Hostname: page-component-78c5997874-t5tsf Total loading time: 0 Render date: 2024-11-10T14:33:13.226Z Has data issue: false hasContentIssue false
  • English
  • Français

Eradicating war memories: Neuroscientific reality and ethical concerns

Published online by Cambridge University Press:  20 December 2018

Marijn C. W. Kroes  and
Rain Liivoja
Get access Rights & Permissions [Opens in a new window]

Abstract

Traumatic memories of war can result in mental disorders such as post-traumatic stress disorder (PTSD). PTSD is characterized by intrusive trauma memories and severe stress responses with devastating personal and societal consequences. Current treatments teach patients to regulate trauma memories, but many experience a return of symptoms even after initially successful treatment. Neuroscience is discovering ways to permanently modify trauma memories and prevent the return of symptoms. Such memory modification techniques (MMTs) have great clinical potential but also important ethical, legal and social implications. In this article, the authors describe PTSD, the role of memory in PTSD, its effects on the brain, and the limitations of current treatment methods. Then, the state of the art of the neuroscience of MMTs is presented. Within this realistic scientific framework the authors will discuss the ethical, legal and social implications of MMTs for the treatment of war-induced PTSD, especially in a military population. Three major sets of issues will be focused on: safety and social justice concerns, concerns about threats to authenticity and identity, and the possible legal and moral duties to retain certain memories. Finally, the article concludes that within scientific reality, concerns are limited and do not outweigh the potential benefits of developing treatments for patients.

Keywords

warpost-traumatic stress disordermemory modificationneuroscienceethics
Type
Ethical challenges: Whether to remember
Information
International Review of the Red Cross , Volume 101 , Issue 910: Memory and war , April 2019 , pp. 69 - 95
Copyright
Copyright © icrc 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

*

While writing this article, both authors were supported by Branco Weiss Fellowships. Marijn C. W. Kroes was also supported by an H2020 Marie Skłodowska-Curie Fellowship.

References

1 Vervliet, Bram, Craske, Michelle G. and Hermans, Dirk, “Fear Extinction and Relapse: State of the Art”, Annual Review of Clinical Psychology, Vol. 9, No. 1, 2013CrossRefGoogle ScholarPubMed.

2 For more information, see the section “Ethical, Legal and Social Issues” below.

3 See, e.g., Roache, Rebecca, “Ethics, Speculation, and Values”, NanoEthics, Vol. 2, No. 3, 2008CrossRefGoogle Scholar.

4 Cabrera, Laura Y. and Elger, Bernice S., “Memory Interventions in the Criminal Justice System: Some Practical Ethical Considerations”, Journal of Bioethical Inquiry, Vol. 13, No. 1, 2016, p. 96CrossRefGoogle ScholarPubMed.

5 Association, American Psychiatric, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Washington, DC, 2010Google Scholar. See also Foa, Edna B., Steketee, Gail and Rothbaum, Barbara Olasov, “Behavioral/Cognitive Conceptualizations of Post-Traumatic Stress Disorder”, Behavior Therapy, Vol. 20, No. 2, 1989CrossRefGoogle Scholar; van der Kolk, Bessel A., “The Psychobiology of Posttraumatic Stress Disorder”, Journal of Clinical Psychiatry, Vol. 58, Suppl. 9, 1997Google ScholarPubMed; Ehlers, Anke and Clark, David M., “A Cognitive Model of Posttraumatic Stress Disorder”, Behaviour Research & Therapy, Vol. 38, No. 4, 2000CrossRefGoogle ScholarPubMed; Brewin, Chris R. and Holmes, Emily A., “Psychological Theories of Posttraumatic Stress Disorder”, Clinical Psychology Review, Vol. 23, No. 3, 2003CrossRefGoogle ScholarPubMed.

6 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5, Washington, DC, 2013Google Scholar.

7 Keane, Terence M., Marshall, Amy D. and Taft, Casey T., “Posttraumatic Stress Disorder: Etiology, Epidemiology, and Treatment Outcome”, Annual Review of Clinical Psychology, Vol. 2, No. 1, 2006CrossRefGoogle ScholarPubMed.

8 Greenberg, Paul E. et al. , “The Economic Burden of Anxiety Disorders in the 1990s”, The Journal of Clinical Psychiatry, Vol. 60, No. 7, 1999CrossRefGoogle ScholarPubMed.

