The development of predictive brain implant (PBI) technology that is able to forecast specific neuronal events and advise and/or automatically administer appropriate therapy for diseases of the brain raises a number of ethical issues. Provided that this technology satisfies basic safety and functionality conditions, one of the most pressing questions to address is its relation to the autonomy of patients. As Frederic Gilbert in his article asks, if autonomy implies a certain idea of freedom, or self-government, how can (...) an individual be considered to decide freely if the implanted device stands at the inception of the causal chain producing his decisions? He claims that PBIs threaten persons’ autonomy by diminishing their post-operative experience of self-control. In this commentary, I wish to discuss this claim. Contrary to Gilbert, I will suggest that PBIs do not pose a significant threat to patient’s autonomy, as self-control, but rather to his/her sense of authenticity. My claim is that the language of authenticity, already introduced in the recent bioethical literature, may offer a better way to voice some of the concerns with PBIs that Gilbert recognized. (shrink)

In this article, I explore select case studies of Parkinson patients treated with deep brain stimulation in light of the notions of alienation and authenticity. While the literature on DBS has so far neglected the issues of authenticity and alienation, I argue that interpreting these cases in terms of these concepts raises new issues for not only the philosophical discussion of neuro-ethics of DBS, but also for the psychological and medical approach to patients under DBS. In particular, I suggest (...) that the experience of alienation and authenticity varies from patient to patient with DBS. For some, alienation can be brought about by neurointerventions because patients no longer feel like themselves. But, on the other hand, it seems alienation can also be cured by DBS as other patients experience their state of mind as authentic under treatment and retrospectively regard their former lives without stimulation as alienated. I argue that we must do further research on the relevance of authenticity and alienation to patients treated with DBS in order to gain a deeper philosophical understanding, and to develop the best evaluative criterion for the behavior of DBS patients. (shrink)

Deep brain stimulation is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual’s personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment (...) refractory conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient’s personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual’s mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient’s responsibility for action and competence of decision and raises a number of questions that need further research. (shrink)

Information and communication technologies , with their increasing and widespread utilization in daily life, may exert an important impact on brain performances. The development of their use for improving several cerebral processes, by abolishing the brain/machine interface, is envisaged and is subject to debate. The scientific research on brain implants and brain gene transfer aiming to restore central nervous system functions, altered by disease or trauma, may contribute to this debate. Indeed, the advances that are (...) enabling non drug-mediated approaches for direct interventions on the brain are raising the possibility not only of restoring neural functions for therapeutic purposes, but also of monitoring, controlling and ultimately modifying from the outside these functions for enhancement. This paper gives an overview of the state of the art of brain implants and brain gene transfer for neurological diseases with a particular emphasis on Parkinson’s disease and a forecast on their possible application for other conditions. In doing so, the authors, who are neuroscientists working in the field of gene transfer for neuropsychiatric diseases, aim to establish a scientifically, medically and technically realistic framework to open up discussion on relevant ethical issues in this domain. (shrink)

Nanotechnology is an important platform technology which will add new features like improved biocompatibility, smaller size, and more sophisticated electronics to neuro-implants improving their therapeutic potential. Especially in view of possible advantages for patients, research and development of nanotechnologically improved neuro implants is a moral obligation. However, the development of brain implants by itself touches many ethical, social and legal issues, which also apply in a specific way to devices enabled or improved by nanotechnology. For researchers (...) developing nanotechnology such issues are rather distant from their daily work in the lab, but as soon as they use their materials or devices in medical applications such as therapy of brain diseases they have to be aware of and deal with them. This paper is intended to raise sensitivity for the ethical, legal and social aspects (ELSA) involved in applying nanotechnology in brain implants or other devices by highlighting the short term problems of testing and clinical trials within the existing regulatory frameworks (A), the short and medium-term questions of risks in the application of the devices (B) and the long-term perspectives related to problems of enhancement (C). To identify and address such issues properly nanotechnologists should involve ethical, legal and social experts and regulatory bodies in their research as early as possible. This will help to remove pressure from regulatory bodies, to settle public concern and to prevent non-acceptable developments for the benefit of the patients. (shrink)

