Internet Resources

United States Department of Health and Human Services — Office of Inspector General. Fraud Prevention & Detection Compliance Guidance. Available from <www.oig.hhs.gov/fraud/ complianceguidance.html>.

United States Department of Health and Human Services — Office of Inspector General. Work Plan Fiscal Year 2003. Available from <www.oig.hhs.gov/publications/workplan>.

United States Sentencing Commission. Federal Sentencing Guidelines Manual and Appendices. 2002. Available from <www.ussc. gov.guidelin.htm>.

Cybernetics, in its purest definition, is the science of control and communication in the animal and the machine. The word was devised by Norbert Wiener in the 1940s and is derived from the Greek word kybernetes, meaning "steersman." In his book The Human Use ofHuman Beings (1950), Wiener wrote that "society can only be understood through a study of the messages and the communication facilities which belong to it; and that in the future development of these messages and communication facilities, messages between man and machines, between machines and man, and between machine and machine, are destined to play an ever-increasing part" (Wiener, p. 16). In 1957, W. Ross Ashby described the focus of this theory of machines as focusing not on what a thing is, but on what it does: "Cybernetics deals with all forms of behavior in so far as they are regular, or determinate, or reproducible. The materiality is irrelevant" (Ashby, p.1). Recognizing that there are significant similarities in biological and mechanical systems, subsequent researchers have pursued the ideal of merging biological and mechanical/electrical systems into what Manfred Clynes and Nathan Kline termed cyborgs or cybernetic organisms. In this sense, cybernetics has taken on the meaning of adding prostheses to the human or animal body to either replace lost function or augment biological activity.

Humans have long used tools to augment various functions, and for centuries have attached some of these tools to their bodies. Filled or artificial teeth, glasses and contact lenses, hearing aids, pacemakers, and artificial limbs are all examples of this phenomenon. By the late twentieth century, significant advances in the fields of neuroscience and computer technologies allowed the direct interface of animal or human nervous systems with electromechanical devices. Examples of this evolving field include the creation of neural-silicon junctions involving transistors and neurons to prepare neuronal circuits, the re-creation of visual images from signals transmitted in the optical pathways of a cat, the remote control of mechanical manipulator arms by implants inserted into the motor cortex of owl monkeys, and a remote control that can move rats over a directed path via implanted electrodes.

While the above are examples of direct internal interfaces between a nervous system and a cybernetic prosthesis, another approach to cybernetic augmentation is through the use of external or wearable computing devices. In this approach, prosthetic enhancement is achieved via miniaturization of traditional computing devices, interface mechanisms, and optical projection devices, and then seamlessly incorporating these devices into clothing, glasses, and jewelry. This form of cybernetic enhancement has moved from the academic to the commercial stage. Aside from allowing the user/wearer of such devices wireless access to the Internet and other databases on a continuous basis, they may also be used for augmented reality, which is the concept of supplementing traditional sensory input with augmented senses or new types of sensory data. Examples include retrograde vision (seeing to one's rear), distant or projected hearing, and infrared vision. Further visual input may be analyzed and correlated with other information such as Global Positioning System (GPS) location identification. Buildings and streets could be labeled, hours of business accessed, and people visually identified (with demographic information provided), with all of this information directly projected on the user's retina.

While these developments may sound like something out of a Star Trek episode, cybernetic technology has developed at a rapid pace, and will no doubt continue to be a growing field of investigation, therapeutic intervention, and commercial development. In June 2002, the National Science Foundation and the U.S. Department of Commerce issued a report recommending substantial U.S. government investment in the development of cybernetic technologies, with the specific goal of augmenting human performance. These technologies will be produced by the synergistic convergence of biotechnology, nanotechnology, information technology, cognitive science, and neurotechnology through a proposed Human Cognome Project.