9 Kessler, Ronald C. et al. , “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication”, Archives of General Psychiatry, Vol. 62, No. 6, 2005Google ScholarPubMed; T. M. Keane, A. D. Marshall and C. T. Taft, above note 7.

10 R. C. Kessler et al., above note 9; T. M. Keane, A. D. Marshall and C. T. Taft, above note 7.

11 R. C. Kessler et al., above note 9; T. M. Keane, A. D. Marshall and C. T. Taft, above note 7.

12 R. C. Kessler et al., above note 9; T. M. Keane, A. D. Marshall and C. T. Taft, above note 7.

13 R. C. Kessler et al., above note 9.

14 Kang, H. K., “Post-Traumatic Stress Disorder and Chronic Fatigue Syndrome-like Illness among Gulf War Veterans: A Population-based Survey of 30,000 Veterans”, American Journal of Epidemiology, Vol. 157, No. 2, 2003CrossRefGoogle ScholarPubMed.

15 Kulka, Richard A. et al. , Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study, Brunner and Mazel, New York, 1990Google Scholar.

16 Farhood, Laila, Dimassi, Hani and Lehtinen, Tuija, “Exposure to War-Related Traumatic Events, Prevalence of PTSD, and General Psychiatric Morbidity in a Civilian Population From Southern Lebanon”, Journal of Transcultural Nursing, Vol. 17, No. 4, 2006CrossRefGoogle Scholar; Stephen Powell, “The Psychosocial Consequences of the 1992–5 War in Bosnia & Herzegovina”, PhD thesis, Middlesex University, 2012; Potts, Marilyn K., “Long-Term Effects of Trauma: Post-Traumatic Stress among Civilian Internees of the Japanese during World War II”, Journal of Clinical Psychology, Vol. 50, No. 5, 19943.0.CO;2-3>CrossRefGoogle ScholarPubMed.

17 Cardozo, Barbara Lopes, “Mental Health, Social Functioning, and Disability in Postwar Afghanistan”, Journal of the American Medical Association, Vol. 292, No. 5, 2004Google ScholarPubMed.

18 C. R. Brewin and E. A. Holmes, above note 5.

19 E. B. Foa, G. Steketee and B. Olasov Rothbaum, above note 5.

20 Brewin, Chris R., Andrews, Bernice and Valentine, John D., “Meta-Analysis of Risk Factors for Posttraumatic Stress Disorder in Trauma-Exposed Adults”, Journal of Consulting and Clinical Psychology, Vol. 68, No. 5, 2000CrossRefGoogle ScholarPubMed; Ozer, Emily J. et al. , “Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: A Meta-Analysis”, Psychological Bulletin, Vol. 129, No. 1, 2003CrossRefGoogle ScholarPubMed.

21 See LaBar, Kevin S. and Cabeza, Roberto, “Cognitive Neuroscience of Emotional Memory”, Nature Reviews Neuroscience, Vol. 7, No. 1, 2006CrossRefGoogle ScholarPubMed.

22 Janoff-Bulman, Ronnie, Shattered Assumptions: Towards a New Psychology of Trauma, Free Press, New York, 1992Google Scholar; Horowitz, Mardi J., Stress Response Syndromes: PTSD, Grief, Adjustment, and Dissociative Disorders, Jason Aronson, Lanham, MD, 2014Google Scholar.

23 Ehlers, Anke et al. , “The Nature of Intrusive Memories after Trauma: The Warning Signal Hypothesis”, Behaviour Research & Therapy, Vol. 40, No. 9, 2002CrossRefGoogle ScholarPubMed.

24 E. B. Foa, G. Steketee and B. Olasov Rothbaum, above note 5; A. Ehlers and D. M. Clark, above note 5; C. R. Brewin and E. A. Holmes, above note 5.

25 Brewin, Chris R. et al. , “Intrusive Images in Psychological Disorders: Characteristics, Neural Mechanisms, and Treatment Implications”, Psychological Review, Vol. 117, No. 1, 2010CrossRefGoogle ScholarPubMed.

26 Bisson, Jonathan I. et al. , “Post-Traumatic Stress Disorder”, British Medical Journal, Vol. 351, No. h6161, 2015Google ScholarPubMed.