In their article published in Nanoethics, “Ethical, Legal and Social Aspects of Brain-Implants Using Nano-Scale Materials and Techniques”, Berger et al. suggest that there may be a prima facie moral obligation to improve neuro implants with nanotechnology given their possible therapeutic advantages for patients [Nanoethics, 2:241–249]. Although we agree with Berger et al. that developments in nanomedicine hold the potential to render brain implant technologies less invasive and to better target neural stimulation to respond to (...) class='Hi'>brain impairments in the near future, we argue against presenting the development of nanobionic clinical devices in terms of a moral obligation to conduct this research. In the first part of the paper, we consider what a duty to pursue new technologies might mean, and in the second we explore some of the negative consequences of defending such development as a moral obligation based on potential benefit. We argue that promoting the advances available to brain implants through developments in nanotechnology and bionics could contribute to medical rhetoric that indirectly increases the risk of exposing patients to harm when participating in clinical trials. We argue that rather than there being a moral obligation to improve nanobionics implants because of their potential benefit, the pursuit of improved neuro implants must be balanced against the prima facie obligations to protect patients against harm and to promote and protect patient autonomy. (shrink)

Drawing on and extending the Foucaultian philosophical framework that Jeffrey Bishop develops in his masterful book, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, we undertake a sociological analysis of the neurological procedure—deep brain stimulation —which implants electrodes in the brain, powered by a pacemaker-like device, for the treatment of movement disorders. Following Bishop’s work, we carry out this analysis through a two-fold strategy. First, we examine how a multidisciplinary team evaluates candidates for this (...) implant at a major medical center. We present excerpts from an ethnographic study of the “case conference” where disease entities are presented, contested, ratified, and made objects for intervention with this technology. The case conference becomes the key site in the transition from “person-with-illness” to “person-with-brain-implant” as a team of health professionals determines a plan of action by interpreting both statistical and “quality of life” data regarding their patients. Second, this article explores these decision-making processes through Bishop’s conceptualization of evidence-based medicine, which relies on statistical approaches as the ultimate authority in knowledge production and medical decisions. We then reflect on Bishop’s critique of the social sciences and the methodological, analytical, and substantive ramifications that The Anticipatory Corpse can offer future sociological work. (shrink)

Revolutions in semiconductor device miniaturization, bioelectronics, and applied neural control technologies are enabling scientists to create machine-assisted minds, science fiction's “cyborgs.” In a paper published in 1999, we sought to draw attention to the advances in prosthetic devices, to the myriad of artificial implants, and to the early developments of this technology in cochlear and retinal implants. Our concern, then and now, was to draw attention to the ethical issues arising from these innovations. Since that time, breakthroughs have (...) occurred at a breathtaking pace. Scientists, researchers, and engineers using differing methodologies are pursuing the possibilities of direct interfaces between brains and machines. Technological innovations as such are neither good nor evil; it is the uses devised for them that create moral implications. As there can be ethical problems inherent in the proper human uses of technologies and because brain chips are a very likely future technology, it is prudent to formulate policies and regulations that will mitigate their ill effects before the technologies are widespread. Unlike genetic technologies, which have received widespread scrutiny within the scientific community, national governments, and international forums, brain–machine interfaces have received little social or ethical scrutiny. However, the potential of this technology to change and significantly affect humans is potentially far greater than that of genetic enhancements, because genetic enhancements are inherently limited by biology and the single location of an individual, whereas hybrids of human and machine are not so restricted. Today, intense interest is focused on the development of drugs to enhance memory; yet, these drugs merely promise an improvement of normal memory, not the encyclopedic recall of a computer-enhanced mind combined with the ability to share information at a distance. The potential of brain chips for transforming humanity are astounding. This paper describes advances in hybrid brain–machine interfaces, offers some likely hypotheses concerning future developments, reflects on the implications of combining cloning and transplanted brain chips, and suggests some potential methods of regulating these technologies. (shrink)

