Informed Consent in Implantable BCI Research: Identifying Risks and Exploring Meaning

Understanding the Ethical Issues of Brain-Computer Interfaces (BCIs): A Blessing or the Beginning of a Dystopian Future?

In recent years, scientific discoveries in the field of neuroscience combined with developments in the field of artificial intelligence have led to the development of a range of neurotechnologies. Advances in neuroimaging systems, neurostimulators, and brain-computer interfaces (BCIs) are leading to new ways of enhancing, controlling, and "reading" the brain. In addition, although BCIs were developed and used primarily in the medical field, they are now increasingly applied in other fields (entertainment, marketing, education, defense industry). We conducted a literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to provide background information about ethical issues related to the use of BCIs. Among the ethical issues that emerged from the thematic data analysis of the reviewed studies included questions revolving around human dignity, personhood and autonomy, user safety, stigma and discrimination, privacy and security, responsibility, research ethics, and social justice (including access to this technology). This paper attempts to address the various aspects of these concerns. A variety of distinct ethical issues were identified, which, for the most part, were in line with the findings of prior research. However, we identified two nuances, which are related to the empirical research on ethical issues related to BCIs and the impact of BCIs on international relationships. The paper also highlights the need for the cooperation of all stakeholders to ensure the ethical development and use of this technology and concludes with several recommendations. The principles of bioethics provide an initial guiding framework, which, however, should be revised in the current artificial intelligence landscape so as to be responsive to challenges posed by the development and use of BCIs.

Identifying risk controls for future advanced brain-computer interfaces: A prospective risk assessment approach using work domain analysis

Brain-computer interface (BCI) technologies are progressing rapidly and may eventually be implemented widely within society, yet their risks have arguably not yet been comprehensively identified, nor understood. This study analysed an anticipated invasive BCI system lifecycle to identify the individual, organisational, and societal risks associated with BCIs, and controls that could be used to mitigate or eliminate these risks. A BCI system lifecycle work domain analysis model was developed and validated with 10 subject matter experts. The model was subsequently used to undertake a systems thinking-based risk assessment approach to identify risks that could emerge when functions are either undertaken sub-optimally or not undertaken at all. Eighteen broad risk themes were identified that could negatively impact the BCI system lifecycle in a variety of unique ways, while a larger number of controls for these risks were also identified. The most concerning risks included inadequate regulation of BCI technologies and inadequate training of BCI stakeholders, such as users and clinicians. In addition to specifying a practical set of risk controls to inform BCI device design, manufacture, adoption, and utilisation, the results demonstrate the complexity involved in managing BCI risks and suggests that a system-wide coordinated response is required. Future research is required to evaluate the comprehensiveness of the identified risks and the practicality of implementing the risk controls.

Use of Invasive Brain-Computer Interfaces in Pediatric Neurosurgery: Technical and Ethical Considerations

Invasive brain-computer interfaces hold promise to alleviate disabilities in individuals with neurologic injury, with fully implantable brain-computer interface systems expected to reach the clinic in the upcoming decade. Children with severe neurologic disabilities, like quadriplegic cerebral palsy or cervical spine trauma, could benefit from this technology. However, they have been excluded from clinical trials of intracortical brain-computer interface to date. In this manuscript, we discuss the ethical considerations related to the use of invasive brain-computer interface in children with severe neurologic disabilities. We first review the technical hardware and software considerations for the application of intracortical brain-computer interface in children. We then discuss ethical issues related to motor brain-computer interface use in pediatric neurosurgery. Finally, based on the input of a multidisciplinary panel of experts in fields related to brain-computer interface (functional and restorative neurosurgery, pediatric neurosurgery, mathematics and artificial intelligence research, neuroengineering, pediatric ethics, and pragmatic ethics), we then formulate initial recommendations regarding the clinical use of invasive brain-computer interfaces in children.

