fMRI in the public eye

"This is Why you've Been Suffering": Reflections of Providers on Neuroimaging in Mental Health Care

Mental health care providers increasingly confront challenges posed by the introduction of new neurotechnology into the clinic, but little is known about the impact of such capabilities on practice patterns and relationships with patients. To address this important gap, we sought providers' perspectives on the potential clinical translation of functional neuroimaging for prediction and diagnosis of mental illness. We conducted 32 semi-structured telephone interviews with mental health care providers representing psychiatry, psychology, family medicine, and allied mental health. Our results suggest that mental health providers have begun to re-conceptualize mental illness with a neuroscience gaze. They report an epistemic commitment to the value of a brain scan to provide a meaningful explanation of mental illness for their clients. If functional neuroimaging continues along its projected trajectory to translation, providers will ultimately have to negotiate its role in mental health. Their perspectives, therefore, enrich bioethical discourse surrounding neurotechnology and inform the translational pathway.

Informed consent for MRI and fMRI research: analysis of a sample of Canadian consent documents

Background

Research ethics and the measures deployed to ensure ethical oversight of research (e.g., informed consent forms, ethics review) are vested with extremely important ethical and practical goals. Accordingly, these measures need to function effectively in real-world research and to follow high level standards.

Methods

We examined approved consent forms for Magnetic Resonance Imaging (MRI) and functional Magnetic Resonance Imaging (fMRI) studies approved by Canadian research ethics boards (REBs).

Results

We found evidence of variability in consent forms in matters of physical and psychological risk reporting. Approaches used to tackle the emerging issue of incidental findings exposed extensive variability between and within research sites.

Conclusion

The causes of variability in approved consent forms and studies need to be better understood. However, mounting evidence of administrative and practical hurdles within current ethics governance systems combined with potential sub-optimal provision of information to and protection of research subjects support other calls for more scrutiny of research ethics practices and applicable revisions.

Mistreating Psychology in the Decades of the Brain

We systematically mistreat psychological phenomena, both logically and clinically. This article explores three contentions: that the dominant discourse in modern cognitive, affective, and clinical neuroscience assumes that we know how psychology/biology causation works when we do not; that there are serious intellectual, clinical, and policy costs to pretending we do know; and that crucial scientific and clinical progress will be stymied as long as we frame psychology, biology, and their relationship in currently dominant ways. The arguments are developed with emphasis on misguided attempts to localize psychological function via neuroimaging, misunderstandings about the role of genetics in psychopathology, and untoward constraints on health-care policy and clinical service delivery. A particular challenge, articulated but not resolved in this article, is determining what constitutes adequate explanation in the relationship between psychology and biology.

From Scanner to Sound Bite

Neuroimaging research is yielding reports of sex differences in the brain. Yet the likelihood of spurious findings of sex differences, the teething problems of new technology, the obscurity of the relation between brain structure and psychological function, and difficulties inferring mental states from neuroimaging data all require us to be considerably cautious in interpreting such results. Unfortunately, these issues are often overlooked in popular accounts. Together with a tendency for people to regard neuroscientific information as more scientific than behavioral data, and as indicative of male and female “nature,” these issues point to the worrisome possibility of public misunderstanding of what contemporary neuroscience tells us about gender.

Contemporary neuroscience in the media

Technological innovations in neuroscience have opened new windows to the understanding of brain function and the neuronal underpinnings of brain activity in neuropsychiatric disorders and social behavior. Public interest and support for neuroscience research through initiatives like the Decade of the Brain project and increasingly diverse brain-related initiatives have created new interfaces between neuroscience and society. Against this backdrop of dynamic innovation, we set out to examine how different features of neuroscience are depicted in print media. We used the 'guided news' function of the LexisNexis Academic database with keyword searches to find news articles published between 1995 and 2004 in major U.S. and U.K. English-language news sources. We performed searches on headlines, lead paragraphs, and body terms to maximize search yields. All articles were coded for overall tone of coverage, details on reported studies, presence of ethical, legal, and social discussion as well as the emerging interpretations of neuroscience - in the form of neuro-essentialism, neuro-realism, and neuro-policy. We found that print media coverage of the use of neurotechnology for diagnosis or therapy in neuropsychiatric disorders was generally optimistic. We also found that, even within articles that were identified as research reports, many did not provide details about research studies. We also gained additional insights into the previously identified phenomena of neuro-essentialism, neuro-realism, and neuro-policy showing some profound impacts of neuroscience on personal identity and policy-making. Our results highlight the implications of transfer of neuroscience knowledge to society given the substantial and authoritative weight ascribed to neuroscience knowledge in defining who we are. We also discuss the impact of these findings on neuroscience and on the respective contributions of the social sciences and the biological sciences in contemporary psychiatry and mental health policy.

