High-tech brain imaging like Dr. Just’s is approaching its own ethical decision points. It’s one thing to study the brain activity of people with a recognized disability and compare that activity to nondisabled peers. Using that knowledge to guide interventions that build up the dysfunctional areas seems like a great thing, and Dr. Just showed that it’s possible with his dyslexia study.
But what if he flipped the study upside down? What if he had studied exceptional readers and then developed exercises to build up typical readers to that level? All of us want to be the best we can be, and I have little doubt that people would volunteer to take part in a study like that. We all want to be smarter. That’s essentially what I hoped for from my TMS experience, except that I substituted emotional intelligence for reading proficiency.
The problem with that notion is that there will always be a top and a bottom in any range of function. We may turn a few people into super-readers, but will that benefit society? In another example, using brain stimulation to relieve the pain of autistic social isolation sounds great, but giving bright college students “emotional ESP” is not so obviously good. It certainly won’t help the masses who don’t get the therapy. When relieving disability takes away suffering we accept it, though my experience suggests that even that may come at a cost. Enhancing performance is not so obviously beneficial, yet there will be strong pressure to do it. A hundred years ago we imagined the prospect of improved humanity through eugenics, breeding the supermen of tomorrow. Soon, brain imaging and stimulation may offer us the ability to make ourselves into those supermen. But what will be the price?
Then there is what I think of as the security aspect of brain exploration. Medical imaging began as a way to see inside the body, but it’s fast developing into a tool that can see patterns that represent our thoughts and feelings. The trouble is, reading those patterns does not tell you which ones a person will act upon. We often feel conflicting things, especially when something or someone is important to us. We may love and hate or be drawn and repelled at the very same moment.
Dr. Just’s technology has obvious implications for the interrogation business. But is there really a circumstance in which such a tool can be used properly and ethically? That’s an important question to discuss, because it may be inevitable that tools that evolve from work like his will be used to “understand” criminals and terrorists. The mind probe of science fiction could be a reality in 2025.
One thing that can help us resolve these looming ethical dilemmas is a closer connection between doctors, researchers, and the people affected by their work. Dr. Minshew showed a great example of that each time I visited her clinic. Whenever I went I saw bright researchers and fascinating projects. But the best part came after hours, with her group dinners. The first time we arrived at the restaurant I was surprised to find a diverse and motley crew of artists, musicians, activists, meditators, doctors, parents, researchers, and even a few financiers who support her research. The eclectic group was not what you’d expect from a staid research organization.
“I am focused on translating science into interventions,” she told me, “testing the efficacy of new treatments and then seeing them disseminated. It’s time for science to pay off on its promises.” I couldn’t agree more, but that’s only part of the story. Nancy reminded me that you don’t always need modern medicine to tap hidden reserves in the mind. Creative people are often different, and bringing them together can accomplish remarkable things.
Dr. Minshew was clearly at the centre of a dynamic and thriving local autism community. Some of the autistic people she knew were severely disabled—even crippled by autism or its associated complications, at least in terms of their capacity to negotiate daily life. Yet everyone in attendance—me included—felt its mix of eccentricity and exceptionality and were empowered and excited by that.
I realized they were all working to make everyone’s lives better—with scientists harnessing technology for tomorrow as clinicians, doctors, and natural practitioners worked to help today, informed by emerging knowledge. The artists and musicians played a valuable role, encouraging creativity, expression, and sharing in the community.
“They help keep me grounded,” she said, and I can’t help but think her own ethical choices will be informed by the wisdom of the group—most of whom have a personal stake in her work. I hope that other researchers can tap into similar resources in their own communities. There’s no better place to discuss the ethics of disability, difference, and treatment choices than with the affected population. It’s when they are excluded that we have problems.
With all of that in mind, I eagerly await the coming revolution in the treatment of brain disorders as these techniques and technologies converge. Psychiatrists already criticize our excessive reliance on drugs. Alvaro and Lindsay have shown that brain stimulation offers an alternative in some cases, and its applicability will likely expand with increased experience. In the future, neurologists like Alvaro and imaging experts like Marcel will work hand in hand with cognitive therapists, combining brain imaging and stimulation with new and existing therapies. They will also work with radiologists to identify and target locations that are implicated in dysfunction. As Nancy pointed out, when this is backed up with genetic testing and other tools we are headed for a future of truly individualized treatment for conditions that, until now, have been thought to be unchangeable.
I hope that this coming convergence will cause neurology, psychology, and psychiatry to begin merging into a new and more holistic discipline, directed at better brain function, and that we’ll soon talk of brain health and “making brains stronger” just as we talk about building muscles and stamina for a marathon. Alvaro’s Brain Fit Club at Beth Israel is one of the first places to begin doing that.
