As our knowledge of the functional and pharmacological architecture of the nervous system increases, we are getting better at treating cognitive and affective disorders. Along with the ability to modify cognitive and affective systems in disease, we are also learning how to modify these systems in health. “Cosmetic neurology,” the practice of intervening to improve cognition and affect in healthy individuals, raises several ethical concerns. However, its advent seems inevitable. In this paper I examine this claim of inevitability (...) by reviewing the evolution of another medical practice, cosmetic surgery. Cosmetic surgery also enhances healthy people and, despite many critics, it is practiced widely. Can we expect the same of cosmetic neurology? The claim of inevitability poses a challenge for both physicians and bioethicists. How will physicians reconsider their professional role? Will bioethicists influence the shape of cosmetic neurology? But first, how did cosmetic surgery become common? (shrink)

Over the past decades, mood enhancement effects of various drugs and neuromodulation technologies have been proclaimed. If one day highly effective methods for significantly altering and elevating one’s mood are available, it is conceivable that the demand for them will be considerable. One urgent concern will then be what role physicians should play in providing such services. The concern can be extended from literature on controversial demands for aesthetic surgery. According to Margaret Little, physicians should be aware that certain aesthetic (...) enhancement requests reflect immoral social norms and ideals. By granting such requests, she argues, doctors render themselves complicit to a collective ‘evil’. In this paper, we wish to question the extent to which physicians, psychiatrists and/or neurosurgeons should play a role as ‘moral gatekeepers’ in dealing with suspect demands and norms underlying potential desires to alter one’s mood or character. We investigate and discuss the nature and limits of physician responsibilities in reference to various hypothetical and intuitively problematic mood enhancement requests. (shrink)

In an editorial to a recent issue of Neurology, Richard Dees expresses the same criticism in an even more rigorous epistemic tone: Veikko Launis, Ph.D., is Professor of Medical Ethics and Adjunct Professor of Ethics and Social Philosophy at the University of Turku, Finland.FootnotesThis article is part of the Neuroethics of Brainreading research project, directed by myself and funded by the Academy of Finland. I am grateful to Olli Koistinen, Pekka Louhiala, Helena Siipi, and an anonymous referee for helpful (...) comments, criticism, and suggestions. (shrink)

In an age of modern technology and an increasing movement towards a 24-h working culture, life for many is becoming more stressful and demanding. To help juggle these work commitments and an active social life, nootropic medication, (the so-called ‘smart pills’) have become a growing part of some people’s lives. Users claim that these drugs allow them to reach their maximal potential by becoming more efficient, smarter and requiring less sleep. The use of these medications and the role of health (...) professionals in their distribution raises many ethical questions. (shrink)

Advances in cognitive neuroscience make cosmetic neurology in some form inevitable and will give rise to extremely difficult ethical issuesConsider the following hypothetical case study. A well heeled executive walks into my cognitive neurology clinic because he is concerned that he is becoming forgetful. It turns out that he is going through a difficult divorce and my clinical impression is that his memory problems stem from the stress he is experiencing. I place him on a selective seratonin (...) reuptake inhibitor, sertraline, and in a few weeks he feels better. Around this time his 13 year old daughter has difficulty at school and is diagnosed by the school psychologist as having attention deficit disorder. I place her on adderall, a stimulant combination drug, which seems to help with her behaviour in school. My patient then comes to me because he is experiencing the “tip of the tongue” phenomena more frequently. He is concerned that his word finding difficulty interferes with his ability to function in high level meetings. I suggest we try a cholinesterase inhibitor to see if this helps. I am careful to explain that the Food and Drug Administration does not approve such a use for this medication. He wants to try it and is pleased with the results.A few months later, this patient visits me with his 16 year old son, a talented middle distance runner. His father thinks if he were just a bit better, among the elite high school runners in the state, he would be far more competitive as an applicant for selective colleges. We discuss various options. Because of a recent report that sildenafil, which is used conventionally for male impotence, may improve oxygen carrying capacity, I prescribe this medication. The son does not object.Encouraged by these pharmacologic successes, my patient …. (shrink)

Neurocognitive enhancement, or cosmetic neurology, offers the prospect of improving the learning, memory and attention skills of healthy individuals well beyond the normal human range. Much has been written about the ethics of such enhancement, but policy-makers in the USA, the UK and Europe have been reluctant to legislate in this rapidly developing field. However, the possibility of discrimination by employers and insurers against individuals who choose not to engage in such enhancement is a serious threat worthy of (...) legislative intervention. While lawmakers should not prevent individuals from freely pursuing neurocognitive enhancement, they should act to ensure that such enhancement is not coerced. This paper offers one model for such legislation, based upon a proposed US law, the Genetic Information Nondiscrimination Act of 2008, to address precisely this particular pitfall of the impending neuroscience revolution. (shrink)

