## 1. The rise and scope of neuroethics



Neuroethics focuses on ethical issues raised by our continually
improving understanding of the brain, and by consequent improvements
in our ability to monitor and influence brain function. Significant
attention to neuroethics can be traced to 2002, when the Dana
Foundation organized a meeting of neuroscientists, ethicists, and
other thinkers, entitled *Neuroethics: Mapping the Field*. A
participant at that meeting, columnist and wordsmith William Safire,
is often credited with introducing and establishing the meaning of the
term "neuroethics", defining it as 'the examination
of what is right and wrong, good and bad about the treatment of,
perfection of, or unwelcome invasion of and worrisome manipulation of
the human brain' (Marcus, 2002, p.5). Others contend that the
word "neuroethics" was in use prior to this (Illes, 2003;
Racine, 2010), although all agree that these earlier uses did not
employ it in a disciplinary sense, or to refer to the entirety of the
ethical issues raised by neuroscience.



Another attendee at that initial meeting, Adina Roskies, in response
to a perceived lack of recognition of the potential novelty of
neuroethics, penned "Neuroethics for the new millennium"
(Roskies, 2002), an article in which she proposed a bipartite division
of neuroethics into the "ethics of neuroscience", which
encompasses the kinds of ethical issues raised by Safire, and
"the neuroscience of ethics", thus suggesting an extension
of the scope of neuroethics to encompass our burgeoning understanding
of the biological basis of ethical thought and behavior and the ways
in which this could itself influence and inform our ethical thinking.
This broadening of the scope of neuroethics highlights the obvious and
not-so-obvious ways that understanding our own moral thinking might
affect our moral views; it is one aspect of neuroethics that
distinguishes it from traditional bioethics. Another way of
characterizing the field is as a study of ethical issues arising from
what we can do to the brain (e.g. with neurotechnologies) and from
what we know about it (including, for example, understanding the basis
of ethical behavior).



Although Roskies' definition remains influential, it has been
challenged in various ways. Some have argued that neuroethics should
not be limited to the neuroscience of ethics, but rather be broadened
to the cognitive science of ethics (Levy, personal communication),
since so much work that enables us to understand the brain takes place
in disciplines outside of neuroscience, strictly defined. This is in
fact in the spirit of the original proposal, since it has been widely
recognized that the brain sciences encompass a wide array of
disciplines, methods, and questions. However, the most persistent
criticisms have been from those who have questioned whether the
neuroscience of ethics should be considered a part of neuroethics at
all: they argue that understanding our ethical faculties is a
scientific and not an ethical issue, and thus should not be part of
neuroethics. This argument is usually followed by a denial that
neuroethics is sufficiently distinct from traditional bioethics to
warrant being called a discipline in its own right.



The response to these critics is different: Whether or not these
various branches of inquiry form a natural kind or are themselves a
focus of ethical analysis is quite beside the point. Neuroethics is
porous. One cannot successfully engage with many of the ethical issues
without also understanding the science. In addition, academic or
intellectual disciplines are at least in part (if not entirely) social
constructs. And in this case the horse is out of the barn: It is clear
that interesting and significant work is being pursued regarding the
brain bases of ethical thought and behavior, and that this theoretical
understanding has influenced, and has the potential to influence, our
own thinking about ethics and our ethical practices. That neuroethics
exists is undeniable: Neuroethical lines of research have borne
interesting fruit over the last 10-15 years; neuroethics is now
recognized as an area of study both nationally and internationally;
neuroethics courses are taught at many universities; and training
programs, professional societies, and research centers for neuroethics
have already been established. The NIH BRAIN Initiative has devoted
considerable resources to encouraging neuroscientific projects that
incorporate neuroethical projects and analyses. Neuroethics is a
discipline in its own right in part because we already structure our
practices in ways that recognize it as such. What is most significant
about neuroethics is not whether both the ethics of neuroscience and
the neuroscience of ethics are given the same overarching disciplinary
name, but that there are people working on both endeavors and that
they are in dialogue (and sometimes, the very same people do
both).



Of course, to the extent that neuroethicists asks questions about
disease, treatment, and so on, the questions will look familiar, and
for answers they can and should look to extant work in traditional
bioethics so as not to reinvent the wheel. But, ultimately, Farah is
correct in saying that "New ethical issues are arising as
neuroscience gives us unprecedented ways to understand the human mind
and to predict, influence, and even control it. These issues lead us
beyond the boundaries of bioethics into the philosophy of mind,
psychology, theology, law and neuroscience itself. It is this larger
set of issues that has...earned it a name of its own"
(Farah 2010, p. 2).


## 2. The ethics of neuroscience



Neuroethics is driven by neurotechnologies: it is concerned with the
ethical questions that attend the development and effects of novel
neurotechnologies, as well as other ethical and philosophical issues
that arise from our growing understanding of how brains give rise to
the people that we are and the social structures that we inhabit and
create. These questions are intimately bound up with scientific
questions about what kinds of knowledge can be acquired with
particular techniques: what are the scope and limits of what a
technique can tell us? With many new techniques, answers to these
questions are obscure not only to the lay public, but often to the
scientists themselves. The uncertainty about the reach of these
technologies adds to the challenge of grappling with the ethical
issues raised.



Many new neurotechnologies enable us to monitor brain processes and
increasingly, to understand how the brain gives rise to certain
behaviors; others enable us to intervene in these processes, to change
and perhaps to control behaviors, traits, or abilities. Although it
will be impossible to fully canvass the range of questions neuroethics
has thus far contemplated, discussion of the issues raised by a few
neurotechnologies will allow me to illustrate the range of questions
neuroethics entertains. The following is a not-exhaustive list of
topics that fall under the general rubric of neuroethics.


### 2.1 The ethics of enhancement



While medicine's traditional goal of treating illness is pursued
by the development of drugs and other treatments that counteract the
detrimental effects of disease or insult, the same kinds of compounds
and methods that are being developed to treat disease may also enhance
normal cognitive functioning. We already possess the ability to
improve some aspects of cognition above baseline, and will certainly
develop other ways of doing so. Thus, a prominent topic in neuroethics
is the ethics of neuroenhancement: What are the arguments for and
against the use of neurotechnologies to enhance one's
brain's capacities and functioning?



Proponents of enhancement are sometimes called
"transhumanists," and opponents are identified as
"bioconservatives". These value-laden appellations may
unnecessarily polarize a debate that need not pit extreme viewpoints
against each other, and that offers many nuanced intermediate
positions that recognize shared values (Parens, 2005) and make room
for embracing the benefits of enhancement while recognizing the need
for some type of regulation (e.g. Lin and Alhoff, 2008). The relevance
of this debate itself depends to some extent upon a philosophical
issue familiar to traditional bioethicists: the notorious difficulty
of identifying the line between disease and normal function, and the
corresponding difference between treatment and enhancement. However,
despite the difficulty attending the principled drawing of this line,
there are already clear instances in which a technology such as a drug
is used with the aim of improving a capacity or behavior that is by no
means clinically dysfunctional, or with the goal of improving a
capacity beyond the range of normal functioning. One common example is
the use, now widespread on college campuses and beyond, of
methylphenidate, a stimulant typically prescribed for the treatment of
ADHD. Known by the brand name Ritalin, methylphenidate has been shown
to improve performance on working memory, episodic memory and
inhibitory control tasks. Many students use it as a study aid, and the
ethical standing of such off-label use is a focus of debate among
neuroethicists (Sahakian, 2007; Greely et al., 2008).



