Publishing the Biotechnical Futures of Alzheimer’s Disease

Research output: Contribution to journalComment/debatepeer-review

Abstract

In “Journeying to Ixtlan,” Peterson and colleagues (Citation2023) evaluate some of the potential ethical implications of treating Alzheimer’s disease (AD) with psychedelic medicines. In this commentary, I suggest a need to critically engage with such bioethical appraisals of promissory biotechnologies because, whether deliberately or inadvertently, they often have a biopolitical function and perform certain types of symbolic work. Most concerningly, they can sometimes advance the interests of private stakeholders at the expense of people affected by AD. They do so by simultaneously simplifying and sensationalizing the nature of the problem, while also substantiating the proposed future solution. Peterson and colleagues may be falling into both traps when they appraise the ethics of prospective psychedelic treatments.

Beginning with the former issue, representations of dementia, be they academic, political, artistic or public, often rely on and hence emphasize the gravity of AD as a problem. This problem can be highlighted in reference to loss of self, carer burden, state expense and other familiar tropes (Fletcher and Maddock Citation2021). Peterson and colleagues continue in this tradition, claiming that “issues are magnified when psychedelics are viewed through the lens of Alzheimer’s disease and related dementias.” Here, semi-implicitly, the argument is made that this paper matters because of the excessive badness of AD as a “death before death.” AD functions as a particular type of problem that raises the stakes. Maximizing effect, contentious notions of “autonomy” and “self” are presented as intrinsic and disease-affected entities, almost as though self is a neuronal network that is killed off by toxic protein aggregation.

Such simplifications of psychosocial concepts are emblematic of the straightforward attribution of complex problems to disease entities. These types of arguments are widely rejected across contemporary dementia research, which instead understands such phenomena as contextually constituted processes. Distressing transformations of self, agency, identity, autonomy, etc. are experienced by many people in later life irrespective of neurocognitive conditions and are hence difficult to attribute to a particular disease. In practice, such matters are contingent on a wide range of extrinsic determinants, from stressful family relationships (Fletcher, Citation2020a, Citation2020c, Citation2021b) through to systemic racism (Fletcher Citation2020b, Citation2021a; Fletcher, Roche and Zubair Citation2022) and discriminatory disability legislation (Fletcher Citation2021c, Citation2023). Hence, the authors’ appeal to “whatever theory of identity and autonomy one adopts” is wrong. Their approach, which I would characterize as a “dread disease” framing, is at odds with much dementia scholarship over the past three decades.

Nonetheless, a “dread disease” framing enables authors, both in this instance and generally, to underscore the terribleness of AD as a master-affliction. The simplification of human life that is manifest in such arguments is not mere sloppiness. It is instrumental because it takes the many problems associated with AD and translates them into a straightforward biotechnical problem. This conceptual wizardry is known as “ontological gestalt switching,” taking one type of thing and replacing it with another thing that better serves one’s purposes (Fletcher and Birk Citation2019). The payoff of switching is that a daunting collection of evils may be amenable to a comparably straightforward biotechnical solution. Acknowledging phenomena such as family relations, structural racism and legislative discrimination would weaken the rationales underpinning psychedelics, whereas a direct “X disease causes X problem” framing offers fertile terrain for extolling the feasibility of said treatments. The problem here is not that AD is misrepresented as bad (for many people it is awful), but rather that the nature of that badness is mischaracterized. The problem is reformulated to better suit the proposed solution.

While AD is misleadingly simplified and sensationalized, psychedelics are misleadingly solidified. To do this, the paper pairs reticence and promise, nurturing an aura of nuanced objectivity in a manner that typifies much of this literature. The underlying therapeutic hypothesis should be robustly pursued, but we are a long way away from substantive long-term phase-III trials. Evidence supporting the efficacy of psychedelics as an AD treatment is, so far, less developed than for other treatment options that have subsequently disappointed. The authors admit that therapeutic claims are unsubstantiated. However, they dilute that acknowledgement with counter-claims: “Nonetheless, these lines of research foreshadow a possible future for psychedelic medicine in AD/ADRD, a future we should begin preparing for now.” Peterson and colleagues are far from alone in these practices. Claims such as: “persons living with AD/ADRD neuropathology might eventually be able to benefit from psychedelic medicine” are commonplace in AD drug discovery, relying on “might”s and “maybe”s. Ultimately, such languages can undermine good science by inflating the futures proposed by organizations who are effectively selling them.

Speculative futures have material impacts on the present. They generate various forms of capital—e.g. media hype, credit lines, popular imagination—that can have profound implications for people’s contemporary lives. In 2007, the promissory future of house price growth was a given. It made some people rich and ruined many lives. Today, self-driving cars can catalyze future-orientated capital that it is difficult for public transport infrastructures to emulate. This is making some people rich and ruining many lives. In each instance, select futures are pursued by stakeholders who stand to benefit from greater adherence to their prophecies. As with all financial speculation, the generation of widespread faith in the desired future is integral to success. When it comes to promissory biotech, bioethical appraisals can help to substantiate those futures. If a stranger in the pub tells you about AD psychedelics, you may be skeptical, but if that same discussion is presented in a peer-reviewed journal by authors with institutional affiliations, then you may deem the enterprise more worthwhile. This is true for you, investors, journalists, regulators, and various other stakeholders who can influence the trajectories of promissory biotech.

The substantiation of promissory biotech futures in this manner is mutually beneficial because it also serves the authors’ interests. Speculative bioethics papers are more likely to be published if the futures that they speak to are deemed plausible. For instance, a paper on the implications of a potential AD test or drug is more likely to be published than a paper on the implications of aliens landing on earth and curing AD with magic. The underlying justification is that we are dealing with very important real-world matters that warrant serious dedicated discussion in notable publications. This gravity and sincerity can cloak self-interest and speculation in a veil of respectability. Speculative bioethical appraisals repeatedly frame imaginary AD interventions in a manner that most befits publication (i.e. possible, likely, perhaps even inevitable), and in doing so enhance the power of those interventions.

Ultimately, these authoritative speculative assessments further a biopolitics that we should be critical of. They can too often advance corporate interests at the expense of people affected by dementia, who are disadvantaged in several ways. First, alarmist othering depicts them as uniquely wretched, trading in popular misconceptions that are at odds with the rich and complex lives of many people affected by dementia. Second, the many, often severe, problems faced by those people are reduced down to a disease entity, distracting from the wide set of constraints that coalesce to aggravate those problems. Third, that reduction facilitates the domination of capital by promissory biotech at the expense of an attentiveness to other considerations, and often robust science, because biotechnical problems are intuitively assumed to warrant biotechnical solutions. Finally, despite longstanding hype, promissory biotech has consistently been found wanting, and is becoming more dangerous (e.g. aducanumab and lecanemab have both been associated with deaths) as regulators and charities increasingly buy into those familiar “dread disease” and “hope” symbolisms. Scholars should be wary of amplifying the danger.
Original languageEnglish
Pages (from-to)124-126
Number of pages3
JournalAJOB Neuroscience
Volume14
Issue number2
DOIs
Publication statusE-pub ahead of print - 25 Apr 2023

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