Dimensions of Ethical Direct-to-Consumer Neurotechnologies

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.

Ethical considerations for integrating multimodal computer perception and neurotechnology

Background

Artificial intelligence (AI)-based computer perception technologies (e.g., digital phenotyping and affective computing) promise to transform clinical approaches to personalized care in psychiatry and beyond by offering more objective measures of emotional states and behavior, enabling precision treatment, diagnosis, and symptom monitoring. At the same time, passive and continuous nature by which they often collect data from patients in non-clinical settings raises ethical issues related to privacy and self-determination. Little is known about how such concerns may be exacerbated by the integration of neural data, as parallel advances in computer perception, AI, and neurotechnology enable new insights into subjective states. Here, we present findings from a multi-site NCATS-funded study of ethical considerations for translating computer perception into clinical care and contextualize them within the neuroethics and neurorights literatures.

Methods

We conducted qualitative interviews with patients (n = 20), caregivers (n = 20), clinicians (n = 12), developers (n = 12), and clinician developers (n = 2) regarding their perspective toward using PC in clinical care. Transcripts were analyzed in MAXQDA using Thematic Content Analysis.

Results

Stakeholder groups voiced concerns related to (1) perceived invasiveness of passive and continuous data collection in private settings; (2) data protection and security and the potential for negative downstream/future impacts on patients of unintended disclosure; and (3) ethical issues related to patients' limited versus hyper awareness of passive and continuous data collection and monitoring. Clinicians and developers highlighted that these concerns may be exacerbated by the integration of neural data with other computer perception data.

Discussion

Our findings suggest that the integration of neurotechnologies with existing computer perception technologies raises novel concerns around dignity-related and other harms (e.g., stigma, discrimination) that stem from data security threats and the growing potential for reidentification of sensitive data. Further, our findings suggest that patients' awareness and preoccupation with feeling monitored via computer sensors ranges from hypo- to hyper-awareness, with either extreme accompanied by ethical concerns (consent vs. anxiety and preoccupation). These results highlight the need for systematic research into how best to implement these technologies into clinical care in ways that reduce disruption, maximize patient benefits, and mitigate long-term risks associated with the passive collection of sensitive emotional, behavioral and neural data.

Ethical issues in direct-to-consumer healthcare: A scoping review

An increasing number of health products and services are being offered on a direct-to-consumer (DTC) basis. To date, however, scholarship on DTC healthcare products and services has largely proceeded in a domain-specific fashion, with discussions of relevant ethical challenges occurring within specific medical specialties. The present study therefore aimed to provide a scoping review of ethical issues raised in the academic literature across types of DTC healthcare products and services. A systematic search for relevant publications between 2011-2021 was conducted on PubMed and Google Scholar using iteratively developed search terms. The final sample included 86 publications that discussed ethical issues related to DTC healthcare products and services. All publications were coded for ethical issues mentioned, primary DTC product or service discussed, type of study, year of publication, and geographical context. We found that the types of DTC healthcare products and services mentioned in our sample spanned six categories: neurotechnology (34%), testing (20%), in-person services (17%), digital health tools (14%), telemedicine (13%), and physical interventions (2%). Ethical arguments in favor of DTC healthcare included improved access (e.g., financial, geographical; 31%), increased autonomy (29%), and enhanced convenience (16%). Commonly raised ethical concerns included insufficient regulation (72%), questionable efficacy and quality (70%), safety and physical harms (66%), misleading advertising claims (56%), and privacy (34%). Other frequently occurring ethical concerns pertained to financial costs, targeting vulnerable groups, informed consent, and potential burdens on healthcare providers, the healthcare system, and society. Our findings offer insights into the cross-cutting ethical issues associated with DTC healthcare and underscore the need for increased interdisciplinary communication to address the challenges they raise.

Governance of research and product improvement studies in consumer mental health apps. Interviews with researchers and app developers

Consumer mental health apps (MHAs) collect and generate mental health-related data on their users, which can be leveraged for research and product improvement studies. Such studies are associated with ethical issues that may be difficult for researchers and app developers to assess. To improve ethical study conduct, governance through rules, agreements and customs could be relied upon, but their translation into practice is subject to barriers. This qualitative interview study with 17 researchers and app developers looked into the role and impact of governance standards on consumer MHA studies. Interviewees experienced a significant number of rules, agreements and customs, although not all of the governance standards that can potentially be applicable. Standards did have an impact on the interests of researchers and app developers, app users and society, but this impact was mediated by several barriers related to their conceptualization and implementation. Conceptualization barriers impacted the development of a standard, the inclusion of relevant concepts and the coordination between standards. Implementation barriers concerned the resource cost of understanding a standard, as well as suboptimal enforcement. The framework developed in this study can support more effective efforts to improve the governance of future consumer MHA studies.