Many experimental brain-computer interfaces (BCIs) are currently being medically tested in paralyzed patients. While the new generations of implantable BCIs move rapidly ahead at trying to increase the patients’ well-being, ethical concerns about their potential effects on patients’ psychological dimensions (e.g. sense of agency and control) are growing. An important ethical concern to explore is how BCIs may introduce unprecedented vulnerabilities to implanted individuals.Our chapter shows that, on the one hand, BCIs can empower the sense of self and control, (...) which contribute to well-being. On the other hand, they can introduce unprecedented vulnerabilities, for example, by inducing radical distress, feelings of loss of control, and a rupture of patient identity, which decrease one’s well-being. To investigate a possible solution to this problem we propose to understand the implementation of a BCI system in one’s body through the capability approach. This calls for a careful ethical examination of new morally salient issues prior to seeing an increase in BCI-related psychological effects in an open market. (shrink)

Deep brain stimulation (DBS) uses electrodes implanted in the brain to modulate dysregulated brain activity related to a variety of neurological and psychiatric conditions. A number of people who use DBS have reported changes that affect their sense of self. In the neuroethics literature, there has been significant debate over the exact nature of these changes. More recently, there have been suggestions that this debate is overblown and detracts from clinically-relevant ways of understanding these effects of DBS. (...) In this paper, we offer an alternative approach to understanding the effects of DBS on the self, drawing on John Sadler’s work on self-illness ambiguity. We argue that self-illness ambiguity is a complex concept, with at least three different aspects, and that each of the three aspects we identify also characterizes one kind of DBS-related change. Our analysis also suggests ways of helping patients to adjust to life as a DBS user. (shrink)

Deep brain stimulation (DBS) uses electrodes implanted in the brain to modulate dysregulated brain activity related to a variety of neurological and psychiatric conditions. A number of people who use DBS have reported changes that affect their sense of self. In the neuroethics literature, there has been significant debate over the exact nature of these changes. More recently, there have been suggestions that this debate is overblown and detracts from clinically-relevant ways of understanding these effects of DBS. (...) In this paper, we offer an alternative approach to understanding the effects of DBS on the self, drawing on John Sadler’s work on self-illness ambiguity. We argue that self-illness ambiguity is a complex concept, with at least three different aspects, and that each of the three aspects we identify also characterizes one kind of DBS-related change. Our analysis also suggests ways of helping patients to adjust to life as a DBS user. (shrink)

We have long used mechanical devices to compensate for physical disability. Soon, however, it may be possible to augment mental capacity—to add memory or upgrade processing power. We should ponder the enormous moral implications of the machine‐assisted mind now, before it is accomplished.

One important concern regarding implantable Brain Computer Interfaces is the fear that the intervention will negatively change a patient’s sense of identity or agency. In particular, there is concern that the user will be psychologically worse-off following treatment despite postoperative functional improvements. Clinical observations from similar implantable brain technologies, such as deep brain stimulation, show a small but significant proportion of patients report feelings of strangeness or difficulty adjusting to a new concept of themselves characterized by a (...) maladaptive je ne sais quoi despite clear motor improvement. Despite the growing number of cases in the DBS literature, there is currently no accepted or standardized tool in neuroethics specifically designed to capture the phenomenological postoperative experience of patients implanted with DBS or BCI devices. Given potential risks of postoperative maladaptation, it is important for the field of neuroethics to develop a qualitative instrument that can serve as a shared method for capturing postoperative variations in patient experience of identity and agency. The goal of this article is to introduce an instrument we have developed for this purpose and call for further neuroethical efforts to assess the phenomenology of implantable brain device use. (shrink)

