Cochlear Implants: An Introduction to FInancial Issues and Social Controversies

“For Some Who Lost Their Hearing, Implants Help”
Author: Jane E. Brody
Publication: New York Times
Date: October 3, 2006

This article gives a great overview of cochlear implants. It covers the mechanism of the implant, the method of implantation, financial issues associated with the device, and the social controversy surrounding cochlear implants. My only prior knowledge about cochlear implants came from a friend who had the device implanted when he was a child. Otherwise, I knew very little about the mechanism and function of cochlear implants.

Considering how our country was founded on the belief of every citizens’ right to “life, liberty and the pursuit of happiness,” it seems hypocritical and unethical to put a price on health. In every realm of biotechnology we have studied, however, money always plays an unavoidable role. Insurance, copays, HMOS… these terms inevitably arise during any discussion involving medical treatments and advances. Cochlear implants are no exception. At a whopping $40,000 per implant, excluding the cost of doctors’ fees, audiologist evaluations and speech therapy, when the priority for low-income families is paying the rent and putting food on the table, cochlear implants for a deaf family member becomes an unaffordable luxury.

Prior to researching this topic, it had never occurred to me that social controversies beyond cost would exist, largely because I have never stopped to consider perspectives from the deaf community. Despite improving technology, cochlear implants do not perfectly restore hearing. Those who receive implants experience hearing that is equivalent to a mild to moderate hearing loss. Because of this, many in the deaf community are opposed to this imperfect technology. Sign language is an effective alternative to audible communication. They believe that a healthy deaf person who is able to communicate through sign language and lip reading has a better self-image than a person with an implant who has trouble hearing. Whereas a deaf person can sign perfectly and skillfully, a deaf person with the current cochlear implant could never hear as well as the non-deaf. Thus, implants present an inherent deficiency that could harm self-image.

It will be interesting to see how this particular controversy develops as cochlear implants improve. The Boston Scientific Corporation is currently developing the Harmony HiResolution Bionic Ear System, which would increase the number of inputs to the hair cells that trigger hearing from 24 to 120. The company says that this new bionic ear would grant improved listening in noisy environments and enhanced pitch recognition for music. If researchers and engineers were to craft a device that could create near-perfect hearing, would these objections from the deaf community still exist?

The Science Behind Cochlear Implants

“Sending Sound to the Brain”
Authors: J.P. Rauschecker and R.V. Shannon
Publication: Science
Date: February 8, 2002

“Sending Sound to the Brain” explores the science behind cochlear implants. I personally knew very little about how cochlear implants worked prior to reading this article, which was very science-heavy and probably intended for people with at least a basic understanding of neuroscience. However, the information in the article was informative and clearly laid out the technical details of the implants.

Profound deafness is caused by the loss of the sensory hair cells that transform sound into electrical impulses. However, people who are profoundly deaf and who still have a functioning auditory nerve can receive a cochlear implant to restore some of their hearing. A cochlear implant does not simply “hear” for the person; instead, it takes the place of the lost hair cells and turns sound into electrical impulses for the auditory nerve to send out to the brain. It serves as a sort of interpreter, turning one form of communication (sound) into another (electrical impulses), which the auditory nerve can then pass on to the brain.

The idea behind cochlear implants is fairly simple. Multiple stimulating electrodes are inserted into the cochlea of the inner ear, with electrodes situated along the basilar membrane such that a wide variety of frequencies can be accessed (the basilar membrane receives high frequencies on one end and low frequencies on the other, with a gradient in the middle). An external microphone collects sound waves, which are converted into electrical impulses by a speech processor. The electrodes use these electrical impulses to stimulate the correct auditory nerve fibers, which causes electrical signals to be sent to the brain for interpretation. All the implant is doing is taking the place of hair cells, which would normally have taken sound and converted it into electrical signals.

The article provides a clear and extremely detailed look at the science and mechanics behind cochlear implants. However, the article is extremely scientifically oriented, and thus appears to assume that, as a proven piece of technology, cochlear implants are “good” in all aspects of the word. The article boldly states that the cochlear implant has “greatly benefited many individuals with profound deafness” and that “the success of these devices is nothing short of miraculous.” There is no mention of the device’s controversy among the deaf community or of the stupendous cost of even just one cochlear implant. While understandable considering its appearance in Science, the article’s firm belief in the infallibility of science detracts from its overall purpose of providing insight into the world of cochlear implants. Even just mentioning the non-scientific aspects of the implants in a short paragraph or two would have improved the article’s overall message.