As in the example above, the enhancements neuroethicists most often
discuss are *cognitive* enhancements: technologies that allow
normal people to function cognitively at a higher level than they
might without use of the technology (Knafo and Venero, 2015). One
standing theoretical issue for neuroethics is a careful and precise
articulation of whether, how and why cognitive enhancement has a
philosophical status different than any other kind of enhancement,
such as enhancement of physical capacities by the use of steroids
(Dresler, 2019).



Often overlooked are other interesting potential neuroenhancements.
These are less frequently discussed than cognitive enhancements, but
just as worthy of consideration. They include social/moral
enhancements, such as the use of oxytocin to enhance pro-social
behavior, and other noncognitive but biological enhancements, such as
potential physical performance enhancers controlled by brain-computer
interfaces (BCIs) (see, e.g. Savulescu and Persson, 2012; Douglas,
2008; Dubljevic and Racine, 2017; Annals of NYAC, 2004). In
many ways, discussions regarding these kinds of enhancement
effectively recapitulate the cognitive enhancement debate, but in some
respects they raise different concerns and prompt different
arguments.


### 2.1.1 Arguments for Enhancement



Naturalness: Although the aim of cognitive enhancement may at first
seem ethically questionable at best, it is plausible that humans
naturally engage in many forms of enhancement, including cognitive
enhancement. Indeed, we typically applaud and value these efforts.
After all, the aim of education is to cognitively enhance students
(which, we now understand, occurs by changing their brains), and we
look askance at those who devalue this particular enhancement, rather
than at those who embrace it. So some kinds of cognitive enhancement
are routine and unremarkable. Proponents of neuroenhancement will
argue that there is no principled difference between the enhancements
we routinely engage in, and enhancement by use of drugs or other
neurotechnologies. Many in fact argue that we are a species whose
nature it is to develop and use technology for augmenting our
capacities, and that continual pursuit of enhancement is a mark of the
human.



Cognitive liberty: Those who believe that "cognitive
liberty" (see
 section
 2.2 below) is a fundamental right argue that an important element of
the autonomy at stake in cognitive liberty is the liberty to determine
for ourselves what to do with our minds and to them, including
cognitive enhancement, if we so choose. Although many who champion
"cognitive liberty" do so in the context of a strident
political libertarianism (e.g. Boire, 2001), one can recognize the
value of cognitive liberty without swallowing an entire political
agenda. So, for example, even if we think that there is a *prima
facie* right to determine our own cognitive states, there may be
justifiable limits to that right. More work needs to be done to
establish the boundaries of the cognitive liberty we ought to
safeguard.



Utilitarian arguments: Many proponents of cognitive enhancement point
to the positive effects of enhancement and argue that the benefits
outweigh the costs. In these utilitarian arguments it is important to
consider the positive and negative effects not only for individuals,
but also for society more broadly (see, e.g. Selgelid, 2007).



Deontological arguments: Sometimes enhancements are argued to be an
avenue for leveling the playing field, in pursuit of fairness and
equity. Such arguments are bolstered by the finding that at least for
some interventions, enhancement effects are greater for those who have
lower baseline functioning than those starting with a higher baseline
(President's Commission on Bioethics, 2015).



Practical arguments: These often point to the difficulty in enforcing
regulations of extant technology, or the detrimental effects of trying
to do so. They tend to be not really arguments in favor of
enhancement, but rather reasons not to oppose its use.


### 2.1.2 Arguments against Enhancement



There are a variety of arguments against enhancement. Most fall into
the following types:



Harms: The simplest and most powerful argument against enhancement is
the claim that brain interventions carry with them the risk of harm,
risks that make the use of these interventions unacceptable. The low
bar for acceptable risk is an effect of the context of enhancement:
risks deemed reasonable to incur when treating a deficiency or disease
with the potential benefit of restoring normal function may be deemed
unreasonable when the payoff is simply augmenting performance above a
normal baseline. Some suggest that no risk is justified for
enhancement purposes. In evaluating the strength of a harm-based
argument against enhancement, several points should be considered: 1)
What are the actual and potential harms and benefits (medical and
social) of a given enhancement? 2) Who should make the judgments about
appropriate tradeoffs? Different individuals may judge differently at
what point the risk/benefit threshold occurs, and their judgments may
depend upon the precise natures of the risks and benefits. Notice,
too, the harm argument is toothless against enhancements that
don't pose any risks.



Unnaturalness: A number of thinkers argue, in one form or another,
that use of drugs or technologies to enhance our capacities is
unnatural, and the implication is that *unnatural* implies
*immoral*. Of course, to be a good argument, more reason has to
be given both for why it is unnatural (see an argument for
naturalness, above), and for why naturalness and morality align. Some
arguments suggest that manipulating our cognitive machinery amounts to
tinkering with "God-given" capacities, and usurping the
role of God as creator can be easily understood as transgressive in a
religious-moral framework. Despite its appeal to religious
conservatives, a neuroethicist may want to offer a more ecumenical or
naturalistic argument to support the link between *unnatural*and *immoral*, and will have to counter the claim, above,
that it is natural for humans to enhance themselves.



Diminishing human agency: Another argument suggests that the effect of
enhancement will be to diminish human agency by undermining the need
for real effort, and allowing for success with morally meaningless
shortcuts. Human life will lose the value achieved by the process of
striving for a goal and will be belittled as a result (see, e.g.
Schermer, 2008; Kass, 2003). Although this is a promising form of
argument, more needs to be done to undergird the claims that effort is
intrinsically valuable. Recent work suggests no general argument to
this effect is forthcoming (Douglas, 2019). After all, few find
compelling the argument that we ought to abandon transportation by car
for horses, walking, or bicycling, because these require more effort
and thus have more moral value.



The hubris objection: This interesting argument holds that the type of
attitude that seems to underlie pursuit of such interventions is
morally defective in some way, or is indicative of a morally defective
character trait. So, for example, Michael Sandel suggests that the
attitude underlying the attempt to enhance ourselves is a
"Promethean" attitude of mastery that overlooks or
underappreciates the "giftedness of human life." It is the
expression and indulgence of a problematic attitude of dominion toward
life to which Sandel primarily objects: "The moral problem with
enhancement lies less in the perfection it seeks than in the human
disposition it expresses and promotes" (Sandel, 2002). Others
have pushed back against this tack, arguing that the hubris objection
against enhancement is at base a religious one, or that it
fundamentally misunderstands the concepts it relies upon (Kahane,
2011).



Equality and Distributive Justice: One question that routinely arises
with new technological advances is "who gets to benefit from
them?" As with other technologies, neuroenhancements are not
free. However, worries about access are compounded in the case of
neuroenhancements (as they may also be with other learning
technologies). As enhancements increase capacities of those who use
them, they are likely to further widen the already unconscionable gap
between the haves and have-nots: We can foresee that those already
well-off enough to afford enhancements will use them to increase their
competitive advantage against others, leaving further behind those who
cannot afford them. Not all arguments in this vein militate against
enhancement. For example, the finding mentioned above -- that at least
with some cognitive enhancement technologies, those who have lower
baseline functioning experience greater improvements than those
starting at a higher level -- could ground pro-enhancement fairness
and equity arguments for leveling the playing field (President's
Commission on Bioethics, 2015). As public consciousness about racial
and economic disparities increases, we should expect more neuroethical
work on this topic. Although one can imagine policy solutions to
distributive justice concerns, such as having enhancements covered by
health insurance, having the state distribute them to those who cannot
afford them, etc., widespread availability of neuroenhancements will
inevitably raise questions about coercion.