Recording and manipulating neuronal ensemble activity is a key requirement in advanced neuromodulatory and behavior studies. Devices capable of both recording and manipulating neuronal activity brain-computer interfaces should ideally operate un-tethered and allow chronic longitudinal manipulations in the freely moving animal. In this study, we designed a new intracortical BCI feasible of telemetric recording and stimulating local gray and white matter of visual neural circuit after irradiation exposure. To increase the translational reliance, we put forward a Göttingen minipig model. (...) The animal was stereotactically irradiated at the level of the visual cortex upon defining the target by a fused cerebral MRI and CT scan. A fully implantable neural telemetry system consisting of a 64 channel intracortical multielectrode array, a telemetry capsule, and an inductive rechargeable battery was then implanted into the visual cortex to record and manipulate local field potentials, and multi-unit activity. We achieved a 3-month stability of the functionality of the un-tethered BCI in terms of telemetric radio-communication, inductive battery charging, and device biocompatibility for 3 months. Finally, we could reliably record the local signature of sub- and suprathreshold neuronal activity in the visual cortex with high bandwidth without complications. The ability to wireless induction charging combined with the entirely implantable design, the rather high recording bandwidth, and the ability to record and stimulate simultaneously put forward a wireless BCI capable of long-term un-tethered real-time communication for causal preclinical circuit-based closed-loop interventions. (shrink)

Patients requiring deep brain stimulation due to intracerebral metallic foreign substances have not been reported elsewhere in the world. Additionally, the long-term effects of metallic foreign bodies on deep brain stimulation are unknown. A 79-year-old man with a 5-year history of Parkinson's disease reported that, 40 years ago, while playing with a pistol, a metallic bullet was accidentally discharged into the left brain through the edge of the left eye, causing no discomfort other than blurry vision in (...) the left eye. DBS was performed due to the short duration of efficacy for oral medication. Because the bullet was on the left subthalamic nucleus electrode trajectory and the patient's right limb was primarily stiff, the patient received globus pallidus interna -DBS implantation in the left hemisphere and STN-DBS implantation in the right hemisphere. During a 6-month postoperative follow-up, the patient's PD symptoms were effectively managed with no noticeable discomfort. (shrink)

Biomedical engineering technologies such as brain–machine interfaces and neuroprosthetics are advancements which assist human beings in varied ways. There are exciting yet speculative visions of how the neurosciences and bioengineering may influence human nature. However, these could be preparing a possible pathway towards an enhanced and even posthuman future. This article seeks to investigate several ethical themes and wider questions of enhancement, transhumanism and posthumanism. Four themes of interest are: autonomy, identity, futures, and community. Three larger questions can be (...) asked: will everyone be enhanced? Will we be “human” if we are not, one day, transhuman? Should we be enhanced or not? The article proceeds by concentrating on a widespread and sometimes controversial application: the cochlear implant, an auditory prosthesis implanted into Deaf patients. Cochlear implantation and its reception in both the deaf and hearing communities have a distinctive moral discourse, which can offer surprising insights. The paper begins with several points about the enhancement of human beings, transhumanism’s reach beyond the human, and posthuman aspirations. Next it focuses on cochlear implants on two sides. Firstly, a shorter consideration of what technologies may do to humans in a transhumanist world. Secondly, a deeper analysis of cochlear implantation’s unique socio-political movement, its ethical explanations and cultural experiences linked with pediatric cochlear implantation—and how those wary of being thrust towards posthumanism could marshal such ideas by analogy. As transhumanism approaches, the issues and questions merit continuing intense analysis. (shrink)

