Global mental health and neuroethics

Global mental health is a relatively new but highly influential field that has emerged
from an awareness that there is ‘no health without mental health’ 1] and that there is a need for psychiatric care that is not only cross-culturally appropriate
2],3] but that can also be scaled up across the globe 4]. Global mental health has relied on a number of pre-existing fields of study. First,
cross-national epidemiological studies have emphasized that mental disorders are prevalent
across the globe, but are underdiagnosed and undertreated, with the treatment gap
widest in low- and middle-income countries 5]. Second, studies in psychiatric anthropology, including work with immigrants and
refugees, have emphasised that understanding of and interventions for mental disorders
need to include an appreciation of the relevant socio-cultural context 6]. Practitioners of global mental health have focused on advocating for measures to
close the treatment gap and on developing novel ways of doing so in under-resourced
regions 7], and such work has already had a significant impact on psychiatric research and practice.

Neuroethics is similarly a relatively new but highly influential field, which has
emerged from ongoing work in the areas of neuroscience, psychiatry, neurology and
bioethics, and that is becoming increasingly international in scope 3],8],9]. On the one hand, neuroethics poses the question of whether and how new findings
in basic and clinical neuroscience shed light on long-standing questions in philosophy,
including the relationship between brain and mind, and the nature of morality (that
is, the ‘neuroscience of ethics’) 10]. On the other hand, neuroethics has addressed the ethical questions fostered by novel
neuroscientific methods and their applications in research and medicine, including
functional brain imaging, neurogenetic screening, psychopharmacological treatments
and enhancements, and the social implications of various neurotechnological interventions,
such as deep brain and transcranial magnetic stimulation (that is, the ‘ethics of
neuroscience’) 11]. Thus the field draws on, but also expands bioethical work, and has given rise to
a rich set of interdisciplinary writings that cover a broad range of issues 12].

While the broader convergences between psychiatry and neuroethics also deserve attention,
in this essay we argue that some of the intersections between the important fields
of global mental health and neuroethics are particularly timely and potentially fruitful.
The foci of the neuroethics of global mental health are likely to range from long-standing
questions in psychiatric ethics, to more recent issues that have emerged as a result
of relatively new developments in the applications of neuroscientific methods to mental
health research and care. We will discuss in turn how both global mental health and
neuroethics have an emphasis on a naturalist and empirical approach, on both disease
and wellness, on human rights in neuropsychiatric care, and on the value of social
inclusion and patient empowerment (Table 1). Indeed, while global mental health and neuroethics are quite different disciplines,
they share a number of important perspectives, and an ongoing dialogue between them
should be encouraged.

Table 1. Intersections between global mental health and neuroethics

Evidence-based medicine/empirical neuroethics

As a discipline, global mental health has emphasised the importance of evidence-based
clinical practices 13]. Of particular relevance to attempts at employing evidence-based medicine (EBM) in
global mental health is the 90:10 research gap: the vast proportion of mental health
research (90%) has focused on the relatively small proportion of the world’s population
that lives in high income countries (10%) 14]. Likewise, clinical neuroscience research has focused primarily on westernised, educated,
industrialised, rich and democratic (WEIRD) populations 15]. Thus, there is a clear need for additional mental health research to be undertaken
in low- and middle-income countries.

The need for empirically defined and articulated research is equally crucial to neuroethics.
A key pillar of the field is a naturalistic view that posits that advances in neuroscience
may well shed light on philosophical issues 16]-18]. For example, the field has emphasised the importance of neuroscientific approaches
to examining fundamental questions about the nature of the self, agency and responsibility,
noting how novel findings about the neuroanatomy, neurophysiology and neurogenetics
of decision-making and impulse control influence current understanding of these constructs.
Neuroethics has also been particularly focused upon empirical approaches to bioethical
questions and has obtained data on a broad range of such issues 18]. For example, advances in neuroimaging have provided impetus to exploring empirical
questions in neuroethics (such as whether imaging findings in psychiatric disorders
increase or decrease stigma? 19]); but with the introduction of each novel instrument or approach new queries and
issues arise as to the validity and value of these tools in research and clinical
practices.