27 Ibid.

28 B. A. van der Kolk, above note 5; Yehuda, Rachel et al. , “Hypothalamic-Pituitary-Adrenal Dysfunction in Posttraumatic Stress Disorder”, Biological Psychiatry, Vol. 30, No. 10, 1991CrossRefGoogle ScholarPubMed; Bremner, J. Douglas and Vermetten, Eric, “Neuroanatomical Changes Associated with Pharmacotherapy in Posttraumatic Stress Disorder”, Annals of the New York Academy of Sciences, Vol. 1032, No. 1, 2004CrossRefGoogle ScholarPubMed; Pitman, Roger K., Rasmusson, Ann M. et al. , “Biological Studies of Post-Traumatic Stress Disorder”, Nature Reviews Neuroscience, Vol. 13, No. 11, 2012CrossRefGoogle ScholarPubMed.

29 van Etten, Michelle L. and Taylor, Steven, “Comparative Efficacy of Treatments for Post-Traumatic Stress Disorder: A Meta-Analysis”, Clinical Psychology & Psychotherapy, Vol. 5, No. 3, 19983.0.CO;2-H>CrossRefGoogle Scholar.

30 Exposure treatment is based on extinction learning in Pavlovian conditioning: see text accompanying notes 46–48 below.

31 Lang, Peter J., “Imagery in Therapy: An Information Processing Analysis of Fear”, Behavior Therapy, Vol. 8, No. 5, 1977CrossRefGoogle Scholar.

32 See C. R. Brewin and E. A. Holmes, above note 5.

33 M. L. van Etten and S. Taylor, above note 29.

34 B. Vervliet, M. G. Craske and D. Hermans, above note 1.

35 See text accompanying notes 48–50 below.

36 Dudai, Yadin, “Memory Concepts”, in Roediger, Henry L., Dudai, Yadin and Fitzpatrick, Susan M. (eds), Science of Memory: Concepts, Oxford University Press, Oxford, 2007Google Scholar.

37 Semon, Richard, The Mneme, Allen & Unwin, London, 1921, p. 12Google Scholar.

38 Henke, Katharina, “A Model for Memory Systems Based on Processing Modes rather than Consciousness”, Nature Reviews Neuroscience, Vol. 11, No. 7, 2010CrossRefGoogle Scholar.

39 See Tulving, Endel, “Episodic and Semantic Memory”, in Tulving, Endel and Donaldson, Wayne (eds), Organization of Memory, Academic Press, New York, 1972Google Scholar; Squire, Larry R., “Memory and the Hippocampus: A Synthesis from Findings with Rats, Monkeys, and Humans”, Psychological Review, Vol. 99, No. 2, 1992Google ScholarPubMed.

40 Squire, Larry R., “Memory Systems of the Brain: A Brief History and Current Perspective”, Neurobiology of Learning & Memory, Vol. 82, No. 3, 2004CrossRefGoogle ScholarPubMed.

41 LeDoux, Joseph E., “Emotion Circuits in the Brain”, Annual Review of Neuroscience, Vol. 23, No. 1, 2000CrossRefGoogle Scholar.

42 A. Ehlers and D. M. Clark, above note 5.

43 L. R. Squire, above note 39.

44 McGaugh, J. L., “Memory: A Century of Consolidation”, Science, Vol. 287, No. 5451, 2000CrossRefGoogle ScholarPubMed.

45 Ibid.

46 Ibid.

47 See text accompanying note 68 below.

48 B. Vervliet, M. G. Craske and D. Hermans, above note 1.

49 Bouton, M. E., “Context and Behavioral Processes in Extinction”, Learning & Memory, Vol. 11, No. 5, 2004CrossRefGoogle ScholarPubMed; Quirk, Gregory J. and Mueller, Devin, “Neural Mechanisms of Extinction Learning and Retrieval”, Neuropsychopharmacology, Vol. 33, No. 1, 2008CrossRefGoogle ScholarPubMed; Myers, Karyn M. and Davis, Michael, “Behavioral and Neural Analysis of Extinction”, Neuron, Vol. 36, No. 4, 2002CrossRefGoogle ScholarPubMed.

50 B. Vervliet, M. G. Craske and D. Hermans, above note 1.

51 Kroes, Marijn C. W. and Fernández, Guillén, “Dynamic Neural Systems Enable Adaptive, Flexible Memories”, Neuroscience & Biobehavioral Reviews, Vol. 36, No. 7, 2012CrossRefGoogle ScholarPubMed.

