Limitation of life sustaining therapy in disorders of consciousness: ethics and practice.

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Neuroethics and AI ethics: a proposal for collaboration.

The scientific relationship between neuroscience and artificial intelligence is generally acknowledged, and the role that their long history of collaboration has played in advancing both fields is often emphasized. Beyond the important scientific insights provided by their collaborative development, both neuroscience and AI raise a number of ethical issues that are generally explored by neuroethics and AI ethics. Neuroethics and AI ethics have been gaining prominence in the last few decades, and they are typically carried out by different research communities. However, considering the evolving landscape of AI-assisted neurotechnologies and the various conceptual and practical intersections between AI and neuroscience-such as the increasing application of AI in neuroscientific research, the healthcare of neurological and mental diseases, and the use of neuroscientific knowledge as inspiration for AI-some scholars are now calling for a collaborative relationship between these two domains. This article seeks to explore how a collaborative relationship between neuroethics and AI ethics can stimulate theoretical and, ideally, governance efforts. First, we offer some reasons for calling for the collaboration of the ethical reflection on neuroscientific innovations and AI. Next, we explore some dimensions that we think could be enhanced by the cross-fertilization between these two subfields of ethics. We believe that considering the pace and increasing fusion of neuroscience and AI in the development of innovations, broad and underspecified calls for responsibility that do not consider insights from different ethics subfields will only be partially successful in promoting meaningful changes in both research and applications.

Returning Individual Research Results from Digital Phenotyping in Psychiatry.

Psychiatry is rapidly adopting digital phenotyping and artificial intelligence/machine learning tools to study mental illness based on tracking participants' locations, online activity, phone and text message usage, heart rate, sleep, physical activity, and more. Existing ethical frameworks for return of individual research results (IRRs) are inadequate to guide researchers for when, if, and how to return this unprecedented number of potentially sensitive results about each participant's real-world behavior. To address this gap, we convened an interdisciplinary expert working group, supported by a National Institute of Mental Health grant. Building on established guidelines and the emerging norm of returning results in participant-centered research, we present a novel framework specific to the ethical, legal, and social implications of returning IRRs in digital phenotyping research. Our framework offers researchers, clinicians, and Institutional Review Boards (IRBs) urgently needed guidance, and the principles developed here in the context of psychiatry will be readily adaptable to other therapeutic areas.

The End of Personhood.

The concept of personhood has been central to bioethics debates about abortion, the treatment of patients in a vegetative or minimally conscious states, as well as patients with advanced dementia. More recently, the concept has been employed to think about new questions related to human-brain organoids, artificial intelligence, uploaded minds, human-animal chimeras, and human embryos, to name a few. A common move has been to ask what these entities have in common with persons (in the normative sense), and then draw conclusions about what we do (or do not) owe them. This paper argues that at best the concept of "personhood" is unhelpful to much of bioethics today and at worst it is harmful and pernicious. I suggest that we (bioethicists) stop using the concept of personhood and instead ask normative questions more directly (e.g., how ought we to treat this being and why?) and use other philosophical concepts (e.g., interests, sentience, recognition respect) to help us answer them. It is time for bioethics to end talk about personhood.

Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation.

The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.

Neuroethics and neurolaw in forensic neuropsychiatry: A guide for clinicians.

As neuroscience technologies develop, ethical and legal questions arise regarding their use and societal impact. Neuroethics and neurolaw are growing interdisciplinary fields that address these questions. This review article presents the research agenda of both areas, examines the use and admissibility of neuroscience in expert testimony and legal settings, and discusses ethical issues related to forensic neuropsychiatrists claiming expertise in neuroscience, formulating medical opinions based on neuroscience, and considering its relevance to criminal responsibility. Forensic neuropsychiatrists should be aware of emerging neuroscientific evidence, its utility and limits in rendering diagnoses and explaining behavior, and, before seeking such evidence for legal purposes, its availability and admissibility. When testifying in matters involving neuroscientific evidence, ensuring truthfulness and balance, having sufficient and validated knowledge (including openness with confirming and disconfirming evidence), understanding standards of practice, and drawing relevant and appropriate conclusions remain important.

Why Moral Bioenhancement Cannot Reliably Produce Virtue.