Advocating for neurodata privacy and neurotechnology regulation

The ability to record and alter brain activity by using implantable and nonimplantable neural devices, while poised to have significant scientific and clinical benefits, also raises complex ethical concerns. In this Perspective, we raise awareness of the ability of artificial intelligence algorithms and data-aggregation tools to decode and analyze data containing highly sensitive information, jeopardizing personal neuroprivacy. Voids in existing regulatory frameworks, in fact, allow unrestricted decoding and commerce of neurodata. We advocate for the implementation of proposed ethical and human rights guidelines, alongside technical options such as data encryption, differential privacy and federated learning to ensure the protection of neurodata privacy. We further encourage regulatory bodies to consider taking a position of responsibility by categorizing all brain-derived data as sensitive health data and apply existing medical regulations to all data gathered via pre-registered neural devices. Lastly, we propose that a technocratic oath may instill a deontology for neurotechnology practitioners akin to what the Hippocratic oath represents in medicine. A conscientious societal position that thoroughly rejects the misuse of neurodata would provide the moral compass for the future development of the neurotechnology field.

A comparative review on neuroethical issues in neuroscientific and neuroethical journals

This study is a pilot literature review that compares the interest of neuroethicists and neuroscientists. It aims to determine whether there is a significant gap between the neuroethical issues addressed in philosophical neuroethics journals and neuroscience journals. We retrieved 614 articles from two specialist neuroethics journals (Neuroethics and AJOB Neuroscience) and 82 neuroethics-focused articles from three specialist neuroscience journals (Neuron, Nature Neuroscience, and Nature Reviews Neuroscience). We classified these articles in light of the neuroethical issue in question before we compared the neuroethical issues addressed in philosophical neuroethics with those addressed by neuroscientists. A notable result is a parallelism between them as a general tendency. Neuroscientific articles cover most neuroethical issues discussed by philosophical ethicists and vice versa. Subsequently, there are notable discrepancies between the two bodies of neuroethics literature. For instance, theoretical questions, such as the ethics of moral enhancement and the philosophical implications of neuroscientific findings on our conception of personhood, are more intensely discussed in philosophical-neuroethical articles. Conversely, neuroscientific articles tend to emphasize practical questions, such as how to successfully integrate ethical perspectives into scientific research projects and justifiable practices of animal-involving neuroscientific research. These observations will help us settle the common starting point of the attempt at "ethics integration" in emerging neuroscience, contributing to better governance design and neuroethical practice.

Development of Korea Neuroethics Guidelines

BACKGROUND

Advances in neuroscience and neurotechnology provide great benefits to humans though unknown challenges may arise. We should address these challenges using new standards as well as existing ones. Novel standards should include ethical, legal, and social aspects which would be appropriate for advancing neuroscience and technology. Therefore, the Korea Neuroethics Guidelines were developed by stakeholders related to neuroscience and neurotechnology, including experts, policy makers, and the public in the Republic of Korea.

METHOD

The guidelines were drafted by neuroethics experts, were disclosed at a public hearing, and were subsequently revised by opinions of various stakeholders.

RESULTS

The guidelines are composed of twelve issues; humanity or human dignity, individual personality and identity, social justice, safety, sociocultural prejudice and public communication, misuse of technology, responsibility for the use of neuroscience and technology, specificity according to the purpose of using neurotechnology, autonomy, privacy and personal information, research, and enhancement.

CONCLUSION

Although the guidelines may require a more detailed discussion after future advances in neuroscience and technology or changes in socio-cultural milieu, the development of the Korea Neuroethics Guidelines is a milestone for the scientific community and society in general for the ongoing development in neuroscience and neurotechnology.

