This analysis of TMS technologies in Israel has highlighted the fact that the Israeli context impels the entrepreneurial development of cognitive enhancement technologies while, for the most part, limiting the moral oversight of these technologies to standard issues of safety and efficacy and glossing over deeper moral philosophical questions raised by the development and application of these technologies. In the final section of this chapter, I provide some reflections on these deeper neuroethical issues. These reflections pertain directly to the development of TMS technologies as outlined in this chapter, although they can, of course, be extended to other cognitive enhancement technologies. I have divided up the ethical issues into the following: enhancement versus treatment, relationship between industry and science, neurocitizenship, the ethics of memory, and, finally, cognitive enhancement as a form of “tikkun olam.”
ENHANCEMENT VERSUS TREATMENT
TMS is increasingly recognized explicitly as a promising cognitive enhancement technology that may improve normal cognition and action. The expanding clinical applications of Brainsway’s deep TMS to treat borderline pathologies and Neuronix’s NeuroAD device to stimulate memory demonstrate how the expanding clinical applications of TMS increasingly blur the distinction between treatment and enhancement. In this regard, the ethical debate about TMS is essentially no different from other medical forms of cognitive enhancement. The moral legitimacy of medical cognitive enhancement technologies recently endorsed by the Israeli Medical Association (IMA) would, therefore, undoubtedly also apply to the application of TMS beyond its present clinical applications. In a position paper for the IMA, Dr. Avinoam Reches, who for many years has chaired the medical ethics committee of the IMA, has articulated the position that the goal of modern medicine includes improving the personal quality of life, even in the situation of non-illness. “Medical enhancement” he argues, is ethical, provided there is clear benefit to the healthy individual, and the danger associated with it is marginal.32
The ethics of discourse is another important issue that sheds light on the ethics of neurotechnologies as enhancement or treatment. Thus, Duecker et al. have distinguished three domains regarding the application of neuroenhancement technologies that should be kept separate: (1) as a research tool, (2) as a therapeutic tool, and (3) applied in healthy people outside of neuroscience.33 They note that “the different domains where neuro-enhancement is now or in the future applicable should be considered separately in discussions about neuro-enhancement, its values, its risks, its desirability, its development and its general pursuit.”33: 3 I would add that, although it is obviously useful to separate the ethical discourse of these three domains, it is equally important to examine the points of contact between these domains for neurotechnologies and especially for a clinically effective and relatively benign technology such as TMS, where the domain boundaries are fluid. Moreover, it is important to analyze the scientific discourse in relation to marketing of particular applications. In claiming only to treat distinct clinical conditions and simultaneously expanding the range of clinical applications of TMS to increase market share, the proponents of TMS technologies gloss over the ethical issues arising from their application of a distinct cognitive enhancement technology.