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Eradicating war memories: Neuroscientific reality and ethical concerns

  • Marijn C. W. Kroes and Rain Liivoja


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.



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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.



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

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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.

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

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, 1991; 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, 2004; Pitman, Roger K., Rasmusson, Ann M. et al. , “Biological Studies of Post-Traumatic Stress Disorder”, Nature Reviews Neuroscience, Vol. 13, No. 11, 2012.

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, 1998.

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, 1977.

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, 2007.

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

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

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, 2000.

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, 2004; Quirk, Gregory J. and Mueller, Devin, “Neural Mechanisms of Extinction Learning and Retrieval”, Neuropsychopharmacology, Vol. 33, No. 1, 2008; Myers, Karyn M. and Davis, Michael, “Behavioral and Neural Analysis of Extinction”, Neuron, Vol. 36, No. 4, 2002.

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, 2012.

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, 2009.

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, 1992; 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, 1995.

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, 2009; 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, 2000.

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, 2004; 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, 2009.

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

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, 2010; 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, 2016.

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, 2016.

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

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.

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, 2002.

70 See Hofmann, Stefan G., “Enhancing Exposure-Based Therapy from a Translational Research Perspective”, Behaviour Research & Therapy, Vol. 45, No. 9, 2007; 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, 2004.

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, 2008; 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, 2011; 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, 2014.

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, 2015.

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, 2015.

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, 2009.

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, 2018.

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, 2015.

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. 131; Parens, Erik, “The Ethics of Memory Blunting and the Narcissism of Small Differences”, Neuroethics, Vol. 3, No. 2, 2010, p. 106.

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. 2324.

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. 29.

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, 2009.

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. 70.

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, 2005; Bouret, Sebastien and Sara, Susan J., “Network Reset: A Simplified Overarching Theory of Locus Coeruleus Noradrenaline Function”, Trends in Neurosciences, Vol. 28, No. 11, 2005.

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. 16; 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. 356.

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

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. 31.

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

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. 30.

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, 2011; Australian Society for HIV Medicine, Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV: Australian National Guidelines, Darlinghurst, 2016.

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

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. 4.

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

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

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

103 See the references cited in above note 62.

104 Damasio, Antonio R., Descartes’ Error: Emotion, Reason and the Human Brain, Avon, New York, 1994; 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, 2014.

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. 1604; 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, 2005; 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, 2007.

107 See, e.g., Wasserman, David, “Making Memory Lose Its Sting”, Philosophy & Public Policy Quarterly, Vol. 24, No. 4, 2004, p. 14; 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. 183; 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, 2010.

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

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

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. 374.

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, 2016.

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. 36.

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. 1300.

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, 2016.

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, 2013.

134 On prison health-care ethics generally, see Wolff, Hans et al. , “Health Care in Custody: Ethical Fundamentals”, Bioethica Forum, Vol. 5, No. 4, 2012; 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, 2007; 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, 2014.

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, 2011.

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

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, 2010.

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

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

* 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.



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