Readers Respond: tDCS ($) Versus TMS ($$$$)

Last week I devoted this space to discussing transcranial direct-current stimulation (tDCS), a much milder form of brain-zapping than electroconvulsive therapy (ECT), but nevertheless in the same category.  Because there are not a lot of studies on tDCS, we do not have extensive statistical evidence that it does much good for conditions such as depression, but I asked readers who might have had experience with tDCS to respond, and two did:  one amateur tDCS user and one doctor who trains and supervises patients to use tDCS.  For reasons of medical confidentiality, their real names will not appear here, but for the purposes of this article I will call them Mr. P. and Dr. D.

Mr. P., a sufferer from depression, has been using a tDCS setup he built himself for about six months to help him during a transition from one drug regime to another.  As to whether it works, he says, "I did experience a slight lightening of mood and a little more energy, and perhaps a more regular sleep pattern."  But he admits that this is not a scientific controlled experiment, as he was also taking his medication at the time and could not therefore separate the effects of tDCS from what the drug was doing for him.

Dr. D. has assisted "patients using tDCS protocols intermittently with supervision to treat pathological conditions," including depression.  He says it seems to be helpful in cases of depression that have proved to be resistant to other treatments.  He "can't disagree when someone with this condition attempts tDCS.  Considering the compromised quality of life, the potential improvement is worth the risk.  Medical supervision would increase the success rate and make the procedure even safer."

Why isn't tDCS used more widely or studied more extensively?  Dr. D. believes that "tDCS is not utilized primarily because of profitability. Transcranial magnetic stimulation (TMS) produces effects and results similar to tDCS. The cost of a 30-treatment protocol for depression costs $15,000 and re-treatments would need to be done at least yearly. And insurance is beginning to cover TMS."  On the other hand, Dr. D. charges only $3,000 for a tDCS stimulator, training, and three years of supervision—a lifetime cost for tDCS, in other words, as opposed to the $15,000 each time a protocol of TMS is administered.

TMS uses a much more complicated piece of machinery than tDCS, a pulse generator that produces powerful magnetic fields which induce currents in the brain without the need for direct contact to the skin.  From an engineering point of view, assuming the end result of small currents in the brain are more or less the same, the difference between tDCS and TMS is the difference between the old wired telephones ("POTS" or "plain old telephone service"), and wireless cellphones.  Cellphones are a lot more complicated, but they have genuine advantages over wired phones.  Whereas it may be that the only advantage TMS has over tDCS is that the machinery costs a lot more and the medical profession, speaking generally, can profit more from a treatment that involves an expensive machine or patented drug, than it can from a gizmo you can build with $30 of parts or a medication you can buy for ten bucks at a drug store without a prescription. 

Fortunately, there are doctors such as Dr. D. around who help patients use less expensive and possibly more effective treatments, but you have to hunt for them.  And as I noted in last week's article, the medical profession, at least that portion of it represented by the Annals of Neurology, has extended something of an olive branch to those who are using tDCS, rather than doing something obstructive such as calling for legislation to stop non-professionals from fooling with it.

Perhaps we can gain a little perspective on this matter if we ask a more basic question:  what if the criteria by which we judge medical care are missing something important?  Here's what I mean.

When we see two kinds of treatment being used for a class of medical conditions, and one costs mucho buckos and the other one is comparatively cheap, and they seem to do about the same amount of good, it's almost a no-brainer to ask, "Why don't we drop the expensive treatment and go to the cheaper one?"  The answer comes back from the medical-scientific establishment:  "Because we have studies that show the expensive treatment is effective, and we don't have anything like that for the cheap treatment."  What is not stated in this interchange are the underlying assumptions shared by doctors, patients, researchers, and medical organizations. 

One of these unstated assumptions is that for every perceived problem, there is a solution that can be discovered, researched, quantified, tested, and implemented efficiently and promptly.  The unconscious image is that of a person in a supermarket, making a consumer's decision as to which technology to use.  The philosopher George Parkin Grant, who made an appearance in this blog not too long ago, recognized that this technological outlook or perspective has become an almost automatic mode of thinking.  In fact, it's hard not to think this way.  He puts it succinctly:  "Technology is the ontology of the age."  And "ontology" is the study of being:  what things really, fundamentally are. 

What he's saying is that we tend to approach the world as though it were a big parts warehouse, or electronics showroom.  Everything is there to be used, and everything is analyzed in terms of its parts and how they can be assembled to do something we want.  Here's a person with depression.  We treat him like a machine in need of repair.  What will fix him?  Certain chemicals?  Expensive TMS treatments?  Or inexpensive tDCS treatments?  We don't stop to ask why he's depressed in the first place. 

It's hard to imagine thinking in some other way, but in the space remaining I'll try.  What if we look at a society in which more than one out of every ten adolescents in the U. S. suffer at least one episode of major depression per year?  The technological fix is to look around for repair parts.  But what if we looked into why being a teenager in this society is so gosh-awful depressing for so many?  And the older they get, the more depressed they become, often.  Try getting funding for that. 

I'm glad Mr. P. is happy with his tDCS, and Dr. D. is helping others like him to get treatment at less cost than alternative treaments.  But as for why so many people are depressed, well, that is, as they say in the technical journals, "outside the scope of this article."