[The cerebralization of fatigue: an analysis of the cerebral hypothesis in the case of chronic fatigue syndrome]

The article analyzes a number of conditions that allowed the brain to become established as an etiological hypothesis in the case of chronic fatigue syndrome (CFS), together with other hypotheses related to organic causes, such as viruses and immunity. It also addresses the process of cerebralization of personhood, which grew out of the use of neuroimaging for research and diagnostic purposes and according to which the brain constitutes the prime place for looking for the cause of the diseases - including CFS - within the context of a somatic culture, intensified at the end of the twentieth century.

Decision neuroscience: neuroeconomics

Few aspects of human cognition are more personal than the choices we make. Our decisions-from the mundane to the impossibly complex-continually shape the courses of our lives. In recent years, researchers have applied the tools of neuroscience to understand the mechanisms that underlie decision making, as part of the new discipline of decision neuroscience. A primary goal of this emerging field has been to identify the processes that underlie specific decision variables, including the value of rewards, the uncertainty associated with particular outcomes, and the consequences of social interactions. Recent work suggests potential neural substrates that integrate these variables, potentially reflecting a common neural currency for value, to facilitate value comparisons. Despite the successes of decision neuroscience research for elucidating brain mechanisms, significant challenges remain. These include building new conceptual frameworks for decision making, integrating research findings across disparate techniques and species, and extending results from neuroscience to shape economic theory. To overcome these challenges, future research will likely focus on interpersonal variability in decision making, with the eventual goal of creating biologically plausible models for individual choice. WIREs Cogn Sci 2010 1 854-871 This article is categorized under: Psychology > Reasoning and Decision Making Neuroscience > Cognition.

Perspectives of Canadian Researchers on Ethics Review of Neuroimaging Research

The current and potential uses of neuroimaging in healthcare and beyond have spurred discussion about the ethical issues related to neuroimaging and neuroimaging research. This study examined the perspectives of neuroimagers on ethical issues in their research and on the ethics review process. One hundred neuroimagers from 13 Canadian neuroscience centers completed an online survey and 35 semi-structured interviews were conducted. Neuroimagers felt that most ethical and social issues identified in the literature were dealt with adequately, well, and even very well by research ethics boards (REBs), but some issues such as incidental findings and transfer of knowledge were problematic. Neuroimagers reported a range of practical problems in the ethics review process. We aimed to gather perspectives from REB on the ethics review process, but insufficient participation by REBs prevented us from reporting their perspectives. Given shortcomings identified by neuroimagers as well as longstanding issues in Canadian ethics governance, we believe that substantial challenges exist in Canadian research ethics governance that jeopardize trust, communication, and the overall soundness of research ethics governance. Neuroimagers and REBs should consider their shared responsibilities in developing guidance to handle issues such as incidental findings, risk assessment, and knowledge transfer.

Parental consent for neuroimaging in paediatric research

BACKGROUND

Functional magnetic resonance imaging (fMRI) is increasingly applied in paediatric research. Parents typically provide research consent for their children; yet, no study has examined the rates of consent, nor factors influencing parental decision making for consent. The present study aimed to determine the proportion of parents that would consent to their child undergoing an fMRI study, and to elicit the reasons, motivators and detractors affecting their decision.

METHODS

Ninety parents of children aged 6 years were invited to participate in a postal survey study.