Auditory Brainstem Implants: The Next Step?

“First Brainstem Implants Aim to Tackle Deafness”
Author: Duncan Graham-Rowe
Publication: New Scientist
Date: January 7, 2004

Cochlear implants help many people who have lost their hearing as a result of problems with their hair cells. However, the implants depend on direct stimulation of an intact auditory nerve. This means that many people cannot be helped by a cochlear implant. However, this article from New Scientist describes a new technique that could potentially restore the hearing of people with a nonfunctioning auditory nerve.

This technique, called the auditory brainstem implant, seems like the natural next step from cochlear implants. Instead of stimulating the auditory nerve, which then sends electrical signals to the brain, auditory brainstem implants directly stimulate the brain by inserting electrodes into the cochlear nucleus in the brainstem. Other than the placement of the electrodes, auditory brainstem implants work in the same way as cochlear implants. As in cochlear implants, an external microphone collects sound waves, which are converted into electrical impulses by a speech processor. The electrodes then use these electrical impulses to stimulate different pitch areas of the brainstem. This hopefully results in the person receiving the implant being able to hear.

There are several problems with the new implants. Current brainstem implants can only stimulate one channel (or frequency), which is enough to improve lip reading by 30 percent but not enough to understand speech. Newer implants will include up to eight electrodes that will stimulate eight different channels. This will be more than enough to understand speech. However, there is also one other problem that is much more significant than the number of channels that are stimulated. Unlike the cochlear implant, the auditory brainstem implant could potentially damage the brainstem. As the article points out, the brainstem carries signals from the entire body to the brain, and thus any damage to the brainstem would have tragic consequences.

The article provides a clear introduction to auditory brainstem implants. It both demonstrates the enormous potential of the implants and points out the problems and dangers inherent in the process. Like the Science article that I wrote on last week, however, the article does not touch upon the deaf community’s reaction to the brainstem implant, and thus completely avoids any mention of the potential controversy. Also, the article does not mention the cost of the brainstem implant, or if insurance will cover the procedure. Nevertheless, the article successfully highlights the fact that this implant could give hope to many who have given up on ever being able to hear.

The Future of Cochlear Implants: Hybrid Technology

“A more sound solution; An experimental ‘hybrid’ device may give many with partial hearing loss the extra boost they need. It’s a new variation on the cochlear implant.”
Author: Regina Nuzzo
Publication: Los Angeles Times
Date: December 2006

In this article, Regina Nuzzo writes about a promising new technology that is a modification on the original cochlear implant. These new implants are referred to as hybrids because they allow the wearer to use their own residual hearing along with the assistance of an implant. At the writing of the article, about 80 hybrid implants had been done, beginning as early as 1999, although clinical tests were still underway. The structure of the device is not much different than the regular model for cochlear implants. However, the hybrid device sounds a lot like the original single-channel cochlear implants: One of the selling points of the hybrid is its thinner and shorter electrode (10 as opposed to 28 millimeters), so implantation does less damage to the cochlea. Sound familiar? I am curious whether the makers of the hybrid implant have any connection to the supporters of the single-channel implants from the 1990’s. I wouldn’t be surprised if it was the same people resurfacing, looking to make a profit off of the same idea again.

However, the hybrid implant is also being used to replace a particular part of hearing loss that single-channel proponents were not advocating in the 1990’s: Hybrids are implanted specifically to replace high-frequency hearing loss. Although some high-frequency hearing loss is a natural part of the aging process, rapid loss of high-pitched hearing, called “ski-slope” loss, is abnormal. The hybrid implant only picks up high frequency sound waves, so it can only help patients with “ski-slope” hearing loss. This has a different effect on hearing speech than one might expect. It is not a matter of hearing higher-pitched voices. Instead, the hybrid cochlear implant helps with hearing certain consonant sounds like “shh” and “sss”, which are a higher frequency than vowel sounds. With this change, speech recognition is vastly improved for people with “ski-slope” hearing loss, clearing up the “muddiness” of speech for people with high-frequency hearing loss.

