauthentic? And the answer to this question rests on the answer to a different question: Are the emotions post-implantation classifiably facilitated or induced?
If the answer turns out to be that psychiatric DBS merely facilitates emotions, then they can count as authentic emotional states. Neuroscientist Helen Mayberg has offered a picture of psychiatric DBS that lends itself to this interpretation of post-implantation emotions. Mayberg’s description of what’s going on post-DBS arguably shows that DBS is facilitating the patient’s feeling emotions. However, there are lots of unknowns still about what’s going on in psychiatric DBS, and in depression. Mayberg’s is just one theory, and there is a dearth of published literature on patient experience of emotions. Success, rather, is measured by improvement on the scale of symptoms of depression. So, it could turn out that psychiatric DBS induces emotions. I offer two ways of arguing that DBS induces emotions.

To sum up, determining whether psychiatric DBS induces or facilitates emotions is crucial for determining whether emotions post-DBS (or any neuromodification technology) are authentic emotions. If psychiatric DBS only facilitates emotions, then, at first pass, the emotions facilitated are authentic. However, if psychiatric DBS induces emotions that are not consistent with one’s held beliefs and values or preclude the possibility of self-knowledge, then a normative concern for authenticity arises.

If we take authenticity seriously as a normative ideal and concern (and there is reason to believe we do), then we should caution against the use of DBS except in extreme cases, when concern about inauthentic affective states are trumped by quality of life concerns. This may not render psychiatric-DBS unethical across the board, but I think it is an important consideration in the discussion about DBS.

(Some) References and Suggestions for Further Reading

S. Copeland (2012). “Categorizing Complexity: The ethics of translational research,” Presenation at Brain Matters 3: Values at the Crossroads of Neurology, Psychiatry, and Psychology, Cleveland, OH.

W. Goodman, K.D. Foote, B.D. Greenberg, et al. (2010). Deep brain stimulation for intractable obsessive compulsive disorder: Pilot study using a blinded, staggered-onset design. Biological Psychiatry 67: 535-542.

I.U. Haq, K.D. Foote, W. Goodman, et al. 2011. Smile and laugher induction and intraoperative predictors of response to deep brain stimulation for obsessive-compulsive disorder. Neuroimage 54(suppl. 1): S247-255.

N. Lipsman, P. Giacobbe, M. Bernstein & A. M. Lozano (2012). Informed Consent for Clinical Trials of Deep Brain Stimulation in Psychiatric Disease: Challenges and Implications for Trial Design. Journal of Medical Ethics 38 (2): 107-111.

E. Racine & E. Bell (2012). Responding Ethically to Patient and Public Expectations About Psychiatric DBS. AJOB Neuroscience 3:1, 21-29

M. Salmela (2011). What is Emotional Authenticity? Journal for the Theory of Social Behavior 35:3.

M. Stocker & E. Hegemon (1996). Valuing Emotions. New York: Cambridge University Press.

M. Synofzik, T. Schleapfer & J. Fins (2012). How Happy is Too Happy? Euphoria, Neuroethics, and deep brain stimulation of the nucleus accumbens. American Journal of Bioethics: Neuroscience 3(1): 30-36, 2012.

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