An XYZ-axis Matrix Approach for the Integration of Neuroscience and Neuroethics

The recent, unprecedented advancement in neuroscience has led to new discoveries about the human brain and its function. Yet at the same time, it has spurred novel ethical and regulatory issues, and the field of neuroethics has emerged as an interdisciplinary endeavor to address these issues. Across the globe, extensive efforts have been underway to achieve the integration of neuroscience and Neuroethics, with active engagement not only from academia but also from the government, the public, and industry. However, in some countries, integrating neuroscience and neuroethics has proved to be a particularly challenging task. For example, in South Korea, the government has primarily driven the integration effort, and only a small group of researchers is properly trained for conducting an interdisciplinary evaluation of ethical, legal, social, and cultural implications (ELSCI) of neurotechnology. On the basis of the last few years of experience pursuing a government-funded neuroethics project in South Korea, we developed a new operational framework to provide practical guidance on ELSCI research. This framework consists of the X, Y, and Z axes; the X-axis represents a target neurotechnology, the Y-axis represents different developmental stages of the technology, and the Z-axis represents ELSCI issues that may arise from the development and use of the neurotechnology. Here we also present a step-by-step workflow to apply this matrix framework, from organizing a panel for a target neurotechnology to facilitating stakeholder discussion through public hearings. This framework will enable meaningful integration of neuroscience and neuroethics to promote responsible innovation in neuroscience and neurotechnology.

How Neurotech Start-Ups Envision Ethical Futures: Demarcation, Deferral, Delegation

Like many ethics debates surrounding emerging technologies, neuroethics is increasingly concerned with the private sector. Here, entrepreneurial visions and claims of how neurotechnology innovation will revolutionize society-from brain-computer-interfaces to neural enhancement and cognitive phenotyping-are confronted with public and policy concerns about the risks and ethical challenges related to such innovations. But while neuroethics frameworks have a longer track record in public sector research such as the U.S. BRAIN Initiative, much less is known about how businesses-and especially start-ups-address ethics in tech development. In this paper, we investigate how actors in the field frame and enact ethics as part of their innovative R&D processes and business models. Drawing on an empirical case study on direct-to-consumer (DTC) neurotechnology start-ups, we find that actors engage in careful boundary-work to anticipate and address public critique of their technologies, which allows them to delineate a manageable scope of their ethics integration. In particular, boundaries are drawn around four areas: the technology's actual capability, purpose, safety and evidence-base. By drawing such lines of demarcation, we suggest that start-ups make their visions of ethical neurotechnology in society more acceptable, plausible and desirable, favoring their innovations while at the same time assigning discrete responsibilities for ethics. These visions establish a link from the present into the future, mobilizing the latter as promissory place where a technology's benefits will materialize and to which certain ethical issues can be deferred. In turn, the present is constructed as a moment in which ethical engagement could be delegated to permissive regulatory standards and scientific authority. Our empirical tracing of the construction of 'ethical realities' in and by start-ups offers new inroads for ethics research and governance in tech industries beyond neurotechnology.

Developments in the mechanistic understanding and clinical application of deep brain stimulation for Parkinson's disease

INTRODUCTION. Deep brain stimulation (DBS) is a life-changing treatment for patients with Parkinson's disease (PD) and gives the unique opportunity to directly explore how basal ganglia work. Despite the rapid technological innovation of the last years, the untapped potential of DBS is still high.

AREAS COVERED. This review summarizes the developments in the mechanistic understanding of DBS and the potential clinical applications of cutting-edge technological advances. Rather than a univocal local mechanism, DBS exerts its therapeutic effects through several multimodal mechanisms and involving both local and network-wide structures, although crucial questions remain unexplained. Nonetheless, new insights in mechanistic understanding of DBS in PD have provided solid bases for advances in preoperative selection phase, prediction of motor and non-motor outcomes, leads placement and postoperative stimulation programming.

EXPERT OPINION. DBS has not only strong evidence of clinical effectiveness in PD treatment, but technological advancements are revamping its role of neuromodulation of brain circuits and key to better understanding PD pathophysiology. In the next few years, the worldwide use of new technologies in clinical practice will provide large data to elucidate their role and to expand their applications for PD patients, providing useful insights to personalize DBS treatment and follow-up.