52 Hirst, William et al. , “Long-term Memory for the Terrorist Attack of September 11: Flashbulb Memories, Event Memories, and the Factors that Influence Their Retention”, Journal of Experimental Psychology: General, Vol. 138, No. 2, 2009Google ScholarPubMed.

53 Neisser, Ulric and Harsch, Nicole, “Phantom Flashbulbs: False Recollections of Hearing the News about Challenger”, in Winograd, Eugene and Neisser, Ulric (eds.), Affect and Accuracy in Recall, Cambridge University Press, Cambridge, 1992Google Scholar; W. Hirst et al., above note 52.

54 In a classic study, researchers asked participants to recall specific events that had happened to them when they were younger; these events were provided to the researchers by relatives of the participants. Intermixed with the real events, respondents were asked to remember a false event – being lost in a shopping mall. A third of participants reported remembering the false event and described it by adding more details to the suggested scenario. See Loftus, Elizabeth F. and Pickrell, Jacqueline E., “The Formation of False Memories”, Psychiatric Annals, Vol. 25, No. 12, 1995CrossRefGoogle Scholar.

55 J. L. McGaugh, above note 44.

56 Nader, Karim and Hardt, Oliver, “A Single Standard for Memory: The Case for Reconsolidation”, Nature Reviews Neuroscience, Vol. 10, No. 3, 2009CrossRefGoogle ScholarPubMed; M. C. W. Kroes et al., above note 51.

57 Nader, Karim, Schafe, Glenn E. and Le Doux, Joseph E., “Fear Memories Require Protein Synthesis in the Amygdala for Reconsolidation after Retrieval”, Nature, Vol. 406, No. 6797, 2000CrossRefGoogle ScholarPubMed.

58 Ibid.

59 Dębiec, Jacek and LeDoux, Joseph E., “Disruption of Reconsolidation but not Consolidation of Auditory Fear Conditioning by Noradrenergic Blockade in the Amygdala”, Neuroscience, Vol. 129, No. 2, 2004CrossRefGoogle Scholar; Kindt, Merel, Soeter, Marieke and Vervliet, Bram, “Beyond Extinction: Erasing Human Fear Responses and Preventing the Return of Fear”, Nature Neuroscience, Vol. 12, No. 3, 2009CrossRefGoogle ScholarPubMed.

60 Monfils, Marie-H. et al. , “Extinction-Reconsolidation Boundaries: Key to Persistent Attenuation of Fear Memories”, Science, Vol. 324, No. 5929, 2009CrossRefGoogle ScholarPubMed; Schiller, Daniela et al. , “Preventing the Return of Fear in Humans Using Reconsolidation Update Mechanisms”, Nature, Vol. 463, No. 7277, 2010CrossRefGoogle ScholarPubMed.

61 D. Schiller et al., above note 60; M. Kindt, M. Soeter and B. Vervliet, above note 59.

62 Soeter, Marieke and Kindt, Merel, “Dissociating Response Systems: Erasing Fear from Memory”, Neurobiology of Learning and Memory, Vol. 94, No. 1, 2010CrossRefGoogle ScholarPubMed; Jacek Dębiec and Margaret Altemus, “Toward a New Treatment for Traumatic Memories”, Cerebrum, September 2006; Elsey, James and Kindt, Merel, “Manipulating Human Memory Through Reconsolidation: Ethical Implications of a New Therapeutic Approach”, AJOB Neuroscience, Vol. 7, No. 4, 2016CrossRefGoogle Scholar.

63 See Kroes, Marijn C. W. et al. , “Translational Approaches Targeting Reconsolidation”, in Robbins, Trevor W. and Sahakian, Barbara J. (eds), Translational Neuropsychopharmacology, Springer, Cham, 2016Google Scholar.

64 Kroes, Marijn C. W. et al. , “An Electroconvulsive Therapy Procedure Impairs Reconsolidation of Episodic Memories in Humans”, Nature Neuroscience, Vol. 17, No. 2, 2014CrossRefGoogle ScholarPubMed.

65 K. Nader and O. Hardt, above note 56; M. C. W. Kroes et al., above note 63.

66 M. C. W. Kroes et al., above note 63.

67 Ibid.

68 Ibid.

69 Pitman, Roger K., Sanders, Kathy M. et al. , “Pilot Study of Secondary Prevention of Posttraumatic Stress Disorder with Propranolol”, Biological Psychiatry, Vol. 51, No. 2, 2002CrossRefGoogle ScholarPubMed.

