VISION FOR THE FUTURE CREATES HISTORY. To determine the evolution and manner in which science, technology, and society will unfold requires vision. The ability to imagine what can be and work towards that goal. Without creativity, without passion, and without perseverance, we are lost to roam shiftless and blind like a ship without a sail in the night. - Eric C. Leuthardt
In the wake of the another mass shooting, especially in this heart breaking episode involving children, I have to ask myself what was the true intention of the Second Amendment. Not being a historian, my general impression from the encoded law “A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed,” is that the government wanted to give people the right to protect themselves. Fine, I get that. There is a technical twist, however. Arms are essentially referring to a technology – a machine that has lethal force. In a free state we are allowed to have these lethal machines to enable the safer wellbeing of the citizens. Again, makes sense. Now fast-forwarding a couple centuries, we have seen the advent of other lethal machines that are widely owned. Cars. High powered, fast, hurtling pieces of steel that serve the purpose of transportation which carry more kinetic energy, momentum, and force than anything Smith & Wesson can produce. Now if these machines had been present in the time of our founding fathers, does that mean the right to have an automobile would fully prohibit any limitation on who can use them? As a neurosurgeon, I often have to tell patients who have had a seizure that they cannot drive for six months, or a patient that has lost vision that they are no longer able to drive at all. If motorist rights were guaranteed by the constitution would we forego driver’s education and hand the keys to sixteen yearold and say best of luck? Would there be a National Motorist Association (NMA) that hysterically opposes any legislation on cars so that people who are blind or epileptic can get them at any time and without any restrictions. No, of course not, that would be dangerous to the person and the society. So why is it that having the right to a technology (i.e. guns) eliminate the social responsibility of having an education in its use and restrictions on who can access that technology? It doesn’t.
Its sometimes hard for me to put into words the visceral pain associated with getting a grant rejected from funding agencies like the National Institute of Health (NIH). The feeling is somewhere in between getting kicked in the crotch and seeing your high school sweetheart kissing another guy. The pain and sense of betrayal runs deep and bitter. For those who don’t do science, a little background is necessary. For any scientist, engineer, or physician running a lab, the way we get funding to answer scientific/technical/medical questions is by making a proposal to the government and then having some agency decide on whether it’s worth paying for. Sounds reasonable. Well maybe, and then maybe not.
Lets look at it a different way. In thinking about future success of the nation, we (or the government really) have to decide how to allocate resources that best serve American interests. Typically, those resources are measured in dollars. How much do we want to pay for health care? For research? How to structure taxes to optimize our competitiveness in the global economy? Thus, when thinking about funding scientific research, the congressional luminati have to measure the value of a scientific advance against all the other national needs. Obviously it’s not a simple task. One problem with the current political equation, however, is that money is not are only resource. A common occurrence through economic cycles is that when the economy is down, the general assumption is that we need to tighten our belts and agencies like the NIH are just going to have to get by with less. That is a more costly choice than people realize. Especially as we approach the fiscal cliff.
Since we are talking about science, lets do another experiment. Lets imagine what would happen in this situation. The US has gone into a substantial recession (after say an increase in tax rates and substantial cuts across government agencies – aka “fiscal cliff”). There is an enormous need for jobs and innovation to recharge the economy. Now what would happen if we took 90% of the scientists and engineers and locked them in a room to prevent them from doing what they do, which is developing new insights into nature and creating new technologies based on those insights. That general output is what creates stuff ranging from the internet to MRI scanners to new drugs for cancer. The impact spans every aspect of the economy from energy to medicine. Alright, so that final 10% who we do let work, they can only work in their labs each time they are able to successfully create a house of cards five feet high. If it falls they need to stop what they are doing and rebuild it. So in sum, most of the brightest people are imprisoned, the rest are doing busy work. The ultimate impact on the economy would be that nobody is creating stuff that American companies can sell to compete in the global economy.
