PERSPECTIVE ARTICLE
published: 18 December 2014
doi: 10.3389/fnhum.2014.00953
HUMAN NEUROSCIENCE
Brain stimulation for treatment and enhancement in
children: an ethical analysis
Hannah Maslen *, Brian D. Earp, Roi Cohen Kadosh and Julian Savulescu
Oxford Uehiro Centre for Practical Ethics and Oxford Martin School, University of Oxford, Oxford, UK
Edited by:
Peter G. Enticott, Deakin University,
Australia
Reviewed by:
Markus Christen, University of
Zurich, Switzerland
Nick J. Davis, Swansea University,
UK
*Correspondence:
Hannah Maslen, Oxford Uehiro
Centre for Practical Ethics and
Oxford Martin School, University of
Oxford, Suite 8, Littlegate House,
16/17 St Ebbe’s Street, Oxford OX1
1PT, UK
e-mail: hannah.maslen@
philosophy.ox.ac.uk
Davis (2014) called for “extreme caution” in the use of non-invasive brain stimulation (NIBS)
to treat neurological disorders in children, due to gaps in scientific knowledge. We are
sympathetic to his position. However, we must also address the ethical implications of
applying this technology to minors. Compensatory trade-offs associated with NIBS present
a challenge to its use in children, insofar as these trade-offs have the effect of limiting
the child’s future options. The distinction between treatment and enhancement has some
normative force here. As the intervention moves away from being a treatment toward
being an enhancement—and thus toward a more uncertain weighing of the benefits, risks,
and costs—considerations of the child’s best interests (as judged by the parents) diminish,
and the need to protect the child’s (future) autonomy looms larger. NIBS for enhancement
involving trade-offs should therefore be delayed, if possible, until the child reaches a
state of maturity and can make an informed, personal decision. NIBS for treatment, by
contrast, is permissible insofar as it can be shown to be at least as safe and effective
as currently approved treatments, which are themselves justified on a best interests
standard.
Keywords: brain stimulation, pediatric ethics, cogntive enhancement, functional trade-offs, autonomy
Davis (2014) has called for “extreme caution” in the use
of non-invasive brain stimulation (NIBS) methods to treat
neurological disorders in children. His focus is on transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), which, respectively, involve passing
either an electro-magnetic field or a small direct current
through the skull in order to modulate neuronal activity. To justify his position, Davis calls attention to four
major issues, framed as “known unknowns” in the current
literature:
(1) unknown effects of brain stimulation, and unknown mechanisms for producing those effects;
(2) unknown side-effects of stimulation (both short- and longterm);
(3) a lack of clear dosing guidelines; and
(4) a lack of translational studies from adults to children.
As Davis rightly points out, “children [cannot] be considered
as ‘small adults’ when testing medical interventions” (p. 2). This
is especially the case for interventions into the central nervous
system, since a child’s developing brain may respond differently
to stimulation compared to that of an adult. Indeed, research
shows that the brain continues to develop even after the age of
majority (Sowell et al., 2003). Nevertheless, Davis balances his
plea for caution with longer-term optimism. He argues that—
when used with care—brain stimulation in children does appear
to be safe and well-tolerated, and may even turn out to be
“associated with fewer and less unpleasant side-effects than the
Frontiers in Human Neuroscience
neuroactive drugs [such stimulation is] intended to replace”
(p. 3).1
We are sympathetic with Davis’ argument (Cohen Kadosh
et al., 2012). Put simply, caution and sustained clinical scrutiny
are required, both for research into the effects of pediatric
brain stimulation and for the application of such technology.
Yet while further empirical studies into appropriate dosing, sideeffects, and so on should allow for brain stimulation in children
to be made generally safer (as well as more effective therapeutically), we must also address the gaps in our understanding of the ethical implications of applying this technology to
minors.
In this article, we aim to contribute to such an understanding.
To frame our discussion, we draw a distinction between the use
of NIBS (but see Davis and van Koningsbruggen, 2013)2 as a
form of treatment for a recognized neurological disorder, and its
1 Consistent
with this perspective, a recent review concluded that there is at
least preliminary evidence of a therapeutic potential for TMS and/or tDCS in
children with conditions such as depression and autism spectrum disorder;
however, it should be noted that many of the studies included in this review
did not have adequate control groups, and should therefore be interpreted
with care (Vicario and Nitsche, 2013).
2 They argue that the term “non-invasive” “is inappropriate and perhaps
oxymoronic, as it obscures both the possibility of side-effects from the
stimulation, and the longer-term effects (both adverse and desirable) that
may result from brain stimulation. [Moreover, the] tendency for the effects of
[such stimulation] to spread from the target brain area to neighboring areas
is in itself contrary to the definition of non-invasiveness” (p. 1). Indeed, this
ability for (intended) effects of brain stimulation to have potentially adverse
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Maslen et al.