Coercion: The prospect of coercion is raised in several ways.
Obviously, if the state decides to mandate an enhancement, treating
its beneficial effects as a public health issue, this is effectively
coercion. We see this currently in the backlash against vaccinations:
they are mandated with the aim of promoting public health, but in some
minds the mandate raises concerns about individual liberty. I would
submit that the vaccination case demonstrates that at least on some
occasions coercion is justified. The question is whether coercion
could be justifiable for enhancement, rather than for harm prevention.
Although some coercive ideas, such as the suggestion that we put
Prozac or other enhancers in the water supply, are unlikely to be
taken seriously as a policy issue (however, see Appel 2010 [2011]),
less blatant forms of coercion are more realistic. For example, if
people immersed in tomorrow's competitive environment are in the
company of others who are reaping the benefits from cognitive
enhancement, they may feel compelled to make use of the same
techniques just to remain competitive, even though they would rather
not use enhancements. The danger is that respecting the autonomy of
some may put pressure on the autonomy of others.



There is unlikely to be any categorical resolution of the ethics of
enhancement debate. The details of a technology will be relevant to
determining whether a technology ought to be made available for
enhancement purposes: we ought to treat a highly enhancing technology
that causes no harm differently from one that provides some benefit at
noticeable cost. Moreover, the magnitude of some of the
equality-related issues will depend upon empirical facts about the
technologies. Are neurotechnologies equally effective for everyone? As
mentioned, there is evidence that some known enhancers such as the
psychostimulants are more effective for those with deficiencies than
for the unimpaired: studies suggest the beneficial effects of these
drugs are proportional to the degree to which a capacity is impaired
(Hussain et al., 2011). Other reports claim that normal
subjects' capacities are not actually enhanced by these drugs,
and some aspects of functioning may actually be impaired (Mattay, et
al., 2000; Ileva et al., 2013). If this is a widespread pattern, it
may alleviate some worries about distributive justice and
contributions to social and economic stratification, since people with
a deficit will benefit proportionately more than those using the drug
for enhancement purposes. Bear in mind, however, that biology is
rarely that equitable, and it would be surprising if this pattern
turned out to be the norm. Since the technologies that could provide
enhancements are extremely diverse, ranging from drugs to implants to
genetic manipulations, assessment of the risks and benefits and the
way in which these technologies bear upon our conception of humanity
will have to be empirically grounded.


### 2.2 Cognitive liberty



Freedom is a cornerstone value in liberal democracies like our own,
and one of the most cherished kinds of freedom is freedom of thought.
The main elements of freedom of thought, or "cognitive
liberty" as it is sometimes called (Sententia, 2013), include
privacy and autonomy. Both of these can be challenged by the new
developments in neuroscience. The value of, potential threat to, and
ways to protect these aspects of freedom are a concern for
neuroethics. Several recent papers have posited novel rights in this
realm, such as rights to cognitive liberty, to mental privacy, to
mental integrity, and to psychological continuity (Ienca and Andorno,
2017), or to psychological integrity and mental self-determination
(Bublitz, 2020).


### 2.2.1 Privacy



As the framers of our constitution were well aware, freedom is
intimately linked with privacy: even being monitored is considered
potentially "chilling" to the kinds of freedoms our
society aims to protect. One type of freedom that has been championed
in American jurisprudence is "the right to be let alone"
(Warren and Brandeis, 1890), to be free from government or other
intrusion in our private lives.



In the past, mental privacy could be taken for granted: the
first-person accessibility of the contents of consciousness ensured
that the contents of one's mind remained hidden to the outside
world, until and unless they were voluntarily disclosed. Instead, the
battles for freedom of thought were waged at the borders where thought
meets the outside world -- in expression -- and were won with the
First Amendment's protections for those freedoms (note, however,
that these protections are only against government infringement). Over
the last half century, technological advances have eroded or impinged
upon many traditional realms of worldly privacy. Most of the avenues
for expression can be (and increasingly are) monitored by third
parties. It is tempting to think that the inner sanctum of the mind
remains the last bastion of real privacy.



This may still be largely true, but even the privacy of the mind can
no longer to be taken for granted. Our neuroscientific achievements
have already made significant headway in allowing others to discern
some aspects of our mental content through neurotechnologies.
Noninvasive methods of brain imaging have revolutionized the study of
human cognition and have dramatically altered the kinds of knowledge
we can acquire about people and their minds. Niether is the threat to
mental privacy as simple as the naive claim that neuroimaging can read
our thoughts, nor are the capabilities of imaging so innocuous and
blunt that we needn't worry about that possibility. A focus of
neuroethics is to determine the real nature of the threat to mental
privacy, and to evaluate its ethical implications, many of which are
relevant to legal, medical, and other social issues (Shen, 2013). For
example, in a world in which the bastion of the mind may be lowering
its drawbridges, do we need extra protections? Doing so effectively
will require both a solid understanding of the neuroscientific
technologies and the neural bases of thought, as well as a sensitivity
to the ethical problems raised by our growing knowledge and
ever-more-powerful neurotechnologies. These dual necessities
illustrate why neuroethicists must be trained both in neuroscience and
in ethics. In what follows I briefly discuss the most relevant
neurotechnology and its limitations and then canvas a few ways in
which privacy may be infringed by it.


#### 2.2.1.2 An illustration: Potential threats to privacy with Functional MRI



One of the most prominent neurotechnologies poised to pose a threat to
privacy is Magnetic Resonance Imaging, or MRI. MRI can provide both
structural and functional information about a person's brain
with minimal risk and inconvenience. In general, MRI is a tool that
allows researchers noninvasively to examine or monitor brain structure
and activity, and to correlate that structure or function with
behavior. Structural or anatomical MRI provides high-resolution
structural images of the brain. While structural imaging in the
biosciences is not new, MRI provides much higher resolution and better
ability to differentiate tissues than prior techniques such as x-rays
or CT scans.



However, it is not structural but functional MRI (fMRI) that has
revolutionized the study of human cognition. fMRI provides information
about correlates of neuronal activity, from which neural activity can
be inferred. Recent advances in analysis methods for neuroimaging data
such as multi-voxel pattern analysis and related techniques now allow
relatively fine-grained "decoding" of brain activity.
Decoding involves probabilistic matching, using machine learning, of
an observed pattern of brain activation with experimentally
established correlations between activity patterns and some kind of
functional variable, such as task, behavior, or content. The kind of
information provided by functional imaging promises to provide
important evidence useful for three goals: Decoding mental content,
diagnosis, and prediction. Neuroethical questions arise in all these
areas.