As it turns out it’s not an experiment. The current grant structure has funding levels at about 10 percent or below. So 90 percent of scientific efforts are going unfunded. Worse, those people running labs and trying to get money to support them are spending the vast majority of their time writing grants to take a crack at the 10% funding line (building the house of cards). Taken together the vast majority of the human capital that America has in science is being wasted by lack of funding and endless busy work to try to get funding. Put another way, if the scientist only has a 10% chance of success at getting a grant, and it takes him or her months of work to put that grant together, they would be better served by cutting grass or cleaning dishes where they are paid an hourly rate and then taking those proceeds and playing at the roulette table. If they played red every time they would have a 50% chance at getting a return on their effort. For the average scientist this is a daunting scenario to build a career on. Furthermore, this is not a recipe that will deliver American innovation.
At the heart of the matter, money is not the only resource in America. It’s certainly an important one, but not the only one. It is hard to put a price tag on lost opportunity, but saving some money now on research will substantially impair heavily in America’s current scientific environment today and will be even worse for our competitiveness in the future. I hope that as Democrats and Republicans attempt to craft a compromise for fixing our ballooning deficit they understand this.
A while ago I received an email from a graduate student telling me I should, in essence, choose between academia and commercialization. That, in his words, “trying to go in both ways will make people in the academic circles concerned.” He was in fact right. Often trying to do translational work and basic science can often raise eyebrows amongst members of the strictly academic community. Why is that? Well let me try to encapsulate some of those arguments. Here are a couple of them. “Knowledge should not be constrained or controlled, thus patenting your discoveries is antithetical to the mission of science.” Another. “Having a financial interest in the results of your research could alter your objectivity and thus corporations and business should never be involved in the scientific process.” A lot of these statements are made with the best ethical intentions. They are, however, all misguided.
Lets start with a very fundamental principle of why we do science. First and foremost, we pursue an improved understanding of nature to improve the human condition. The scientific method is one of the greatest inventions by man to pull our species out of a million year history in the wilderness. Put simply, science serves humanity, not the other way around. That principle can be stretched pretty far, ranging from why we study fungi to astrophysics, but ultimately all of them are there to enhance our lives in one way or another, period. So if we take that core principle – science serves man- as our north star it can help guide us through some fairly confused issues in science and medicine.
The mandate for the National Institute of Health is to promote the health of the citizens of the United States. The NIH is one of the dominant funding sources of American science. Now an important question here. What happens to those scientific discoveries? How do they get translated (big buzz word at the NIH) to create drugs, medical devices, new imaging techniques that improve patient’s lives in a myriad of ways? Simple answer - Industry. This is not a function that is performed by medical schools, research institutes, or government agencies. Companies need to invest extraordinary amounts of money to the tune of tens to hundreds of million dollars to bring a discovery to something that is safe and effective in the treatment of disease.
Now let me introduce another very simple principle – economics. Finance and the exchange of money are the fuel for powering human activities. Again, to be overly simplistic about this, we need money to do things. This is not a moral situation. Money in and of itself is not an evil, no more than gravity or other natural forces are evil. It is a force that strongly influences human behavior like gravity governs the movement of planets. So when thinking about translating discoveries to clinical treatments, one has to consider financial forces at work. Why? Because it is really expensive.
Alright, given those two concepts, what is a scientist to do when he or she finds something that could significantly improve human health. Say Dr. Scientist has discovered something that could treat a disease. Now what? How do we get it to humans? How does Dr. Scientist turn this into a therapy that grandma can take? Well someone, or a group of people, have to test the safety and efficacy of that concept. Typically this involves clinical trials that have to pass through the Food and Drug Administration. All of this costs money and most of it is NOT paid for by government. Rather, it’s a cost because of the government. Moreover, this is a risky process that that may fail at multiple steps along the way. Maybe the drug has a bad side effect, maybe it doesn’t work in humans, maybe maybe, maybe. So who is going to pay for this?