The article also includes an information box with several other upcoming hearing aid technologies. These little blurbs are tantalizing: they briefly describe innovations such as hearing aids which selectively amplify sounds with little distortion (these are likely to be speech or music, according to the article) and tune down sounds with greater distortion (such as engines and other background noise). Also described are responsive microphones, which pick up noise from directly in front of the wearer in a loud setting and from all around the wearer in a quiet setting, and hearing aides with anti-whining technology that transmits a sound that cancels out any whining sound the hearing aide may make if it is not fit tightly into the ear. Hearing aide technology is still a growing, active field. There is much on the horizon and in use, and we have already come a great way in the field.

The Cost of Hearing

"Aid for Deaf as Possible Cost-Saver, Too"
Author: Eric Nagourney
Publication: New York Times
Date: August 22, 2000

Although cochlear implants have helped thousands of deaf children to hear in the past ten years, two-thirds of insurance companies still do not cover the cost of the expensive technology, thus limiting access to cochlear implants to wealthier families. Insurance companies refuse to pay for the implants because of a lack of evidence to support the cost-effectiveness of the devices. Recently, however, a John Hopkins University study of 78 families of deaf children concluded that “Cochlear implants in profoundly deaf children have a positive effect on quality of life, at reasonable direct costs, and appear to result in a net saving to society.” As mentioned previously, a single implant costs over $10,000, but the report found that special education for a profoundly deaf child and the reduced work productivity of a deaf person would cost society over $1 million. Thus the report concludes that cochlear implants may save more than $50,000 in costs associated with deafness. In addition, the report also highlighted the improved quality of life among the children who received implants.

An important question to ask is: will the outcome of this study have any impact on the opinions of insurance companies regarding cochlear implant coverage? Although the report concluded that cochlear implants save society money, we shouldn’t forget that insurance companies are private corporations that seek to promote their own prosperity. To believe insurance companies would act to benefit society as a whole would be asking for too much utilitarianism from a private company. Other important questions are: do insurance companies cover special education for disabilities? If so, would a cochlear implant offset the cost of this? If this is true, it would surely be an incentive for insurance companies to pay for the implants.

History of the Cochlear Implant and Historical Controversies

“A Socio-cognitive Model of Technology Evolution: The Case of Cochlear Implants”
Authors: Raghu Garud and Michael A. Rappa
Publication: Organization Science
Date: August 3, 1994

This was the most interesting article I encountered in my search for information on cochlear implantation because it approaches the issue from an entirely different angle. The journal Organization Science seems to include articles that analyze greater trends in science. In the case of this article, information on cochlear implants is simply being used to illustrate “A Socio-Cognitive Model of Technology Evolution” which is an analysis of the way in which the attitudes of the scientific community affect the way the development of technology. Although the case of cochlear implants is only a case study, this paper seems to be the most inclusive collection of information on cochlear implants up to the article's publication date in 1994. According to the article, the authors sat in on meetings of cochlear implant manufacturing and development companies, attended conferences on the topic, and did thorough research of articles published on the topic. The authors of the study claim to have amassed a database of 1,329 articles, all of which were then thoroughly analyzed for their content, rated, and placed in a chronological and social context. The authors of this paper were willing to perform such rigorous research because they considered cochlear implants to be “‘sociopsychological’ products because several different interpretations of their safety and effectiveness have been possible.” This ststus for cochlear implants provided a fertile field for the authors' analysis of scientific bias and technology.

The scientific and business bias that plays a major part in the early implementation of cochlear implant technology was between single- and multi-channel cochlear implants, but even before this became an issue, the idea of implants themselves had to be dealt with. Before 1973, the National Institutes of Health would not support any technology that involved implantation because of a belief that implantation technology was “morally and scientifically unacceptable.” This changed, of course, but this background shows that the early researchers in cochlear implantation were dealing with several great unknowns. The most important of these unknowns was the possibility of neuro-physiological damage due to the insertion of electrodes into the cochlea.

The early supporters of the single-channel (single electrode) cochlear implant used this unknown to their business advantage, promoting the single-channel with shallow insertion into the cochlea as the least likely to cause damage. The company that produced the single-channel implant, and that was therefore its largest supporter, was the 3M Corporation. The article also mentions that 3M originally promoted the single-channel device, and the crude sound recognition it provided, as what the deaf community was looking for. In retrospect, and in the face of the mounting opposition of the deaf community to cochlear implants, this may be in fact true. However research in cochlear implants has recently been exclusively geared towards providing normal hearing to otherwise profoundly deaf individuals.