70 See Hofmann, Stefan G., “Enhancing Exposure-Based Therapy from a Translational Research Perspective”, Behaviour Research & Therapy, Vol. 45, No. 9, 2007CrossRefGoogle ScholarPubMed; Ressler, Kerry J. et al. , “Cognitive Enhancers as Adjuncts to Psychotherapy: Use of D-Cycloserine in Phobic Individuals to Facilitate Extinction of Fear”, Archives of General Psychiatry, Vol. 61, No. 11, 2004CrossRefGoogle Scholar.

71 Brunet, Alain, Orr, Scott P. et al. , “Effect of Post-Retrieval Propranolol on Psychophysiologic Responding during Subsequent Script-Driven Traumatic Imagery in Post-Traumatic Stress Disorder”, Journal of Psychiatric Research, Vol. 42, No. 6, 2008CrossRefGoogle ScholarPubMed; Brunet, Alain, Poundja, Joaquin et al. , “Trauma Reactivation Under the Influence of Propranolol Decreases Posttraumatic Stress Symptoms and Disorder: 3 Open-Label Trials”, Journal of Clinical Psychopharmacology, Vol. 31, No. 4, 2011CrossRefGoogle ScholarPubMed; Brunet, Alain, Thomas, Émilie et al. , “Trauma Reactivation Plus Propranolol is Associated with Durably Low Physiological Responding during Subsequent Script-Driven Traumatic Imagery”, Canadian Journal of Psychiatry, Vol. 59, No. 4, 2014CrossRefGoogle ScholarPubMed.

72 M. C. W. Kroes et al., above note 63.

73 Wood, Nellie E. et al. , “Pharmacological Blockade of Memory Reconsolidation in Posttraumatic Stress Disorder: Three Negative Psychophysiological Studies”, Psychiatry Research, Vol. 225, Nos 1–2, 2015CrossRefGoogle ScholarPubMed.

74 C. R. Brewin et al., above note 25.

75 Soeter, Marieke and Kindt, Merel, “An Abrupt Transformation of Phobic Behavior After a Post-Retrieval Amnesic Agent”, Biological Psychiatry, Vol. 78, No. 12, 2015CrossRefGoogle ScholarPubMed.

76 Holmes, Emily A. et al. , “Can Playing the Computer Game ‘Tetris’ Reduce the Build-Up of Flashbacks for Trauma? A Proposal from Cognitive Science”, PLoS ONE, Vol. 4, No. 1, 2009CrossRefGoogle ScholarPubMed.

77 Iyadurai, Lalitha et al. , “Preventing Intrusive Memories after Trauma via a Brief Intervention Involving Tetris Computer Game Play in the Emergency Department: A Proof-of-Concept Randomized Controlled Trial”, Molecular Psychiatry, Vol. 23, No. 3, 2018CrossRefGoogle Scholar.

78 James, Ella L. et al. , “Computer Game Play Reduces Intrusive Memories of Experimental Trauma via Reconsolidation-Update Mechanisms”, Psychological Science, Vol. 26, No. 8, 2015CrossRefGoogle ScholarPubMed.

79 M. C. W. Kroes et al., above note 63.

80 More broadly on the need for a contextualized case-by-case assessment, see, e.g., President's Council on Bioethics, Beyond Therapy: Biotechnology and the Pursuit of Happiness, October 2003, p. 208; Levy, Neil, Neuroethics: Challenges for the 21st Century, Cambridge University Press, Cambridge, 2007, p. 131CrossRefGoogle Scholar; Parens, Erik, “The Ethics of Memory Blunting and the Narcissism of Small Differences”, Neuroethics, Vol. 3, No. 2, 2010, p. 106CrossRefGoogle Scholar.

81 President's Council on Bioethics, above note 80, is a case in point.

82 Cf. N. Levy, above note 80, p. 131.

83 But see J. Elsey and M. Kindt, above note 62.

84 Hall, Wayne and Carter, Adrian, “Debunking Alarmist Objections to the Pharmacological Prevention of PTSD”, American Journal of Bioethics, Vol. 7, No. 9, 2007, pp. 23–24CrossRefGoogle ScholarPubMed.