Brain stimulation in children—ethics
use as a form of enhancement in healthy children. Although we
have argued in previous work that the treatment/enhancement
distinction tends to break down in the case of adults (see Earp
et al., 2014), in the case of children, we suggest, it has greater
normative force. This is because, we argue, the relative weights
of (parental judgements of) beneficence vs. respect for autonomy
shift as the decision pertains more to “enhancement” than to
“treatment”.3,4
The tension between these two factors arises because some
interventions may involve compensatory trade-offs or functional
losses, such as potential cognitive costs in the case of brain
stimulation. When these trade-offs have the effect of limiting the
child’s future options, they pose a threat to his or her (future)
autonomy. Whilst choosing to “treat” a child will sometimes be
in his or her best interests even if it precipitates cognitive tradeoffs, interventions intended to “enhance” may not be justified in
this way. In the absence of a clear pathology, we suggest, greater
relative weight should be placed on the child’s (future) autonomy,
at least in part because the certainty with which the parents can
determine what would be in his or her best interests is likely to be
significantly reduced.
Given this, we argue that brain stimulation for “enhancement”—insofar as it involves a more controversial weighting of
benefits vs. risks and costs—should be delayed until the child
has reached a state of maturity. In this way, she can make an
informed, personal decision about the proposed intervention.
Brain stimulation for “treatment”, by contrast, is permissible
insofar it can be shown to be at least as safe and effective as
currently approved treatments (which are themselves justified on
a best interests standard).
THE PERMISSIBILITY OF TREATING NEUROLOGICAL
DISORDERS IN CHILDREN
To begin our discussion, we ask, what makes pediatric “treatment”
permissible in general? By “treatment” we intend to call to mind
such interventions as surgery to correct a heart defect, or the
administration of antibiotics to address an infection. In these
cases, a disease or deformity is present that threatens the child’s
well-being, and the treatment is the best available means (or
a good-enough means) to mitigate that threat. Thus, although
(a) the child cannot strictly consent to the intervention, (b) the
ramifications for other brain areas (and/or functions) is a key component of
our ethical analysis.
3 We do not suggest, of course, that there is a clear-cut, universally agreed-upon
distinction between treatment and enhancement (see Maslen et al., 2014).
Instead, we envision a sliding scale from interventions that are intended simply
to sharpen a certain cognitive skill in a healthy child (“enhancement”) to those
intended to relieve a child of pain or another burden that significantly affects
his or her ability to pursue the normal range of activities that children pursue
(“treatment”).
4 Throughout this paper we invoke three overlapping considerations: the
child’s “developing autonomy” (her learning to be self-governing), the child’s
“future autonomy” (her prospects for pursuing the life plans that she will come
to value as an adult) and the child’s “self-determination” (the freedom for her
actions to be “up to her”). All three are relevant and closely related in our
discussion. However, we use the term “future autonomy” more prominently,
as this denotes best the concern with preserving options for the child to
evaluate herself, once she has sufficient capacity to make such assessments.
Frontiers in Human Neuroscience
intervention may carry considerable risk, and (c) it may involve
even a gross intrusion into the child’s bodily sphere, it is nevertheless considered to be morally permissible. Such an intervention
is permissible because, and insofar as, it is in the child’s best
interests—all things considered (see Hope et al., 2008).
We can extend this reasoning to the case of brain stimulation.
If a child is experiencing significant psychological and/or physical
burdens due to a neurological disorder, the benefits of treatment
with stimulation might very well be in the child’s best interests
in the sense just described. In fact, this could turn out to be the
case even if some significant negative side-effects were generated,
so long as the overall costs to the child (including the cost to
autonomy) were outweighed by the benefits of performing the
stimulation before an age of consent. On these grounds, it could
be considered permissible, assuming that it were shown to be at
least as safe and effective as other, more established treatment
paradigms.5
ENHANCEMENT AND THE CHILD’S INTEREST IN AUTONOMY
What about the case of “enhancement”? Ethicists are divided
on the question of whether parental enhancement choices are
in the child’s best interests and this is often framed in terms
of a consideration of the child’s interest in (future) autonomy,
or self-determination. Some have argued that the enhancement
of a child might lead her to feel unfree to pursue her own
life-projects due to the fact that decisions about her traits and
capacities have been chosen for her. In developing this argument,
Habermas (2003, p. 50) has argued that, in the case of genetic
enhancement (i.e., selecting for specific traits, such as intelligence), the parents’ choices represent intentions and expectations
relating to their child’s life. Such expectations, he suggests, lead
to the stifling of the child’s freedom to develop in his or her own
way.