Despite concerns over neuro-physiological damage, many researchers and companies went along with research on multiple-channel implants. This research was driven by the Nucleus Corporation and by Graem Clark, a researcher at the University of Melbourne. The multi-channel devices were developed in the interest of providing deaf patients with the ability to recognize speech patterns and to distinguish between voices.

A bitter rivalry ensued between the 3M and Nucleus corporations, in which the support and approval of the FDA was contested, and each side accused the other of poor research practices. In the end, and when faced with evidence to the contrary, the supporters of multi-channel devices apologized for accusing that single-channel devices did not allow for speech pattern recognition, although for most of the debate neither side actually conducted that research. Multi-channel devices, which do provide a significantly higher level of speech recognition than do single-channel devices, eventually won favor and a three-day conference between the FDA and the NIH in 1988 produced a consensus that multi-channel implants were preferable.

In the article, the controversy over cochlear implants and the blindness experienced by each side in response to data which did not favor their product was analyzed according to three organizational principles. These are: evaluation routines (the process of evaluating a new technology, which may be suitable for the old technology and be unsuitable for application to a new technology), beliefs, and artifacts (the physical manifestations of a new technology, such as the cochlear implants themselves). Not only does the paper analyze the information on cochlear implants in an entirely new way, a “socio-cognitive model of technology evolution,” it also provided detailed information on a historical debate on cochlear implants which is entirely different from the current controversy. This historical controversy has been completey disguised by the current controversy about cochlear implants. In a sense, the historical controversy shaped the contemporary controversy: if single-channel implants had won out, cochlear implants would have been limited to providing a very basic sense of the sounds in the world, and would not be threatening the existence of a community based on sign language, the Deaf World.

Are Cochlear Implants Appropriate for Young Children?

"Aural Argument: Toddlers’ Implants Bring Upheaval To Deaf Education; Cochlear Devices Help Kids Join Mainstream Classes; Will Sign Language Die?; A Picket Against Dr. Green"
Author: Paul Davies
Publication: The Wall Street Journal
Date: March 29, 2005

Cochlear implants were originally approved for adults in 1985. In 2000, the FDA authorized their use in children as young as 12 months old, further inflaming the outraged deaf community. Members of the deaf community insist that deafness is not a disability and so perceive implants as an effort to fix what is not broken. Deafness, they argue, ought not be labeled as a pathological condition, but accepted as a natural state. Their more practical objection is that the invasive implant surgery destroys residual hearing such that patients are forever dependent on the device. Given the magnitude of the intervention, deaf advocates claim it is unethical for young healthy children to come under the knife before they are old enough to decide for themselves. However, proponents of the technology contend that the operation must be performed on very young children to maximize their likelihood of developing speech. It is the hearing world’s overriding preoccupation with speech that so concerns deaf advocates. They fear parents are forcing their deaf children down the auditory/oral communication route to the exclusion of sign language, even when the latter could prove beneficial. They reprove parents for taking the more convenient approach, instead of offering their children all the valuable tools at their disposal.

Davies’ article examines, in particular, how adjustments to deaf education have been necessitated by the rise in cochlear implant use among young children. Confronted by declining enrollment rates, schools for the deaf have begun introducing programs for children with cochlear implants. For instance, the South Dakota School for the Deaf was divided into two departments, one which focused on auditory and oral skills, and the other which focused on American Sign Language. Deaf advocates protested this new arrangement, claiming that the implant program would divert resources from the hearing aid program. This isolated dispute in deaf education is illustrative of the wider conflict between those who value normalization and those who want to preserve deaf culture.

With its own language and history, the deaf community has created for itself a unique culture; yet the threat of cultural extinction looms ever more ominously as larger numbers of children receive cochlear implants. It is reported that more than 90% of all deaf children are born to hearing parents. Not surprisingly, their training is focused on oral and auditory communication in preparation for life in the mainstream hearing world. So our preliminary question of the appropriateness of cochlear implants for young children takes us to a new question: To what extent can parents choose what is right for their children?

To What Extent Can Parents Choose For Their Children?