The emphasis of global mental health on evidence-based practice and of neuroethics
on empirical ethics, are not entirely without controversy. It has often been pointed
out that an absence of evidence does not always reflect evidence of absent efficacy
or effect 20]. Given that most mental health research has been undertaken in areas where only a
minority of the population lives, it must be acknowledged that straightforward extrapolation
of the existing evidence-base is not always appropriate. For example, there is a paucity
of psychotherapy trials conducted in the low- and middle-income world, so that the
extent to which Western psychotherapies require adaptation in such contexts is somewhat
unclear. In addition, there may well be a need for value-based orientations to supplement
EBM 21]. Within meta-philosophy, there are strong arguments that philosophy should not simply
be reduced to science 22]. Similarly, in bioethics, there may well remain complex problems that are best apprehended
by conceptual rather than empirical analysis.

Nevertheless, there are good reasons to support an empirical approach in both global
mental health and neuroethics. Global mental health has emphasised that precisely
because so much work has been done in areas where only a minority live, it is important
to expand research efforts in the low- and middle-income world. Priorities for such
research have been carefully set, and this has facilitated requests for proposals
to fund such research 23]. In neuroethics, empirical research has contributed to a range of discussions, including
work on childhood development, ageing research, the use and value of various neurotechnologies,
as well as how neuroscientific and psychosocial approaches can be employed to develop
improved assessment and treatment of mental, neurological, and substance use disorders
11].

Focus on both disorder and wellness

The World Health Organization (WHO) definition of health encompasses the concept of
wellness, noting that health is ‘a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity’. This focus is consistent with
the emphasis in global mental health on human rights to access healthcare, and on
patient empowerment 1], and we can expect that global mental health will pay increasing attention not only
to disorders but also to well-being. Clinical trials of task-shifting of mental health
interventions to lay community health workers in low- and middle-income countries,
for example, may well include outcomes designed to measure both symptom severity and
also patient recovery 24].

There is ongoing neuroethical discussion about whether the introduction of new neurotechnologies
for the assessment and treatment of neuropsychiatric disorders should also be used
in those with sub-threshold symptoms, or to exceed ordinary capacities 25]. While part of the neuroethical focus is to ensure that novel technologies are appropriately
developed and correctly used, another part reflects a commitment to employing such
technologies in ways that maximise the potential (and relative) benefit for individuals
and for societies 17].

There are, however, clear concerns with an emphasis on well-being. While there is
some agreement on what constitutes a typical physical or mental disorder (for example,
a severe acute infection), there are persistent ambiguities about the boundaries of
normality (for example, should binge-drinking be considered a mental disorder?) 8], and there is even more disagreement about what constitutes ‘well-being’ and flourishing
(for example, some definitions of well-being include notions of ‘career consolidation’,
which may not be equally relevant in all parts of the globe) 26]. Furthermore, while there are relatively good data on the efficacy and cost-effectiveness
of certain interventions for psychiatric disorders (for example, antidepressants for
severe depression), there is a paucity of data on the efficacy and effectiveness of
interventions for ‘well-being’ 26]. To a great extent, such criteria and definitions may be cultural, and Parens 27] and Sandel 28] have written persuasively about the problem of relying upon both Western constructs
of, and technological approaches for addressing and attempting to resolve, social
ills.

It is our view that such controversies surrounding the concept and/or conceptualisations
of well-being and flourishing demand and deserve attention. Both global mental health
and neuroethics have been critical of a reductionistic approach to disorder 29],30]. Global mental health is likely to focus initial research efforts on the prevention
and treatment of serious mental disorders, rather than on maximising well-being in
the community 23], but even in this work it will be important to address and emphasise patient recovery
and empowerment. Similarly, while neuroethics will seek to carefully monitor and guide
the appropriate use and just provision of new neurotechnologies, novel opportunities
to improve individual and societal flourishing will become an increasingly prominent
topic for debate and practice 17].

Human rights/parity for mental health

Global mental health has placed significant emphasis on acknowledging the human rights
of those suffering from mental illness 31]. A fundamental premise in this discourse is the right to appropriate treatment; there
is ‘no health without mental health’ 1] and any meaningful approach to ‘global health’ must entail parity in resourcing for
physical and mental health services. Mental health policies are required that ensure
mental health and medical services are equivalently prioritised, and which indicate
how the human rights of those suffering from mental disorders will be vouchsafed during
the development of such services. Such policies should ensure that mental health will
be integrated into health services, and that these will be made available in community
settings.

Neuroethics, too, has been concerned with broad issues of social policy. Indeed, the
intersection of neuroscience and social policy has been characterised as one of the
four pillars of neuroethics 16], concerned with the social and legal implications of neuroscientific advances, including
health care disparities, and unequal access to the benefits of such advances. For
example, in considering issues of neuroenhancement, it has been argued that social
resources should be conserved for treatment (rather than enhancement), and that enhancement
(for example, the use of stimulant medications by students and professionals to increase
performance) may unfairly favour more privileged sections of society that can afford
such interventions 28]. Therefore, it is important to address if, and ensure that, neurotechnologies are
not inappropriately used or purposefully misused to fortify asymmetrical relationships
between individuals, groups and nations 8].

