Biomedical Implantation and Patient Autonomy

Preface: This was my final paper for my Philosophical Methods course in my junior year of college, Fall 2018. Some of the information and views may be outdated, but I wanted to share as this was my first serious philosophical research paper and I put a lot of heart into it. Please enjoy!

I. INTRODUCTION

With the advent and growing prevalence of new biomedical implantable technologies, there are enormous risks and rewards for people to be treated with these revolutionary devices. These technologies can allow a person to control their external environment with their brainwaves, predict and prevent epileptic seizures, and effectively treat debilitating symptoms of neurodegenerative diseases. But manic behavior, information hijacking, and euthanasia are also possible with the implants of the past and present; these issues and many more will plague us in the future. As technology advances to science-fiction-level abilities, so too must bioethics advance to both guide our understanding and treatment of implantation, as well as protect patients from potential harms and reap benefits from these devices.

In this paper, I will illustrate why implants present problems for autonomy. I will then outline Kantian, Utilitarian, and Principlist approaches to autonomy, and describe the problems with each in the context of biomedical implantation. I argue that Principlism is the most fitting model for bioethical concerns about implants, although Kantian and Utilitarian conceptions of autonomy should be taken into consideration when engaging in ethical discourse about implants.

II. IMPLANTS AND AUTONOMY

Biomedical implantable technologies, referred to here as just implants, are pieces of engineered technology made of inorganic materials that are designed to carry out an electrical or pharmaceutical action that helps to rectify a medical problem within the recipient’s body. There are dozens of types of implants designed to treat everything from diabetes to chronic pain to Parkinson’s disease, and this technology has been around since the first pacemaker in 1958. I will be focusing on neural implants, as these technologies tend to have the most potential for impacting autonomy because of their direct physical and electrical interference with the brain.

Autonomy is highly contested in many circles of ethical discussions. Some assert that there should be a moratorium on the term, and some believe it has received an undue amount of attention in recent years. Much of the debate includes how to define it. No two definitions of autonomy are exactly alike, and some often come with multiple conditions. However, the biggest obstacle lies in the fact that autonomy definitions differ wildly from discipline to discipline. Bioethics’ definitions of autonomy are scrambled, but are even more so when compared to, say, political philosophy’s different definitions of autonomy. It is clear that the term (and its application) is rife with problems.

Implants present a special problem for autonomy. Neural implants are especially problematic due to the severity of the types of conditions they treat, highly advanced technology, an extremely invasive implantation process, and potential for extreme side effects. All these factors combine to create problems of unprecedented scale. While other technologies, drugs, and treatments have the power to commit basically the same violations of autonomy as neural implants, it is widely agreed upon in the bioethical community that the severity, invasiveness, and intimacy of neural implants set them apart from any other autonomy-influencing technology, external or internal, which raises more complex ethical questions and requires special consideration.

III. APPROACHES AND PROBLEMS

Under a Deontological approach, Immanuel Kant asserts that human beings are valuable above all else because of our ability to reason. As rational agents, morality always applies to us. Kantianism has two categorical imperatives, which are rules that always apply. The first categorical imperative is to “[a]ct as if the maxim of thy action were to become by thy will a universal law of nature.” In layman’s terms, this means that we should act in a way that would be okay if everyone were to act that way. The second categorical imperative is to “[a]ct that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means.” In this context, we understand an end as something inherently valuable and deserving of respect, and a means as something that is valuable only to achieve these ends. Putting this together, we can see that the second categorical imperative instructs us to always use humanity as something valuable, not just as a way of achieving something else. However, if someone else’s means are your own means, it is okay to use them as a means, as long as they are not a mere means.

Autonomy is one of the most important factors in Kant’s moral theory. Autonomy is a property of rational agents. People have autonomy if and only if they knowingly act in accordance with the principles that abide by the first categorical imperative. Impeding autonomy is immoral under Kantianism because of this. In doing so, you are inhibiting a person’s ability to be rational. Kant also argued that a person could not own themselves because it is impossible to own a thing and be the thing that is owned at the same time.

The problems with this approach are as follows. Most of modern medical practice relies on obtaining informed consent to respect and protect the rights of patients and research participants. Informed consent is an acknowledgement that you relinquish a portion of your autonomy for medical or research purposes. It requires competency, permission, understanding of relevant information, and a lack of coercion. Under Kantianism, obtaining informed consent is morally impermissible. Giving up any portion of your autonomy is irrational; it is treating yourself as a mere means to the end of research or medical progress. You do not have the ownership over your body to be able to relinquish control over it in such a way. Another problem is that patients with a medical situation severe enough to necessitate implantation are too dependent on caretakers and medical professionals to fulfill the standards for Kantian autonomy, which is rooted in independence.

When applying this principle to implants, we can see the problems arise. Take the case of a predictive automated brain implant. Predictive brain implants are electrode array chips implanted in the brain using surgery. They take in data from brain waves and use statistical learning algorithms to predict a neurological event. This is sent through an external receiver to a device that displays the readout of the prediction. An automated implant predicts an event, and then takes its own course of action to deal with that event, as opposed to merely recommending a course of action. This exemplary implant is used to treat epilepsy by predicting when the recipient is going to have a seizure, and then administering anti-seizure medications through the implant. This is without any consultation or approval of the recipient between the time of prediction and the time of the automated treatment.

A Kantian would be opposed to such an implant. Under the first categorical imperative, if we were all to let such implants make decisions for us, we would not be able to fully act as rational agents, since something else is acting for us. We are valuing the implant’s reasoning over our own, when humans should be valued the highest because of our ability to reason. This does not take into account that the implant might actually be able to reason better in this specific instance. Humans, even as full rational agents, cannot read brain waves with the same precision and react with the timeliness required to prevent a seizure, something the automated implant is capable of.