Minimally Invasive Local-Skull Electrophysiological Modification With Piezoelectric Drill

The research on non-invasive BCI is nowadays hitting the bottleneck due to the humble quality of scalp EEG signals. Whereas invasive solutions that offer higher signal quality in contrast are suffocated in their spreading because of the potential surgical complication and health risks caused by electrode implantation. Therefore, it puts forward a necessity to explore a scheme that could both collect high-quality EEG signals and guarantee high-level operation safety.This study proposed a Minimally Invasive Local-skull Electrophysiological Modification method to improve scalp EEG signals qualities at specific brain regions. Six eight-month-old SD rats were used for in vivo verification experiment. A hole with a diameter of about 500 micrometers was drilled in the skull above the visual cortex of rats. Significant changes in rsEEG and SSVEP signals before and after modification were observed. After modification, the skull impedance of rats decreases by about 84 %, the average maximum bandwidth of rsEEG increase by 57 %, and the broadband SNR of SSVEP is increased by 5.13 dB. The time of piezoelectric drilling operation is strictly controlled under 30 seconds for each rat to prevent possible brain damage from overheating. Compared with traditional invasive procedures such as ECoG, Minimally Invasive Local-skull Electrophysiological Modification operation time is shorter and no electrode implantation is needed while it remarkably boosts the scalp EEG signal quality. This technical solution has the potential to replace the use of ECoG in certain application scenarios and further invigorate studies in the field of scalp EEG in the future.

Ethical implications of visual neuroprostheses-a systematic review

Objective. The aim of this review was to systematically identify the ethical implications of visual neuroprostheses.Approach. A systematic search was performed in both PubMed and Embase using a search string that combined synonyms for visual neuroprostheses, brain-computer interfaces (BCIs), cochlear implants (CIs), and ethics. We chose to include literature on BCIs and CIs, because of their ethically relavant similarities and functional parallels with visual neuroprostheses.Main results. We included 84 articles in total. Six focused specifically on visual prostheses. The other articles focused more broadly on neurotechnologies, on BCIs or CIs. We identified 169 ethical implications that have been categorized under seven main themes: (a) benefits for health and well-being; (b) harm and risk; (c) autonomy; (d) societal effects; (e) clinical research; (f) regulation and governance; and (g) involvement of experts, patients and the public.Significance. The development and clinical use of visual neuroprostheses is accompanied by ethical issues that should be considered early in the technological development process. Though there is ample literature on the ethical implications of other types of neuroprostheses, such as motor neuroprostheses and CIs, there is a significant gap in the literature regarding the ethical implications of visual neuroprostheses. Our findings can serve as a starting point for further research and normative analysis.

Brain-Computer Interfaces in Neurorecovery and Neurorehabilitation

Recent advances in brain-computer interface technology to restore and rehabilitate neurologic function aim to enable persons with disabling neurologic conditions to communicate, interact with the environment, and achieve other key activities of daily living and personal goals. Here we evaluate the principles, benefits, challenges, and future directions of brain-computer interfaces in the context of neurorehabilitation. We then explore the clinical translation of these technologies and propose an approach to facilitate implementation of brain-computer interfaces for persons with neurologic disease.

Researcher Perspectives on Ethical Considerations in Adaptive Deep Brain Stimulation Trials

Interest and investment in closed-loop or adaptive deep brain stimulation (aDBS) systems have quickly expanded due to this neurotechnology's potential to more safely and effectively treat refractory movement and psychiatric disorders compared to conventional DBS. A large neuroethics literature outlines potential ethical concerns about conventional DBS and aDBS systems. Few studies, however, have examined stakeholder perspectives about ethical issues in aDBS research and other next-generation DBS devices. To help fill this gap, we conducted semi-structured interviews with researchers involved in aDBS trials (n = 23) to gain insight into the most pressing ethical questions in aDBS research and any concerns about specific features of aDBS devices, including devices' ability to measure brain activity, automatically adjust stimulation, and store neural data. Using thematic content analysis, we identified 8 central themes in researcher responses. The need to measure and store neural data for aDBS raised concerns among researchers about data privacy and security issues (noted by 91% of researchers), including the avoidance of unintended or unwanted third-party access to data. Researchers reflected on the risks and safety (83%) of aDBS due to the experimental nature of automatically modulating then observing stimulation effects outside a controlled clinical setting and in relation to need for surgical battery changes. Researchers also stressed the importance of ensuring informed consent and adequate patient understanding (74%). Concerns related to automaticity and device programming (65%) were discussed, including current uncertainties about biomarker validity. Additionally, researchers discussed the potential impacts of automatic stimulation on patients' autonomy and control over stimulation (57%). Lastly, researchers discussed concerns related to patient selection (defining criteria for candidacy) (39%), challenges of ensuring post-trial access to care and device maintenance (39%), and potential effects on personality and identity (30%). To help address researcher concerns, we discuss the need to minimize cybersecurity vulnerabilities, advance biomarker validity, promote the balance of device control between patients and clinicians, and enhance ongoing informed consent. The findings from this study will help inform policies that will maximize the benefits and minimize potential harms of aDBS and other next-generation DBS devices.