“A Tight Little Island in the World of Deafness”
Author: Anita Gates
Publication: New York Times
Date: April 8, 2000

As we previously discussed, the deaf community deems it unethical for hearing parents to peremptorily decide for their deaf children to use cochlear implants. However, hearing parents rejoin that it is irrational to discount the weight of parental authority over minors. Given this argument, let us now consider the opposite situation: Could deaf parents use the same justification to reject cochlear implants for their deaf children?

It is not unreasonable for parents to exercise the right to make decisions on their children’s behalf. Nor does it seem unjust for parents to expect their children to join the community of which they themselves are members. Yet, by this light, do deaf parents have the express right to raise their children within a separatist subculture? This is, as Gates points out, essentially what the Amish have been doing for quite some time.

Understandably, no parent desires for the lines of communication with his children to be diminished, let alone severed. Yet, it seems unfair, even cruel, for parents to deny their children any kind of beneficial treatment within the family’s means. Gates’ article reviews the documentary film “Sound and Fury,” which follows one family’s painful dispute over cochlear implant use. In the film, Peter Artinian (the father of the household) candidly states that he was delighted all three of his children were born deaf like himself. Not surprisingly, he feels betrayed when his daughter expresses the desire to get a cochlear implant—what amounts essentially to the desertion of their deaf community. By contrast, Peter’s hearing brother, Chris Artinian, unreservedly goes ahead with the implant surgery for his newborn deaf son. In further proof of the inter-family friction, Peter’s father (who is not deaf) remarks to his son, “It’s not intended for people to have handicaps…If I didn’t know you, I would say you were an abusing parent.”

It seems brutal to accuse a loving parent of abusing his child, but there is a clear difference in the permissibility of one parent’s decision over the other’s. This distinction lies in the irreversibility of the decision reached. If a child who has received a cochlear implant is unhappy with the outcome, he may, at any time, deactivate the device and take up sign language. Of course, he would have pointlessly undergone an invasive operation and sacrificed his residual hearing; nevertheless, he would always have the two options—either to continue or discontinue use—open to him. On the other hand, if a child were denied a cochlear implant, but later desired one as an adult, he would never be able to see the dramatic improvements common for infants implanted with the device. As mentioned in an earlier entry, the timing of the implant surgery is critical to its success because younger children are far more adept at acquiring new language skills than adults. Therefore, the parents’ right to decide what is best for their children is really only a secondary consideration. What is of genuine concern to us is that such valuable technology not be ignored, regardless of what parents think.

In a democratic society which champions diversity, we assert that “no particular skin color, religion, sexual orientation, political ideology, chronological age or physical attribute is superior to another.” Yet, if we truly believe that differences should be embraced, does this not also mean that physical handicaps should be accepted as is? Or have we all become so afraid of offending anyone that we now promote the preservation of disabilities? These are deeply divisive questions, but perhaps they may be answered by first assessing what they all presuppose: that deafness is definitely a handicap.

Should Deaf Culture Be Preserved?

“Some Deaf Advocates Denounce Ear Implants That Reproduce Sound; Medicine: They contend that being unable to hear is no handicap and oppose ‘invasive surgery.’ Doctors say they’re mystified by that view.”
Author: Scott Maxwell
Publication: Lost Angeles Times
Date: October 31, 1993

It is admirable that, in spite of prevalent prejudices, the deaf community has stood fast and built an effective support network. This network has become so dear to many that they cannot accept its ever becoming obsolete. Thus, the mounting use of cochlear implants represents, to them, a subtle form of genocide. However, I must respectfully disagree with their viewpoint because this general conversion to cochlear implant use is nothing like the systematic extermination of a people. This trend simply represents the inexorable push toward greater technological heights. Since sign language was an invention born of necessity, it should be subject, like any other outmoded model, to replacement by a better one. No coercion or hostility would be involved if sign language—and the deaf culture itself—grew obsolete through disuse or abandonment. And, in my estimation, there is a huge difference between full-blown cultural genocide and natural assimilation into the mainstream world.

It is bewildering that the deaf community should even prevent its own members from receiving implants since other handicapped groups do not intervene so fiercely in similar circumstances. In the words of Dr. Karen Jo Doyle, an otolaryngologist at UC-Irvine, “You wouldn’t expect people who have a handicap to not want others with handicaps to get help. You don’t see the blind coming out against surgeries and treatments that help improve vision and you don’t see quadriplegics coming out against the new technology in electronic limbs.” It does not seem fair for staunch deaf advocates to bar others from new technology simply because they themselves boycott the implants.