Before discussing these issues, it is important to remember that
neuroimaging is a technology that is subject to a number of
significant limitations, and these technical issues limit how precise
the inferences can be. For example:


* The correlations between the fMRI signal and neural activity are
rough: the signal is delayed in time from the neuronal activity, and
spatially smeared, thus limiting the spatial and temporal precision of
the information that can be inferred.
* A number of dynamic factors relate the fMRI signal to activity,
and the precise underlying model is not yet well-understood.
* There is relatively low signal-to-noise, necessitating averaging
across trials and often across people.
* Individual brains differ both in brain structure and in function.
Variability makes determining when differences are clinically or
scientifically relevant difficult, and leads to noisy data. Due to
natural individual variability in structure and function, and brain
plasticity (especially during development), even large differences in
structure or deviation from the norm may not be indicative of any
functional deficiency. Cognitive strategies can also affect
variability in the data. These sources of variability can complicate
the analysis of data and provide even more leeway for differences to
exist without implying dysfunction.
* Activity in a brain area does not entail that the region is
necessary for performance of the task.
* fMRI is so sensitive to motion that it would be virtually
impossible to get information from a noncompliant subject. This makes
the prospect of reading content from an unwilling mind virtually
impossible.



Without appreciating these technical issues and the resulting limits
to what can legitimately be inferred from fMRI, one is likely to
overestimate or mischaracterize the potential threat that it poses. In
fact, much of the fear of mindreading expressed in non-scientific
publications stems from a lack of understanding of the science
(Racine, 2015). For example, there is no scientific basis to the worry
that imaging would enable the reading of mental content without our
knowing it. Thus, fears that the government is able to remotely or
covertly monitor the thoughts of citizens are unfounded.


#### 2.2.1.1 Decoding of mental content



Noninvasive ways of inferring neural activity have led many to worry
that mindreading is possible, not just in theory, but even now. Using
decoding techniques fMRI can be used, for example, to reconstruct a
visual stimulus from activity of the visual cortex while a subject is
looking at a scene or to determine whether a subject is looking at a
familiar face, or hearing a particular sound. If mental content
supervenes on the physical structure and function of our brains, as
most philosophers and neuroscientists think it does, then in principle
it should be possible to read minds by reading brains. Because of the
potential to identify mental content, decoding raises issues about
mental privacy.



Despite the remarkable advances in brain imaging technology, however,
when it comes to mental content, our current abilities to
"mind-read" are relatively limited, but continually
improving (Roskies, 2015, 2020). Although some aspects of content can
be decoded from neural data, these tend to be quite general and
nonpropositional in character. The ability to infer semantic meaning
from ideation or visual stimulation tends to work best when the realm
of possible contents are quite constrained. Our current abilities
allow us to infer some semantic atoms, such as representations
denoting one of a prespecified set of concrete objects, but not
unconstrained content, or entire propositions. Of course, future
advances might make worries about mindreading more pressing. For
example, if we develop robust means for decoding compositional
meaning, we may one day come to be able to decode propositional
thought.



Still, some worries are warranted. Even if neuroimaging is not at the
stage where mindreading is possible, it can nonetheless threaten
aspects of privacy in ways that should give us pause. It is possible
to identify individuals on the basis of their brain scans (Valizadeh
et al., 2018). In addition, neuroimaging can provide some insights
into attributes of people that they may not want known or disclosed.
In some cases, subjects may not even know that these attributes are
being probed, thinking they are being scanned for other purposes. A
willing subject may not want certain things to be monitored. In what
follows, I consider a few of these more realistic worries.



Implicit bias: Although explicitly acknowledged racial biases are
declining, this may be due to a reporting bias attributable to the
increased negative social valuation of racial prejudice. Much
contemporary research now focuses on examining implicit racial biases,
which are automatic or unconscious reflections of racial bias. With
fMRI and EEG, it is possible to interrogate implicit biases, sometimes
without the subject's awareness that that is what is being
measured (Checkroud, 2014)[3]. While there is disagreement about how
best to interpret implicit bias results (e.g., as a measure of
perceived threat, as in-group/out-group distinctions, etc.), and what
relevance they have for behavior, the possibility that implicit biases
can be measured, either covertly or overtly, raises scientific and
ethical questions (Molenberghs and Louis, 2018). When ought this
information be collected? What procedures must be followed for
subjects legitimately to consent to implicit measures? What
significance should be attributed to evidence of biases? What kind of
responsibility should be attributed to people who hold them? What
predictive power might they hold? Should they be used for practical
purposes? One can imagine obvious but controversial potential uses for
implicit bias measures in legal situations, in employment contexts, in
education, and in policing, all areas in which concerns of social
justice are significant.



Lie detection: Several neurotechnologies are being used to detect
deception or neural correlates of lying or concealing information in
experimental situations. For example, both fMRI measures and EEG
analysis techniques relying on the P300 signal have been used in the
laboratory to detect deception with varying levels of success. These
methods are subject to a variety of criticisms (Farah et al., 2014).
For example, almost all experimental studies fail to study
*real* lying or deception, but instead investigate some version
of instructed misdirection. The context, tasks, and motivations differ
greatly between actual instances of lying and these experimental
analogs, calling into question the ecological validity of these
experimental techniques. Moreover, accuracy, though significantly
higher than chance, is far from perfect, and because of the inability
to determine base rates of lying, error rates cannot be effectively
assessed. Thus, we cannot establish their reliability for real-world
uses. Finally, both physical and mental countermeasures decrease the
accuracy of these methods (Hsu et al., 2019). Despite these
limitations, several companies have marketed neurotechnologies for
this purpose.



Character traits: Neurotechnologies have shown some promise in
identifying or predicting aspects of personality or character. In an
interesting study aimed at determining how well neuroimaging could
detect lies, Greene and colleagues gave subjects in the fMRI scanner a
prediction task in a game of chance that they could easily cheat on.
By using statistical analysis the researchers could identify a group
of subjects who clearly cheated and others who did not (Greene and
Paxton, 2009). Although they could not determine with neuroimaging on
which trials subjects cheated, there were overall differences in brain
activation patterns between cheaters and those who played fair and
were at chance in their predictions. Moreover, Greene and colleagues
repeated this study at several months remove, and found that the
character trait of honesty or dishonesty was stable over time:
cheaters the first time were likely to cheat (indeed, cheated even
more the second time), and honest players remained honest the second
time around. Also interesting was the fact that the brain patterns
suggested that cheaters had to activate their executive control
systems more than noncheaters, not only when they cheated, but also
when deciding not to cheat. While the differential activations cannot
be linked specifically to the propensity to cheat rather than to the
act of cheating, the work suggests that these task-related activation
patterns may reflect correlates of trustworthiness.



The prospect of using methods for detecting these sorts of traits or
behaviors in real-world situations raises a host of thorny issues.
What level of reliability should be required for their employment? In
what circumstances should they be admissible as evidence in the
courtroom? For other purposes? Using lie detection or decoding
techniques from neuroscience in legal contexts may raise
constitutional concerns: Is brain imaging a search or seizure as
protected by the 4th Amendment? Would its forcible use be
precluded by 5th Amendment rights? These questions, though
troubling, might not be immediately pressing: in a landmark case
(*US v. Semrau,* 2012) the court ruled that fMRI lie detection
is inadmissible, given its current state of development. However, the
opinion left open the possibility that it may be admissible in the
future, if methods improve. Finally, to the extent that relevant
activation patterns may be found to correlate significantly with
activation patterns on other tasks, or with a task-free measure such
as default-network activity, it raises the possibility that
information about character could be inferred merely by scanning them
doing something innocuous, without their knowledge of the kind of
information being sought. Thus, there are multiple dimensions to the
threat to privacy posed by imaging techniques.