The second approach, Utilitarianism, aims to achieve the most good for the most people. The Principle of Utility states that “[a]ctions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness, i.e., pleasure or absence of pain.” Put simply, maximizing happiness and minimizing suffering is the ultimate goal. Utilitarianism is agent-neutral, and assigns no value to the individual person, but only to the mental states carried by that person. It is also impartial and aggregated, so whose utility does not matter and the utility is tallied from everyone affected. There are two main types of Utilitarianism: Act Utilitarianism and Rule Utilitarianism. These dictate how the Principle of Utility should be applied. As the names suggest, Act Utilitarianism applies the Principle of Utility on a case-by-case basis, and Rule Utilitarianism applies the Principle of Utility as a rule to a group of actions that should always be followed.

Because Utilitarianism is agent-neutral, autonomy is essentially a non-issue because Utilitarians don’t have concern for autonomy. This aligns with Hippocratic paternalism that some bioethicists advocate for. Often bioethicists will default to this view because the way the medical field is structured in our society necessitates the simplicity of leaving autonomy out of the equation and only dealing with net benefits of happiness and suffering. When operating on a large-scale medical model, this approach is much more applicable than complex notions of the self as a rational agent, like Kantianism demands.

Let us revisit the example of the predictive automated brain implant intended to prevent epileptic seizures. A Utilitarian would be in full support of such an implant. Preventing a seizure prevents a great deal of suffering and pain in the patient. If we are able to avoid it in this way, we absolutely should, even if it means a machine makes a decision for a person from inside of the person. This acceptance brings to light the problem of over-reliance on the implant, as well as Utilitarianism’s permissibility of sweeping away a patient’s control over their own body, something a Kantian would never neglect. Because the measure of utility is impartial and aggregated, a researcher or medical professional who benefits immensely from a patient’s implantation could outweigh a significant amount of suffering experienced by the patient. This opens the door wide for medical malpractice and violating the rights and wishes of a patient, something Kantianism accounts for. Act Utilitarianism may provide slightly more insulation from this, but the net balance of researcher happiness to patient suffering would still pose a problem.

The third and final approach is Principlism. Championed by Tom Beauchamp and James Childress, Principlism is considered to be the dominant view in bioethics. Principles of Biomedical Ethics, which first articulated this view, has become the Bible of the field due to its timely release as bioethics was just emerging as a field, and has been released in seven editions to keep up with the rapid rate of biotechnological development between 1977 and 2013. It holds that there are four basic principles of bioethics: respect for autonomy, non-maleficence, beneficence, and justice. These are in no particular order and are not ranked by importance or preference.

Principlism defines autonomy as that which makes judgements and actions one’s own. Its three-part theory of autonomy is meant to be used under non-ideal conditions. It consists of intentionality, understanding, and non-control. Intentionality is a binary, which means that either a person does intend or does not intend for an action to happen. Understanding is a person’s accessibility to relevant information and their ability to grasp that information, which both come in degrees. Non-control is a lack of coercive forces or limited options that can influence a person’s decision. This too comes in degrees.

Let us use the Brain-Computer Interface implant, or BCI, to assess this approach. BCIs consist of an electrode array chip implanted in the motor cortex of the brain. It takes in brainwave data, just like a predictive brain implant, but it has an outside receiver connected to the head at the point of implantation. This receiver connects to a computer, which gives the patient control over a computer prosthesis, such as a cursor or a robotic arm. These implants are typically given to patients with debilitating physical handicaps, such as locked-in syndrome caused by damage to the brain stem. This technology gives a patient huge amounts of options and lessens controlling influences on them by a great deal, so it is extremely beneficial for the non-control aspect of autonomy. However, this technology may reduce their understanding, as the patient requires time to learn how to grasp controlling the attached prosthesis. Here we face a puzzling question of whether autonomy was amplified, impeded, or both; by how much, and by what metric we ought to use to measure this. Principlism has been criticized heavily for its lack of philosophical substance and narrow focus on American ideals. As we can see from this case, it is extremely difficult to apply, despite its status as the prevailing approach.

IV: WHY DO WE CARE?

As we can see from the approaches above, there is no satisfying answer to the quandary of autonomy and implants.

After completing this research, I can say with confidence that biomedical implantation technologies are the most unprecedented technology being created by the technological gold rush we are currently living in. Science has historically gone the way of science fiction — look no further than the advent of cell phones and Bluetooth from fantasy technologies in Star Trek. The science fiction of present that has yet to come into existence is not very far behind at the rate we’re progressing. The first successful BCI implantation was completed in 2006, and there is much more in store for the future.

We have very limited data on the effects and success of these implants. The enrollment for BrainGate2, the premier BCI research team, was 15 participants, whereas an average test group for a new pharmaceutical would be well over 1,000. It is imperative that we track these technologies as they develop in order to maintain an accurate picture of the bioethical landscape moving forward.

V: CONCLUSION

As we can see from the approaches above, there is no satisfying answer to the quandary of autonomy and implants. I have recapitulated the three main approaches to autonomy in the context of biomedical implantation. Kantianism presents staunch absolutes that are difficult to work around in a clinical setting, Utilitarianism’s indiscriminate metrics of measuring happiness and suffering opens the door to medical malpractice, and Principlism can easily contradict itself and lock us in concerning of one of the most groundbreaking, if not one of the most important, implant cases to date. Ultimately, the best approach is to apply theories on a case-by-case basis as needed in order to best protect the patient, help the researcher, and challenge the philosopher. This too is unsatisfying, but the philosophical and technological prospects of the future are a welcome challenge to the ever-expanding field of bioethics.

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