85 President's Council on Bioethics, above note 80, pp. 226, 228; Bell, Jennifer A., “Preventing Post-Traumatic Stress Disorder or Pathologizing Bad Memories?”, American Journal of Bioethics, Vol. 7, No. 9, 2007, p. 29CrossRefGoogle ScholarPubMed.

86 See, e.g., Moret, C., Isaac, M., and Briley, M., “Problems Associated with Long-Term Treatment with Selective Serotonin Reuptake Inhibitors”, Journal of Psychopharmacology, Vol. 23, No. 8, 2009CrossRefGoogle ScholarPubMed.

87 Donovan, Elise, “Propranolol Use in the Prevention and Treatment of Posttraumatic Stress Disorder in Military Veterans: Forgetting Therapy Revisited”, Perspectives in Biology & Medicine, Vol. 53, No. 1, 2010, p. 70Google Scholar.

88 Aston-Jones, Gary and Cohen, Jonathan D., “An Integrative Theory of Locus Coeruleus-Norepinephrine Function: Adaptive Gain and Optimal Performance”, Annual Review of Neuroscience, Vol. 28, No. 1, 2005CrossRefGoogle ScholarPubMed; Bouret, Sebastien and Sara, Susan J., “Network Reset: A Simplified Overarching Theory of Locus Coeruleus Noradrenaline Function”, Trends in Neurosciences, Vol. 28, No. 11, 2005CrossRefGoogle ScholarPubMed.

89 E. Donovan, above note 87, p. 70.

90 Henry, Michael, Fishman, Jennifer R. and Youngner, Stuart J., “Propranolol and the Prevention of Post-Traumatic Stress Disorder: Is it Wrong to Erase the ‘Sting’ of Bad Memories?”, AJOB Neuroscience, Vol. 7, No. 9, 2007, p. 16Google ScholarPubMed; Aoki, Cynthia R. A., “Rewriting My Autobiography: The Legal and Ethical Implications of Memory-Dampening Agents”, Bulletin of Science, Technology & Society, Vol. 28, No. 4, 2008, p. 356CrossRefGoogle Scholar.

91 Doya, Kenji, “Modulators of Decision Making”, Nature Neuroscience, Vol. 11, No. 4, 2008Google Scholar; Rogers, Robert D. et al. , “Effects of Beta-Adrenoceptor Blockade on Components of Human Decision-Making”, Psychopharmacology, Vol. 172, No. 2, 2004CrossRefGoogle ScholarPubMed; Sokol-Hessner, Peter et al. , “Determinants of Propranolol's Selective Effect on Loss Aversion”, Psychological Science, Vol. 26, No. 7, 2015CrossRefGoogle ScholarPubMed.

92 N. Levy, above note 80, pp. 187–195; Craigie, Jillian, “Propranolol, Cognitive Biases, and Practical Decision-Making”, American Journal of Bioethics, Vol. 7, No. 9, 2007, p. 31CrossRefGoogle ScholarPubMed.

93 Terbeck, Sylvia et al. , “Beta Adrenergic Blockade Reduces Utilitarian Judgement”, Biological Psychology, Vol. 92, No. 2, 2013, p. 325Google ScholarPubMed.

94 See Protocol Additional (I) to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts, 1125 UNTS 3, 8 June 1977 (entered into force 7 December 1978), Art. 51(5)(b). The article prohibits the launching of “an attack which may be expected to cause incidental loss of civilian life, injury to civilians, damage to civilian objects, or a combination thereof, which would be excessive in relation to the concrete and direct military advantage anticipated”.

95 Wolfendale, Jessica, “Performance-Enhancing Technologies and Moral Responsibility in the Military”, American Journal of Bioethics, Vol. 8, No. 2, 2008, p. 30CrossRefGoogle ScholarPubMed.

96 See, e.g., Benn, P., Fisher, M. and Kulasegaram, R., “UK Guideline for the Use of Post-Exposure Prophylaxis for HIV Following Sexual Exposure (2011)”, International Journal of STD & AIDS, Vol. 22, No. 12, 2011CrossRefGoogle Scholar; Australian Society for HIV Medicine, Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV: Australian National Guidelines, Darlinghurst, 2016Google Scholar.

97 See, for example, Brown, Kevin, PHE Guidelines on Rabies Post-Exposure Treatment, Public Health England, London, June 2017Google Scholar.