#### 2.2.1.2 Diagnosis



Increasingly, neuroimaging information can bear upon diagnoses for
diseases, and in some instances may provide predictive information
prior to the onset of symptoms. Work on the default network is
promising for improving diagnosis in certain diseases without
requiring that subjects perform specific tasks in the scanner (Buckner
et al., 2008). For some diseases, such as in Alzheimer's
disease, MRI promises to provide diagnostic information that
previously could only be established at autopsy (Liu et al., 2018).
fMRI signatures have also been linked to a variety of psychiatric
diseases, although not yet with the reliability required for clinical
diagnosis (Aydin et al., 2019). Neuroethical issues also arise
regarding ways to handle incidental findings, that is, evidence of
unsymptomatic tumors or potentially benign abnormalities that appear
in the course of scanning research subjects for non-medical purposes
(Illes et al. 2006; Illes and Sahakian, 2011).



The ability to predict future functional deficits raises a host of
issues, many of which have been previously addressed by genethics (the
ethics of genetics), since both provide information about future
disease risk. What may be different is that the diseases for which
neurotechnologies are diagnostically useful are those that affect the
brain, and thus potentially mental competence, mood, personality, or
sense of self. As such they may raise peculiarly neuroethical
questions (see below).


#### 2.2.1.3 Prediction



As discussed, decoding methods allow one to associate observed brain
activity with previously observed brain/behavior correlations. In
addition, such methods can also be used to predict future behaviors,
insofar as these are correlated with observations of brain activity
patterns. Some studies have already reported predictive power over
upcoming decisions (Soon et al., 2008). Increasingly, we will see
neuroscience or neuroimaging data that will give us some predictive
power over longer-range future behaviors. For example, brain imaging
may allow us to predict the onset of psychiatric symptoms such as
psychotic or depressive episodes. In cases in which this behavior is
indicative of mental dysfunction it raises questions about stigma, but
also may allow more effective interventions.



One confusion regarding neuro prediction should be clarified
immediately: When neuroimages are said to "predict" future
activity, it means they provide *some* statistical information
regarding likelihood. Prediction in this sense does not imply that the
predicted behavior necessarily will come to pass; it does not mean a
person's future is fated or determined. Although scientists
occasionally make this mistake when discussing their results, the fact
that brain function or structure may give us some information about
future behaviors should not be interpreted as a strong challenge to
free will. The prevalence of this mistake among both philosophers and
scientists again illustrates the importance for neuroethicists of
sophistication in both neuroscience and philosophy.



Perhaps the most consequential and most ethically difficult potential
use of predictive information is in the criminal justice system. For
example, there is evidence that structural brain differences are
predictive of scores on the PCL-R, a tool developed to diagnose
psychopathy. It is also well-established that psychopaths have high
rates of recidivism for violent offenses. Thus, in principle
neuroimaging could be used to provide information about an
individual's likelihood of recidivism. Indeed, brain information
appears to offer some predictive value when combined with other
factors (Poldrack et al., 2019; Delfin et al., 2019). One cautionary
tale comes from a recent exchange in the literature: A report
suggested that brain activity on a cognitive task predicts recidivism
(Aharoni et al., 2013), but a critical reanalysis of the data suggests
that methodological concerns led to an overestimate of the predictive
value of the neural data (Poldrack et al., 2019; Aharoni et al.,
2014), highlighting the importance of technical expertise in assessing
the findings and for translating the results of scientific experiments
for practical purposes and ethical analysis.



Neuroethical analysis here is essential. Should neural data be
admissible for determining sentences or parole decisions? Would that
be equivalent to punishing someone for crimes they have not committed?
Or is it just a neutral extension of current uses of actuarial
information, such as age, gender, and income level? At an extreme, one
could imagine using predictive information to detain people who have
not yet committed a crime, arresting them before they do. This
dystopian scenario, portrayed in the film Minority Report (Speilberg,
2002), also illustrates how our abilities to predict can raise
difficult ethical and policy questions when they collide with
intuitions about and the value of free will and autonomy. More
generally, work in neuroethics could be of significant practical use
for the law, and indeed is often called by another moniker,
"neurolaw" (see section 2.7).



In sum, neuroimaging techniques raise a number of neuroethical issues.
The ones discussed above pertain to the use of fMRI, currently an
expensive and cumbersome technique. But other imaging methods exist
that could be far more widespread. If car companies install imaging
methods, for example using NIRS (near infrared spectroscopy), which is
an imaging method that could be used at a distance and without the
subject's knowledge, or some other form of brain monitoring
(https://www.jaguarlandrover.com/news/2015/06/jaguar-land-rover-road-safety-research-includes-brain-wave-monitoring-improve-driver)
to monitor levels of attention in order to alert drivers who begin to
doze off, could that data be used in a court of law in the event of an
accident? Even though the kind of information these methods provide is
very crude and generally unsuitable for decoding mental content, there
are conceivable everyday situations on the horizon in which issues of
mental privacy and neurotechnology might arise.


### 2.2.2 Autonomy and authenticity



A second way in which cognitive liberty could be impacted is by
limiting a person's autonomy. Autonomy is the freedom to be the
person one wants to be, to pursue one's own goals without
unjustifiable hindrances or interference, to be self-governing.
Although definitions of autonomy differ, it is widely appreciated as a
valuable aspect of personhood. Autonomy of the mental can be impacted
in a number of ways. Here are several:



Direct interventions: The ability to directly manipulate our brains to
control our thoughts or behavior is an obvious threat to our autonomy
(Gilbert, 2015; Walker and Mackenzie, 2020). Some of our
neurotechnologies offer that potential, although these sorts of
neurotechnologies are invasive and used only in cases where they are
medically justified. Other types of interventions, such as the
administration of drugs to calm a psychotic person, may also impact
autonomy.



We know that stimulating certain brain areas in animals will lead to
repetitive and often stereotyped behaviors. Scientists have implanted
rats with electrodes and have been able to control their foraging
behaviors by stimulating their cortex. In theory we could control a
person's behavior by implanting electrodes in the relevant
regions of cortex. In practice, we have a few methods that can do
this, but only in a limited way. For example, Transcranial Magnetic
Stimulation (TMS) applied to motor cortex can elicit involuntary
movements in the part of the body controlled by the cortical area
affected, or when repetitively administered it can inhibit activity
for a period of time, acting as a temporary lesion. Effects will vary
depending on what area of the brain is stimulated; higher cognitive
functions can be impacted as well. Relatively invasive methods,
such as Deep Brain Stimulation (DBS, discussed below) and
electrocorticography (ECOG), both techniques requiring brain surgery,
demonstrate that direct interventions can affect cognition, action,
and emotion, often in very particular and predictable ways.



