Bioethics Discussion Blog: “I’ll Forget All the Bad and Remember Only the Good”





Monday, October 01, 2007

“I’ll Forget All the Bad and Remember Only the Good”

From Chapter 9 of Louisa May Alcott’s “Little Women”, Meg says to her mother regarding any disturbing events experienced at the party she had attended, “I won't let it hurt me. I'll forget all the bad and remember only the good..”

Perhaps in the time of Louisa May Alcott, Meg’s response to her mother’s concerns was more in the way of wishful thinking. However, this is the 21st Century and things have changed. We now have neuro and psychopharmacology research and practice and there is an increasing probability that people with traumatic experiences of all sorts and who would be candidates for the post-traumatic stress disorder (PTSD) symptoms and associated deteriorated quality of life now may,indeed,have the chance to “forget all the bad” and live more comfortable lives. In fact, currently there is use of beta-blocker drugs to attempt to do just that and there is a good possibility that more effective and safe drugs can be available in the future. But as the target article and commentaries about the subject of drug prevention of PTSD in the September 2007 issue of The American Journal of Bioethics suggests, there are conflicting views about whether memory should be “tampered with”.

Here is the question for my blog visitors: If a safe and effective drug was available to block out a person’s bad memories and preserve the good ones, should that drug be approved for everyone to use? If not everyone, then who? Or is this “tampering” with memory just plain wrong and shouldn’t be done? What would you say? ..Maurice.


At Tuesday, October 02, 2007 4:33:00 AM, Blogger Unknown said...

I think that to deny someone suffering from severe PTSD relief because of the notion that we shouldn't be tampering with memory would be wrong. If there is an option to reduce their suffering, they should be given it (albeit with complete informed consent and all the applicable warnings).

That being said, tampering with and eliminating memories is not something to be taken lightly. I think that such a drug or treatment should be available by prescription only, and only in cases where other, less intrusive forms of therapy have already failed. Perhaps because of the seriousness of memory alteration, the drug should require two prescribing physicians to reduce the potential for over-prescription.

At Tuesday, October 02, 2007 7:39:00 AM, Blogger Maurice Bernstein, M.D. said...

Amanda, as a devil's advocate, I would ask what do you see as the "seriousness of memory alteration"? Normal and healthy people forget all the time and as one ages forgetfulness becomes more frequent. Is there something more serious or more compelling for supervision if the forgetfulness is prescribed and therapeutic rather than spontaneous? ..Maurice.

At Tuesday, October 02, 2007 8:14:00 AM, Blogger LisaMarie said...

When you get right down to what this really means, I truly can't imagine actually facing someone and saying "I'm worried about the abstract consequences of tampering with memory. Therefore, it's really better for everyone if you relive the sight of your best friend being blown to pieces by a roadside bomb before your very eyes for years to come. I'm really more comfortable that way." I believe an ethicist who was on a presidential panel actually expressed a view like that, saying that emotional trauma is part of what makes us who we are, and therefore he felt people just needed to live with it. Being an ethicist appointed by the prez, he presumably was qualified to decide that for everyone. Telling other people that they have to deal with their horrible traumas in a way that doesn't make me feel ethically squishy seems both very arrogant and very cold. That is such a painful, personal struggle that it really shouldn't be up for a majority vote.

At Tuesday, October 02, 2007 10:53:00 AM, Blogger Maurice Bernstein, M.D. said...

LisaMarie, as I recall,I think the entire President's Ethics Panel came up with the final conclusion that was similar to what you described to that ethicist. I will check on the details of that. But isn't that what you would expect to be a conclusion by a Bush panel? ..Maurice.

At Tuesday, October 02, 2007 2:49:00 PM, Blogger Maurice Bernstein, M.D. said...

To understand The President's Council on Bioethics October 2003 Report “Beyond Therapy: Biotechnology and the Pursuit of Happiness” you, of course, have to read it and see for yourself whether you agree with the view taken by the Council. There are 6 Chapters. To get an overview of the report and the final conclusion, you can go directly to Chapter 6. Here is the link to the beginning,Chapter 1.