RESULTS

Fifty-three parents (59%) responded and one-third (34%, 18/53) reported that they would consent. The main reason for consent was that participation could benefit children in the future (89%, 16/18). Common reasons for not consenting included that fMRI may be anxiety-provoking (54%), or was an unnecessary medical procedure (23%).

CONCLUSIONS

Our preliminary data suggest that researchers may have to approach three times the number of participants required in order to recruit a suitable number of healthy children to fMRI studies. Further research examining the influence of recruitment approaches (e.g. phone vs. postal) and the various factors influencing decision making regarding consent is required. For example, careful examination of the language used in describing the procedure could facilitate parental understanding about fMRI and alleviate anxiety associated with the procedure. This is an important consideration for recruitment to future fMRI studies given that anxiety was a key factor influencing parental non-consent.

Neurotalk: improving the communication of neuroscience research

There is increasing pressure for neuroscientists to communicate their research and the societal implications of their findings to the public. Communicating science is challenging, and the transformation of communication by digital and interactive media increases the complexity of the challenge. To facilitate dialogue with the public in this new media landscape, we suggest three courses of action for the neuroscience community: a cultural shift that explicitly recognizes and rewards public outreach, the identification and development of neuroscience communication experts, and ongoing empirical research on the public communication of neuroscience.

Defining neuromarketing: practices and professional challenges

Neuromarketing has recently generated controversies concerning the involvement of medical professionals, and many key questions remain-ones that have potentially important implications for the field of psychiatry. Conflicting definitions of neuromarketing have been proposed, and little is known about the actual practices of companies, physicians, and scientists involved in its practice. This article reviews the history of neuromarketing and uses an exploratory survey of neuromarketing Web sites to illustrate ethical issues raised by this new field. Neuromarketing, as currently practiced, is heterogeneous, as companies are offering a variety of technologies. Many companies employ academicians and professionals, but few list their clients or fees. Media coverage of neuromarketing appears disproportionately high compared to the paucity of peer-reviewed reports in the field. Companies may be making premature claims about the power of neuroscience to predict consumer behavior. Overall, neuromarketing has important implications for academic-industrial partnerships, the responsible conduct of research, and the public understanding of the brain. We explore these themes to uncover issues relevant to professional ethics, research, and policy. Of particular relevance to psychiatry, neuromarketing may be seen as an extension of the search for quantification and certainty in previously indefinite aspects of human behavior.

Negotiating the Relationship Between Addiction, Ethics, and Brain Science

Advances in neuroscience are changing how mental health issues such as addiction are understood and addressed as a brain disease. Although a brain disease model legitimizes addiction as a medical condition, it promotes neuro-essentialist thinking, categorical ideas of responsibility and free choice, and undermines the complexity involved in its emergence. We propose a 'biopsychosocial systems' model where psycho-social factors complement and interact with neurogenetics. A systems approach addresses the complexity of addiction and approaches free choice and moral responsibility within the biological, lived experience and socio-historical context of the individual. We examine heroin-assisted treatment as an applied case example within our framework. We conclude with a discussion of the model and its implications for drug policy, research, addiction health care systems and delivery, and treatment of substance use problems.

Neurociências, neurocultura e autoajuda cerebral

Este artigo pretende analisar o fenômeno denominado de neuroascese, ou autoajuda cerebral no contexto do crescente impacto das neurociências e do surgimento da neurocultura e do sujeito cerebral. Para tanto, é importante compreender o âmbito sóciocultural mais amplo no qual a neuroascese se insere e que corresponde ao que vem se chamando de 'cultura somática' ou, mais especificamente, de biossociabilidade. O objetivo do artigo é explorar como uma forma de subjetividade reducionista, o sujeito cerebral, dá lugar à aparição de práticas de si cerebrais, isto é, práticas de como agir sobre o cérebro para maximizar a sua performance, que levam a formação de novas formas de sociabilidade.

Neuroculture

Neuroscience addresses questions that, if resolved, will reveal aspects of our individuality. Therefore neuroscientific knowledge is not solely constrained within laboratories, but readily captures the attention of the public at large. Ideas, concepts and images in neuroscience widely circulate in culture and are portrayed in literature, film, works of art, the mass media and commercial products, therefore shaping social values and consumer practices. The interaction between art and science offers an opportunity to make the scientific community and the public aware of the social and ethical implications of the scientific advances in neuroscience.