Researchers' Ethical Concerns About Using Adaptive Deep Brain Stimulation for Enhancement

The capacity of next-generation closed-loop or adaptive deep brain stimulation devices (aDBS) to read (measure neural activity) and write (stimulate brain regions or circuits) shows great potential to effectively manage movement, seizure, and psychiatric disorders, and also raises the possibility of using aDBS to electively (non-therapeutically) modulate mood, cognition, and prosociality. What separates aDBS from most neurotechnologies (e.g. transcranial stimulation) currently used for enhancement is that aDBS remains an invasive, surgically-implanted technology with a risk-benefit ratio significantly different when applied to diseased versus non-diseased individuals. Despite a large discourse about the ethics of enhancement, no empirical studies yet examine perspectives on enhancement from within the aDBS research community. We interviewed 23 aDBS researchers about their attitudes toward expanding aDBS use for enhancement. A thematic content analysis revealed that researchers share ethical concerns related to (1) safety and security; (2) enhancement as unnecessary, unnatural or aberrant; and (3) fairness, equality, and distributive justice. Most (70%) researchers felt that enhancement applications for DBS will eventually be technically feasible and that attempts to develop such applications for DBS are already happening (particularly for military purposes). However, researchers unanimously (100%) felt that DBS ideally should not be considered for enhancement until researchers better understand brain target localization and functioning. While many researchers acknowledged controversies highlighted by scholars and ethicists, such as potential impacts on personhood, authenticity, autonomy and privacy, their ethical concerns reflect considerations of both gravity and perceived near-term likelihood.

Brazilian research on noninvasive brain stimulation applied to health conditions

BACKGROUND

Brazil has a top position regarding scientific production on noninvasive neuromodulation worldwide. Knowledge of scientometric phenomena involving Brazilian researchers who produce science on this theme may aid confidence in Brazilian clinical and research professionals.

OBJECTIVE

To investigate the scenario of research on the theme of noninvasive neuromodulation in Brazil.

METHODS

This was a scientometric study for mapping scientific production on this subject involving network phenomena, the professions of researchers, institutional affiliation, main research unit, total number of scientific articles on noninvasive neuromodulation published in journals, research sub-area and year of obtaining the PhD title. Public data from Lattes Platform curricula vitae and from VOSViewer© were used.

RESULTS

A total of 54 Brazilian researchers were identified, of whom 16 are research productivity fellows. Most of them are linked to institutions in southeastern Brazil, involving the professions of biology, biochemistry, physical education, physiotherapy, speech therapy, gerontology, medicine and psychology, with 1175 articles published in journals. These studies involve experimental animal and human models to account for mechanisms, observational studies, case reports, randomized clinical trials, systematic reviews, meta-analyses, product and process development, computer modeling and guidelines.

CONCLUSIONS

Brazil occupies a prominent place in the world scenario of research on noninvasive neuromodulation, which is used by different professions for treatment of brain dysfunctions, with a trend towards expansion to other fields.

'Personal Health Surveillance': The Use of mHealth in Healthcare Responsibilisation

There is an ongoing increase in the use of mobile health (mHealth) technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses 'medical monitoring', and the second 'personal health surveillance'. After outlining two problems which the use of mHealth might seem to enable us to overcome-fairness of burdens and reliance on self-reporting-I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim.

What Should We Do With People Who Cannot or Do Not Want to Be Protected From Neurotechnological Threats?

Neurotechnologies can pose a threat to people's privacy and mental integrity. Hence the proposal of establishing neurorights (Ienca and Andorno, 2017) and technical principles for the implementation of these rights (Lavazza, 2018). However, concepts such as "the extended mind" and what might be called "the post-human objection" can be said to challenge this protection paradigm. On the one hand, it may be difficult to outline the cognitive boundaries between humans and machines (with the consequent ethical and legal implications). On the other hand, those who wish to make strong use of neurotechnologies, or even hybridize with them, reject the idea that privacy and mental integrity should be protected. However, from the latter view, issues may arise relating to the protection of persons entering into relationships with posthumanist people. This article will discuss these scenarios as well as the ethical, legal, social, and political issues that could follow from them.

Recommendations for Responsible Development and Application of Neurotechnologies

Advancements in novel neurotechnologies, such as brain computer interfaces (BCI) and neuromodulatory devices such as deep brain stimulators (DBS), will have profound implications for society and human rights. While these technologies are improving the diagnosis and treatment of mental and neurological diseases, they can also alter individual agency and estrange those using neurotechnologies from their sense of self, challenging basic notions of what it means to be human. As an international coalition of interdisciplinary scholars and practitioners, we examine these challenges and make recommendations to mitigate negative consequences that could arise from the unregulated development or application of novel neurotechnologies. We explore potential ethical challenges in four key areas: identity and agency, privacy, bias, and enhancement. To address them, we propose (1) democratic and inclusive summits to establish globally-coordinated ethical and societal guidelines for neurotechnology development and application, (2) new measures, including "Neurorights," for data privacy, security, and consent to empower neurotechnology users' control over their data, (3) new methods of identifying and preventing bias, and (4) the adoption of public guidelines for safe and equitable distribution of neurotechnological devices.