After reading the conclusion, I would tend to agree with Henry, Fishman and Youngner writing that target article in the American Journal of Bioethics that “while never actually calling for a restrictive policy, the document hints at a deeply conservative moral adjenda…”
As an example of this conservative moral view, within Chapter 6 is written:

“And yet, as we suggested in Chapter Five, there seems to be something misguided about the pursuit of utter and unbroken psychic tranquility or the attempt to eliminate all shame, guilt, and painful memories. Traumatic memories, shame, and guilt, are, it is true, psychic pains. In extreme doses, they can be crippling. Yet, short of the extreme, they can also be helpful and fitting. They are appropriate responses to horror, disgraceful conduct, injustice, and sin, and, as such, help teach us to avoid them or fight against them in the future. Witnessing a murder should be remembered as horrible; doing a beastly deed should trouble one’s soul. Righteous indignation at injustice depends on being able to feel injustice’s sting. And to deprive oneself of one’s memory—including and especially its truthfulness of feeling—is to deprive oneself of one’s own life and identity.
These feeling states of soul, though perhaps accompaniments of human flourishing, are not its essence. Ersatz pleasure or feelings of self-esteem are not the real McCoy. They are at most shadows divorced from the underlying human activities that are the essence of flourishing. Most people want both to feel good and to feel good about themselves, but only as a result of being good and doing good.
At the same time, there appears to be a connection between the possibility of feeling deep unhappiness and the prospects for achieving genuine happiness. If one cannot grieve, one has not truly loved. To be capable of aspiration, one must know and feel lack. As Wallace Stevens put it: Not to have is the beginning of desire. In short, if human fulfillment depends on our being creatures of need and finitude and therewith of longings and attachment, there may be a double-barreled error in the pursuit of ageless bodies and factitiously happy souls: far from bringing us what we really need, pursuing these partial goods could deprive us of the urge and energy to seek a richer and more genuine flourishing. “

It is not clear from the discussion whether in specific case like the Post-Traumatic Stress Disorder whether it is the prophylaxis, the prevention of the symptoms or the actual treatment of PTSD when the symptoms appear which the Council might consider “beyond therapy”. However, I get the feeling that the President’s Bioethics Council is cautioning us all in general not to tamper with our memories. You will remember that, won't you? ..Maurice.

At Tuesday, October 02, 2007 11:18:00 PM, Blogger Placebogirl said...

My worry about this type of therapy is that it will reduce (further) in the eyes of the public the seriousness of crimes like rape, that often leave no physical scars. There is already the "what is she worried about, he didn't beat her or anything" attitude -- how much worse would this be if you could also say "and she isn't even going to have any long term side effects from it"?

Like one of the earlier commenters, I worry too about the over prescription of this type of drug -- we learn and grow from our pain in many cases, and taking a pill to avoid this learning seems counterproductive to our very humanity (and the fact that the jury is still out on whether antidepressants are overprescribed demonstrates the risks involved in marketing a drug like this).

Having said that I agree with LisaMarie, that we cannot, when there is pharmacological help available, deny someone genuinely disordered and unable to cope due to trauma the right to a second chance at life.

How do we decide where to draw the line? I don't have any ready answers, but I hope for the sake of PTSD sufferers that we can

At Wednesday, October 03, 2007 7:29:00 AM, Blogger Maurice Bernstein, M.D. said...

Placebogirl, I get your point. But you know, after reading a recent article by Adam Kolber in the Vanderbilt Law Review, Vol 59, p.1561, 2006 titled "Therapeutic Forgetting: The Legal and Ethical Implication of Memory Dampening", I see that your concern with the possiblity that some might look at the rape in view of the dampening therapy of memory as: "and she isn't even going to have any long term side effects from it" is real. But even more disturbing from the article for both the rape victim and society would be if the victim could no longer be a witness in a court of law because of her loss of memory and the case against a specific defendant couldn't be supported by her testimony. Another interesting aspect which is in part related to the above concern is "who owns a person's memory?" and therefore who beyond the person has a right to establish what is to be done with it?

Those who are interested in reading the entire paper by Professor Kolber can download it free here. Here is the abstract of the paper.

Neuroscientists have made significant advances in identifying drugs to dampen the intensity of traumatic memories. Such drugs hold promise for victims of terrorism, military conflict, assault, car accidents, and natural disasters who might otherwise suffer for many years from intense, painful memories. In 2003, the President's Council on Bioethics released a report entitled Beyond Therapy: Biotechnology and the Pursuit of Happiness, which analyzed memory dampening in some detail. While the Council acknowledged the potential benefits of memory dampening, some Council members were concerned that it may: (1) discourage us from authentically coping with trauma, (2) tamper with personal identity, (3) demean the genuineness of human life and experience, (4) encourage us to forget memories that we are obligated to keep, and (5) inure us to the pain of others.