Healing versus Augmentation

As has already been indicated, the mechanical or prosthetic manipulation of human beings is not a new idea or practice. In the past, however, such interventions have almost always been in the context of repair or replacement of absent, diseased, or disordered function. The goal of visual lenses is to restore vision to biological norms, not to augment or improve function beyond normal. Similarly, prosthetic limbs replace those congenitally absent, malformed, or traumati-cally severed or injured. Pacemakers replace the electrical pacing of heart contractions lost through injury, aging, or disease. In this context, new tools to restore sight to the blind, hearing to the deaf, and movement and normal function to the lame or paralyzed are tremendous advances fully in keeping with the traditional goals of medicine (healing, restoring, palliation, and prevention of injury). Yet humans also use telescopes, microscopes, night vision, and other means of augmenting visual function for specific purposes. The difference is that these tools are not permanent fixtures of the body. Wearable computing devices and implantable brain chips, however, are being produced and marketed to enhance the normal, not necessarily heal the afflicted. This raises a number of challenging ethical questions, including whether or not human augmentation should even be permitted, let alone pursued?

Before the question ofwhether augmentation should be permitted, promoted, or prohibited can be addressed, a more basic issue must be considered: Can a distinction between healing and augmentation be delineated? This question poses equal challenges to a variety of areas in addition to cybernetics, particularly the more immediate possibilities of genetic therapy or enhancement and pharmacotherapy for behavior control, mood enhancement, and cognitive enhancement.

The difficulty lies in trying to define a clear line of demarcation between a disease state and normal structure and function. It is sometimes easy to pick out extremes of phenotype, particularly if an underlying pathophysiological mechanism for the deviation can be demonstrated. Examples include hemophilia, congenital dwarfism, and impaired vision. Other situations raise difficulties, illustrating that many times the definition of disease or abnormality can be socially, rather than objectively or scientifically determined. How much deviation from ideal body weight is within the bounds of normal variation, and when does the deviation become pathologic? While anorexia nervosa and morbid obesity are clearly pathologic in that they can influence survival and other health issues, a significant number of individuals are on the edges of the norms, where the threshold of pathology is unclear.

A striking example of the cultural variation in the definition of disease is the response of many congenitally deaf individuals to the suggestion that they are afflicted and in need of therapy. Many deaf parents of deaf children have refused to allow their children to receive cochlear implants to correct the deafness because this would remove the children from the deaf community. At a 1997 conference of deaf individuals, 16 percent of the delegates were interested in prenatal diagnosis for deafness, but, of that group, 29 percent indicated that they would use these techniques to select for deafness in the child (see Middleton, et al.).

Cognitive and neurological function, the areas most impacted by cybernetics, are particularly fraught with difficulty, in part because certain deviations from the norm may impart certain functional advantages in addition to social or behavioral liabilities. For instance, while attention-deficit/ hyperactivity disorder (ADHD) and autism are diseases, many of the individuals who have these conditions also manifest significant brilliance and creativity in mathematics, music, art, science and engineering. Both the positive and negative manifestations are part of the same disease entity, and what degree of negative manifestation requires treatment becomes subjective. The treatments employed may suppress the undesired manifestation, but they may also impair the desirable expressions. The situation becomes even more complex when these challenges are extended to a measure of cognitive function such as memory, mathematical calculation, musical ability or language processing. Who doesn't think of himself or herself as being deficient in cognitive abilities or able to benefit from enhancement of cognitive function?

In addition, necessary cognitive function may be very task or profession specific. Should individuals who would be considered cognitively normal be allowed to receive enhancing technologies to permit them to pursue a career otherwise beyond their intrinsic ability? And, as these technologies become available, should professions that demand high levels of cognitive excellence be allowed to require the use of enhancing technologies? Given that books and computers are forms of information exchange enhancement that are currently required for education in the professions, one could argue that the only thing that has changed is the intimacy of the enhancing method. Because, these technologies may intrinsically carry certain risks that are absent from current information technologies, however, many believe that such means should never be mandated, but only available by free choice. The reality, however, is that competition with peers will serve as a strong coercive force to pursue enhancement.

Safety Questions

The answers to these questions require the consideration of additional issues. At the most basic, cybernetic technologies, both implantable and wearable, must demonstrate physical, emotional, and cognitive safety. While physical safety will, in general, be the most easily addressed, there are still new challenges beyond those typically encountered by medical devices. Traditional medical-device safety issues include the risk of infection, local reaction, tissue injury, and involuntary or undesired neural or muscular stimulation. Current devices, however, tend to function in isolation in the specific local environment of the recipient body. Cybernetic devices, on the other hand, will often be connected to a shifting network environment, dependent upon software and the exchange of external information as well as hardware. As such, viral code could potentially disrupt function of the device, and possibly injure the user. Even wearable devices could potentially be turned into weapons, and so need to be strongly regulated, with proof of software and hardware safeguards against injury by rogue software agents.

