Closed Loop medical devices such as Closed Loop Deep Brain Stimulation (CL-DBS) and Brain Computer Interface (BCI) are some of the emerging neurotechnologies. New generations of implantable brain–computer interfaces have recently gained success in human clinical trials. These implants detect specific neuronal patterns and provide the subject with information to respond to these patterns. Further, Closed Loop brain devices give control to the subject so that he can respond and decide on a therapeutic goal. Although the implants have improved subjects’ quality of life, their use has raised varied ethical concerns. The aim of this study is to provide an overview of the ethical implications specific to the therapeutic goals of closed loop brain implants. The authors analyze the related work qualitatively and quantitatively so as to help readers in understanding the various ethical implications of closed loop brain implants.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Agid, Y., Schüpbach, M., Gargiulo, M., Mallet, L., Houeto, J. L., Behar, C., et al. (2006). Neurosurgery in Parkinson’s disease: The doctor is happy, the patient less so? Parkinson’s disease and related disorders (pp. 409–414). Vienna: Springer.
Akcakaya, M., Peters, B., Moghadamfalahi, M., Mooney, A. R., Orhan, U., Oken, B., et al. (2014). Noninvasive brain–computer interfaces for augmentative and alternative communication. IEEE Reviews in Biomedical Engineering,7, 31–49.
Allison, B.Z. (2011). Future BNCI: A roadmap for future directions in Brain Neuronal Computer Interaction Research. Retrieved February 2014 from http://futurebnci.org/images/stories/Future_BNCI_Roadmap.pdf.
Barclay, L. (2000). Autonomy and the social self.
Baylis, F. (2013). “I am who I am”: On the perceived threats to personal identity from deep brain stimulation. Neuroethics,6(3), 513–526.
Beauchamp, T. & Childress, J. F. (2009). Principles of Biomedical Ethics, 5.
Birbaumer, N., Gallegos-Ayala, G., Wildgruber, M., Silvoni, S., & Soekadar, S. R. (2014). Direct brain control and communication in paralysis. Brain Topography,27(1), 4–11.
Bonaci, T., Calo, R., & Chizeck, H. J. (2015). App stores for the brain: Privacy and security in brain–computer interfaces. IEEE Technology and Society Magazine,34(2), 32–39.
Brock, D. W. (1993). Life and death: Philosophical essays in biomedical ethics. Cambridge: Cambridge University Press.
Brown, T., Thompson, M. C., Herron, J., Ko, A., Chizeck, H., & Goering, S. (2016). Controlling our brains—A case study on the implications of brain–computer interface-triggered deep brain stimulation for essential tremor. Brain-Computer Interfaces,3(4), 165–170.
Burwell, S., Sample, M., & Racine, E. (2017). Ethical aspects of brain computer interfaces: A scoping review. BMC Medical Ethics,18(1), 60.
Center, E. (2011). Automatic adaptation of neurostimulation therapy in response to changes in patient position: Results of the Posture Responsive Spinal Cord Stimulation (PRS) Research Study. Pain Physician,14, 407–417.
Clausen, J. (2009). Man, machine and in between. Nature,457(7233), 1080.
Clausen, J. (2011). Conceptual and ethical issues with brain–hardware interfaces. Current Opinion in Psychiatry,24(6), 495–501.
Denning, P. J. (2009). Beyond computational thinking. Communications of the ACM,52(6), 28–30.
Erickson-Davis, C. O. R. D. E. L. I. A. (2012). Ethical concerns regarding commercialization of deep brain stimulation for obsessive compulsive disorder. Bioethics,26(8), 440–446.
Farah, M. J. (2005). Neuroethics: The practical and the philosophical. Trends in Cognitive Sciences,9(1), 34–40.
Fenton, A., & Alpert, S. (2008). Extending our view on using BCIs for locked-in syndrome. Neuroethics,1(2), 119–132.
Fins, J. J., Schlaepfer, T. E., Nuttin, B., Kubu, C. S., Galert, T., Sturm, V., et al. (2011). Ethical guidance for the management of conflicts of interest for researchers, engineers and clinicians engaged in the development of therapeutic deep brain stimulation. Journal of Neural Engineering,8(3), 033001.
Gardner, J. & Warren, N. (2018). Learning from deep brain stimulation: the fallacy of techno-solutionism and the need for ‘regimes of care’. Medicine, Health Care and Philosophy, 1–12.