In this Article, I describe possible legal and ethical implications of memory dampening. For example, I note that traumatic events frequently lead to legal proceedings that rely on memories of those events. Drugs that dampen traumatic memories may someday test the boundaries between an individual's right to medically modify his memories and society's right to stop him from altering valuable evidence. More broadly, I respond to the Council by arguing that many of its concerns are founded on controversial premises that unjustifiably privilege our natural cognitive abilities. While memory dampening may eventually require thoughtful regulation, broad-brushed restrictions are unjustified: We have a deeply personal interest in controlling our own minds that entitles us to a certain freedom of memory.

I look forward toward more discussion regarding the consequences of tampering with a person's memory. ..Maurice.

At Wednesday, October 03, 2007 8:10:00 AM, Blogger LisaMarie said...

The thing I find worrisome about your comment: Why wouldn't your concerns apply to physical pain as well? The "and she isn't even going to have any long term side effects from it" comment could apply just as well to treating a victim's physical pain from a very violent sexual assault. Should we have the same reservations about treating physical pain because it's somehow detrimental to a person's spiritual development or the societal view of the seriousness of a crime?
Dr. Bernstein,
I don't think I'd be as concerned about the issue of testimony, but my views of criminal justice are different from a lot of people's- I think crimes are treated as though they are committed against "society", not individuals, and this is often to the detriment of the actual victim. If a rape victim wishes to forgo prosecution because she prefers to be able to treat the trauma, even if it means memory loss, then I believe that the handling of the case should be determined by her wishes.

At Wednesday, October 03, 2007 10:17:00 AM, Blogger Maurice Bernstein, M.D. said...

LisaMarie, are you not concerned that by forgoing prosecution, the victim is possibly allowing a criminal to go free and harm other women? Actually, the whole issue boils down to "whose best interest"--the single victim who wishes to prevent or have relief from her suffering--or society who wants to protect other women from having to suffer and to attain this goal, society looks toward the process prosecution and confinement of a criminal. There are many events in our lives where the best interest of society trumps our own. Could the value of memory for society in the courtroom be one? ..Maurice.

At Friday, October 05, 2007 9:46:00 AM, Anonymous Anonymous said...

Dr.Bernstein, first I would like to thank you for bringing such an interesting and controversial topic to light. Having never heard of this kind of memory alteration I found your thoughts very informative. I think what is the most difficult descision regarding memory alteration is deciding who is worthy and who isn't.

Should everyday people have the option of this drug and forget their mistakes ala "Eternal Sunshine of the Spotless Mind"? Do we have the right to determine which traumatic experiences may, in fact, be beneficial in their decision making down the road? I don't know the answers to these questions, but hope that someday there is a clear and "ethical" answer.

At Sunday, October 07, 2007 1:53:00 PM, Blogger LisaMarie said...

Dr. Bernstein,
So far as I know, if rape victims do not wish to testify in court against their accused rapists, we do not compel them to do so. If your point is correct, and the interests of "society" being protected from crime outweigh the interests of any particular victim, would it not be ethically justifiable to coerce rape victims into participating in the prosecution of their rapists by whatever means are necessary, including threatening them with jail for contempt if they balk? If the answer is no, I fail to see the difference between allowing a victim to "erase" the memory of the assault and allowing her to decide not to testify about her ordeal in court.

At Sunday, October 07, 2007 3:40:00 PM, Blogger Maurice Bernstein, M.D. said...

But, Lisamarie, that's just it! One might argue that the very "erasing" of her memory would bias the rape victim's decision whether or not to testify against her alleged rapist. With no or poor memory, she might easily decide that no action is necessary, whereas in the same case, if she retained her memory of the details and the pain, she might very well decide to testify. ..Maurice.

At Monday, October 08, 2007 11:57:00 AM, Anonymous Anonymous said...

I can easily imagine circumstances where I would support the therapeutic use of a "forgetfulness" treatment, IF less drastic therapies aimed at helping one to cope with trauma were found to be ineffective. Similarly, there are circumstances where, for the patient's good, it's necessary to surgically excise infected tissues -- but not if less drastic measures, like a course of antibiotics, would do the job.

At Monday, October 08, 2007 1:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Bob, I wonder how you feel about the balancing of the best interest of the victim through memory dampening with the best interest of society by having the victim's memory to be unimpaired so that she can testify in court. ..Maurice.

At Monday, October 08, 2007 3:39:00 PM, Anonymous Anonymous said...

Maurice - 'Balance' is definitely the right word to use here, and I take it as a given that individual circumstances will require different balancing acts.