Reports in the popular press suggest that smart drugs or “nootropics” such as methylphenidate, modafinil and piracetam are increasingly being used by the healthy to augment cognitive ability. Although current nootropics offer only modest improvements in cognitive performance, it appears likely that more effective compounds will be developed in the future and that their off-label use will increase. One sphere in which the use of these drugs may be commonplace is by healthy students within academia. This article reviews the ethical (...) and pragmatic implications of nootropic use in academia by drawing parallels with issues relevant to the drugs in sport debate. It is often argued that performance-enhancing drugs should be prohibited because they create an uneven playing field. However, this appears dubious given that “unfair” advantages are already ubiquitous and generally tolerated by society. There are concerns that widespread use will indirectly coerce non-users also to employ nootropics in order to remain competitive. However, to restrict the autonomy of all people for fear that it may influence the actions of some is untenable. The use of potentially harmful drugs for the purposes of enhancement rather than treatment is often seen as unjustified, and libertarian approaches generally champion the rights of the individual in deciding if these risks are acceptable. Finally, whether the prohibition of nootropics can be effectively enforced is doubtful. As nootropics use becomes widespread among students in the future, discussion of this issue will become more pressing in the years to come. (shrink)

One of the most fascinating issues in the emerging field of neuroethics is pharmaceutical cognitive enhancement. The three main ethical concerns around CE were identified in a Nature commentary in 2008 as safety, coercion and fairness; debate has largely focused on the potential to help those who are cognitively disabled, and on the issue of ‘cosmetic neurology’, where people enhance not because of a medical need, but because they want to. However, the potential for CE to improve public (...) health has been neglected. This paper examines the prospect of improving health outcomes through CE among sections of the population where health inequalities are particularly pronounced. I term this enhancement of the public’s health through CE ‘neuroenhancing health’. It holds great promise, but raises several ethical issues. This paper provides an outline of these issues and related philosophical problems. These include the potential effectiveness of CE in reducing health inequalities; issues concerning autonomy and free will; whether moral enhancement might be more effective than CE in reducing health inequalities; and the problem of how to provide such CE, including the issue of whether to provide targeted or universal coverage. (shrink)

One of the most fascinating issues in the emerging field of neuroethics is pharmaceutical cognitive enhancement (CE). The three main ethical concerns around CE were identified in a Nature commentary in 2008 as safety, coercion and fairness; debate has largely focused on the potential to help those who are cognitively disabled, and on the issue of “cosmetic neurology”, where people enhance not because of a medical need, but because they want to (as many as 25% of American students (...) already use nootropic cognitive enhancers such as ritalin). However, the potential for CE to improve public health has been neglected. This paper examines the prospect of improving health outcomes through cognitive enhancement among sections of the population where health inequalities are particularly pronounced. I term this enhancement of the public's health through CE “neuroenhancing health”. It holds great promise, but raises several ethical issues. This paper provides an outline of these issues and related philosophical problems. These include the potential effectiveness of CE in reducing health inequalities; issues concerning autonomy and free will; whether moral enhancement might be more effective than cognitive enhancement in reducing health inequalities; and the problem of how to provide such CE, including the issue of whether to provide targeted and universal coverage. (shrink)

This article reviews the development of a new set of practices within modern medicine that can generally be called “cosmetic medicine,” practices that include cosmetic surgery, cosmetic dermatology, and cosmetic gynecology. I argue that the development of such fields indicates a fundamental change in the practice of medicine. After reviewing the possible explanations proposed for such developments, in order to indicate the social and cultural origin of the driving forces, I discuss the implications of these revolutionary (...) changes for the perceived goal of medicine. Of particular importance is the development of beauty as the main goal in cosmetic medicine. The development of the new fields supports the idea that... (shrink)