Others have argued that enhancement technologies would
not undermine autonomy, insofar as they increase the options
available in an individual’s choice set. For example, Bostrom
(2005) claims that an enhanced child might “enjoy significantly
more choice and autonomy in her life, if the modifications were
such as to expand her basic capability set. Being healthy, smarter,
having a wide range of talents, or possessing greater powers
of self-control are blessings that tend to open more life paths
than they block” (p. 212). Such an analysis tends to assume
that enhancement has the overall effect of increasing objective
opportunities, even if a child might experience her freedom as
being constrained by parental expectations. However, as we will
now discuss, in the case of brain stimulation, the assumption
of “more choice” may sometimes be mistaken. The arguments
5 However,
note that the permissibility of parents’ choosing the intervention
would depend in part on what specific “negative side effects” might be
incurred by the stimulation, as well as the magnitude of the risk. As we discuss
later on, one high-risk side-effect of some kinds of brain stimulation is the
diminishment of a non-targeted cognitive capacity. In this case, the persistence
of symptoms due to the neurological condition would have to be worse—
that is, more contrary to the child’s interests—than the cognitive trade-offs
incurred by the stimulation (alongside any other negative side-effects and
costs) for the stimulation to be considered permissible on the best interests
test.
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Maslen et al.
Brain stimulation in children—ethics
we make in what follows are about objective, not subjective,
curtailment(s) of freedom.
BRAIN STIMULATION AND COGNITIVE TRADE-OFFS
While early research into brain stimulation in healthy adults has
focused on its potential to enhance cognitive functions, the cognitive costs that might be associated with such enhancement have
largely been neglected. However, as Davis points out, no brain
region exists in isolation. Indeed, there is evidence that enhancing
one aspect of cognition may be detrimental to other cognitive
faculties, making neuromodulation “a zero-sum proposition”
(Brem et al., 2014; but see Luber, 2014). For example, it has been
shown that enhancing cognitive performance on one task can be
associated with poorer performance on a different cognitive task
(Iuculano and Cohen Kadosh, 2013; Sarkar et al., in press).
It must be acknowledged that the evidence for such
enhancement tradeoffs has thus far been obtained only from
well-controlled laboratory experiments that have poor ecological
validity. However, this preliminary evidence should alert us to
the possibility of similar trade-offs that might occur in more
ecologically valid settings. Laboratory experiments can help to
demonstrate what would be theoretically expected, based on the
cognitive function that is targeted and the brain regions that
are stimulated. Crucially, such experiments suggest that it is
theoretically likely that enhancement of one domain of cognition
will sometimes come at the cost of impairment in another. Thus,
any decision to enhance could be also a decision to impair. When
this is coupled with the emerging probability of long lasting
effects on the brain (see Snowball et al., 2013), a situation arises
in which parents might inadvertently or even knowingly limit (at
least some) future options for their children when they choose to
enhance particular capacities at the expense of others.
For example, imagine a parent who has aspirations for her
child to be the star of the school’s quiz team. The parent encourages the child to memorize facts whilst her brain is stimulated to
enhance long-term memory. However, as a result, the child’s visuospatial working memory is impaired and her ability to quickly
solve mental arithmetic problems suffers (see de Jongh et al., 2008
for a review of such trade offs with respect to pharmacological
enhancements). Although the child performs well on general
knowledge tests, she performs less well in mental arithmetic:
mathematics-related pursuits are, to a certain degree, limited as
a result of the intervention.
In this example, by choosing to enhance the child’s long-term
memory and, correspondingly, the ease with which activities
employing this particular cognitive capacity can be pursued,
the parent is also choosing to impair a different capacity,
making the pursuit of activities involving visuospatial working
memory more difficult. It is our contention that making these
opportunity-limiting choices on behalf of the child may not be
permissible. This is the case even if opportunities associated with
the enhanced cognitive domain are increased. Parents cannot
know what the child will grow up to value and so should not
restrict opportunities based on what they want their child to
pursue. Whilst there are many decisions that parents can make
in the best interests of their child, which cognitive capacities are
more valuable, we contend, is usually not one.
Frontiers in Human Neuroscience
This argument applies most strongly to cases in which
there is (roughly) a one-to-one trade-off. However, if a given
enhancement intervention substantially increased function in one
domain, while only slightly reducing function in another (as
judged by a reasonable observer), then the decision would turn
more heavily on considerations of what would be in the best
interests of the child, overall. Such valuations are hard to make,
and are likely to be highly subjective in many cases. The more
subjective they are (that is, the less clear an “objective” observer
would be about the relative weights to assign to the enhanced
vs. diminished capacities), the more the decision about intervening should be left to the individual who must live with the
consequences.