However much of a threat to autonomy these methods pose in theory,
they are rarely used with the aim of compromising autonomy. On the
contrary, direct brain interventions, when used, are largely aimed at
augmenting or restoring rather than bypassing or diminishing autonomy
(Roskies, 2015; Brown, 2015). For example, one rapidly advancing field
in neuroscience is the area of neural prostheses and brain computer
interfaces (Jebari, 2013; Klein et al. 2015). Neural prostheses are
artificial systems that replace defective neural ones, usually of
sensory systems. Some of the more advanced and widely-known are
artificial cochleas. Other systems have been developed that allow
vision-like information to feed to touch-specific receptors, enabling
blind people to navigate the visual world. Brain computer interfaces,
on the other hand, are systems that read brain activity and use it to
guide robotic prostheses for limbs, or to move a cursor on a video
screen. Prosthetic limbs that are guided by neural signals have
restored motor agency to paraplegics and quadriplegics, and other BCIs
have been used to communicate with people who are "locked
in" and cannot move their bodies (Abbott and Peck, 2017).
Advisory and predictive implants use neural information to warn
patients about the risk of, for example, an upcoming seizure, allowing
them to prophylactically self-medicate (Brown, 2015; Lazaro-Munoz et
al., 2017). Thus, although in principle brain interventions could be
used to control people and diminish their autonomy, in general, direct
interventions are being developed to restore and enhance it (Lavazza,
2018).



Neuroeconomics and neuromarketing: There are more subtle ways to
impact autonomy than direct brain manipulations, and these are well
within our grasp: Our thoughts can be manipulated indirectly: old
worries prompted by propaganda and subliminal advertising have taken
on a renewed currency with the advent of neuroeconomics and
neuromarketing (Spence, 2020). By better understanding how we process
reward, how we make decisions more generally, and how we can bias or
influence that process, we open the door to more effective external
indirect manipulations. Indeed, social psychology has been showing how
subtle alterations to our external environment can affect beliefs,
moods, and behaviors. The precise threats posed by understanding the
neural mechanisms of decision making have yet to be fully articulated
(Stanton et al., 2017). Is neuromarketing being used merely to design
products that satisfy our desires more fully or is it being used to
manipulate us? Depending on how you see it, it could be construed as a
good or an evil. Does understanding the neural substrates of choice
and reward provide advertisers more effective tools than they had
merely by using behavioral data, or just more costly ones? Do
consumers consequently have less autonomy? How can we compensate for
or counteract these measures? These questions have yet to be
adequately addressed.



Regulation: Yet another way that autonomy can be impacted is by
restricting the things that a person can do with and to her own mind.
For instance, banning mind-altering drugs is an externally imposed
restraint on people's ability to choose their states of
consciousness (Biore, 2001). The degree to which a person should be
prevented from doing what he wishes to his or her self, body or mind,
is an ethical issue on which people have differing opinions. Some
claim this kind of regulation is a problematic infringement of
autonomy, but certain regulations of this type are already largely
accepted in our society. Regulation of drugs does impact our autonomy,
but it arguably averts potentially great harms. Allowing cognitive
enhancing technologies only for treatment uses but not for enhancement
purposes is another restriction of mental autonomy. Whether it is one
we want to sanction is still up for debate. Regardless, as the
coronavirus pandemic has made abundantly clear, complete autonomy is
not practically possible in a world in which one person's
actions affect the well-being of others.



Belief in free will: Advances in neuroscience have been frequently
claimed to have bearing upon the question of whether we have free will
and on whether we can be truly morally responsible for our actions.
Although the philosophical problem of free will is generally
considered to be a metaphysical problem, demonstrable lack of freedom
would have significant ethical consequences. A number of
neuroscientists and psychologists have intimated or asserted that
neuroscience can show or has shown that free will is an illusion
(Brembs, 2010; Libet, 1983; Soon, 2010; Harris, 2012). Others have
countered with arguments to the effect that such a demonstration is in
principle impossible (Roskies 2006). Regardless of what science
actually shows about the nature of free will, the fact that people
believe neuroscience evidence supports or undermines free will has
been shown to have practical consequences. For example, evidence
merely supporting the premise that our minds are a function of our
brains, as most of neuroscience does, is perceived by some people to
be a challenge to free will. And in several studies, manipulating
belief in free will affects the likelihood of cheating (e.g. Vohs and
Schooler 2008). The debate within neuroscience about the nature and
existence of free will will remain relevant to neuroethics in part
because of its impact on our moral, legal and interpersonal practices
of blaming and punishing people for their harmful actions.


## 2.3 Personal Identity



One of the aspects of neuroethics that makes it distinctive and
importantly different from traditional bioethics is that we recognize
that, in some yet-to-be-articulated sense, the brain is the seat of
*who we are*. For example, we now have techniques that alter
memories by blunting them, strengthening them, or selectively editing
them. We have drugs that affect sexuality, and others that affect
mood. Here, neuroethics rubs up against some of the most challenging
and contentious questions in philosophy: What is the self? What sorts
of changes can we undergo and still remain ourselves? What is it that
makes us the same person over time? Of what value is this temporal
persistence? What costs would changing personhood incur?



Because neuroscience intervention techniques can affect memory,
desires, personality, mood, impulsivity and other things we might
think of as constitutive of the person or the self, the changes they
can cause (and combat) have a unique potential to affect both the
meaning and quality of the most intimate aspects of our lives.
Although neuroethics is quite different from traditional bioethics in
this regard, it is not so different from genethics. For a long time,
it was argued that "you are your genes", and so the
ability to interrogate our genomes, to change them, or to select among
them was seen as both a promising and potentially problematic one,
enabling us to understand and manipulate human nature to an extent far
beyond any we had previously enjoyed. But as we have discovered, we
are not (just) our genes. Our ability to sequence the human genome has
not laid bare the causes of cancer, the genetic basis for
intelligence, or of psychiatric illness, as many had anticipated. One
reason is that our genome is a distal cause of the people we come to
be: many complex and intervening factors matter along the way. Our
brains, on the other hand, are a far more proximal cause of who we are
and what we do. Our moment-to-moment behavior and our long-range plans
are directly controlled by our brains, in a way they are not directly
controlled by our genomes. If "You are your genes" seemed
a plausible maxim, "You are your brain" is far more
so.



Despite its plausibility, it is notoriously difficult to articulate
the way in which we are our brains: What aspects of our brains makes
us the people that we are? What aspects of brain function shape our
memories, our personality, our dispositions? What aspects are
irrelevant or inessential to who we are? What makes possible a
coherent sense of self? The lack of answers we have to these deep
neurophilosophical questions does little to alleviate the pragmatic
worries raised by neuroscience, since our ability to intervene in
brains outstrips our understanding of what we are doing, and can
affect all these aspects of our being.



In philosophy, work focusing on persons may address a variety of
distinct issues using different constructs. Philosophers might be
interested in the nature of personhood, in the nature of the self, in
the kinds of traits and psychological states or processes that give an
experienced life coherence or authenticity, or in the ingredients for
a flourishing life. Each calls for its own analysis. Outside of
philosophy, many of these issues are run together, and confusion often
results. Neuroethics, while in a unique position to leverage these
issues and apply them in a fruitful way, often fails to make the most
of the conceptual work philosophers have done in this area. For
example, papers in neuroethics often conflate a number of these
distinct concepts, referring them under the rubric of "personal
identity". This conflation further muddies already difficult
waters, and diminishes the potential value of neuroethical work. Below
I try to give a brief roadmap of the separate strands that
neuroethicists have been concerned with.