Moral bioenhancement presents the possibility of enhancing morally desirable emotions and dispositions. While some scholars have proposed that moral bioenhancement can produce virtue, we argue that within a virtue ethics framework moral bioenhancement cannot reliably produce virtue. Moreover, on a virtue ethics framework, the pursuit of moral bioenhancement carries moral risks. To make this argument, we consider three aspects of virtue-its motivational, rational, and behavioral components. In order to be virtuous, we argue, a person must (i) take pleasure in doing the right thing and have the correct motivational attitudes; (ii) reason correctly about what is called for in a particular ethical dilemma; and (iii) intentionally and continuously practice and cultivate virtues. These dimensions of morality-in short: precisely those emphasized in a virtue ethics framework-cannot be consistently or reliably met using existing moral bioenhancement technology.

When Two Become One: Singular Duos and the Neuroethical Frontiers of Brain-to-Brain Interfaces.

Advances in brain-brain interface technologies raise the possibility that two or more individuals could directly link their minds, sharing thoughts, emotions, and sensory experiences. This paper explores conceptual and ethical issues posed by such mind-merging technologies in the context of clinical neuroethics. Using hypothetical examples along a spectrum from loosely connected pairs to fully merged minds, the authors sketch out a range of factors relevant to identifying the degree of a merger. They then consider potential new harms like loss of identity, psychological domination, loss of mental privacy, and challenges for notions of autonomy and patient benefit when applied to merged minds. While radical technologies may seem to necessitate new ethical paradigms, the authors suggest the individual-focus underpinning clinical ethics can largely accommodate varying degrees of mind mergers so long as individual patient interests remain identifiable. However, advanced decisionmaking and directives may have limitations in addressing the dilemmas posed. Overall, mind-merging possibilities amplify existing challenges around loss of identity, relating to others, autonomy, privacy, and the delineation of patient interests. This paper lays the groundwork for developing resources to address the novel issues raised, while suggesting the technologies reveal continuity with current healthcare ethics tensions.

Social issues relating to Vladimir Bekhterev's concept of reflexology: a hitherto underestimated aspect of his work.

This article investigates the diversity of social and political assertions in the work of Vladimir M Bekhterev. Its findings reveal that he drew social and political conclusions based on his doctrine of reflexology. Moreover, he propagated the use of statistical investigations by scientific and governmental institutions to estimate the social and healthcare needs of the population. These conclusions accord with Bekhterev's desire for a transformation of society that would bring continued progress to people's social and living conditions. Additionally, the findings of this research work also support the idea that Bekhterev should be regarded as an important protagonist of neuroethics, a relatively recent field of research.

Emulating future neurotechnology using magic.

Recent developments in neuroscience and artificial intelligence have allowed machines to decode mental processes with growing accuracy. Neuroethicists have speculated that perfecting these technologies may result in reactions ranging from an invasion of privacy to an increase in self-understanding. Yet, evaluating these predictions is difficult given that people are poor at forecasting their reactions. To address this, we developed a paradigm using elements of performance magic to emulate future neurotechnologies. We led 59 participants to believe that a (sham) neurotechnological machine could infer their preferences, detect their errors, and reveal their deep-seated attitudes. The machine gave participants randomly assigned positive or negative feedback about their brain's supposed attitudes towards charity. Around 80% of participants in both groups provided rationalisations for this feedback, which shifted their attitudes in the manipulated direction but did not influence donation behaviour. Our paradigm reveals how people may respond to prospective neurotechnologies, which may inform neuroethical frameworks.

Neuromodulation and Opioid Use Disorder: Ethical Opportunities for Canada.

Despite increased efforts of government and non-government organisations to intervene via harm reduction and education initiatives, the opioid crisis has continued to worsen and has been exacerbated by the COVID-19 pandemic. In British Columbia, Canada, opioid overdose deaths in 2021 are the highest ever recorded. Neuromodulation procedures such as deep brain stimulation and repetitive transcranial magnetic stimulation have gained traction as treatments for opioid use disorder in various countries such as Germany, the Netherlands, the United States and China. However, these treatment options have been met with apprehension from both clinicians and patients, likely owing to fear, stigma and reluctance to label addiction as a brain disorder. Further complicating this landscape are socio-demographic factors, as marginalised communities are disproportionately burdened by addiction, while having poor access to care and a history of distrust in the health system. This multifactorial challenge involving many sociocultural factors requires culturally sensitive, interdisciplinary approaches to ensure direct-to-brain innovations are implemented ethically and equitably. This review summarises the state of the science for using neuromodulation to treat opioid use disorder, as well as the available ethical discourse surrounding the expansion of clinical trials and eventual widespread clinical implementation. Additional ethics discussions highlight opportunities for the engineering and clinical evolution of neuromodulation for opioid use disorder trials.