AT WHAT AGE CAN CHILDREN DECIDE TO BE “ENHANCED”?
Let us summarize our argument so far. First, when “enhancement” interventions involve a functional trade-off, the agent
whose relevant capacities will be altered should usually be the one
to make a decision about whether the intervention is desirable,
all-things-considered. However, young children are unlikely to
know which capacities they will value later in life, since their
self-knowledge and ability to make and pursue long-term goals
is yet to develop. Therefore, there is a problem in terms of a
child’s capacity to consent—that is, to fully understand what
an intervention involves and what the material consequences
will be. Moreover, there is a problem in terms of the child’s
limited insight into what she will value over time. At what
point, then, can children make meaningful decisions regarding
self-enhancement, taking into consideration the apparent risk of
cognitive trade-offs?
To begin with, we should point out that a child’s inability to
provide informed consent does not make pediatric interventions
impermissible per se. As we have already suggested, when it comes
to treatment, at least, parents (or legal guardians) can legitimately make decisions in the best interests of the child. Similarly,
when an intervention is carried out for purposes of medical
research, a child’s lack of capacity to consent is not necessarily
prohibitive either. In these cases, clinicians or researchers must
seek (and obtain) the child’s assent to participate in the study
(as well meet all other ethical requirements, see Caldwell et al.,
2004).6
For minor interventions, then—such as venipuncture for
the purposes of a study—a child’s assent may be all that is
needed. This is because the risks that are associated with such a
6 What
is assent? Although there are several different theories of assent, at its
most basic, it involves agreement to or acceptance of the intervention. It is
often argued that the requirements for assent are less cognitively demanding
than for consent (see John et al., 2008; Waligora et al., 2014), such that
individuals whose capacities to make informed judgments are still developing
may nevertheless be able to meet them. In relation to assent for pediatric
research, for example, Roth-Cline and Nelson suggest that the child should
“understand why he or she is being asked to participate and what will be his
or her experience if he or she decides to participate” (Roth-Cline and Nelson,
2013, p. 296). Precise age ranges vary, but a child’s assent is thought to be
(ethically) obtainable by approximately age five or six, depending upon the
specific intervention being proposed (including its risk profile, etc.), and also
adjusting for the child’s individual stage of development.
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Maslen et al.
Brain stimulation in children—ethics
procedure are either immediate and transitory (e.g., pain, stress,
or discomfort) or rare (e.g., hemorrhage or infection), assuming that the intervention is properly performed. By contrast,
the effects of brain stimulation for “enhancement” may have
consequences that reach far into the child’s future. Therefore,
in order to evaluate the reasons one might have for refusing
such an “enhancement” (such as a desire to leave one’s cognitive
functions intact), one must be capable of meaningful temporal
self-projection. Yet such projection is usually not possible for very
young children.7
It may be possible, however, for older children and/or adolescents. Accordingly, some scholars have suggested that genuine
consent may be possible before an age of legal majority (typically
18), at least for certain kinds of “medical” interventions (see,
e.g., Levy et al., 2003). For simple procedures with minimal risks,
children as young as 10 may be capable of giving age-appropriate
consent. As the risks increase, however, and as the need for temporal projection becomes more central to the decision-making
process, a higher threshold for consent is required. In the case of
“enhancement” decisions involving potential trade-offs, such as
the impairment of a cognitive capacity, the threshold should be
higher still.
This is for two reasons: first, as we have discussed, a child’s
brain is still developing, and in numerous ways that are not yet
understood. Indeed, even adolescent and adult brains continue
to develop. Nevertheless, and second, adolescents (and adults)
have much greater insight—compared to very young children—
into their own future values. It is this forward-looking capacity,
we contend, that is especially important when making decisions
about how to weigh the relative value of different cognitive
functions; and younger children seem to lack this capacity. Therefore, in the case of pediatric enhancement involving long-term
cognitive tradeoffs, we suggest that consent may be (ethically)
obtainable by later adolescence, perhaps around the age of 16, but
usually not earlier than this.
PARENTS’ TRADITIONAL INFLUENCE ON CHILDREN’S SKILL
DEVELOPMENT
A first response to our argument might be to point out that
parents already make many (relatively unproblematic) decisions
when, for example, they allow their children to take part in certain
extra-curricular activities but not others. A parent might encourage her child to go to drama club instead of French lessons or to
practice football rather than sing. However, there are important
differences between these decisions and the sorts of cognitive
trade-offs under discussion.8
7 Therefore,
a simple understanding of the immediate experience of the
intervention would not be sufficient to make the enhancement intervention
morally permissible. Indeed, the acceptance that is characteristic of child assent
must be supplemented with a strong, considered preference in cases in which
long-term trade-offs are under consideration.