Although deaf advocates claim one can lead a fulfilling life without hearing, I do not believe anyone should lose sight of the fact that human beings were intended to hear. Why else would we have evolved such sophisticated auditory organs? Therefore, deafness—like any other genetic or acquired defect—should not be received as a natural state. It should be understood as an atypical state that can and ought to be remedied. In Maxwell’s article, one deaf advocate protests that professionals treat deaf Americans "as though they’re hearing people who don’t hear. It’s like treating black people as white people with a skin disease.” I contest the accuracy of this analogy because a claim that black people are supposed to have pale skin would not make any biological sense, whereas the claim that deaf people are supposed to hear corresponds with evolutionary history. The fact that deaf people have ears—structures specifically formed to transmit auditory signals—proves that they were intended to hear, but were prevented by some physical impairment.

I began this investigation without any prior knowledge of cochlear implant technology. Even if I had known of the device, it would never have occurred to me that anyone could oppose giving the gift of sound to the deaf. Of course, even the way I phrased that sentence betrays how favorably disposed I was towards the implementation of cochlear implants. Even now, I remain unshaken in my belief that deafness is a deficiency which requires correction.

While sign language was an immediately viable solution to the communication problem, its scope of efficacy was limited to those who knew how to sign. Now that cochlear implant technology is available—enabling deaf people to communicate by spoken word—the scope of efficacy has expanded to the larger hearing population. The ability to interact—even if on an unequal footing—with a larger population must be preferable to interacting with a smaller group. Moreover, as technology becomes more refined, this slight imbalance will eventually be eliminated. The difference, then, is of leading an insulated life versus leading one with a greater potential for discourse and exchange of knowledge. The choice, to me, is an easy one to make.

To What Extent Does Speech Develop After Implantation?

“Speech Development in Children after Cochlear Implantation”
Author: Bakhshaee et al.
Publication: European Archives of Oto-Rhino-Laryngology
Date: July 2007

This paper addresses the topic of speech development in prelingually-deaf children who receive cochlear implants. The authors point out that while improvement in speech perception (or the ability to understand speech) is well documented, improvement in spoken language has not been as well studied. This is obviously a major concern for parents whose children are deaf and are likely candidates for cochlear implants. Part of the controversy among the deaf community surrounding cochlear implantation is that the implants only serve to make recipients less proficient at something that “normal” people can do, while before the implants they were perfectly proficient at other forms of communication (like sign language or lip reading). However, the paper suggests that children who are implanted gain a fairly advanced mastery of speech.

The paper details a study of 47 deaf children who received cochlear implants and whose speech development was tracked for up to five years after implantation. Speech development was quantified using the speech intelligibility rating (SIR). SIR rates speech from 1 to 5, with 1 being unintelligible and 5 being completely intelligible and easily understood in everyday contexts. All of the children started out with SIR categories of 1 or 2. After only one year with the implant, the average SIR rating for the children jumped up to 3 (where speech is intelligible if the listener concentrates and lip-reads). The average SIR rating after two and three years was 4 (where speech is intelligible if the listener has a little experience with a deaf person’s speech). Amazingly, the average SIR rating after four or five years was 5, and no children had a rating below 4. This seems to indicate that after four or five years, prelingually-deaf children can obtain a significant mastery of the spoken language.

There are several issues with the paper, however. The number of children that remained in the study dropped as the years passed, and only 9 children remained at the end of five years. Also, as the paper acknowledges, the differences between years 3 and 4 and 4 and 5 were not statistically significant, probably because of the extremely small number of children that remained in the study for 4 or 5 years. Finally, even completely intelligible speech (SIR of 5) doesn’t necessarily mean that the children still didn’t have a noticeable speech impediment, which is the reason why the deaf community views cochlear implants as such a controversial topic. However, the paper notes that speech development does not halt after five years, and that it is possible that the children had not reached their full speech intelligibility at the end of the study. Further studies are needed, but at the very least this paper reveals that cochlear implantation can have a much more profound impact on speech development in children than was previously believed.