Disagreements with implications: diverging discourses on the ethics of non-medical use of methylphenidate for performance enhancement

Background

There is substantial evidence that methylphenidate (MPH; Ritalin), is being used by healthy university students for non-medical motives such as the improvement of concentration, alertness, and academic performance. The scope and potential consequences of the non-medical use of MPH upon healthcare and society bring about many points of view.

Methods

To gain insight into key ethical and social issues on the non-medical use of MPH, we examined discourses in the print media, bioethics literature, and public health literature.

Results

Our study identified three diverging paradigms with varying perspectives on the nature of performance enhancement. The beneficial effects of MPH on normal cognition were generally portrayed enthusiastically in the print media and bioethics discourses but supported by scant information on associated risks. Overall, we found a variety of perspectives regarding ethical, legal and social issues related to the non-medical use of MPH for performance enhancement and its impact upon social practices and institutions. The exception to this was public health discourse which took a strong stance against the non-medical use of MPH typically viewed as a form of prescription abuse or misuse. Wide-ranging recommendations for prevention of further non-medical use of MPH included legislation and increased public education.

Conclusion

Some positive portrayals of the non-medical use of MPH for performance enhancement in the print media and bioethics discourses could entice further uses. Medicine and society need to prepare for more prevalent non-medical uses of neuropharmaceuticals by fostering better informed public debates.

Functional MRI at the crossroads

Since the observation of the blood oxygenation level dependent (BOLD) effect on measured MR signal in the brain, functional magnetic resonance imaging (fMRI) has rapidly become the tool of choice for exploring brain function in cognitive neuroscience. Although fMRI is an exciting and powerful means to examining the brain in vivo, the field has sometimes permitted itself to believe that patterns of BOLD activity reveal more than it is possible to measure given the method's spatial and temporal sampling, while concurrently not fully exploring the amount of information it provides. In this article, we examine some of the constraints on the kinds of inferences that can be supported by fMRI. We critique the concept of reverse inference that is often employed to claim some cognitive function must be present given activity in a specific region. We review the consideration of functional and effective connectivity that remain infrequently applied in cognitive neuroimaging, highlighting recent thinking on the ways in which functional imaging can be used to characterize inter-regional communication. Recent advances in neuroimaging that make it possible to assess anatomical connectivity using diffusion tensor imaging (DTI) and we discuss how these may inform interpretation of fMRI results. Descriptions of fMRI studies in the media, in some instances, serve to misrepresent fMRI's capabilities. We comment on how researchers need to faithfully represent fMRI's promise and limitations in dealing with the media. Finally, as we stand at the crossroads of fMRI research, where one pathway leads toward a rigorous understanding of cognitive operations using fMRI and another leads us to a predictable collection of observations absent of clear insight, we offer our impressions of a fruitful path for future functional imaging research.

Perspectives on engaging the public in the ethics of emerging biotechnologies: from salmon to biobanks to neuroethics

In anticipation of increasing interest in public engagement, this article seeks to expand the current discussion in the neuroethics literature concerning what public engagement on issues related to neuroscience might entail and how they could be envisioned. It notes that the small amount of available neuroethics literature related to public engagement has principally discussed only communication/education or made calls for dialogue without exploring what this might entail on a practical level. The article links across three seemingly disparate examples-salmon, biobanks, and neuroethics-to consider and clarify the need for public engagement in neuroscience.

Non-invasive brain stimulation in the detection of deception: scientific challenges and ethical consequences

Tools for noninvasive stimulation of the brain, such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), have provided new insights in the study of brain-behavior relationships due to their ability to directly alter cortical activity. In particular, TMS and tDCS have proven to be useful tools for establishing causal relationships between behavioral and brain imaging measures. As such, there has been interest in whether these tools may represent novel technologies for deception detection by altering a person's ability to engage brain networks involved in conscious deceit. Investigation of deceptive behavior using noninvasive brain stimulation is at an early stage. Here we review the existing literature on the application of noninvasive brain stimulation in the study of deception. Whether such approaches could be usefully applied to the detection of deception by altering a person's ability to engage brain networks involved in conscious deceit remains to be validated. Ethical and legal consequences of the development of such a technology are discussed.