"Re-identifying yourself": a qualitative study of veteran views on implantable BCI for mobility and communication in ALS

OBJECTIVES

Brain-computer interface (BCI) technology to assist with mobility and communication is an active area of research in amyotrophic lateral sclerosis (ALS). Implantable BCI offers promise for individuals with severe disease, such as locked-in syndrome, but also raises important ethical issues. We undertook in-depth qualitative interviews with ALS patients from a Veterans Administration hospital ALS multi-disciplinary clinic and explored their perspectives on issues of identity, privacy, enhancement, informed consent, and responsibility related to implantable BCI.

METHODS

Semi-structured interviews were conducted with sixteen (n = 16) individuals, and transcripts were analysed using a modified grounded theory approach.

RESULTS

Emergent themes included: (1) attitudes towards BCI were characterised by fear, hope, and hesitation about adoption of BCI technology; (2) analogies to other technologies were a useful tool in understanding and communicating opinions about ethical issues in BCI; (3) concerns about potentially socially stigmatising effects of BCI and the burden of adjustment to new therapeutic devices were important considerations to be weighed against the potential functional benefit of BCI use; (4) therapeutic decision-making in ALS often intimately involves loved ones; and (5) prospective decision-making about BCI was significantly affected by weighing the timing of the intervention with the progression of illness.

CONCLUSION

The interest in BCI and views on ethical issues raised by BCI is moderated by the experience of living with ALS. The findings from this study can help guide the development of implantable BCI technology for persons with ALS.Implications for rehabilitationLoved ones will play crucial roles in helping patients think through the possible benefits and burdens of getting a BCI device.Providers should consider how the ideal timing for getting an implantable BCI device will vary based on the priorities of persons with ALS and their disease stage.Concerns about social stigma, burden of adjustment, and the desire to maximise time left with loved ones may outweigh the potential functional benefits of BCI devices for some persons with ALS.

Sensor Modalities for Brain-Computer Interface Technology: A Comprehensive Literature Review

Brain-computer interface (BCI) technology is rapidly developing and changing the paradigm of neurorestoration by linking cortical activity with control of an external effector to provide patients with tangible improvements in their ability to interact with the environment. The sensor component of a BCI circuit dictates the resolution of brain pattern recognition and therefore plays an integral role in the technology. Several sensor modalities are currently in use for BCI applications and are broadly either electrode-based or functional neuroimaging-based. Sensors vary in their inherent spatial and temporal resolutions, as well as in practical aspects such as invasiveness, portability, and maintenance. Hybrid BCI systems with multimodal sensory inputs represent a promising development in the field allowing for complimentary function. Artificial intelligence and deep learning algorithms have been applied to BCI systems to achieve faster and more accurate classifications of sensory input and improve user performance in various tasks. Neurofeedback is an important advancement in the field that has been implemented in several types of BCI systems by showing users a real-time display of their recorded brain activity during a task to facilitate their control over their own cortical activity. In this way, neurofeedback has improved BCI classification and enhanced user control over BCI output. Taken together, BCI systems have progressed significantly in recent years in terms of accuracy, speed, and communication. Understanding the sensory components of a BCI is essential for neurosurgeons and clinicians as they help advance this technology in the clinical setting.