Sources:  I thank Mr. P. and Dr. D. for permission to quote from their emails.  I was clued to the words of George Parkin Grant by a comment made by philosopher Antonio López on Vol. 130 of Ken Myers' excellent Mars Hill Audio Journal, a by-subscription podcast about which more can be found at https://marshillaudio.org.  The Grant quotation itself is from his article "Thinking About Technology," Technology and Justice (Notre Dame Press, 1987), pp. 11-34, and can be downloaded at http://www.communio-icr.com/files/grant28-3.pdf.  The statistic about the incidence of depression among adolescents is from the National Institute of Mental Health at http://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adolescents.shtml.

Take the Moral Limits Test

Every once in a great while I raise a philosophical issue in this space.  Most people who have tried teaching engineering ethics know that a little philosophy goes a long way, at least with undergraduates.  The subject has a reputation of being dry, abstract, and far removed from everyday considerations.  And another count against it is that it never seems to go anywhere—philosophers today argue about some of the same things that Plato and his students argued about in the garden called the Akademeia near Athens around 400 B. C. 

Nevertheless, I find that philosophers can clarify and put names to things that most of us deal with a lot, but have trouble thinking clearly about.  One such philosopher I came across lately is George Parkin Grant, and a question he asks in his book Philosophy in the Mass Age is one I'd like to raise here.

Writing in 1960, Grant was worried about many of the same things that bother us today:  whether the products and effects of our technological smarts will carry us over the brink to extinction, for example.  Back then, the big concern was nuclear war between the old USSR and the United States.  Nowadays it's climate change, but while the subject of the fear is different, the anxieties are similar. 

Grant saw two worldviews or states of mind that were locked in a complex struggle—a struggle that continues today.  He stated the terms of the struggle succinctly in this way:  "To put this issue simply:  are we truly and finally responsible for shaping what happens in the world, or do we live in an order for which we are not ultimately responsible, so that the purpose of our lives is to discover and serve that order?" 

If we are truly in charge—if there's no higher authority or source of guidance than our own wits and ability to work together—then you are likely to take a different view of the world and a different approach to life, than if you think otherwise.  Later in the book, he poses a question, which I'm calling the Moral Limits Test.  It's not a question to be answered lightly or quickly.  But your answer to it could tell you something about yourself and where you stand on the issue that Grant raised in the quotation above.

The question is this: "Is there anything that we should never under any circumstances do to another human being?"

Now we can get all tangled up in details—"Define 'human being,'" you might say, or "What if the circumstances are unlikely and extreme, such as whether torturing one person will save the lives of millions?"  Let's not get too technical here.  The intent of the question is to probe your own beliefs about one's ultimate responsibilities to other humans, and whether there is some rock-bottom limit below which it is always forbidden to go.  Not knowing what you'll answer, I'll take each of the two possible responses in turn.

Let's say you answer in the negative.  No, you say, I can't think of anything I would absolutely rule out.  You may argue that at any rate, they've all been tried over the bloody course of history, and you would not be far from the truth there.  From genocides authorized by religious prophecies to the Nazi death camps, man's inhumanity to man seems to know no bounds.  That doesn't make these acts right, of course, but despite all the terrible things that have been done, the species has survived.  Other things being equal, you wouldn't choose to torment two-year-olds with hot branding irons, but who knows what urgent technical or societal need will come up in the future? 

I realize that the question is a little bit like trying to find out how many bigots there are in a population by sending out a survey that asks, "Are you a bigot?  Answer yes or no."  Even if you are, you don't want to admit it.  So there's a strong social pressure to agree that yes, there must be something that we shouldn't do to other people, even though you may not be able to think of anything at the moment.  The same bloody history I referred to a minute ago tells me, though, that a lot of people have answered that question to themselves in the negative, at least judging by their heinous behavior.

Now let's say you honestly answered yes—there are things we should never under any circumstances do to someone else.  You may even be able to think of a few—running death camps, or keeping slaves, or performing abortions, for example.  Whatever your example, or even if you can't think of one, by saying "yes" to that question, Grant believes you have admitted that, in his words, "we live in an order for which we are not ultimately responsible."  And in his view, this means that God has entered the picture:  ". . . the idea of limit is unavoidably the idea of God," as he puts it.

This is a problem for modern people, he admits, because the whole thrust of civilization since the scientific and industrial revolutions has been to pretend there are no limits, and to use nature as raw material for making the Earth into a place that satisfies our desires.  One of the paradoxes of modern life is that in trying to make ourselves happy, we often cause tremendous distress and harm to others, which is really the problem of evil.  And we're not going to solve that one in a thousand-word blog. 

But the point I would like to leave you with is this:  if you really think there are some things that are "categorically wrong"—forbidden to do under any circumstances—then Grant thinks you have admitted that there is something, or Someone, higher than just humankind.  And that limitation, that absolute of the moral realm, did not come from us, but from outside. 

Working out the implications of that thought will be left as an exercise for the reader, as annoying textbooks sometimes say.  But the implications are not trivial, and if you are honest with yourself, you may find out something about yourself and your beliefs that you had not suspected.

Sources:  George Parkin Grant (1918-1988) was a Canadian philosopher, who according to the Wikipedia article on him was heavily influenced in his early work by G. W. F. Hegel.  (We don't talk about Hegel in this blog, as I don't want to lose the readers I have.)  The quotations from his book Philosophy in the Mass Age (New York:  Hill and Wang, 1960) are taken from p. 51 ("To put this issue. . ."), p. 91 ("Is there anything. . ."), and p. 93 (". . . the idea of limit . . .").  I learned about Grant from comments by Ken Myers, who produces the admirable Mars Hill Audio Journal, a periodic interview series on Christianity and culture (www.marshillaudio.org).