8 There will, of course, be examples of “hyperparenting” (see Sandel, 2009),
which may in fact be as problematic as electing opportunity-limiting
interventions involving direct intervention into a child’s brain—and for similar reasons. This will be the case particularly when the child is made to spend
a considerable amount of time developing a certain skill despite her sustained
dissent. Whilst parents should encourage children to try different activities,
Frontiers in Human Neuroscience
First, developing a skill through participation in an extracurricular activity does not directly impair the skills that would
have been developed had a different activity been selected: practicing music, for example, does not directly impair the ability
to speak French. The significance of this disanalogy with cognitive trade-offs will depend upon two things. First, the extent
to which the failure to develop a capacity is comparable (in
an opportunity-limiting sense) to directly impairing it: if, later
in life, non-developed skills can more easily be developed than
impaired skills, then the child retains more options. Second, the
permanency of the impairment will be highly relevant: temporary enhancement may only result in temporary impairment. If
impairment to a capacity subsides, or is compensated for, then it
becomes equivalent to a non-developed capacity and the (moral)
distance between traditional intervention and neuro-intervention
decreases.
Thus, neuroscientific evidence regarding the permanency—
and extent—of cognitive costs associated with brain stimulation
will be essential to determining the permissibility of parental
“enhancement” decisions. It will also be crucial to know how
these effects differ between one-off vs. repeated interventions,
as well as whether the sought-after benefit can be achieved later
in life, when the (future) adult can decide for himself or herself.
Such knowledge is currently lacking. Accordingly, we highlight
the need for careful consideration of these variables, and conclude
that “enhancements” involving significant long-term cognitive
tradeoffs should be delayed until the individual to be affected can
express a considered preference (i.e., adolescence).
CONCLUSION
Whilst adults are in a position to decide whether effect X is
valuable enough (to them) to justify incurring impairment Y,
children do not yet have the capacity or the life experience to
make such trade-off decisions. They do not know what they
will value when they grow up and nor do their parents. Whilst
an intervention that improves X may count as an enhancement
for the individual who does not care much about Y, another
individual, valuing Y over X, will view the very same outcome
as an impairment. In such cases—that is, cases in which the very
status of an intervention’s being an (overall) enhancement vs. an
impairment is controversial—the weight of considerations should
shift toward delaying the intervention until the individual who
will actually be affected by it has sufficient capacity to decide.
The more permanent and substantial the trade-off, the more this
argument has force.
The gaps Davis identifies in the literature on brain stimulation
suggest that we do not currently have enough evidence to
properly assess the magnitude and permanency of any trade-offs
and, consequently, that the caution he recommends is indeed
warranted. However, we have suggested that even when science
and sometimes override dissent when a child is less-than-enthusiastic on
a particular occasion, a child’s long-term resistance to an extra-curricular
activity renders parental force morally questionable at best, and morally
impermissible at worst. This is due to the failure of such parental pressure to
nurture the child’s developing autonomy and its prevention of the child’s pursuit of alternative extra-curricular options, which may become increasingly
difficult to master as time goes on.
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December 2014 | Volume 8 | Article 953 | 4
Maslen et al.
Brain stimulation in children—ethics
can tell us about the effects of brain stimulation in more detail,
the permissibility of parental decision-making may remain
limited in some cases in which the aim is only to “enhance” an
intact cognitive capacity. In contrast, the treatment of atypical
cognitive abilities using brain stimulation will be permissible
insofar as the stimulation is (at least) as safe and effective as
existing treatments in providing an overall benefit to the child.
ACKNOWLEDGMENTS
This work was supported by the Wellcome Trust [086041/Z/08/Z];
the Oxford Martin School; and the Uehiro Foundation on Ethics
and Education.
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Conflict of Interest Statement: Roi Cohen Kadosh has filed a patent entitled
“Apparatus for Improving and/or Maintaining Numerical Ability” (International
Application PCT/GB2011/050211).
Received: 25 September 2014; accepted: 09 November 2014; published online: 18
December 2014.
Citation: Maslen H, Earp BD, Cohen Kadosh R and Savulescu J (2014) Brain
stimulation for treatment and enhancement in children: an ethical analysis. Front.
Hum. Neurosci. 8:953. doi: 10.3389/fnhum.2014.00953
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December 2014 | Volume 8 | Article 953 | 5