Gilbert, F. (2015). A threat to autonomy? The intrusion of predictive brain implants. AJOB Neuroscience,6, 4.
Gilbert, F., Cook, M., O’Brien, T., & Illes, J. (2019). Embodiment and estrangement: Results from a first-in-human “intelligent BCI” trial. Science and Engineering Ethics,25(1), 83–96.
Gilbert, F., Viaña, J.N.M. & Ineichen, C. (2018). Deflating the “DBS causes personality changes” bubble. Neuroethics. 1–17.
Glannon. (2009). Stimulating brains, altering minds. Journal of Medical Ethics, 35(5).
Glannon, W. (2014). Neuromodulation, agency and autonomy. Brain Topography,27(1), 46–54.
Glannon, W. (2016). Ethical issues in neuroprosthetics. Journal of Neural Engineering,13(2), 021002.
Glannon, W., & Ineichen, C. (2016). Philosophical aspects of closed-loop neuroscience. In Closed loop neuroscience (pp. 259–270).
Goering, S., Klein, E., Dougherty, D. D., & Widge, A. S. (2017). Staying in the loop: Relational agency and identity in next-generation DBS for psychiatry. AJOB Neuroscience,8(2), 59–70.
Haggard, P. (2017). Sense of agency in the human brain. Nature Reviews Neuroscience,18(4), 196.
Haselager, P., Vlek, R., Hill, J., & Nijboer, F. (2009). A note on ethical aspects of BCI. Neural Networks,22(9), 1352–1357.
Kellmeyer, P., Cochrane, T., M€uller, O., et al. (2016). The effects of closed-loop medical devices on the autonomy and accountability of persons and systems. Cambridge Quarterly of Healthcare Ethics,25(4), 623–633.
Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., et al. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke,45(7), 2160–2236.
Klein, E. (2016). Informed consent in implantable BCI research: Identifying risks and exploring meaning. Science and Engineering Ethics,22(5), 1299–1317.
Klein, E., Brown, T., Sample, M., Truitt, A. R., & Goering, S. (2015). Engineering the brain: ethical issues and the introduction of neural devices. Hastings Center Report,45(6), 26–35.
Klein, E., Goering, S., Gagne, J., Shea, C. V., Franklin, R., Zorowitz, S., et al. (2016). Brain–computer interface-based control of closed-loop brain stimulation: Attitudes and ethical considerations. Brain-Computer Interfaces,3(3), 140–148.
Klein, E., & Ojemann, J. (2016). Informed consent in implantable BCI research: Identification of research risks and recommendations for development of best practices. Journal of Neural Engineering,13(4), 043001.
Kotchetkov, I. S., Hwang, B. Y., Appelboom, G., Kellner, C. P., & Connolly, E. S. (2010). Brain–computer interfaces: Military, neurosurgical, and ethical perspective. Neurosurgical Focus,28(5), E25.
Lavazza, A. (2018). Freedom of thought and mental integrity: The moral requirements for any neural prosthesis. Frontiers in Neuroscience,12, 82.
Lee, K.Y. & Jang, D. (2013). February. Ethical and social issues behind brain–computer interface. In 2013 International Winter Workshop on Brain-Computer Interface (BCI) (pp. 72–75). New York: IEEE.
Little, S., Pogosyan, A., Neal, S., Zavala, B., Zrinzo, L., Hariz, M., et al. (2013). Adaptive deep brain stimulation in advanced Parkinson disease. Annals of Neurology,74(3), 449–457.
Mastroianni, A. C., Faden, R., & Federman, D. (Eds.). (1994). Women and health research: Ethical and legal issues of including women in clinical studies (Vol. 1). Washington, DC: National Academies Press.
McAdams, D. P., & McLean, K. C. (2013). Narrative identity. Current directions in psychological science,22(3), 233–238.
McCullagh, P.J., Ware, M., Mulvenna, M., Lightbody, G., Nugent, C.D., & McAllister, H.G. (2010). Can brain computer interfaces become practical assistive devices in the community?
Mele, A. R. (2001). Autonomous agents: From self-control to autonomy. Oxford: Oxford University Press on Demand.
Morrell, M. J. (2011). Responsive cortical stimulation for the treatment of medically intractable partial epilepsy. Neurology,77(13), 1295–1304.