Antitrust as a Guardrail for Socially Responsible Neurotechnology Design.

The neurotechnology sector is likely to develop under pressure towards commercialized, nonmedical products and may also undergo market consolidation. This possibility raises ethical, social, and policy concerns about the future responsibility of neurotechnology innovators and companies for high-consequence design decisions. Present-day internet technology firms furnish an instructive example of the problems that arise when providers of communicative technologies become too big for accountability. As a guardrail against the emergence of similar problems, concerned neurotechnologists may wish to draw inspiration from antitrust law and direct efforts, where appropriate, against undue consolidation in the commercial neurotechnology market.

Emerging Neurotechnologies: Implications for Professional Relations and Communication.

Rapid advances in neurotechnology and neurosurgery are positioned to revolutionize care for patients suffering from debilitating neurological and psychiatric disease. Enthusiasm for the adoption of these technologies is tempered by ethical dilemmas regarding resource allocation, provision of care, communication with patients and other providers, and other potential pitfalls. In the present work, we discuss bioethical implications of novel neurotechnologies for medical practice. In particular, we examine the implications of neurotechnological advancement through the lens of professional communication. Emerging challenges within this domain are presented in the context of physician interactions with four key partners: (i) patients; (ii) other physicians; (iii) industry; and (iv) society-at-large. Anticipated issues as well as mitigation strategies are discussed as they relate to communication with these stakeholders.

Mapping the Landscape of Equitable Access to Advanced Neurotechnologies in Canada.

Geographic, social, political, and economic factors shape access to advanced neurotechnologies, yet little previous research has explored the barriers, enablers, and areas of opportunity for equitable and meaningful access for diverse patient communities across Canada. We applied a mixed-mode approach involving semi-structured interviews and rating scale questions to consult with 24 medical experts who are involved in the care of patients who undergo functional neurosurgery targeting the brain. Seven major themes emerged from the qualitative analysis: Health care system, Neurotechnology features, Patient demographics, Target condition features, Ethics, Upstream barriers and enablers, and Areas of opportunity. Descriptive statistics of the Likert-scale responses suggest that interviewees perceive a disparity between the imperative of access to advanced neurotechnologies for people living in rural and remote areas and the likelihood of achieving such access. The results depict a complex picture of access to functional neurosurgery in Canada with pockets of excellence and a motivation to improve the availability of care for vulnerable populations through the expansion of distributed care models, improved health care system efficiencies, increasing funding and support for patient travel, and increasing awareness about and advocacy for advanced neurotechnologies.

Views about neuromodulation interventions for depression by stakeholder group, treatment modality, and depression severity.

BACKGROUND: The past few decades have seen the emergence both of new neuromodulation treatment protocols and novel applications of standard neuromodulation interventions in psychiatry. Yet little is known about different stakeholders' views about these interventions. METHODS: We administered an online survey with an embedded video vignette experiment to four national samples: the general public (N = 1022), caregivers for people with depression (N = 1026), patients living with depression (N = 1050), and board-certified psychiatrists (N = 505). We randomly assigned subjects to one of eight conditions in our full factorial design: four neuromodulation interventions [electroconvulsive therapy, repetitive transcranial magnetic stimulation, deep brain stimulation, or adaptive brain implants] by two depression severity levels [moderate or severe]. In this paper we present results from ANOVA and linear regression models explaining how views about these four neuromodulation interventions-as measured in five attitudinal scales (general affect, perceived influence on self, perceived benefit, perceived risk, and perceived invasiveness)-vary by (1) intervention, (2) depression severity, and/or (3) stakeholder group. RESULTS: Our results provide evidence that psychiatrists views differ significantly in important ways from other stakeholder groups. Type of intervention also shaped participants' attitudes, including perceptions of invasiveness, effectiveness, and safety. CONCLUSIONS: Given the differing affective valence among stakeholders and the differences found by modality and stakeholder groups across the different scales, future targeted educational initiatives could be developed to help address key misunderstandings and misinformed perceptions.