Cosmetic dentistry is a divisive discipline. Within discourses that raise questions of the purpose of the dental profession, cosmetic dentistry is frequently criticised on the basis of it being classified as a non‐therapeutic intervention. This article re‐evaluates this assertion through examination of ethics of care of the self, healthcare definitions and the social purpose of dentistry, finding the traditional position to be wanting in its conclusions. The slide of dentistry from a healthcare vocation towards being a predominantly business‐focused (...) interaction between clinician and consumer conflicts with traditional notions of dentistry as a profession. Whilst it is undeniable that cosmetic dental treatment particularly lends itself to the commercial paradigm, this is not exclusive to this area of professional practice. The cultural basis of dental appearance and the potential of the dental profession to exert coercive pressure upon the public to undergo treatment that is based upon social norms is discussed. This essay concludes that cosmetic dentistry is undeniably part of the professional purpose of 21st Century dentistry. However, the caveat that may be placed upon this, is that this status is conditional upon the professional conduct of dental practitioners remaining resilient to commercial practices not compatible with professional obligations. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

Leading feminist scholars have been brought together for the first time in this comprehensive volume to reveal the complexity of feminist engagements with the exponentially growing cosmetic surgery phenomenon. Offering a diversity of theoretical, methodological and political approaches Cosmetic Surgery: A Feminist Primer presents not only the latest, cutting-edge research in this field but a challenging and unique approach to the issue that will be of key interest to researchers across the social sciences and humanities.

Recently, there has been a shift in attitude among some feminists towards the practice of cosmetic surgery away from that of outright rejection. Kathy Davis, for instance, offers a guarded `defence' of the practice as a strategy that enables women to exercise a degree of control over their lives in circumstances where there are very few other opportunities for self-realization. Others, such as Kathryn Morgan, Anne Balsamo and Orlan, though highly critical of the current practice of cosmetic surgery, (...) go even further than Davis in advocating its redeployment as a tool to subvert the dominant patriarchal ideals of feminine beauty. In this article I critically appraise this `rehabilitation' of cosmetic surgery, arguing, in the case of Davis, that she leaves unchallenged the social structures of inequality responsible for women's dissatisfaction with their bodies. The proposal to use cosmetic surgery as a tool of political critique is equally problematic insofar as it shares with the cosmetic industry its instrumentalization of the body as mere matter, which is almost infinitely transformable, and also effaces the economic inequalities within which such body transformations occur. (shrink)

In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with the (...) doctor's ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large. (shrink)

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the market (...) and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing. (shrink)

I argue that the televisual cosmetic surgical makeover is usefully understood as a contemporary manifestation of normalization, in Foucault’s sense—a process of defining a population in relation to its conformity or deviance from a norm, while simultaneously generating narratives of individual authenticity. Drawing on detailed analysis of “Extreme Makeover,” I suggest that the show erases its complicity with creating homogeneous bodies by representing cosmetic surgery as enabling of personal transformation through its narratives of intrinsic motivation and authentic becoming, (...) and its deployment of fairy tale tropes. (shrink)

We are developing the Neurological Disease Ontology (ND) to provide a framework to enable representation of aspects of neurological diseases that are relevant to their treatment and study. ND is a representational tool that addresses the need for unambiguous annotation, storage, and retrieval of data associated with the treatment and study of neurological diseases. ND is being developed in compliance with the Open Biomedical Ontology Foundry principles and builds upon the paradigm established by the Ontology for General Medical Science (OGMS) (...) for the representation of entities in the domain of disease and medical practice. Initial applications of ND will include the annotation and analysis of large data sets and patient records for Alzheimer’s disease, multiple sclerosis, and stroke. (shrink)

The paper identifies the phenomenal rise of increasingly invasive forms of elective cosmetic surgery targeted primarily at women and explores its significance in the context of contemporary biotechnology. A Foucauldian analysis of the significance of the normalization of technologized women's bodies is argued for. Three "Paradoxes of Choice" affecting women who "elect" cosmetic surgery are examined. Finally, two utopian feminist political responses are discussed: a Response of Refusal and a Response of Appropriation.

One of the primordial functions of the brain is the acquisition of knowledge. The apparatus that it has evolved to do so is flexible enough to allow it to acquire knowledge about unambiguous conditions on the one hand, and about situations that are capable of two or more interpretations, each one of which has equal validity with the others. However, in the latter instance, we can only be conscious of one interpretation at any given moment. The study of ambiguity thus (...) gives us some insights into how activity at different stations of the brain can result in a micro-consciousness for an attribute, and also tell us something about interactions between different cerebral areas that result in several potential micro-conscious correlates, though only one predominates at any given time. Finally, the study of ambiguity also gives us insights into the neurological machinery that artists have tapped to create the ambiguity that is commonly a hallmark of great works of art. (shrink)