The philosopher's conception of personal identity refers to the
issue of what makes a person at one time numerically identical to a
person at another time. This metaphysical question has been addressed
by a variety of philosophical theories. For example, some theorists
argue that what it is to be the numerically identical over time is to
be the same human organism (Olson, 1999), and that being the same
organism is determined by sameness of life. If having the same life is
the relevant criterion, one could argue that life-sustaining areas of
the brainstem are essential to personal identity (Olson, 1999). For
those who believe instead that bodily integrity is what is essential,
the ability of neuroscience to alter the brain will arguably have
little effect on personal identity. Many other philosophers have
identified the same person as being grounded in psychological
continuity of some sort (e.g., Locke). If this criterion is the
correct one, then the stringency of that criterion may be crucial:
radical brain manipulation may cause an abrupt enough shift in
memories and other psychological states that a person after brain
intervention is no longer the same person he or she was prior. The
more stringent the criterion, the greater is the potential threat of
neurotherapies to personal identity (Jecker and Ko, 2017; Pascalev et
al. 2016). On the other hand, if the standards for psychological
continuity or connectedness are high enough, changes in personal
identity may in fact be commonplace even without neurotherapies.
Recognizing this may prompt us to question the criterion and/or the
importance or value of personal identity. Parfit, for example, argues
that what makes us one and the same person over time, and what we
value (psychological continuity and connectedness) come apart (Parfit,
1984).



For some, the question of personhood comes apart from the question of
identity. Even if personal (i.e. numerical) identity is unchallenged
by neurotechnologies and by brain dysfunction, important neuroethical
questions may still be raised. Philosophers less concerned with
metaphysical questions about numerical identity have focused more on
the self, and on notions of authenticity and self-identification,
emphasizing the importance of the psychological perspective of the
person in question in creating a coherent self (Mackenzie and Walker,
2015; Erler, 2011; Pugh et al., 2017). In this vein, Schectman has
suggested that what is important is the ability to create a coherent
narrative, or "narrative self" (Schectman, 2014). There is
evidence that the ability to create and sustain a coherent narrative
in which we are the protagonist and with which we identify, is a
measure of psychological health (Waters et al., 2014). On the other
hand, some philosophers deny that they have a narrative self and
locate selfhood in a synchronic property (Strawson, 2004). To further
complicate matters, it has been suggested that there is a distinction
between the narrative person and the narrative self, these being
differentiable via degrees of appropriation. Concerns about the nature
and coherence of the narrative self, and about authenticity and
autonomy, tend to be the ones most relevant to neuroethics, since
these constructs clearly can be affected by even modest brain changes.
For example, how do we evaluate the costs and ethical issues attending
a dramatic change in personality, or a modification of key memories?
What are the criteria governing whether one is authentic or
inauthentic, and what is the value of authenticity? If
neurointerventions promise to result in dramatic shifts in a
person's values and commitments, whose interests should take
priority if one person must be favored - the original or the resulting
person? The relevance of personhood, self, agency, identity and
identification needs further elaboration for neuroethics. In what
follows we discuss how one neurotechnology can bear upon some of these
questions.


#### 2.3.1 Example: Deep Brain Stimulation



Deep Brain Stimulation (DBS) involves the stimulation of chronically
implanted electrodes deep in the brain, and it is FDA approved for
treating Parkinson's Disease, a neurodegenerative disease
affecting the dopamine neurons in the striatum. Neuromodulation with
DBS often restores motor function in these patients, permitting many
to live much improved lives. It is also being explored as treatments
for treatment-resistant depression, OCD, addiction, and other
neurological and psychiatric issues. Although DBS is clearly a boon to
many people suffering from neurological diseases, there are a number
of puzzling issues that arise from its adoption. First, it is a highly
invasive treatment, requiring brain surgery and permanent implantation
of a stimulator, thus posing a real possibility of harm and raising
questions of cost/benefit tradeoffs. This is coupled with the fact
that scientists have little mechanistic understanding of how the
treatment works when it does, and treatment regimes and electrode
placement tend to be symptomatic. Occasionally DBS causes unusual side
effects, such as mood changes, hypomania or mania, addictive
behaviors, or hypersexual behavior. In one case a patient with
wide-ranging musical tastes developed a fixation for Johnny
Cash's music, which persisted until stimulation was ceased
(Mantione et al., 2014). Other reported cases involve changes in
personality. The ethical questions in this area revolve around the
ethics of intervening in ways that alter mood and/or personality,
which is often discussed in terms of personal identity or
"changing who the person is", and around questions of
autonomy and alienation (Klaming et al, 2013; Kraemer, 2013a).



One poignant example from the literature tells of a patient who,
without intervention, was bedridden and had to be hospitalized due to
severe motor dysfunction caused by Parkinson's Disease
(Leentjens et al., 2003). DBS resulted in a marked improvement in his
motor symptoms but also caused him to be untreatably manic, which
required institutionalization. Thus, this unfortunate man had to
choose between being bedridden and catatonic, or manic and
institutionalized. He made the choice (in his unstimulated state) to
remain on stimulation (the literature does not mention whether his
stimulated self concurred, as he was not deemed mentally competent in
that state) (Kraemer, 2013b). While it did not happen in this case,
one could imagine a situation in which the patient will choose, while
unstimulated, to undergo chronic stimulation, but, while under
stimulation, would choose otherwise (or *vice versa*). The
possibility for dilemmas or paradoxes will arise when, for example, we
try to determine the value of two potential outcomes that are
differently valued by the people who might exist. To which person (or
to the person in which state) should we give priority? Or, even more
perplexing: if the "identity" (narrative or numerical) of
the person is indeed shifted by the treatment, should we give one
person the authority to consent to a procedure or choose an outcome
that in practice affects a different person? DBS cases like this will
provide fodder for neuroethicists for years to come (Skorburg and
Sinnott-Armstrong, 2020).



Many other neurotechnologies that have been developed for treating
brain dysfunction have primary or side effects that affect some aspect
of what we may think of as related to human agency (Zuk et al., 2018).
The ethical issues that arise with these neurotechnologies involve
determining 1) in which way they do impact our selves or our agency;
2) what value, positive or negative we should put on this impact (or
ability to so affect agency); and 3) how to weigh the positive gains
against the negatives. One issue that has been raised is whether we
possess a clear enough conception of the elements of agency in order
to effectively perform this sort of analysis (Roskies, 2015).
Moreover, given the likelihood that no objective criteria exist for
how to evaluate tradeoffs in these elements, and the fact that
different people may value different aspects of themselves
differently, the weighing process will likely have to be subjectively
relativized.



Finally, DBS as well as neural prostheses and BCIs raise another
neuroethical issue: our conception of humanity and our relations to
machines. Some contend that these technologies effectively turn a
person into a cyborg, making him or her something other than human.
While some find this an ethically unproblematic natural extension of
our species' characteristic drive to invent and improve our
selves with technology (Clark, 2004), others fear that creating a
bio-cybernetic organism raises troubling questions about the nature or
value of humanity, about the bounds of self, or about Promethean
impulses. These questions too fall squarely in the domain of
neuroethics.