Morrell, M. J., & Halpern, C. (2016). Responsive direct brain stimulation for epilepsy. Neurosurgery Clinics,27(1), 111–121.
Müller, O., & Rotter, S. (2017). Neurotechnology: Current developments and ethical issues. Frontiers in Systems Neuroscience,11, 93.
Nijboer, F., Clausen, J., Allison, B. Z., & Haselager, P. (2013). The asilomar survey: Stakeholders’ opinions on ethical issues related to brain–computer interfacing. Neuroethics,6(3), 541–578.
Osorio, I., Frei, M. G., Manly, B. F., Sunderam, S., Bhavaraju, N. C., & Wilkinson, S. B. (2001). An introduction to contingent (closed-loop) brain electrical stimulation for seizure blockage, to ultra-short-term clinical trials, and to multidimensional statistical analysis of therapeutic efficacy. Journal of Clinical Neurophysiology,18(6), 533–544.
Parastarfeizabadi, M., & Kouzani, A. Z. (2017). Advances in closed-loop deep brain stimulation devices. Journal of Neuroengineering and Rehabilitation,14(1), 79.
Patuzzo, S., & Manganotti, P. (2014). Deep brain stimulation in persistent vegetative states: ethical issues governing decision making. Behavioural Neurology, 2014.
Rabins, P., Appleby, B. S., Brandt, J., DeLong, M. R., Dunn, L. B., Gabriëls, L., et al. (2009). Scientific and ethical issues related to deep brain stimulation for disorders of mood, behavior, and thought. Archives of General Psychiatry,66(9), 931–937.
Rahman, M. A., Khan, A. H., Ahmed, T., & Sajjad, M. M. (2013). Design, analysis and implementation of a robotic arm—the animator. American Journal of Engineering Research (AJER),2(10), 298–307.
Santos, F. J., Costa, R. M., & Tecuapetla, F. (2011). Stimulation on demand: Closing the loop on deep brain stimulation. Neuron,72(2), 197–198.
Schechtman, M. (2009). Getting our stories straight: Self-narrative and personal identity.
Schermer, M. (2010). Philosophical reflections on narrative and deep brain stimulation. Journal of Clinical Ethics,21(2), 133–139.
Schermer, M. (2011). Ethical issues in deep brain stimulation. Frontiers in Integrative Neuroscience,5, 17.
Schlaepfer, T. E., & Fins, J. J. (2010). Deep brain stimulation and the neuroethics of responsible publishing: When one is not enough. JAMA,303(8), 775–776.
Tamburrini, G. (2009). Brain to computer communication: Ethical perspectives on interaction models. Neuroethics,2(3), 137–149.
Vlek, R. J., Steines, D., Szibbo, D., Kübler, A., Schneider, M. J., Haselager, P., et al. (2012). Ethical issues in brain–computer interface research, development, and dissemination. Journal of Neurologic Physical Therapy,36(2), 94–99.
Vogeley, K., & Gallagher, S. (2011). Self in the brain (p. 111). na.
Ward, M. P., & Irazoqui, P. P. (2010). Evolving refractory major depressive disorder diagnostic and treatment paradigms: Toward closed-loop therapeutics. Frontiers in Neuroengineering,3, 7.
Widge, A. S., Dougherty, D. D., & Moritz, C. T. (2014). Affective brain–computer interfaces as enabling technology for responsive psychiatric stimulation. Brain-Computer Interfaces,1(2), 126–136.
Witt, K., Kuhn, J., Timmermann, L., Zurowski, M., & Woopen, C. (2013). Deep brain stimulation and the search for identity. Neuroethics,6(3), 499–511.
Wolpaw, J. R., Birbaumer, N., McFarland, D. J., Pfurtscheller, G., & Vaughan, T. M. (2002). Brain–computer interfaces for communication and control. Clinical Neurophysiology,113(6), 767–791.
Wolpe, P. R. (2007). Ethical and social challenges of brain–computer interfaces. AMA Journal of Ethics,9(2), 128–131.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Aggarwal, S., Chugh, N. Ethical Implications of Closed Loop Brain Device: 10-Year Review. Minds & Machines 30, 145–170 (2020). https://doi.org/10.1007/s11023-020-09518-7
- Closed Loop Brain Implants
- Deep Brain Stimulation (DBS)
- Brain Computer Interfaces (BCI)
- Ethical implications