Proof to Complicate the Ethical Debate: Cochlear Implant Efficacy in Aiding Language Development

“Language Development in Profoundly Deaf Children With Cochlear Implants”
Authors: Mario A. Svirsky, Amy M. Robbins, Karen Iler Kirk, David B. Pisoni and Richard T. Miyamoto
Publication: Psychological Science
Date: March 2000

This article, while being from the scientific press, nonetheless gives a good background to the debate surrounding the use of cochlear implants. I came across the article through a search in Brown University’s InfoGate. The article introduced me to the Deaf World community, who argue against the use of cochlear implants, and use such strong words as “genocide” to characterize the impact of cochlear implants on the Deaf World. About the Deaf World community, the authors of this article write, “Members of this culture use a sign language as their primary language and do not view themselves as handicapped: They see their use of a sign language and their hearing impairment as part of normal human variation.” This is an absurd way to characterize the deaf world. It is true, “normal human variation” does include deafness, but it also includes people more prone to high cholesterol and heart attacks. Would people in the latter category refuse available treatment because they are simply a normal part of human variation? To me, this interpretation of the Deaf World is significantly incomplete, and somewhat incomprehensible.

The article goes on to say that regardless of the debate surrounding the ethical implications of implantation they will focus on development of English language when aided by the implant, “which has been recognized as the most important outcome measure by both proponents and opponents of cochlear implants.” It is difficult to imagine that the Deaf World community, which was so violently opposed to cochlear implants, would appreciate its value in learning the English language. The article, which is otherwise well annotated, lacks a reference here.

The authors of this study conducted a previous study, the results of which were used to analyze the new data presented in this article. The previous study collected information on the language development of profoundly deaf children who lost their hearing before they developed language (or who were born without hearing), and who used traditional hearing aides instead of cochlear implants. This information was used in the newer study to compare the language development of the implanted children to their expected development had they used traditional hearing aides instead.The study found exactly what they were looking for: while all deaf children experienced a delay in language acquirement compared to normal-hearing children, implantation prevented the gap in language acquisition from broadening as it would for unimplanted children. This is shown in a number of complicated graphs in the article, but all seem to draw the same conclusion: despite a wide individual variance in results, the implant does help profoundly deaf children acquire language.

Despite being a scientific article, this article provided me with only a superficial understanding of the direct effects of cochlear implantation on language acquisition. However, scientific evidence that the cochlear implant is effective in aiding language development is essential information for understanding the ethical debate over cochlear implantation.

Deaf Culture and Parenting

"Wanting Babies Like Themselves, Some Parents Choose Genetic Defects"
Author: Darshak M. Sanghavi, MD
Publication: New York Times
Date: December 5, 2006

This essay in the New York Times provides an additional piece of information to the ongoing ethics debate surrounding cochlear implants. Examined in detail in previous posts, one of the strongest forces of opposition against cochlear implants is the advocates for the deaf community who fear the disappearance of a deaf culture upon the advent of advancing technologies. Within the deaf community, some deaf parents believe that having a deaf child would create a bond that would allow parents and children to share in an intimate culture. This article offers the lay public a glimpse of deaf parents who are willing to choose genetic defects for their children in order to create a tighter relationship through deaf culture. These parents have a goal that is the antithesis to cochlear implants: instead of enabling hearing for the deaf, they choose deafness over hearing.

P.G.D, or preimplantation genetic diagnosis, is an expensive and invasive process in which embryos with genetic diseases such as cystic fibrosis or Huntington’s disease can be identified and eliminated, leaving only healthy embryos for implantation. Not everyone uses the procedure to eliminate diseases, however. A John Hopkins University study surveyed 190 American P.G.D clinics and found 3% of cases had intentionally used P.G.D. to select an embryo for the presence of a disability, including deafness and dwarfism.

At first glance, the fact that some parents purposefully choose disabilities for their children is alarming. It is easy to label the act as unethical and selfish. The online magazine Slate called it “the deliberate crippling of children.” After consideration of the parents’ reasoning, however, the ethics of the situation are not so well-defined.

Commentary on this article broaches a discussion about the definition of disability. While those who can hear would define deafness as a disability due to the lack of an ability to hear, members of the deaf community would argue that a deaf person is just as proficient at communicating with developed skills in sign language and lip-reading.Many doctors who administer P.G.D., however, do not accept requests to select for disabilities. In an interview, Dr. Robert J. Stillman of the Shady Grove Fertility Center in Rockville, Md., said “In general, one of the prime dictates of parenting is to make a better world for our children. Dwarfism and deafness are not the norm.” Thus, contrary to the ardent advocates of deaf culture, medicine has resolutely defined deafness as a disability.