Criminologists have long acknowledged the link between a number of cognitive deficits, including low intelligence and impulsivity, and crime. A new wave of research has demonstrated that pharmacological intervention can restore or improve cognitive function, particularly executive function, and restore neural plasticity. Such restoration and improvement can allow for easier acquisition of new skills and as a result, presents significant possibilities for the criminal justice system. For example, studies have shown that supplements of Omega-3, a fatty acid commonly found in (...) food such as tuna, can decrease frequency of violent incidents in an incarcerated population. Research has also begun to explore the use of selective serotonin reuptake inhibitors to reduce impulsivity in some violent offenders. However, there are significant legal and ethical implications when moving from dietary supplements to prescription pharmaceuticals and medical devices for cognitive intervention. This paper will explore the legal and ethical issues surrounding the use of pharmacological intervention on prisoners as an effort to reduce crime and recidivism. (shrink)

A new view of the functional role of the left anterior cortex in language use is proposed. The experimental record indicates that most human linguistic abilities are not localized in this region. In particular, most of syntax (long thought to be there) is not located in Broca's area and its vicinity (operculum, insula, and subjacent white matter). This cerebral region, implicated in Broca's aphasia, does have a role in syntactic processing, but a highly specific one: It is the neural home (...) to receptive mechanisms involved in the computation of the relation between transformationally moved phrasal constituents and their extraction sites (in line with the Trace-Deletion Hypothesis). It is also involved in the construction of higher parts of the syntactic tree in speech production. By contrast, basic combinatorial capacities necessary for language processing – for example, structure-building operations, lexical insertion – are not supported by the neural tissue of this cerebral region, nor is lexical or combinatorial semantics. The dense body of empirical evidence supporting this restrictive view comes mainly from several angles on lesion studies of syntax in agrammatic Broca's aphasia. Five empirical arguments are presented: experiments in sentence comprehension, cross-linguistic considerations (where aphasia findings from several language types are pooled and scrutinized comparatively), grammaticality and plausibility judgments, real-time processing of complex sentences, and rehabilitation. Also discussed are recent results from functional neuroimaging and from structured observations on speech production of Broca's aphasics. Syntactic abilities are nonetheless distinct from other cognitive skills and are represented entirely and exclusively in the left cerebral hemisphere. Although more widespread in the left hemisphere than previously thought, they are clearly distinct from other human combinatorial and intellectual abilities. The neurological record (based on functional imaging, split-brain and right-hemisphere-damaged patients, as well as patients suffering from a breakdown of mathematical skills) indicates that language is a distinct, modularly organized neurological entity. Combinatorial aspects of the language faculty reside in the human left cerebral hemisphere, but only the transformational component (or algorithms that implement it in use) is located in and around Broca's area. Key Words: agrammatism; aphasia; Broca's area; cerebral localization; dyscalculia; functional neuroanatomy; grammatical transformation; modularity; neuroimaging; syntax; trace deletion. (shrink)

I much appreciate the honour of being invited to deliver the first Manson lecture, which, its founder has laid down, is to be devoted to the consideration of some subject of common interest to philosophy and medicine. I cannot think of anything which better fulfils that condition than the neurological approach to the problem of perception. The neurologist holds the bridge between body and mind. Every day he meets with examples of disordered perception and he learns from observing the effects (...) of lesions produced by disease, or by the physiologist's experiments, something of how the neural basis of perception is organized. It is possible to study perception as though this was largely irrelevant. How far that view is right will be for you to judge when I have finished. (shrink)

Free games that are monetized by selling virtual items, such as cosmetic microtransactions for one’s avatar, seem to offer a better gaming experience to paying players. To experimentally explore this phenomenon, the effects of character customization with cosmetic microtransactions on objective and self-estimated player performance, subjective identification with the avatar, fun and the players’ perceived competence were examined in the game League of Legends. This study introduces a new laboratory-based, experimental task to objectively measure within-game player performance. Each (...) participant performed this game-based task in two different conditions: With a character that was customized using a provided set of cosmetic microtransactions and with a default character. Results showed that customization increased subjective identification with the player character. However, objective performance measures were unaffected by this manipulation although the novel experimental approach provided reliable performance results. Additionally, identification was positively related to perceived competence, fun, and self-estimated performance. Implications for the design of cosmetic microtransactions and their influence on competitive gaming are discussed. (shrink)

