Translational Neuroethics: A Vision for a More Integrated, Inclusive, and Impactful Field.

As early-career neuroethicists, we come to the field of neuroethics at a unique moment: we are well-situated to consider nearly two decades of neuroethics scholarship and identify challenges that have persisted across time. But we are also looking squarely ahead, embarking on the next generation of exciting and productive neuroethics scholarship. In this article, we both reflect backwards and turn our gaze forward. First, we highlight criticisms of neuroethics, both from scholars within the field and outside it, that have focused on speculation and lack of skepticism; the dearth of consideration of broader social issues such as justice and equality, both with regard to who speaks for neuroethics as a field and who benefits from its recommendations and findings; and the insufficient focus on the practical impact of our ethical work. Second, we embrace the concept of "translational neuroethics" to outline a vision for neuroethics that is integrated, inclusive, and impactful. Integration can help us identify more pertinent, real-world issues, and move away from speculation; inclusivity can help ensure that the questions we attend to are not merely relevant to a single subgroup but aim toward just distribution of benefits; and impact can help us think beyond guidelines and recommendations to focus on implementation. Our goal is for this call to action to help shape neuroethics into a discipline that develops rigorous research agendas through relationships with interdisciplinary partners, that is broadly inclusive and attends to issues beyond novel neurotechnologies, and that is devoted to the translation of scholarship into practice.

Neurofeedback as placebo: a case of unintentional deception?

The use of placebo in clinical practice has been the topic of extensive debate in the bioethics literature, with much scholarship focusing on concerns regarding deception. While considerations of placebo without deception have largely centred on open-label placebo, this paper considers a different kind of ethical quandary regarding placebo without an intent to deceive-one where the provider believes a treatment is effective due to a direct physiological mechanism, even though that belief may not be supported by rigorous scientific evidence. This is often the case with complementary and alternative medicine (CAM) techniques and also with some mainstream therapies that have not proven to be better than sham. Using one such CAM technique as a case study-electroencephalography (EEG) neurofeedback for attention-deficit/hyperactivity disorder (ADHD)-this paper explores the ethics of providing therapies that may have some beneficial effect, although one that is likely due to placebo effect. First, we provide background on EEG neurofeedback for ADHD and its evidence base, showing how it has proven to be equivalent to-but not better than-sham neurofeedback. Subsequently, we explore whether offering therapies that are claimed to work via specific physical pathways, but may actually work due to the placebo effect, constitute deception. We suggest that this practice may constitute unintentional deception regarding mechanism of action. Ultimately, we argue that providers have increased information provision obligations when offering treatments that diverge from standard of care and we make recommendations for mitigating unintentional deception.

Mistaken Compassion: Tibetan Buddhist Perspectives on Neuroethics.

For more than 20 years, Western science education has been incorporated into Tibetan Buddhist monastics' training. In this time, there have been a number of fruitful collaborations between Buddhist monastics and neuroscientists, neurologists, and psychologists. These collaborations are unsurprising given the emphasis on phenomenological exploration of first-person conscious experience in Buddhist contemplative practice and the focus on the mind and consciousness in Buddhist theory. As such, Tibetan monastics may have underappreciated intuitions on the intersection of science, medicine, and ethics. Yet despite their overlapping interests, Buddhist perspectives are largely absent in contemporary neuroethical analysis, apart from conceptual arguments for their relevance. This article attempts to fill this gap by presenting the results of eleven semi-structured interviews with Tibetan Buddhist monastics in India on three issues in neuroethics: identity and authenticity, enhancement, and disorders of consciousness. The results of this empirical study reinforce the conclusions of theoretical work on Buddhism and neuroethics while also identifying future areas of inquiry, including the importance of community, the challenges in acting from compassion, and the value of self-directed mental cultivation.

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.

More than consent for ethical open-label placebo research.