Here is where market forces take hold. If there is a big need, there may be the opportunity to sell this therapy and generate a profit. So investors need to put money together to fund this idea. A key here in these early stages is to ask what are they investing in? An idea? If it takes ten years and a hundred million dollars to develop this concept, what if somebody else tries to copy all those efforts and sell something identical right before the original group gets to the finish line? That is not only unfair, it also is financially too risky for anyone to consider as a reasonable investment. So there needs to be some guarantee that if someone is putting all this time and effort into a high-risk idea, that when the idea proves successful they can benefit from their hard work. This is what a patent is. It essentially allows for investors to reduce the risk of putting money behind a good idea. It is the American patent system that was drafted into the Constitution that has driven innovation in the US like no other nation. Is it limiting the dissemination of information? No, quite the opposite; by providing a limited monopoly on the idea for twenty years, the idea has to be fully disclosed in the patent so that it can be used for the good of the public after the expiration of the patent. So returning to fundamental principles – science is there to serve man – creating a system that facilitates the development of an idea into something that improves health is fundamentally moral. Not having these guarantees, essentially allowing an anarchy and predatory situation where someone can unfairly capitalize on another person’s ideas would actually lead people to be more secretive and unlikely to invest in risky concepts.
Next irrational fear — scientists or physicians should not have a “conflict of interest” (another big buzz word) in their research. Concern here is that the opportunity for getting financially rewarded for creating and translating a medical therapy would lead the individual to falsify or misrepresent their work. Therefore, if they really stand to benefit they shouldn’t do the research. There are several issues here that need to be addressed. First, the idea that to maintain one’s objectivity you have to remove all interest from the task. Quite frankly, when really looked at closely, this is just silly. Humans do things because they have an interest in doing them. If they didn’t they would be something akin to a zombie. Now financial interest is simply one thing that motivates humans. For the scientist, getting published in a high impact journal, getting promoted to professor, being recognized for one’s accomplishments are also potent motivators. Because a scientist is motivated to succeed should not be considered a detraction from the quality of their work whether it be financial boons or professional accolades.
Now will a small subset of people make unethical choices for a potential gain? Yes they will. This brings us to another point of social cost. Which is better – try to eliminate the actions of a few bad apples by making policies that make translation harder for everyone, or create scenarios that reward people for achieving positive medical advances with the knowledge that a small percent may cheat. Again put more simply, prevent a whole lot of good things by avoiding a few bad things, or have a whole bunch of good things happen knowing a few bad events may occur. At the end of the day, there is no free risk free scenario. But the question is which risks are we willing to tolerate. Once again considering the two fundamental principles that science is intended to serve man, and that market forces govern human behavior, it is better to create policies that enable market forces to support socially positive outcomes (more translation advances) rather than creating policies that reduce that social motivation.
Now in advocating rewarding people for socially positive scientific and translational efforts, does that mean that we simply shrug our shoulders if someone violates ethical standards in their scientific research for some gain? No absolutely not. If someone were to falsify data in a clinical trial for a therapeutic for financial gain they should be criminally prosecuted. This act is in effect a form of malicious intent no different from fraud, insider trading, or even possibly assault. If a drug is falsely represented and patients take it, which results in a physical complication, the person or persons should be held criminally liable. Today, falsifying data leads to social and professional penalties (loss of a job, retraction of a paper, etc) but nothing that actually speaks to the justice of the harm they could or actually caused. Taken together, when a scientist is translating a technology to a clinical therapy the stakes should be raised for both the positives and negatives. Namely, if they do something that helps people –reward them handsomely. If they behave unethically – punish them severely. In this scenario we are likely to properly motive the right people, and halt the unethical behavior. This is likely better than the current scenario that prevents appropriately motivated and successful people from getting rewarded, and not really punishing the others when they transgress.
I went into Brain Computer Interface research with the intention of enabling spinal cord injury patients to move and locked-in patients to communicate. After working on this for 10 years it still hasn’t happened. There has been enormous excitement around the possibilities, smart people are poring into the field, and government agencies are funding the research like never before. But still – it hasn’t happened yet – why?
Most would say that there is still a lot that needs to be done, key technical hurdle to be overcome, issues of reliability, there would be a lot of hand waving and declarative words like “milestones,” “stakeholders,” and other useless technical jargon used. Lets ask this question, if there was an infinite amount of money available and all the research and technology was created next week, would we be able to help people with devastating spinal cord injury. Sadly the answer is still no.