One idea that I’ve come back to throughout this book is the notion that my brain (or anyone else’s) might differ from the brain of a typical person. But the truth is, there is really no such thing as a “typical” brain, because every human is atypical in some or many ways. The “neurotypical person” is a construct, established by scientists who need parameters by which to measure the disparate statistics of different individuals.
Last year, Dr. Just tried a new kind of experiment with interesting implications for what “neurotypical” and “different” mean. Marcel put thirty-four young adults in his fMRI scanner and asked them to imagine the following verbs: compliment, insult, adore, hate, hug, kick, encourage, and humiliate. Then he asked them to consider the verbs from the perspective of applying them to another person, as well as to themselves.
In previous experiments he had already identified characteristic brain activity patterns that were associated with subjects imagining each of these actions, but this time he introduced a new twist. Half of these new subjects were autistic; the other half were not. His findings were remarkable, to say the least. Dr. Just was able to separate the autistic from the non-autistic subjects just by comparing their responses to those verbs, and the difference that set them apart was striking. He observed that the autistic people had a different pattern of activation of the brain areas associated with emotional response. Yet they showed the same activation as the non-autistic subjects to the logical meaning. Not only were the autistic responses different, they were consistent. In other words, the pattern of emotional response was similar in all the non-autistics and similar (but different from the first group) in all the autistics.
Dr. Just cautioned me that this study only included thirty-four subjects, and a much larger study would be needed to draw population-wide conclusions. But with that caveat, his research may point the way to a noninvasive tool that can identify autistic brains through a brief session in an fMRI scanner. That alone would be a major breakthrough.
But there’s more. . . .
The finding that his subjects had similar brain response patterns to those stimulations suggests an answer to that age-old question, “Is my perception of red the same as yours?” At the same ti
me, the fact that the autistic subjects had a collectively different response in some areas shows that neurological difference (in this case, autism) may alter our perceptions in a very elemental way. That should be a potent piece of knowledge for any therapist.
Alvaro and Lindsay made a similar discovery in their own lab. They found that autistic people were more affected by a brief burst of TMS, and for a longer time, than non-autistic subjects. They interpreted that finding as evidence that autistic people have more plastic brains, a factor that could explain both gift and disability.
When your brain is too changeable in the parts that acquire basic skills, you won’t be able to learn enough to function, because your brain will be unlearning whatever you are taught five minutes after you learn it. Yet a touch of extra plasticity could be an element of genius, if it helped your brain rewire itself for new abilities faster than an ordinary person’s brain.
It will take us years to fully explore insights and issues like these. For every answer, we are presented with new questions. It’s an exciting time!
Doctors will face more and more ethical dilemmas as they try to decide what should be treated and what might be left alone. The decision to treat brain damage after a stroke, for example, is fairly straightforward. But in other cases, “treatment” may become more about making patients aware of their differences and learning to see the aspects that are gifts. Who are we to say what’s disabled and what’s different, unique, and special in another person? As Howard Gardner first wrote decades ago in Multiple Intelligences, there are a variety of distinct intellectual capacities and orientations that contribute to our understanding of ourselves and our place in society.
Sometimes, a touch of disability is what makes us great. Consider a few historical figures who were touched by autism, serious eccentricity, or some other disability in addition to their well-recognized gifts:
Leonardo da Vinci
Michelangelo
Ludwig van Beethoven
Isaac Newton
Wolfgang Amadeus Mozart
Albert Einstein
Today, we might add to the list folks like Bill Gates and Dan Aykroyd.* Where would we be if we’d made those people “normal” in childhood? As Temple Grandin says, “We’d be living in caves and using our social skills to tell each other jokes by firelight.” My vote is for a renaissance in which psychology, psychiatry, neurology, and radiology (with the latest brain imaging techniques) come together to achieve unprecedented success in treating formerly untreatable neurological differences and disorders. The brain scientists I’ve been privileged to meet are truly pointing us toward a better tomorrow.
* Cambridge autism researcher Simon Baron-Cohen and Trinity College professor Michael Fitzgerald have both written about historical figures who were likely autistic. In modern times, Bill Gates has been widely described as exhibiting many traits of autism, but he has not to my knowledge made a statement. Dan Aykroyd disclosed his Asperger’s in an interview with the Daily Mail in December 2013.
Afterword
Marcel Adam Just, PhD
THE STORIES THAT John Elder Robison tells in these pages come together in a fascinating journey, one that reveals facets of daily life that are often not evident to people who are not on the spectrum, told from the unique perspective of an autistic person. Perhaps the most dramatic part of this story is John’s experience following his participation in a TMS study at Harvard and Beth Israel Hospital. That brief journey brings chills to one’s spine as John describes in eloquent detail how his own thinking and perceptions temporarily changed after the experimental treatment. This is probably the most articulate description ever written of a phenomenological experience triggered by TMS. I am not sure what to make of it. I somewhat envy him the experience, and I would like to think that I would be brave enough to embark on a similar trip.