Wired Emotions: Ethical Issues of Affective Brain-Computer Interfaces

Ethical issues concerning brain-computer interfaces (BCIs) have already received a considerable amount of attention. However, one particular form of BCI has not received the attention that it deserves: Affective BCIs that allow for the detection and stimulation of affective states. This paper brings the ethical issues of affective BCIs in sharper focus. The paper briefly reviews recent applications of affective BCIs and considers ethical issues that arise from these applications. Ethical issues that affective BCIs share with other neurotechnologies are presented and ethical concerns that are specific to affective BCIs are identified and discussed.

What is it like to use a BCI? - insights from an interview study with brain-computer interface users

Background

The neurotechnology behind brain-computer interfaces (BCIs) raises various ethical questions. The ethical literature has pinpointed several issues concerning safety, autonomy, responsibility and accountability, psychosocial identity, consent, privacy and data security. This study aims to assess BCI users’ experiences, self-observations and attitudes in their own right and looks for social and ethical implications.

Methods

We conducted nine semi-structured interviews with BCI users, who used the technology for medical reasons. The transcribed interviews were analyzed according to the Grounded Theory coding method.

Results

BCI users perceive themselves as active operators of a technology that offers them social participation and impacts their self-definition. Each of these aspects bears its own opportunities and risks. BCIs can contribute to retaining or regaining human capabilities. At the same time, BCI use contains elements that challenge common experiences, for example when the technology is in conflict with the affective side of BCI users. The potential benefits of BCIs are regarded as outweighing the risks in that BCI use is considered to promote valuable qualities and capabilities. BCI users appreciate the opportunity to regain lost capabilities as well as to gain new ones.

Conclusions

BCI users appreciate the technology for various reasons. The technology is highly appreciated in cases where it is beneficial in terms of agency, participation and self-definitions. Rather than questioning human nature, the technology can retain and restore characteristics and abilities which enrich our lives.

Ethics and the emergence of brain-computer interface medicine

Brain-computer interface (BCI) technology will usher in profound changes to the practice of medicine. BCI devices, broadly defined as those capable of reading brain activity and translating this into operation of a device, will offer patients and clinicians new ways to address impairments of communication, movement, sensation, and mental health. These new capabilities will bring new responsibilities and raise a diverse set of ethical challenges. One way to understand and begin to address these challenges is to view them in terms of the goals of medicine. In this chapter, different ways in which BCI technology may subserve the goals of medicine is explored. This is followed by articulation of additional goals particularly relevant to BCI technology: neural diversity, neural privacy, agency, and authenticity. The goals of medicine provide a useful ethical framework for the introduction of BCI devices into medicine.

Brain Computer Interfaces in Rehabilitation Medicine

One innovation currently influencing physical medicine and rehabilitation is brain-computer interface (BCI) technology. BCI systems used for motor control record neural activity associated with thoughts, perceptions, and motor intent; decode brain signals into commands for output devices; and perform the user's intended action through an output device. BCI systems used for sensory augmentation transduce environmental stimuli into neural signals interpretable by the central nervous system. Both types of systems have potential for reducing disability by facilitating a user's interaction with the environment. Investigational BCI systems are being used in the rehabilitation setting both as neuroprostheses to replace lost function and as potential plasticity-enhancing therapy tools aimed at accelerating neurorecovery. Populations benefitting from motor and somatosensory BCI systems include those with spinal cord injury, motor neuron disease, limb amputation, and stroke. This article discusses the basic components of BCI for rehabilitation, including recording systems and locations, signal processing and translation algorithms, and external devices controlled through BCI commands. An overview of applications in motor and sensory restoration is provided, along with ethical questions and user perspectives regarding BCI technology.