98 R. K. Pitman, K. M. Sanders et al., above note 69.

99 Bell, J., “Propranolol, Post-Traumatic Stress Disorder and Narrative Identity”, Journal of Medical Ethics, Vol. 34, No. e23, 2008, p. 4CrossRefGoogle ScholarPubMed.

100 President's Council on Bioethics, above note 80, p. 227.

101 Locke, John, An Essay Concerning Humane Understanding, Book II, London, 1690, chap. 27Google Scholar.

102 See, in particular, Erler, Alexandre, “Does Memory Modification Threaten Our Authenticity?”, Neuroethics, Vol. 4, No. 3, 2011CrossRefGoogle ScholarPubMed; Vukov, Joseph, “Enduring Questions and the Ethics of Memory Blunting”, Journal of the American Philosophical Association, Vol. 3, No. 2, 2017CrossRefGoogle Scholar.

103 See the references cited in above note 62.

104 Damasio, Antonio R., Descartes’ Error: Emotion, Reason and the Human Brain, Avon, New York, 1994Google Scholar; Phelps, Elizabeth A., Lempert, Karolina M. and Sokol-Hessner, Peter, “Emotion and Decision Making: Multiple Modulatory Neural Circuits”, Annual Review of Neuroscience, Vol. 37, No. 1, 2014CrossRefGoogle ScholarPubMed.

105 See, along the same lines, Kolber, Adam J., “Therapeutic Forgetting: The Legal and Ethical Implications of Memory Dampening”, Vanderbilt Law Review, Vol. 59, No. 5, 2006, p. 1604Google Scholar; J. Bell, above note 99, p. 3; E. Donovan, above note 87, p. 68.

106 This is true even after controlling for physical illness and other mental disorders. See Sareen, Jitender, Houlahan, Tanya et al. , “Anxiety Disorders Associated with Suicidal Ideation and Suicide Attempts in the National Comorbidity Survey”, Journal of Nervous & Mental Disease, Vol. 193, No. 7, 2005CrossRefGoogle ScholarPubMed; Sareen, Jitender, Cox, Brian J. et al. , “Physical and Mental Comorbidity, Disability, and Suicidal Behavior Associated with Posttraumatic Stress Disorder in a Large Community Sample”, Psychosomatic Medicine, Vol. 69, No. 3, 2007CrossRefGoogle Scholar.

107 See, e.g., Wasserman, David, “Making Memory Lose Its Sting”, Philosophy & Public Policy Quarterly, Vol. 24, No. 4, 2004, p. 14Google Scholar; A. J. Kolber, above note 105, p. 1604; J. Bell, above note 99, p. 4; E. Donovan, above note 87, p. 72.

108 Schacter, Daniel L., The Seven Sins of Memory: How the Mind Forgets and Remembers, Houghton Mifflin, Boston, MA, 2001, p. 183Google Scholar; President's Council on Bioethics, above note 80, p. 226; Holmes, Emily A., Sandberg, Anders and Iyadurai, Lalitha, “Erasing Trauma Memories”, British Journal of Psychiatry, Vol. 197, No. 5, 2010CrossRefGoogle ScholarPubMed.

109 Tedeschi, Richard G. and Calhoun, Lawrence G., “Posttraumatic Growth: Conceptual Foundations and Empirical Evidence”, Psychological Inquiry, Vol. 15, No. 1, 2004CrossRefGoogle Scholar.

110 Warnick, Jason E., “Propranolol and Its Potential Inhibition of Positive Post-Traumatic Growth”, American Journal of Bioethics, Vol. 7, No. 9, 2007, p. 37CrossRefGoogle ScholarPubMed.

111 E. Parens, above note 80, p. 102.

112 M. Henry, J. R. Fishman and S. J. Youngner, above note 90, p. 16.

113 A. J. Kolber, above note 105, pp. 1599, 1600.

114 E. Donovan, above note 87, p. 70.

115 D. L. Schacter, above note 108, p. 183.

116 A. J. Kolber, above note 105, p. 1600 (emphasis in original).

117 E. Donovan, above note 87, p. 70.

118 J. E. Warnick, above note 110, p. 37.

119 E. A. Holmes, A. Sandberg and L. Iyadurai, above note 108.

120 President's Council on Bioethics, above note 80, p. 231.

121 C. R. A. Aoki, above note 90, p. 357.

122 Robin Marantz Henig, “The Quest to Forget”, New York Times Magazine, 4 April 2004; D. Wasserman, above note 107, p. 12; C. R. A. Aoki, above note 90, pp. 356–357.