Brain imaging and brain privacy: a realistic concern?

Functional neuroimaging has been used to study a wide array of psychological traits, including aspects of personality and intelligence. Progress in identifying the neural correlates of individual differences in such traits, for the sake of basic science, has moved us closer to the applied science goal of measuring them and thereby raised ethical concerns about privacy. How realistic are such concerns given the current state of the art? In this article, we describe the statistical basis of the measurement of psychological traits using functional neuroimaging and examine the degree to which current functional neuroimaging protocols could be used for this purpose. By analyzing the published data from 16 studies, we demonstrate that the use of imaging to gather information about an individual's psychological traits is already possible, but to an extremely limited extent.

Foundations of neuroeconomics: from philosophy to practice

How can we use neuroscience to better understand economic behavior? By quelling concerns about the nascent field of neuroeconomics, the authors defend future integrations of the biological and social sciences.

Neuroethics and neuroimaging: moving toward transparency

Without exaggeration, it could be said that we are entering a golden age of neuroscience. Informed by recent developments in neuroimaging that allow us to peer into the working brain at both a structural and functional level, neuroscientists are beginning to untangle mechanisms of recovery after brain injury and grapple with age-old questions about brain and mind and their correlates neural mechanisms and consciousness. Neuroimaging, coupled with new diagnostic categories and assessment scales are helping us develop a new diagnostic nosology about disorders of consciousness which will likely improve prognostication and suggest therapeutic advances. Historically such diagnostic refinement has yield therapeutic advances in medicine and there is no reason to doubt that this will be the case for disorders of consciousness, perhaps bringing relief to a marginalized population now on the periphery of the therapeutic agenda. In spite of this promise, the translation of research findings into the clinical context will be difficult. As we move from descriptive categories about disorders of consciousness, like the vegetative or minimally conscious states, to ones further specified by integrating behavioral and neuroimaging findings, humility not hubris should be the virtue that guides the ethical conduct of research and practice.

Media coverage of the persistent vegetative state and end-of-life decision-making

BACKGROUND

Conflicting perspectives about the diagnosis and prognosis of the persistent vegetative state (PVS) as well as end-of-life (EOL) decision-making were disseminated in the Terri Schiavo case. This study examined print media coverage of these features of the case.

METHODS

We retrieved print media coverage of the Schiavo case from the LexisNexis Academic database and used content analysis to examine headlines and text of articles describing Schiavo's neurologic condition, behavioral repertoire, prognosis, and withdrawal of life support. The accuracy of claims about PVS was assessed.

RESULTS

Our search yielded 1,141 relevant articles published (1990-2005) in the four most prolific American newspapers for this case. The most frequent headline themes featured legal (31%), EOL (25%), and political (22%) aspects of the case. Of the articles analyzed, 21% reported that Schiavo "might improve" and 7% that she "might recover." Statements explicitly denying the PVS diagnosis were found in 6% of articles. Explanations of PVS and other chronic disorders of consciousness were rare (<or=1%). Most frequently cited descriptions of behaviors were that the patient responds (10%), reacts (9%), is incapacitated (6%), smiles (5%), and laughs (5%). Withdrawal of life support was described as murder in 9% of articles.

CONCLUSIONS

Media coverage included refutations of the persistent vegetative state (PVS) diagnosis, attributed behaviors inconsistent with PVS, and used charged language to describe end of life decision-making. Strategies are needed to achieve better internal agreement within the professional community and effective communication with patient communities, families, the media, and stakeholders.