Recent studies have explored the effectiveness of open-label placebos (OLPs) for a variety of conditions, including chronic pain, cancer-related fatigue and irritable bowel syndrome. OLPs are thought to sidestep traditional ethical worries about placebos because they do not involve deception: with an OLP, patients or subjects are told outright that they are not given an active substance. As deception is framed as the primary hurdle to ethical placebo use, the door is ostensibly opened to ethical studies of OLPs. In this article, I suggest that even though OLPs seemingly do not involve deception, there are other ethical considerations in their clinical investigation and subsequent use. Research ethics often focusses on informed consent-of which, deception and honesty are a piece-as a means to justify research practices with human subjects. Yet, it is but one of the ethical considerations that should be taken into account. With research into placebo effects in particular, I argue that the history of clinical placebo use grounds special considerations for OLP research that go beyond respect for the autonomy of individual patients through informed consent and encompass structural concerns about the type of patient for whom a placebo has historically been thought appropriate.

Current barriers and ethical considerations for clinical implementation of epidural stimulation for functional improvement after spinal cord injury.

Context/objective: To determine current barriers for clinical implementation of epidural stimulation for functional improvement after spinal cord injury and highlight applicable ethical constructs to approach future research. Design: Survey of spinal cord injury medicine physicians, January 2019. Setting: Spinal cord injury model systems hospital sites across the United States. Participants: Spinal cord injury medicine physicians. Interventions: NA. Outcome measures: Physician-identified current barriers to clinical implementation of epidural stimulation. Results: The response rate for the survey was 54.6% (n = 42), with the majority of physicians (61.9%) having been asked by patients with spinal cord injuries about epidural stimulation. Numerous current barriers to clinical implementation were identified, including need for additional efficacy studies (92.9%), lack of clear guidelines on stimulation parameters (83.3%), and inability to identify which patients will benefit (76.2%). Conclusions: With multiple barriers to clinical implementation currently identified, evaluating this research with an eye toward the ethical construct of equipoise is increasingly relevant. Addressing these barriers may require modifications in both physician expectations and how researchers approach this work.

Insight and the no-self in deep brain stimulation.

Ethical analyses of the effects of neural interventions commonly focus on changes to personality and behavior, interpreting these changes in terms of authenticity and identity. These phenomena have led to debate among ethicists about the meaning of these terms for ethical analysis of such interventions. While these theoretical approaches have different criteria for ethical significance, they agree that patients' reports are concerning because a sense of self is valuable. In this paper, I question this assumption. I propose that the Buddhist theory of no-self offers a novel approach to making ethical sense of patients' claims following deep brain stimulation. This alternative approach is based on the value of insight into patterns of cause and effect among mental states and actions.

Dynamic axes of informed consent in Japan.

Scholarship in cross-cultural bioethics routinely frames Japanese informed consent in contrast to informed consent in North America. This contrastive analysis foregrounds cancer diagnosis disclosure and physician paternalism as unique aspects of Japanese informed consent that deviate from American practices. Drawing on in-depth interviews with 15 Japanese medical professionals obtained during fieldwork in Japan from 2013 to 15, this article complicates the informed consent discourse beyond East-West comparisons premised on Anglo-American ethical frameworks. It expands professional perspectives to include nurses, medical social workers, clinical psychologists, and ethicists and it addresses informed consent for a broad range of conditions in addition to cancer. The results suggest that division of affective labor is an under-theorized dimension of informed consent that is perceived as at odds with principled demands for universal informed consent. These practical tensions are conceptualized as cultural differences, with Japan identified in terms of omakase as practical and supportive and the United States identified in terms of jiko kettei as principled and self-determining. These results have implications for the methodology of cross-cultural bioethics as well as for theories and practices of informed consent in both Japan and the United States. I conclude that responsible cross-cultural work in bioethics must begin from the ground up, incorporating all relevant stakeholder perspectives, attitudes, and experiences.

Medical maternalism: beyond paternalism and antipaternalism.

This paper argues that the concept of paternalism is currently overextended to include a variety of actions that, while resembling paternalistic actions, are importantly different. I use the example of Japanese physicians' non-disclosures of cancer diagnoses directly to patients, arguing that the concept of maternalism better captures these actions. To act paternalistically is to substitute one's own judgement for that of another person and decide in place of that person for his/her best interest. By contrast, to act maternalistically is to decide for another person based on a reasonable understanding of that person's own preferences. The concept of maternalism allows for a more thorough assessment of the moral justification of these types of actions. I conclude that it is possible, at least in principle, to justify Japanese physicians' non-disclosures, and that this justification must be based on an understanding of these actions as maternalistic.