Brain–Computer Interface research is an interdisciplinary area of study within Neural Engineering. Recent interest in end-user perspectives has led to an intersection with user-centered design. The goal of user-centered design is to reduce the translational gap between researchers and potential end users. However, while qualitative studies have been conducted with end users of BCI technology, little is known about individual BCI researchers’ experience with and attitudes towards UCD. Given the scientific, financial, and ethical imperatives of UCD, we sought to (...) gain a better understanding of practical and principled considerations for researchers who engage with end users. We conducted a qualitative interview case study with neural engineering researchers at a center dedicated to the creation of BCIs. Our analysis generated five themes common across interviews. The thematic analysis shows that participants identify multiple beneficiaries of their work, including other researchers, clinicians working with devices, device end users, and families and caregivers of device users. Participants value experience with device end users, and personal experience is the most meaningful type of interaction. They welcome end-user input, but are skeptical of limited focus groups and case studies. They also recognize a tension between creating sophisticated devices and developing technology that will meet user needs. Finally, interviewees espouse functional, assistive goals for their technology, but describe uncertainty in what degree of function is “good enough” for individual end users. Based on these results, we offer preliminary recommendations for conducting future UCD studies in BCI and neural engineering. (shrink)

Brain implants, such as Deep Brain Stimulation (DBS), which are designed to improve motor, mood and behavioural pathology, present unique challenges to our understanding of identity, agency and free will. This is because these devices can have visible effects on persons' physical and psychological properties yet are essentially undetectable when operating correctly. They can supplement and compensate for one's inherent abilities and faculties when they are compromised by neuropsychiatric disorders. Further, unlike talk therapy or pharmacological treatments, patients (...) need not ‘do’ anything for the treatment to take effect. If one accepts, as we argue here, that brain implants are unique among implantable types of devices, then this can have significant implications for what it means to persist as the same person and be the source of one's thoughts and actions. By examining two of the most common indications for DBS in current use, namely in the motor (Parkinson's Disease) and psychiatric (Major Depression) domains, we further argue that although DBS, as it is currently applied, does not necessarily represent a unique threat to personal identity and agency per se, it introduces an unprecedented ‘third party’ into the debate on these concepts. In this way, DBS can be used as a tool to begin probing, both conceptually and empirically, some of philosophy's most perennial metaphysical questions. (shrink)

In a world surrounded by smart objects from sensors to automated medical devices, the ubiquity of ‘smart’ seems matched only by its lack of clarity. In this article, we use our discussions with expert stakeholders working in areas of implantable medical devices such as cochlear implants, implantable cardiac defibrillators, deep brain stimulators and in vivo biosensors to interrogate the difference facets of smart in ‘implantable smart technologies’, considering also whether regulation needs to respond to the autonomy that such (...) artefacts carry within them. We discover that when smart technology is deconstructed it is a slippery and multi-layered concept. A device’s ability to sense and transmit data and automate medicine can be associated with the ‘sting’ of autonomy being disassociated from human control as well as affecting individual, group, and social environments. (shrink)

In a world surrounded by smart objects from sensors to automated medical devices, the ubiquity of ‘smart’ seems matched only by its lack of clarity. In this article, we use our discussions with expert stakeholders working in areas of implantable medical devices such as cochlear implants, implantable cardiac defibrillators, deep brain stimulators and in vivo biosensors to interrogate the difference facets of smart in ‘implantable smart technologies’, considering also whether regulation needs to respond to the autonomy that such (...) artefacts carry within them. We discover that when smart technology is deconstructed it is a slippery and multi-layered concept. A device’s ability to sense and transmit data and automate medicine can be associated with the ‘sting’ of autonomy being disassociated from human control as well as affecting individual, group, and social environments. (shrink)

Implantable brain–computer interface technology is an expanding area of engineering research now moving into clinical application. Ensuring meaningful informed consent in implantable BCI research is an ethical imperative. The emerging and rapidly evolving nature of implantable BCI research makes identification of risks, a critical component of informed consent, a challenge. In this paper, 6 core risk domains relevant to implantable BCI research are identified—short and long term safety, cognitive and communicative impairment, inappropriate expectations, involuntariness, affective impairment, and privacy and (...) security. Work in deep brain stimulation provides a useful starting point for understanding this core set of risks in implantable BCI. Three further risk domains—risks pertaining to identity, agency, and stigma—are identified. These risks are not typically part of formalized consent processes. It is important as informed consent practices are further developed for implantable BCI research that attention be paid not just to disclosing core research risks but exploring the meaning of BCI research with potential participants. (shrink)