The issues of emotional and cognitive safety will be more challenging to understand and regulate. In the era of the Internet there is a growing literature addressing problems with personality fragmentation, breakdown of direct personal interaction in favor of cyber relationships, increasing dissatisfaction with reality, addiction to cybersex and pornography, and other psychosocial concerns. These concerns can only increase when individuals are cybernetically connected most, if not all, of the time. The long-term consequences of virtual environments are unknown. The variability of involvement and susceptibility to dysfunctional utilization will vary tremendously between individuals, making generalized regulation difficult. However, some form of registered informed consent as to potential negative consequences, with mandatory, periodic, and long-term follow-up, may be helpful.

The Nature of Medicine

The issue of safety introduces yet another question: What sorts of individuals should be involved in implanting devices for internal cybernetic enhancements or for fitting wearable devices with optical interfaces? Because of the invasive nature of the implants, it would seem a logical requirement that physicians, particularly neurosurgeons, place these devices in humans. This certainly would be necessary for cybernetic devices of a therapeutic nature, but what about devices that are solely for enhancement purposes? Placing devices for nonmedical indications leads the physician into participating in interventions that are potentially harmful, have no therapeutic necessity, and thus are outside the traditional goals of medicine. A strong argument could be made that physicians should not participate in applying these technologies for other than therapeutic purposes. Yet few would want someone with less training than a neurosurgeon to invade their nervous system.

An analogy can be made to cosmetic surgery. Some ethicists, such as Franklin Miller and Howard Brody, contend that such interventions are outside the bounds of appropriate goals of medicine and should not be performed. Others counter that an individual should have the freedom to manipulate his or her own body, and, if a physician is willing to provide the service, restriction would be wrong and counter to the cherished goals of autonomy. Anders Sandberg takes the argument further, stating that each person has the fundamental right to pursue whatever means are available that might enhance or prolong life. The implications of this approach for medicine, however, are to change the profession from a group committed to healing (with a dominant ethos of beneficence in trust and nonmaleficence) to individuals skilled in surgical technique who are merely technicians providing whatever service may be requested.

Justice and Social Values

In the end, safety considerations may mandate that physicians and healthcare resources be used to implant cybernetic devices for nontherapeutic purposes, but justice may require that third-party healthcare dollars not be used to cover the costs of the devices or resources utilized. This raises concerns that access to enhancement technologies will be accessible only to those who already possess economic, educational, and technical advantages, further widening the gap between the haves and have-nots. As some members of society become incrementally enhanced and plugged in to cybernetic communities, these individuals will share less and less in common with the unenhanced, fragmenting society; potentially generating decreasingly compatible, or even competing, separate societies.

This is not necessarily a new phenomenon, for technologies have created boundaries between social groups in the past, the Amish and some Native Americans being notable examples. The difference is that the Amish have always wished to remain a distinct society, while some individuals who wish to reject personal enhancement may still desire participation in and access to the goods of the larger social structure. Deliberate efforts to maintain tolerance of individuals and groups who choose to forgo the use of certain technologies must be pursued if democratic-republican ideals are to be preserved, and inclusive means of communication must remain available to all members of society.

Cognitive cybernetic devices must also be equipped with reliable means of filtering incoming information, especially against information that might be designed for repetitive or subliminal influence. Privacy is a similar critical issue, and must be deliberately and prospectively defended in the cybernetic age. Technologies such as functional magnetic-resonance imaging are being proposed to sense, process, and interpret thought patterns. Not only is the accuracy of such technology a critical requirement, but the concept of invading the mind is at issue.

To Prohibit, Permit, or Pursue?

Cybernetics offers wonderful devises of healing for significant, age-old disabilities, and it can be welcomed when utilized in that context. It is likely that using such tools to enhance normal function will be possible, but great caution is needed, as well as a commitment to the preservation of privacy and justice. Rigorous safeguards for demonstrating the safety of cybernetics devices, and requirements for government approval and licensing, need to be set in place.

The government, the academy, and industry should commit significant resources to the exploration of the ethical and social implications of these technologies, and to the development of appropriate analysis and preparation of guidelines for implementation.

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