The part of John’s journey that is closest to my heart describes his learning about contemporary cognitive neuroscience. Of course, that field is changing as I type this sentence, and it will surely have changed by the time anyone reads it. But it seems to me that understanding how we get mind from brain is one of the most interesting questions faced by humankind. How is it that those three pounds of tissues containing eighty-six billion neurons can invent a flying machine, write a poem, and raise a child? Those are remarkable achievements for such a small organ, one that we almost never see or even sense (given that it doesn’t have pain receptors, for example). Consider the miracle that occurs in each pregnant mother as her unborn child’s brain is gradually constructed according to the world’s most complex blueprint. It is of course amazing that newborns come with beating hearts and working lungs, that they can eat and poop. But to me what’s most amazing is that they also come with an organ of thought that can sense and respond to the world, and which can eventually invent drones, write essays, and develop web start-ups.
Cognitive neuroscience is the discipline that tries to explain how a brain gives rise to a mind. The brain-mind combo can get us through day-to-day life, and it can think deep thoughts. It governs how we perceive and interact with other people. It enables us to provide food and shelter for ourselves and those we care for. It is only a bit of an overstatement to say that human beings are brains in a body. Our personalities, skills, feelings, and knowledge all reside in our brains. That is why cognitive neuroscience is such a fundamental human science. It attempts to explain who we are. Brain imaging, particularly fMRI, has arguably taught us more about human brain function in the last twenty-five years than we ever previously knew.
The gift that imaging of brain function (the “f” in fMRI) has bestowed on us is a picture of brains at work. At first, in the 1990s, those fMRI pictures showed us the hot spots in our brain while a particular type of thinking task was being performed. Those early pictures provided several fascinating insights. They showed that every task evoked activation (a hot spot) not just in one area but in an entire set of brain areas, showing that thinking was a collaboration among ten to twenty brain centres, like a team sport among specialists whose work is intricately coordinated. The early fMRI pictures also showed that in people with neurological or psychiatric disorders, the activation pattern was often disordered. In people with high-functioning autism, the alteration was manifested as poorer synchronization between frontal brain areas and other brain areas. Because many types of thinking (particularly social processing) involve coordinated activity between frontal and other areas, this lower level of synchronization provides an explanation of the social thought alteration in autism.
A second brain imaging revolution occurred at the beginning of the twenty-first century, when new computational techniques, particularly the branch of computer science called machine learning, began to be applied to brain imaging data. I was fortunate to be part of this adventure in a collaboration with Tom Mitchell, a pioneer in machine learning, as well as with many extremely talented postdoctoral fellows, graduate students, and research staff. We set off to relate the patterns of brain activity to specific thoughts, and not just treat them as hot spots. This is the ongoing work that John refers to as mind reading. As John explains, it is now possible to tell what concept a person is thinking about from its brain activation signature. Our work started by identifying the signatures of concrete concepts, like the thought of an apple or a hammer or an igloo. We progressed to identifying experiences of emotions, so that we could tell whether someone was feeling happiness or disgust, for example. We also found, as John says, that thoughts of social interactions like hugging were altered in people with high-functioning autism. This discovery suggests that many if not all thought disorders may be amenable to diagnosis with our mind-reading techniques. And the way in which a thought is altered may indicate where to target a therapy.
It would be very satisfying if fMRI mind reading progressed from being the world’s greatest parlour trick to being a tool that reveals the inner structure and workings of human thought. The most promising aspect is that not only can a co
ncept’s fMRI signature be detected, but it can also be decomposed into its main components, revealing the building blocks of the concept. The experimental fMRI findings illuminate which set of brain regions underpins each building block. As we discover the building blocks of more and more types of concepts, we hope to understand the nature of all types of thoughts, from the thought of an apple to the thought of “The old man threw the stone into the lake” (which is a thought of the complexity that we can currently read).
Aside from the satisfaction of revealing the brain’s Lego pieces for building thoughts, this type of research has the potential to tangibly change our world in two main ways. First, as mentioned in the book and above, this approach has the potential to change our understanding and treatment of many types of thought disorders. Rather than simply knowing that some aspect of thought is disordered—say, for example, that a person has an exaggerated sense of being persecuted—it may become possible to say precisely which building block of thought is absent or misshapen and how the functioning of the underlying brain areas is altered. For example, someday, instead of saying “This child has dyslexia,” we may say “the anatomical connections between two regions in the frontal cortex of this child are undermyelinated.” With such a diagnosis, it could be possible to apply a therapy that improves the connectivity and improves the reading to near-normal levels. That “someday” has already occurred, and was described in the journal Neuron in 2009 in an article by Tim Keller and myself (available at ccbi.cmu.edu/publications.html). More generally, many thought disorders may eventually be traceable to their brain basis in a way that suggests a therapeutic intervention.