Seeing is believing: the effect of brain images on judgments of scientific reasoning

Brain images are believed to have a particularly persuasive influence on the public perception of research on cognition. Three experiments are reported showing that presenting brain images with articles summarizing cognitive neuroscience research resulted in higher ratings of scientific reasoning for arguments made in those articles, as compared to articles accompanied by bar graphs, a topographical map of brain activation, or no image. These data lend support to the notion that part of the fascination, and the credibility, of brain imaging research lies in the persuasive power of the actual brain images themselves. We argue that brain images are influential because they provide a physical basis for abstract cognitive processes, appealing to people's affinity for reductionistic explanations of cognitive phenomena.

Neuroethical responsibilities

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the French-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

Law, responsibility, and the brain

Brain-imaging studies have reinvigorated the neurophilosophical and legal debate of whether we are free agents in control of our own actions or mere prisoners of a biologically determined brain.

Interacting and paradoxical forces in neuroscience and society

Discoveries in the field of neuroscience are a natural source of discourse among scientists and have long been disseminated to the public. Historically, as news of findings has travelled between communities, it has elicited both expected and unusual reactions. What scientific landmarks promote discourse within the professional community? Do the same findings achieve a place in the public eye? How does the media choose what is newsworthy, and why does the public react the way it does? Drawing on examples of past challenges at the crossroads of neuroscience and society and on a case study of trends in one neurogenetic disease, autism, we explore the dialectical forces interacting in scientific and public discourse.

Noradrenergic modulation of working memory and emotional memory in humans

RATIONALE

Noradrenaline (NA) is implicated in arousal. Working memory is dependent upon prefrontal cortex, and moderate levels of NA are thought to facilitate working memory whereas higher levels during extreme stress may impair working memory and engage more posterior cortical and sub-cortical circuitry. The NA system also influences emotional memory via modulation of the amygdalae and related mediotemporal structures. NA dysfunction and abnormalities in arousal-dependent memory functions are evident in a variety of neuropsychiatric illnesses.

OBJECTIVES

The authors provide a concise overview of pharmacological studies that have investigated effects of selective NA manipulations on working memory and emotional memory functions in healthy human volunteers.

MATERIALS AND METHODS

Selection of relevant peer-reviewed publications was based on a PubMed search.

RESULTS

Studies to date indicate that: (1) the beta-blocker propranolol impaired working and emotional memory, (2) clonidine frequently impaired working memory, and (3) reboxetine, a selective noradrenaline reuptake inhibitor, enhanced emotional memory for positive material.

CONCLUSIONS

Improved understanding of coupling between NA, cortico-subcortical circuitry and human mnemonic functions will suggest novel therapeutic directions for the treatment of neuropsychiatric conditions, such as attention deficit hyperactivity disorder and post-traumatic stress disorder. Future research directions are discussed in relation to neuroimaging techniques, functional central nervous system polymorphisms and study designs.

Brain Imaging: A Decade of Coverage in the Print Media

Advances in neuroscience are increasingly intersecting with issues of ethical, legal, and social interest. This study is an analysis of press coverage of an advanced technology for brain imaging, functional magnetic resonance imaging, that has gained significant public visibility over the past ten years. Discussion of issues of scientific validity and interpretation dominated over ethical content in both the popular and specialized press. Coverage of research on higher order cognitive phenomena specifically attributed broad personal and societal meaning to neuroimages. The authors conclude that neuroscience provides an ideal model for exploring science communication and ethics in a multicultural context.

Responsabilités Neuroéthiques

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the English-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

ELSI priorities for brain imaging

As one of the most compelling technologies for imaging the brain, functional MRI (fMRI) produces measurements and persuasive pictures of research subjects making cognitive judgments and even reasoning through difficult moral decisions. Even after centuries of studying the link between brain and behavior, this capability presents a number of novel significant questions. For example, what are the implications of biologizing human experience? How might neuroimaging disrupt the mysteries of human nature, spirituality, and personal identity? Rather than waiting for an ethical agenda to emerge from some unpredictable combination of the concerns of ethicists and researchers, the attention of journalists, or after controversy is sparked by research that cannot be retracted, we queried key figures in bioethics and the humanities, neuroscience, media, industry, and patient advocacy in focus groups and interviews. We identified specific ethical, legal and social issues (ELSI) that highlight researcher obligations and the nonclinical impact of the technology at this new frontier.