In a world surrounded by smart objects from sensors to automated medical devices, the ubiquity of ‘smart’ seems matched only by its lack of clarity. In this article, we use our discussions with expert stakeholders working in areas of implantable medical devices such as cochlear implants, implantable cardiac defibrillators, deep brain stimulators and in vivo biosensors to interrogate the difference facets of smart in ‘implantable smart technologies’, considering also whether regulation needs to respond to the autonomy that such (...) artefacts carry within them. We discover that when smart technology is deconstructed it is a slippery and multi-layered concept. A device’s ability to sense and transmit data and automate medicine can be associated with the ‘sting’ of autonomy being disassociated from human control as well as affecting individual, group, and social environments. (shrink)

In this article, a practical look is taken at some of the possible enhancements for humans through the use of implants, particularly into the brain or nervous system. Some cognitive enhancements may not turn out to be practically useful, whereas others may turn out to be mere steps on the way to the construction of superhumans. The emphasis here is the focus on enhancements that take such recipients beyond the human norm rather than any implantations employed merely for (...) therapy. This is divided into what we know has already been tried and tested and what remains at this time as more speculative. Five examples from the author’s own experimentation are described. Each case is looked at in detail, from the inside, to give a unique personal experience. The premise is that humans are essentially their brains and that bodies serve as interfaces between brains and the environment. The possibility of building an Interplanetary Creature, having an intelligence and possibly a consciousness of its own, is also considered. (shrink)

"Cet essai de bioéthique propose de penser l'Homme et son avenir à travers une innovation technologique extraordinaire : les implants cérébraux. Utilisés déjà dans des contextes de maladies, leur développement actuel laisse espérer pouvoir contrôler bientôt des dispositifs robotiques en connectant le cerveau à des ordinateurs équipés d'intelligences artificielles. Si les premiers résultats sont très encourageants, ces interfaces cerveau-machines posent néanmoins un questionnement éthique majeur. Que devient l'Homme si son cerveau fonctionne avec un dispositif électronique "intelligent" implanté? Pourrait-on percer (...) les secrets de ses pensées? Pourrait-on augmenter son intelligence ou sa mémoire? Afin d'appréhender ces trois questions, cet essai commence par penser l'Homme et son rapport aux technologies : la vulnérabilité humaine n'appelle-t-elle pas le recours aux techniques et technologies pour habiter le monde? Pour aider certaines personnes en situation de handicap, n'a-t-on pas besoin parfois de dépasser techniquement les limites de la nature humaine? Mais peut-on pour autant tout se permettre, même pour compenser un handicap? Comment accompagner les chercheurs dans leur propre questionnement? Ne serait-ce qu'une question de bon et de mauvais usage des techniques et technologies? C'est cette aventure philosophique et bioéthique que propose cet essai.". (shrink)

This article provides an ethnographic account of pediatric cochlear implantation, revealing an important shift in the definition of deafness from a sensory loss to a neurological processing problem. In clinical and long-term therapeutic practices involved in pediatric implantation, the cochlear implant is recast as a device that merely provides access to the brain. The “real” treatment emerges as long-term therapeutic endeavors focused on neurological training. This redefinition then ushers in an ensuing responsibility to “train the brain,” subsequently displacing (...) failure from the device onto the individual’s ability to train his or her brain. New caregiving techniques that accompany implantation are understood through neuropolitics, showing how parents are encouraged to engage in neuro-self-governance, and how the concept of neuroplasticity is used to cultural ends. (shrink)