Even so, a focus on human rights and mental illness is not without controversy. First,
concepts of human rights, and indeed the idea of human rights itself may not represent
a fixed natural kind, but rather may be bound to specific times and places 32]. In light of this, a good deal of conceptual work may be required in order to argue
for specific universal human rights. Further, the range of moral concepts that can
be employed to understand and evaluate an ethical issue goes far beyond the class
of rights; such additional moral concepts include ‘duty’, ‘the good’ and ‘virtue’
33]. This point again emphasises the need for additional conceptual analysis in this
area.

Nevertheless, emphasising that the need for appropriate treatment of mental disorders
is closely linked to human rights has provided global mental health with an important
ethical foundation. Similarly, there is an ongoing need to emphasise human rights
in the conduct of neuroscience, so as to sustain ethical practices in basic and clinical
neuroscientific research, and sound ethical precepts in establishing and implementing
clinical assessments and interventions. Such concerns constitute a second pillar of
neuroethics 12],16]. As the agenda of global mental health gives increasing impetus to mental health
research being undertaken in low- and middle-income countries 23], so, too, will there be a need to concomitantly increase attention and dedication
to neuroethical issues arising in and from these settings 17].

Social inclusion/consumer movements

A recurring rallying cry in global mental health has been ‘nothing for us, without
us’, emphasising the importance of including consumers in decision-making about services
and research 34]. The voice of the consumer movement has played a crucial role in disability studies
in general and is particularly relevant to mental health concerns 35]. Global mental health publications have emphasised the importance of consulting consumers
and the value of a ‘recovery perspective’ that seeks to establish and enhance patient
empowerment 24]. Similarly, much of the literature in global mental health has emphasised the importance
of ensuring that assessments and interventions developed for use in low- and middle-income
countries are, in fact, feasible and acceptable to individuals who live in these contexts
36].

Likewise, neuroethics has acknowledged the importance of individuals’ subjective experiences
and of patient empowerment. Brain imaging, for example, provides certain objective
correlates of human cognition and affect. Yet, imaging data cannot reveal or ‘describe’
an individual’s unique thoughts and emotions 18]. A gap persists between subjectivity and objectivity, which is important to acknowledge
and address if, and when, considering the utility and limitations of specific neuroscientific
approaches to diagnostics and clinical intervention. A third pillar of neuroethics
has focused upon the role, relevance, and importance of brain science to concepts
of the ‘self’ 12],16]; for instance, data that certain genetic variants are associated with decreased impulse
control may lead to more nuanced discussion of the nature of moral responsibility
and free will. Similarly, literature on psychopharmacology has discussed issues such
as the meaning of medication for patients, the extent to which the self is transformed
by pharmacotherapy, and the extent to which psychotropic agents not only improve symptom
outcomes but may also contribute to human flourishing 37].

Still, an emphasis on patients’ subjective experience and empowerment is not without
controversy. Robert Spitzer, a key architect of the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), argued that including patients when revising psychiatric nosology would be ‘…political
correctness taken too far’ 38]. Advances in neuroscience seem to promise a world in which clinical diagnosis will
be made using biomarkers, neuroimaging and neurogenetics, rather than by merely assessing
patients’ history and symptoms 39]. To be sure, neurobiologically-based models (for example, that are reliant upon and
derived from neurogenetics, neuroanatomy and/or neurochemistry) of mental disorder(s)
may well have important advantages to the extent that neurotechnologies, such as brain
imaging and biomarker analyses, may enable more accurate diagnosis and effective treatment
40],41], provided that potential burdens and harms are minimised 8],12],17].

Nevertheless, an emphasis on social inclusion, consumer voices and patient empowerment
is sure to remain important for global mental health, neuroethics and their intersection.
The global mental health movement is likely to pay particular attention to any suggestion
that it is ignoring such issues 42]. Neuroethics has a strong commitment to proactive and preparatory stances that promote
both responsible social and public policies, and the value of empowerment 18],43]. Moreover, in mental health and neuroethics – as in medicine, in general – there
is a need for an integrative, conceptual approach that addresses biological mechanisms
that underlie the symptoms of mental disorders, as well as patients’ expression and
experience of such symptoms 12],37].