Narrative Devices: Neurotechnologies, Information, and Self-Constitution

This article provides a conceptual and normative framework through which we may understand the potentially ethically significant roles that information generated by neurotechnologies about our brains and minds may play in our construction of our identities. Neuroethics debates currently focus disproportionately on the ways that third parties may (ab)use these kinds of information. These debates occlude interests we may have in whether and how we ourselves encounter information about our own brains and minds. This gap is not yet adequately addressed by most allusions in the literature to potential identity impacts. These lack the requisite conceptual or normative foundations to explain why we should be concerned about such effects or how they might be addressed. This article seeks to fill this gap by presenting a normative account of identity as constituted by embodied self-narratives. It proposes that information generated by neurotechnologies can play significant content-supplying and interpretive roles in our construction of our self-narratives. It argues, to the extent that these roles support and detract from the coherence and inhabitability of these narratives, access to information about our brains and minds engages non-trivial identity-related interests. These claims are illustrated using examples drawn from empirical literature reporting reactions to information generated by implantable predictive BCIs and psychiatric neuroimaging. The article concludes by highlighting ways in which information generated by neurotechnologies might be governed so as to protect information subjects' interests in developing and inhabiting their own identities.

Neuroethics: Fostering Collaborations to Enable Neuroscientific Discovery

The NIH-funded Brain Research through Advancing Innovative Neurotechnologies^® (BRAIN) Initiative has led to significant advances in what we know about the functions and capacities of the brain. This multifaceted and expansive effort supports a range of experimentation from cells to circuits, and its outputs promise to ease suffering from various neurological injuries, diseases, and neuropsychiatric conditions. At the midway point of the 10-year BRAIN Initiative, we pause to consider how these studies, and neuroscience research more broadly, may bear on human characteristics and moral concepts such as identity, agency, and others. This midway point also offers us an opportunity to evaluate the sociology and impacts of BRAIN Initiative-funded investigations to ensure that ethical standards of fairness and justice pervade the scientific process itself. Neuroethics inquiry provides a mechanism to invite relevant, novel expertise from the wide array of disciplines that intersect with biomedicine in neuroscience research. As the BRAIN Initiative and the broader field of neuroscience proceed, neuroethics serves as a central component of neuroscience inquiry to i) foster necessary and beneficial collaborations for responsible discovery; ii) ensure a rigorous, reproducible, and representative neuroscience research process; and iii) explore the unique nature of study of the human brain through accurate and representative models of its function and dysfunction.

Privacy Challenges to the Democratization of Brain Data

Wearable devices that record brain signals may present privacy concerns for consumers. Industry leaders discussed four such concerns with us that pertain to data collection and management, user autonomy and information transparency, exceptionalism of brain data, and regulatory systems.

Neuroenhancement for sale: assessing the website claims of neurofeedback providers in the United States

Although electroencephalographic (EEG) neurofeedback is a technique that has been in existence for many decades, it has remained controversial, largely due to questions about efficacy. Yet neurofeedback is being widely offered to the public, often at great expense. To date, however, there has not been empirical data on which providers are utilizing neurofeedback, what they are offering it for, and how they are advertising the technique. The present study aimed to fill that gap by systematically analyzing the websites of neurofeedback practitioners in the United States. To that end, we obtained data from four directories of neurofeedback providers, extracting practitioner names, geographical locations, professional training, and website URLs. Only websites offering neurofeedback services (N=371) were included in the next step, wherein two coders independently coded the websites based on a codebook developed from preliminary analyses. We found that nearly all websites (97.0%) contained claims about at least one clinical indication, most commonly anxiety, ADHD/ADD, and depression; however, only 36.0% of providers had either a medical degree (MD) or a doctoral-level degree in psychology. The majority of websites advertised neurofeedback for cognitive (90.0%) or performance (67.9%) enhancement, and roughly three-quarters utilized language related to complementary and alternative medicine (CAM). In sum, there is a considerable divergence between the scientific literature on neurofeedback and the marketing of neurofeedback services to the general public, raising concerns regarding the misrepresentation of services and misleading advertising claims.