LAUSR

Deep brain stimulation (DBS)—a neurosurgical procedure in which electrodes are used to stimulate regions of the brain—is being investigated as a therapy for treatment-resistant depression. Lawrence and colleagues (2019) note that this experimental therapy is the subject of controversy within neuroethics. In particular, they reference worries that depressive patients’ beliefs and decisions concerning DBS may be compromised. They highlight possibilities that patients may be unable to cogently evaluate the benefits and drawbacks of DBS; may make decisions out of desperation; or may, due to media portrayal, have inflated hopes about the effectiveness of DBS (Lawrence et al. 2019). In evaluating these ethical concerns, the authors also consider the possibility that patients’ beliefs and decision-making processes may be affected by relational vulnerabilities, that is, vulnerabilities arising from the effects of patients’ interpersonal relationships (Lawrence et al. 2019). To gain insight into these issues, Lawrence and colleagues interviewed 24 patients with treatment-resistant depression so as to assess their “interest level, hopes, fears, and decision-making process” with respect to DBS (2019, 211). The authors conclude that, at least with respect to their study, the aforementioned ethical concerns may be overstated: “Participants seemed very aware of the risks, and very aware of their own difficulties processing information, and there was no indication that participants would make quick decisions to undergo deep brain stimulation” (217). In this commentary, we question the authors’ approach to investigating the role of relational vulnerabilities in patients’ beliefs and decision-making processes. First, we argue that the authors’ conclusion—i.e. that ethical concerns may be overstated—is unwarranted. We argue further that their conception of and approach to investigating relational vulnerability are overly narrow in scope. Finally, we suggest that their analysis could have benefited from reflexively considering relational vulnerabilities arising from their own study protocol. The authors identify two forms of relational vulnerability, which we address in turn. The first, described in a paper by Bell et al. (2014), is the vulnerability a research participant experiences as a result of asymmetrical power relations existing between investigators and participants. In the context of studies on DBS for depression, the relevant power asymmetries arise from patients’ “active depressive symptoms, less knowledge about the device, and less understanding of alternatives” (Lawrence et al. 2019, 216). Let’s call this form power-relational vulnerability. In their analysis of power-relational vulnerability, the authors consider patient responses to the following interview question: “Receiving a deep brain stimulator is an important decision. Many people would want to discuss it before making a decision. If you were offered a deep brain stimulator, who is the most important person you would want to help you with that decision?” (Lawrence et al. 2019, 211). Many patients (n1⁄4 14) stated that they would consult multiple providers, family members, and Internet resources. From this, the authors infer that patients “seemed to respond to [power-relational vulnerability] by expanding the number of people participating in the decision-making process” (Lawrence et al. 2019, 211). Based on the authors’ analysis, one might be tempted to draw the following conclusion: Given that patients would seek others’ advice in making decisions about DBS, we have less reason to worry than we otherwise would about the impact of power-relational vulnerabilities. Indeed, such a conclusion might seem the natural one to draw in the context of the authors’ overarching claim that ethical concerns related to patient decision making are overstated. However, to warrant such a conclusion, we would need to know more than the mere fact that patients would seek advice from others. We would need to know whether and under what conditions patients think such advice would be helpful—and whether it would in fact be helpful—in mitigating power-relational vulnerabilities. The authors could, for instance, have addressed this question by asking patients whether they had sought advice when making past medical decisions, and how this advice impacted their sense