123 Dallaire, Roméo, Shake Hands with the Devil: The Failure of Humanity in Rwanda, Carroll & Graf, New York, 2004, p. 374Google Scholar.

124 This is the subject of another book: Dallaire, Roméo and Humphreys, Jessica Dee, Waiting for First Light: My Ongoing Battle with PTSD, Random House, Toronto, 2016Google Scholar.

125 C. R. A. Aoki, above note 90, p. 357; cf. D. Wasserman, above note 107, p. 12.

126 D. Wasserman, above note 107, p. 12.

127 Arthur Caplan, quoted in Miller, Greg, “Learning to Forget”, Science, Vol. 304, No. 5667, 2004, p. 36CrossRefGoogle Scholar.

128 Bublitz, Christoph and Dresler, Martin, “A Duty to Remember, a Right to Forget? Memory Manipulations and the Law”, in Clausen, Jens and Levy, Neil (eds), Handbook of Neuroethics, Springer, Dordrecht, 2015, p. 1300Google Scholar.

129 See such concerns summarized in, e.g., A. J. Kolber, above note 105, pp. 1579–1582.

130 President's Council on Bioethics, above note 80, pp. 206–207, 212, 232; D. Wasserman, above note 107, pp. 14–15; E. Parens, above note 80; A. Erler, above note 102; C. Bublitz and M. Dresler, above note 128, p. 1299; J. Vukov, above note 102, p. 243.

131 E. Parens, above note 80, p. 106.

132 For a careful examination of this issue, see Kreitmair, Karola, “Memory Manipulation in the Context of Punishment and Atonement”, AJOB Neuroscience, Vol. 7, No. 4, 2016CrossRefGoogle Scholar.

133 Ardino, Vittoria, Milani, Luca and Blasio, Paola di, “PTSD and Re-Offending Risk: The Mediating Role of Worry and a Negative Perception of Other People's Support”, European Journal of Psychotraumatology, Vol. 4, 2013CrossRefGoogle Scholar.

134 On prison health-care ethics generally, see Wolff, Hans et al. , “Health Care in Custody: Ethical Fundamentals”, Bioethica Forum, Vol. 5, No. 4, 2012Google Scholar; Andres Lehtmets and Jörg Pont, Prison Health Care and Medical Ethics: A Manual for Health-Care Workers and Other Prison Staff with Responsibility for Prisoners’ Well-Being, Council of Europe, November 2014.

135 There is broad support for the “principle of equivalence of care”, which requires prisoners to be provided health care equivalent in quality to that provided to the general public. For critical discussions of this concept, see Niveau, Gérard, “Relevance and Limits of the Principle of ‘Equivalence of Care’ in Prison Medicine”, Journal of Medical Ethics, Vol. 33, No. 10, 2007CrossRefGoogle Scholar; Jotterand, Fabrice and Wangmo, Tenzin, “The Principle of Equivalence Reconsidered: Assessing the Relevance of the Principle of Equivalence in Prison Medicine”, American Journal of Bioethics, Vol. 14, No. 7, 2014CrossRefGoogle ScholarPubMed.

136 For a discussion of associated human rights issues in a different context, see Amon, Joseph and Lohman, Diederik, “Denial of Pain Treatment and the Prohibition of Torture, Cruel, Inhuman or Degrading Treatment or Punishment”, Interights Bulletin, Vol. 16, No. 4, 2011Google Scholar.

137 Paul McHugh, quoted in Giles, Jim, “Beta-Blockers Tackle Memories of Horror”, Nature, Vol. 436, No. 7050, 2005CrossRefGoogle ScholarPubMed.

138 For a brief discussion, see René Provost, “Targeting Child Soldiers”, EJIL: Talk!, 12 January 2016.

139 Booth-Kewley, Stephanie et al. , “Factors Associated with Antisocial Behavior in Combat Veterans”, Aggressive Behavior, Vol. 36, No. 5, 2010Google ScholarPubMed.

140 C. R. A. Aoki, above note 90, p. 356.

141 See, for example, E. Donovan, above note 87, pp. 70, 72.