This chapter provides a brief overview of the history of behavioral neurology, dividing it roughly into six eras. In the ancient and classical eras, emphasis is placed on two transitions: firstly, from descriptions of head trauma and attempted neurosurgical treatments to the exploratory dissections during the Hellenistic period and the replacement of cardiocentrism; and secondly, to the more systematic investigations of Galenus and the rise of pneumatic ventricular theory. In the medieval through post-Renaissance eras, the scholastic consolidation of knowledge (...) and the role of compendia are emphasized, along with the use of new methods from within a mechanistic framework. With the discovery of electrical conductance and the rise of experimentalism, we frame the modern era as period of intense debate over localization, decomposition, and other mechanistic principles, and marked by rapid discovery about the brain. The chapter ends with a discussion of the contemporary era, focusing on the establishment of behavioral neurology research on aphasia, apraxia, and neuropsychiatric conditions. (shrink)

Terminally ill patients in 10 states plus Washington, D.C. have the right to take prescribed medications to end their lives (medical aid in dying). But otherwise-eligible patients with neuromuscular disabilities (ALS and other illnesses) are excluded if they are physically unable to “self-administer” the medications without assistance. This exclusion is incompatible with disability rights laws that mandate assistance to provide equal access to health care. This contradiction between aid-in-dying laws and disability rights laws can force patients and clinicians into violating (...) one or the other, potentially creating an underclass of patients denied medical care that is available to those with other (less physically disabling) terminal illnesses. The immediacy of this issue is demonstrated by a lawsuit in Federal court filed in August 2021, requesting assistance in self-administration for terminally ill patients with neuromuscular diseases. This paper discusses the background of this conflict, the ethical issues at the heart of the dilemma, and recommends potential remedies. (shrink)

‘Cosmetic psychopharmacology’ is a term coined by Peter Kramer in his 1993 best‐seller, Listening to Prozac. It has come to refer to the use of psychoactive substances to effect changes in function for conditions that are either normal or subclinical variants. In this paper, I ask: What distinguishes an existential ailment from clinical depression, or either of those from normal depressed mood, melancholic temperament, dysthymia or other depressive disorders? Can we reliably distinguish one from the other? Are the boundaries (...) of illness and disorder really so distinct? If not, how can we know that treatment of ‘depression’ with Prozac in any given instance constitutes a cosmetic as opposed to, say, a medical or clinical use of psychopharmacology – a distinction that seems to turn on our ability to clearly differentiate the clinical from the cosmetic. If we cannot reliably distinguish between such conditions, can we even have a cosmetic psychopharmacology that is not a form of malpractice, broadly speaking? What if we unplugged Prozac from all the amplitude and hype that resulted in Listening to Prozac becoming an instant best‐seller and simply asked whether or not we can clearly distinguish an appropriate cosmetic use of Prozac for ‘depression’ from an inappropriate cosmetic use of Prozac, and both of those from Prozac's appropriate clinical, that is, non‐cosmetic uses? If we cannot make these distinctions, perhaps it is too early to say there can be such a thing as a cosmetic psychopharmacology. (shrink)

Some patients who have been diagnosed as “dead by neurologic criteria” continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of “brain death” or “brainstem death” is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be “dead” (...) would be a false positive, in any nation with so-called “whole brain death” laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either “brain death” or “brainstem death.”. (shrink)

In the UK, female genital mutilation is unlawful, not only when performed on minors, but also when performed on adult women. The aim of our paper is to examine several arguments which have been advanced in support of this ban and to assess whether they are sufficient to justify banning female genital mutilation for competent, consenting women. We proceed by comparing female genital mutilation, which is banned, with cosmetic surgery, towards which the law has taken a very permissive stance. (...) We then examine the main arguments for the prohibition of the former, assessing in each case both (a) whether the argument succeeds in justifying the ban and, if so, (b) whether a parallel argument would not also support a ban on the latter. We focus on the following arguments. Female genital mutilation should be unlawful because: (1) no woman could validly consent to it; (2) it is an oppressive and sexist practice; (3) it involves the intentional infliction of injury; (4) it causes offence. Our view is that arguments (3) and (4) are unsound and that, although arguments (1) and (2) may be sound, they support not only a ban on female genital mutilation, but also one on (some types of) costmetic surgery. Hence, we conclude that the present legal situation in the UK is ethically unsustainable in one of the following ways. Either the ban on female genital mutilation is unjustified because arguments (1) and (2) are not in fact successful; or the law's permissive attitude towards cosmetic surgery is unjustified because arguments (1) and (2) are in fact successful and apply equally to female genital mutilation and (certain forms of) cosmetic surgery. The people of the countries where female genital mutilation is practised resent references to ‘barbaric practices imposed on women by male‐dominated primitive societies’, especially when they look at the Western world and see women undergoing their own feminization rites intended to increase sexual desirability: medically dangerous forms of cosmetic plastic surgery, for instance …. (shrink)