Strategic and principled approach to the ethical challenges of epilepsy monitoring unit triage.

Electroencephalographic monitoring provides critical diagnostic and management information about patients with epilepsy and seizure mimics. Admission to an epilepsy monitoring unit (EMU) is the gold standard for such monitoring in major medical facilities worldwide. In many countries, access can be challenged by limited resources compared to need. Today, triaging admission to such units is generally approached by unwritten protocols that vary by institution. In the absence of explicit guidance, decisions can be ethically taxing and are easy to challenge. In an effort to address this gap, we propose a two-component approach to EMU triage that takes into account the unique landscape of epilepsy monitoring informed by triage literature from other areas of medicine. Through the strategic component, we focus on the EMU wait list management infrastructure at the institutional level. Through the principled component, we apply a combination of the ethical principles of prioritarianism, utilitarianism and justice to triage; and we use individual case examples to illustrate how they apply. The effective implementation of this approach to specific epilepsy centres will need to be customised to the nuances of different settings, including diverse practice patterns, patient populations and constraints on resource distribution, but the conceptual consolidation of its components can alleviate some of the pressures imposed by the complex decisions involved in EMU triage.

Withering Minds: towards a unified embodied mind theory of personal identity for understanding dementia.

A prominent view on personal identity over time, Jeff McMahan's 'Embodied Mind Account' (2002) holds that we cease to exist only once our brains can no longer sustain the basic capacity to uphold consciousness. One of the many implications of this view on identity persistence is that we continue to exist throughout even the most severe cases of dementia, until our consciousness irreversibly shuts down. In this paper, I argue that, while the most convincing of prominent accounts of personal identity over time, McMahan's account faces serious challenges in explanatory power of dementias and related neurodegenerative conditions. Particularly, this becomes visible in the face of emerging methods for neural tissue regeneration, and the possibility of 're-emerging patients'. I argue that medical professionals' neglecting qualitative aspects of identity risks resulting in grave misunderstandings in decision-making processes, and ethically objectionable outcomes in future practices. Finally, I propose revisions which could potentially salvage the great benefits that Embodied Mind Theory still can bring to the field of dementia care in terms of understanding life, death, and identity across the lifespan.

Response to the ISSCR guidelines on human-animal chimera research.

The International Society for Stem Cell Research (ISSCR) has recently released the 2021 update of its guidelines. The update includes detailed new recommendations on human-animal chimera research. This paper argues that the ISSCR recommendations fail to address the core ethical concerns raised by neurological chimeras-namely, concerns about moral status. In minimising moral status concerns, the ISSCR both breaks rank with other major reports on human-animal chimera research and rely on controversial claims about the grounds of moral status that many people will rightly reject. A more robust framework for regulating human-animal chimera research still needs to be developed.

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.

Neuroethics and cultural context: The case of electroconvulsive therapy in Argentina.

As neuroethics continues to grow as an established discipline, it has been charged with not being sufficiently sensitive to the way in which the identification, conceptualization, and management of the ethical issues raised by neuroscience and its applications are shaped by local systems of knowledge and structures. Recently there have been calls for explicit recognition of the role played by local cultural contexts and for the development of cross-cultural methodologies that can facilitate meaningful cultural engagement. In this article, we attempt to fill this perceived gap by providing a culturally situated analysis of the practice of electroconvulsive therapy (ECT) in Argentina. ECT was introduced as a psychiatric treatment in Argentina in the 1930s but it is largely underutilized. While the use of ECT remains low in several countries, what makes the Argentinian case interesting is that the executive branch of government has taken a stance regarding both the scientific and moral appropriateness of ECT, recommending its prohibition. Here, we begin with a recent controversy over the use of ECT in Argentina and explain the legal recommendation to ban its application. Next, we offer an overview of some of the salient aspect of the international and local discussions on ECT. We argue that the governmental recommendation to ban the procedure should be rethought. While acknowledging the role that contexts and local conditions play in shaping the identification and assessment of the relevant ethical issues, we caution against using contextual and cultural considerations to avoid a necessary ethical debate on controversial issues.