Identifying Criteria for the Evaluation of the Implications of Brain Reading for Mental Privacy

Contemporary brain reading technologies promise to provide the possibility to decode and interpret mental states and processes. Brain reading could have numerous societally relevant implications. In particular, the private character of mind might be affected, generating ethical and legal concerns. This paper aims at equipping ethicists and policy makers with conceptual tools to support an evaluation of the potential applicability and the implications of current and near future brain reading technology. We start with clarifying the concepts of mind reading and brain reading, and the different kinds of mental states that could in principle be read. Subsequently, we devise an evaluative framework that is composed of five criteria-accuracy, reliability, informativity, concealability and enforceability-aimed at enabling a clearer estimation of the degree to which brain reading might be realistically deployed in contexts where mental privacy could be at stake. While accuracy and reliability capture how well a certain method can access mental content, informativity indicates the relevance the obtainable data have for practical purposes. Concealability and enforceability are particularly important for the evaluation of concerns about potential violations of mental privacy and civil rights. The former concerns the degree with which a brain reading method can be concealed from an individual's perception or awareness. The latter regards the extent to which a method can be used against somebody's will. With the help of these criteria, stakeholders can orient themselves in the rapidly developing field of brain reading.

Embodiment and Estrangement: Results from a First-in-Human "Intelligent BCI" Trial

While new generations of implantable brain computer interface (BCI) devices are being developed, evidence in the literature about their impact on the patient experience is lagging. In this article, we address this knowledge gap by analysing data from the first-in-human clinical trial to study patients with implanted BCI advisory devices. We explored perceptions of self-change across six patients who volunteered to be implanted with artificially intelligent BCI devices. We used qualitative methodological tools grounded in phenomenology to conduct in-depth, semi-structured interviews. Results show that, on the one hand, BCIs can positively increase a sense of the self and control; on the other hand, they can induce radical distress, feelings of loss of control, and a rupture of patient identity. We conclude by offering suggestions for the proactive creation of preparedness protocols specific to intelligent-predictive and advisory-BCI technologies essential to prevent potential iatrogenic harms.

Ethical aspects of brain computer interfaces: a scoping review

BACKGROUND

Brain-Computer Interface (BCI) is a set of technologies that are of increasing interest to researchers. BCI has been proposed as assistive technology for individuals who are non-communicative or paralyzed, such as those with amyotrophic lateral sclerosis or spinal cord injury. The technology has also been suggested for enhancement and entertainment uses, and there are companies currently marketing BCI devices for those purposes (e.g., gaming) as well as health-related purposes (e.g., communication). The unprecedented direct connection created by BCI between human brains and computer hardware raises various ethical, social, and legal challenges that merit further examination and discussion.

METHODS

To identify and characterize the key issues associated with BCI use, we performed a scoping review of biomedical ethics literature, analyzing the ethics concerns cited across multiple disciplines, including philosophy and medicine.

RESULTS

Based on this investigation, we report that BCI research and its potential translation to therapeutic intervention generate significant ethical, legal, and social concerns, notably with regards to personhood, stigma, autonomy, privacy, research ethics, safety, responsibility, and justice. Our review of the literature determined, furthermore, that while these issues have been enumerated extensively, few concrete recommendations have been expressed.

CONCLUSIONS

We conclude that future research should focus on remedying a lack of practical solutions to the ethical challenges of BCI, alongside the collection of empirical data on the perspectives of the public, BCI users, and BCI researchers.

Informed consent in implantable BCI research: identification of research risks and recommendations for development of best practices

OBJECTIVE

Implantable brain-computer interface (BCI) research promises improvements in human health and enhancements in quality of life. Informed consent of subjects is a central tenet of this research. Rapid advances in neuroscience, and the intimate connection between functioning of the brain and conceptions of the self, make informed consent particularly challenging in BCI research. Identification of safety and research-related risks associated with BCI devices is an important step in ensuring meaningful informed consent.

APPROACH

This paper highlights a number of BCI research risks, including safety concerns, cognitive and communicative impairments, inappropriate subject expectations, group vulnerabilities, privacy and security, and disruptions of identity.

MAIN RESULTS

Based on identified BCI research risks, best practices are needed for understanding and incorporating BCI-related risks into informed consent protocols.

SIGNIFICANCE

Development of best practices should be guided by processes that are: multidisciplinary, systematic and transparent, iterative, relational and exploratory.