That said, a couple points seem relevant to this discussion.

We should note that when talking about the best interests of victims, we are talking about "enlightened interests," -- where it's recognized as being in one's interest to make short-term sacrifices in order to promote long-term benefits. And we shouldn't neglect the interest each of us has in living in a society where citizens help to convict criminals. With that in mind, wouldn't it make sense to at least try to persuade victims/witnesses to wait until after giving testimony to take the "forgetfulness pill?"

Still, we shouldn't "force" people to testify, especially if there's good reason to think a victim or witness will be severely traumatized by testifying. That's just common sense and common humanity at work.

At Sunday, January 12, 2020 2:13:00 PM, Anonymous JR said...

Dr. B.,

You knew that sooner or later I would post here.

As far as erasing memory, that is what the medical establishment does thousands of time each day when they administer versed or like drugs. They are deciding what a patient can or cannot remember. They are trying erase a patient's memory of what took place during prep, the procedure, and recovery so the patient will not be able to use what happened against them. This is willful tampering of another's memory for personal gain. These type of drugs used as freely and without full disclosure is part of the issue of what medical care is not trusted. To tell someone that what is being given to them is just something to relax them is beyond misleading. It is an outright. It merely relaxes the medical staff so they can strip the patient for surgeries not requiring genital exposure & allows them not to follow established teaching of covering the genitals and keeping the patient warm. It also allows the staff to carry on conversations that the patient may not remember including making fun of the patient or other patients. If drugs like versed must be used, then their usage should be severely restricted and with definite, precise warnings and CONSENT. Not the fluff consent that only protects the medical staff but consent that actually is patient friendly. Otherwise, you have what happens nowadays, is that medical staff are able to decide what memories a patient is allowed to have or not have.

At Sunday, January 12, 2020 6:23:00 PM, Blogger Maurice Bernstein, M.D. said...

JR, "willful tampering of another's memory for personal gain"-- what is the difference between the common behavior of lying to another for "personal gain" and use of a memory impairing drug for the same purpose. Is it simply the pharmacologic risks with the latter or is there a more philosophical, ethical or other difference. ..Maurice.

At Monday, January 13, 2020 5:21:00 AM, Anonymous JR said...

They are the along the same line but are different. You could use this same argument for priests who molest because they lie as well as teachers or anyone in power. It could be used on a family member who lies to you but in this case I am only talking about medical instances. And yes, they too are lying about the effects of versed (benzo type of drugs or any others that do what they do). Yes, there is an ethical aspect to this as those people are holding power over the patient. Medicine is supposed to represent healing and truth I healing or at least that is what many people think. Most people don't seek healing with the thought the provider might actually do harm to them. Sure they are given some risks but then some information is not given, omitted, or glossed over. However the big difference is that you have the ability to discover the truth about a lie while the pharma induced memory altering may be gone or blocked forever. Therein lies the big difference. While both is on purpose, the truth may surface for one but the other might not ever be known. For some, the fear of the unknown is worse.

As I have pointed out, the just using the term conscious sedation or the explanation that you are being given just a little something to help you relax is at the very least a misguided, uninformed answer. However, I feel it is more than that as a medical person knows what the true properties of such drugs are and what they do. If they don't, they should not be administering them because not having all the information is dangerous.

Versed (benzos) are not painkillers. They are an anti-anxiety drug. The rationale is that we as patients are too scared by seeing bright lights and equipment to withstand the procedure so we need this drug. I could see using it for this purpose only after discussing it with the patient and or seeing that the patient is indeed very anxious. But not given to everyone regardless.
However, in doing my research on versed (benzos) I have found that articles aimed towards patients and providers are much different in explaining the desired effects of versed and why they are used. That is a red flag. It also is hiding the truth from patients.

For patients, it is said that it is a little to help you relax. It is also explained that you are not knocked out but that is not exactly true. Versed puts you in a twilight sleep which is more like a dream state when falling asleep while watching tv but deeper. You are in the dream cycle meaning you can be easily awakened by touch or voice but you are sleeping. With versed alone, you will still experience pain which is not explained. When I think of being conscious, I think of being mentally capable. With versed, you are not mentally capable. Sedation is I term I think of as being less than mentally and physically capable. Conscious does not belong with sedation as the two contradict one another. Many facilities warn patients not to make life altering decisions, drive, operate machinery, etc. for a 24 hour period after taking versed.
For providers, versed is explained differently. The most glaring difference is that it is highlighted that versed will cause memory loss. It is touted as the drug to use so the patient won't remember the scary procedure because they are incapable of being "present" during the procedure. Descriptions go on to say that patients are easily commanded during the procedure to do whatever is asked of them. Descriptions are also given that during prep, versed helps to make the job easier as versed acts as an uninhibitor meaning the patient won't fight against being exposed even unnecessarily. Versed is also described as allowing the staff to interact without the patient interfering. End of Part I

At Monday, January 13, 2020 1:37:00 PM, Blogger Biker said...