Final Thoughts

The initial focus of our blog was the technological progression of cochlear implants. The mechanism of the device is actually quite simple. An electrode is inserted into the cochlea and an external sound processor transmits electrical impulses to the electrode to stimulate the basilar membrane near the auditory nerve. At first, there were two different schools of thought on the design of cochlear implants. One believed that we should preserve the cochlea by inserting the shortest device possible (the one-electrode cochlear implant), and another wished to improve the technology such that it would provide hearing that was virtually indistinguishable from normal hearing (the multi-electrode cochlear implant). Now that the technology has progressed, we anticipate many new and exciting developments. For example, scientists have been working to preserve hearing in semi-hearing people by using the “hybrid” cochlear implant, which consists of a shorter electrode. Another emerging technology is the auditory brainstem implant. Instead of implanting electrodes to stimulate the auditory nerve, the brainstem implant would directly stimulate the brainstem itself. Since cochlear implants depend on stimulating the auditory nerve, the implants do not work for those without the nerve. The auditory brainstem implant, on the other hand, bypasses the auditory nerve altogether, and thus could potentially restore the hearing of many people. However, there are still several major problems facing researchers of the brainstem implant. The biggest issue, as many scientists have pointed out, is that the brainstem carries signals from the entire body to the brain, and if a brainstem implant accidentally damaged the brainstem, the consequences could be deadly. Nevertheless, the future of cochlear implant technology looks bright.

Every device and procedure in biotechnology that we studied in class carried a hefty fee. Therefore, we were interested in learning how money plays a role in the world of cochlear implants. Sure enough, we found that the cost of hearing is beyond the means of many families. The $10,000 price tag of each implant creates a divide between low-income families and upper-middle class families. As most insurance companies do not cover the cost of cochlear implants, it is difficult for a child from a low-income household to obtain one.

When we began our research, we had expected any controversy over the device to be financial in nature. With just a few article searches, however, we discovered a heated debate concerning the ethics and the necessity of cochlear implants. As people born with normal hearing, we automatically assumed that technology to restore hearing was unquestionably good. Yet upon further probing, we learned of a rich community built exclusively on sign language, which vehemently opposes the development of cochlear implants. Members of this community see the emergence of this technology as a threat to their unique deaf culture. They worry that, in the future, fewer people will join the signing community as cochlear implant use becomes more common—especially amongst younger children who undergo surgery at their parents’ discretion. We explored the many social ramifications of the technology—from consequences as broad as the extinction of deaf culture and the reformation of deaf education, to those more private, such as the inter-family strife among households of both deaf and hearing members. As an extreme example, we were surprised to discover a small group of deaf parents who strongly advocate the use of pre-implantation genetic diagnosis to select for deafness. Admittedly, their desire is one which all parents share—the desire to sustain the parent-child relationship through the medium of shared culture. Yet, this desire to deliberately give children a defect was difficult for us to accept, and seems to demonstrate just how far certain members of the deaf community will go to preserve their culture.

With every breakthrough in biotechnology, we must pause to reflect on the moral implications of our research. In Our Posthuman Future, Francis Fukuyama argues that the continual progress in biotechnology will force us to redefine the very meaning of humanity. Similarly, as advancements in cochlear implant technology enable hearing that more closely resembles normal hearing, we will be forced to redefine what deafness is. In former times, deafness could be embraced by the deaf community as an opportunity to communicate via alternative methods. However, with the advent of cochlear implants, deafness is increasingly being perceived as a disability that can be cured with the implantation of a device.

Engineers and scientists are continuously working to develop an implant that will enable virtually normal hearing, and they will eventually succeed. Perfect hearing with cochlear implants is not a question of if, but, rather, a question of when. When these devices become available, will the deaf community disappear altogether? If so, should we lament its extinction? Should deaf parents allow their deaf children to be implanted at the risk of weakening familial bonds? Will the government pay for cochlear implants for children from low-income households? Will the devices come to be covered by all insurance companies? Advances in all areas of biotechnology engender many difficult questions. The development of cochlear implants is no exception. As we look to the future, financial decision-makers and leaders of the deaf community will play leading roles in the continued controversy over cochlear implants. Make sure you listen up to what is said.