The reason lies in the story of a company called Cyberkinetics. The company raised millions of dollars from venture capitalists, they got FDA approval, and even demonstrated that quadriplegics could use robotic arms. The reason for the failure was over inflated hype around the market. Namely, that once they went through all this, there were only a handful of patients who would actually require the technology. By handful, I mean several thousand patients per year, which is small in market terms (not small in terms of human suffering). There were also some technical and engineering shortcomings, but at the end of the day there were not enough customers that wanted the product and the company regressed into a corporate acquisition footnote.
Before getting cynical on the idea that money is all that matters, lets look at the food truck guys outside the med school where I work. They have these great touch screen billing devices that are portable and wireless. They’re called iPads. When you think about it, iPads were not created for food truck workers. Nor were they created for any other niche business operator. If they were, nobody would invest that much money to make such a slick and highly refined technology. Instead they were created for the largest market possible, everyone. As a result there was a collateral benefit for all these additional uses.
Similarly for neuroprosthetics, we have to be smarter and think more strategically to get our technology to markets that favor the creation of this technology so that they can then collateralize to all the niche clinical needs. This is in no way minimizing the needs of patients with severe motor disability, rather its finding better ways to get the technology to them. That path is not linear. Going back to the analogy of market forces being similar to gravity, rather than fruitlessly trying to push a boulder up a hill why not use a waterfall to drive a waterwheel that pulls it up. Use gravity to work for you, rather than against you. In the same light, capturing market forces that favor BCI applications will necessarily help brain computer interface (BCI) applications towards small market applications. This is in part why my BCI efforts turned towards solutions to stroke. There are 700,000 strokes per year that leave patients with motor impairment (versus 10,000 per year with spinal cord injury). That’s a market.
The stroke market is a pretty decent stream to power the possibility of BCIs getting clinically applied. To really push this technology, however, to every clinical corner require we need something like the Three Gorges Dam that generates twenty three thousand megawatts (minus the ecological disaster). To big river app, the Yangtze of BCI, is a device, like the iPad, that serves everyone. Similar to the Apple we need to create technologies that enhance everyday lives. We need to figure out how to make neural augments and neural complements to our brains that add to the usual grind of our lives. Use these technologies to make us smarter, more creative, have better memories. Once we do this then all the people who really need this stuff actually benefit.
Time and again I have seen the debate over nature versus nurture unfold in the courts, in media, and in classrooms when people try to articulate why a person committed a crime. Was it because they are a terrible person with malign intentions or where they the result of a lifetime of poor nurturing and abuse that manifests as a learned antisocial response that absolves them of their culpability. It gets to the notion of how free is our ability to make choices. What are the limits and how much are we governed by our environment such that we are nothing more than pin balls following a path determined by the bumpers of events and life experiences.
I would argue when considering our ability to choose freely, that the choice is heavily taxed by our biology. As an analogy, if you put me on a football field I can easily choose which direction that I want to walk in. Well sort of – I can move left, right, forward, and backward. Those choices come at a relatively small cost. What about moving up and down. I can go up and down, but it’s a whole lot harder. To go down I am going to have to swing a pick ax and push a shovel. To move up I am going to have to learn how to fly. Not technically impossible but very very hard. Similarly, I think that our ability to choose certain behaviors given the physical and social realities that a person lives in also create bumpers that, while not impossible, make it very very hard. As an example, the question raised was why didn’t any one speak put against Hitler or Saddam Hussien in their repressive regime to stop moral atrocities from happening. In isolation the choice seems quite easy – say that killing people is wrong. That is in isolation when there aren’t things like the very real social gravity pushing the individual to conform, to not ask questions, to agree. That social gravity is equivalent to the gravity that holds us the earth. The force of it is very hard to resist. Hence when we do see examples of people moving against it – we can understand the true herculean task that it was to accomplish. It is the same reason that we celebrate the accomplishments of the Wright Brothers in their ability to move beyond the physical constraints of our bodies. Henceforth, the choice to fight gravity becomes that much easier. This also true with social justice. Similarly, when people like Gandhi and Martin Luther King are able to first break the social gravity that compel immortal behavior, such as racism, they make it easier for all the rest of us.
So when we talk about our capability of free will, yes we can make any choice that we want. The question is do we have the strength and will to pay the price that decision requires.