JR said it eloquently. Medical staff choosing to erase patient's memories without obtaining informed consent is about as unethical as it gets. Versed and the like are universally presented as helping the patient relax, not as an amnesiac. It is usually emphasized that you will be awake throughout the procedure which infers something very different than what really occurs.

I am fine with patients receiving versed if there has been informed consent. Some patients don't want to remember anything about the procedure and that's OK. Then it would be the patient's choice. As noted on a different thread, I know from personal experience that some procedures can be safely done w/o sedation w/o the patients being traumatized by the process. That's OK too, but it is not an option that is even offered.

At Tuesday, January 14, 2020 4:21:00 PM, Anonymous JR said...

Part II

Some of the things that are not mentioned as side effects of versed and such is that it may forever alter your sleep pattern (for instance, one may have trouble falling to sleep as you will awaken with a start because it could change brain waves), cause of lost of more memories than anticipated, keep one from retaining future memories, act as a truth serum, or cause nightmares from repressed memories. These are just a few. Go on sites such as versedbuster and there are some others like MedicalPatientModesty. Sometimes nagging thoughts can linger but because of the versed you can't figure out why you have those thoughts.

On some medical sites, medical "professionals" have talked about some the things patients on versed have done. They may be very talkative, funny, flirty (a property of versed is to like being nude), angry/violent, etc. Some of told of how they command patients to do stupid things because another property of versed is it makes patients submissive, compliant. It just depends on who you get and how "professional" they plan to be or are you going to provide entertainment for them?

Some patients are given versed but no pain killers. They experience real pain in real time. Versed may make them forget the pain but the fact is they did suffer pain.

So why is it okay for a medical person to decide that a procedure is one of those things a patient shouldn't remember. I, as a patient, would like to be "present" during my treatment. You can be given a local in many cases and still retain memories and your mental capability. It has become too easy to just give everyone regardless a dose of not conscious sedation. It is done to protect the provider rather than the patient because they don't want the patient present during a procedure for potential malpractice claims. They also don't want to take the time or make the effort to treat patients with the right to personal dignity and respect that all patients are entitled to have. Versed is a drug of convenience for medical providers. It is what allows them to not treat patients in an ethical and moral manner in regards to personal dignity.

Consent forms do not explain the effects of versed. It is always a little something. They know they can get away with not fully explaining bc they can blame and get away with it bc it is accepted that versed could have erased that explanation. It is funny how versed protect the provider and not the patient. There have been many patients who have objected to versed but got it anyway. They just shoot it w/o knowledge into an IV. A minute later they have a compliant patient who may not remember there was an issue or lack of real informed consent.

At Tuesday, January 14, 2020 4:33:00 PM, Anonymous JR said...

I don't disagree that the use of versed should be a patient's choice but often it is not a real choice but a requirement of you are going to have it. But true informed consent is not done most of the time. Cardiac cath is done in Europe without conscious sedation and they don't have issues. Here how medical treatment is delivered is shrouded in secrecy. They don't seem to want the principle of their attention knowing what is happening to them. Patients are not worth being included but rather just part of the process in their line of work.
It is because of this that I am opposed to the use of versed and such. If the medical community were honest and open, there would be no reason to distrust their actions of using versed. But as it stands now, versed is just a tool they use to control and have power over the patient and the patient is totally defenseless.
It is wrong to assume that the erase of bad memories is a cure all. For those who have had memories forcibly erased, the situation cause undue stress and issues for the rest of their life. I know because I live with a man who has had forced memory loss due to unconsented injection of versed. The lasting effects are horrendous and never-ending. So how did the purposeful removal of his memory actually help him? Rather it caused more issues as he does remember parts of what happened so he has a nagging (I am not the nag for those who might think otherwise) feeling of things probably were worse. He also remembers he told them he did not want versed as he clearly remembers that as I do too. But they were intent to make sure they could erase his memory. There are others like him who have suffered long-term traumatic effects for being this drug against their will. How is that in keeping with this country's emphasis on personal rights?


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