### 2.4 Consciousness, life, and death



The Hard Problem of consciousness (Chalmers, 1995) has yielded little
to the probings of neuroscience, and it is not clear whether it ever
will. However, in the last decade impressive advances have been made
in other realms of consciousness research. Most impressive have been
the improvements in detecting altered levels of consciousness with
brain imaging. Diagnosing behaviorally unresponsive patients has long
been a problem for neurology, although as long as 20 years ago,
neurologists had recognized systematic differences between and
prognoses for a persistent vegetative state (PVS), a minimally
conscious state (MCS), and locked-in syndrome, a syndrome in which the
patient has normal levels of awareness but cannot move. Functional
brain imaging has fundamentally changed the problems faced by those
caring for these patients. Owen and colleagues have shown that it is
possible to identify some patients mischaracterized as being in PVS by
demonstrating that they are able to understand commands and follow
directions (Owen, 2006). In these studies, both normal subjects and
brain injured patients were instructed to visualize doing two
different activities while in the fMRI scanner. In normal subjects
these two tasks activated different parts of cortex. Owen showed that
one patient diagnosed as in PVS showed this normal pattern, unlike
other PVS patients, who showed no differential activation when given
these instructions. This data suggests that some PVS diagnosed
subjects can in fact process and understand the instructions, and that
they have the capacity for sustained attention and voluntary mental
action. These results were later replicated in other such patients,
and based on small cohorts, it is estimated that approximately 20% of
PVS patients have been misdiagnosed. In a later study the same group
used these imagination techniques to elicit from some patients with
severe brain injury answers to Yes/No questions (Monti et al., 2010).
More recent work aims to adapt these methods for EEG, a cheaper and
more portable neurotechnology (Bai et al., 2019). Neuroimaging
provides new tools for evaluating and diagnosing patients with
disorders of consciousness (Owen, 2013; Campbell, 2020).



These studies have the potential to revolutionize the way in which
patients with altered states of consciousness are diagnosed and cared
for, may have bearing on when life support is terminated, and raise
the possibility of allowing patients to have some control over
questions regarding their care and end of life decisions (Peterson et
al., 2020; Braddock, 2017). This last possibility, while in some ways
alleviating some worries about how to treat severely brain-damaged
individuals, raises other thorny ethical problems. One of the most
pressing is how to deal with questions of competence and informed
consent: These are people with severe brain damage, and even when they
do appear capable on occasion of understanding and answering
questions, there are still questions about whether their abilities are
stable, how sophisticated they are, and whether they can competently
make decisions about such weighty issues, as well as whether it is
really in their interest to remain on life support (Kahane and
Savalescu, 2009; Fischer and Truog, 2017). Nonetheless, these methods
open up new possibilities for diagnosis and treatment, and for
restoring a measure of autonomy and self-determination to people with
severe brain damage.


### 2.5 Practical neuroethics



Medical practice and neuroscientific research raise a number of
neuroethical issues, many of which are common to bioethics. For
example, issues of consent, of incidental findings, of competence, and
of privacy of information arise here. In addition, practicing
neurologists, psychologists and psychiatrists may routinely encounter
certain brain diseases, disabilities, or psychological dysfunctions
that raise neuroethical issues that they must address in their
practices. (For a more detailed discussion of these more applied
issues approached from a pragmatic point of view, see for example
Racine, 2010; Martineau and Racine, 2020).


### 2.6 Public perception of neuroscience



The advances of neuroscience have become a common topic in the popular
media, with colorful brain images becoming a pervasive illustrative
trope in news stories about neuroscience. While no one doubts that
popularizing neuroscience is a positive good, neuroethicists have been
legitimately worried about the possibilities for misinformation. These
include worries about "the seductive allure" of
neuroscience, and of misleading and oversimplified media coverage of
complex scientific questions.


### 2.6.1 The seductive allure



There is a documented tendency for the layperson to think that
information that makes reference to the brain, or to neuroscience or
neurology, is more privileged, more objective, or more trustworthy
than information that makes reference to the mind or psychology. For
example, Weisberg and colleagues report that subjects with little or
no neuroscience training rated bad explanations as better when they
made reference to the brain or incorporated neuroscientific
terminology (Weisberg et al., 2008). This "seductive allure of
neuroscience" is akin to an unwarranted epistemic deference to
authority. This differential appraisal extends into real-world
settings, with testimony from a neuroscientist or neurologist judged
to be more credible than that of a psychologist. The tendency is to
view neuroscience as a hard science, in contrast to "soft"
methods of inquiry that focus on function or behavior. With
neuroimaging methods, this belies a deep misunderstanding of the
genesis and significance of the neuroscientific information. What
people fail to realize is that neuroimaging information is classified
and interpreted by its ties to function, so (barring unusual
circumstances) it cannot be more reliable or "harder" than
the psychology it relies upon.



Brain images in particular have prompted worries that the colorful
images of brains with "hotspots" that accompany media
coverage could themselves be misleading. If people intuitively
appreciate brain images as if they were akin to a photograph of the
brain in action, that this could mislead them into thinking of these
images as objective representations of reality, prompting them to
overlook the many inferential steps and nondemonstrative decisions
that underlie creation of the image they see (Roskies, 2007). The
worry is that the powerful pull of the brain image will lend a study
more epistemic weight than is justified, and discourage people from
asking the many complicated questions that one must ask in order to
understand what the image signifies, and what can be inferred from the
data. Further work, however, has suggested that once one takes into
account the privilege accorded to neuroscience over psychology, the
images themselves do not further mislead (Schweitzer et al.,
2011).


### 2.6.2 Media Hype



In this era of indubitably exciting progress in brain research, there
is a "brain-mania" that is partially warranted but holds
its own dangers. The culture of science is such that it is not
uncommon for scientists to describe their work in the most dramatic
terms possible in order to secure funding and/or fame. Although the
hyperbole can be discounted by knowledgeable readers, those less
sophisticated about the science may take it at face value. Studies
have shown that the media is rarely critical of the scientific
findings they report, and they tend not to present alternative
interpretations (Racine, 2006, 2015). The result is that the popular
media conveys sometimes wildly inaccurate pictures of legitimate
scientific discoveries, which can fuel both overly optimistic
enthusiasm as well as fear. One of the clear pragmatic goals of
neuroethics, whether it regards basic research or clinical treatments,
is to exhort and educate scientists and the media to better convey
both the promise and complexities of scientific research. It is the
job of both these groups to teach people enough about science in
general, and brain science in particular, that they see it as worthy
of respect, and also of the same critical assessment that to which
scientists themselves subject their own work.



It is admittedly difficult to accurately translate complicated
scientific findings for the lay public, but it is essential.
Overstatement of the significance of results can instill unwarranted
hope in some cases, fear in others, and jadedness and suspicion going
forward. Providing fodder for scientific naysayers has policy
implications that go far beyond the reach of neuroscience. Mistrust of
science is its own epidemic that needs to be inoculated against by
careful, early, and continuing education of the public. This is
essential for the future status and funding of the basic sciences,
and, as we have seen, for the health of democracy and our planet more
generally.


### 2.7 Neuroscience and justice



Social justice is a concern of ethics, and of neuroethics. Many of the
ethical questions are not new, but some have novel aspects. Bioethics
also has traditionally been concerned with issues of respect for
patient's autonomy and right to self-determination. As mentioned
above, these questions take on added weight when the organ at issue is
the patient's brain, and questions about competence arise.



Ethical issues also attend doing neuroscientific research on
nonhumans. Like traditional bioethics, neuroethics must address
questions about the ethical use of animals for experimental purposes
in neuroscience. In addition, however, it ought to consider questions
regarding the use of animals as model systems for understanding the
human brain and human cognition (Johnson et al., 2020). Animal studies
have given us the bulk of our understanding of neural physiology and
anatomy and have provided significant insight into function of
conserved biological capacities. However, the further we push into
unknown territory about higher cognitive functions, the more we will
have to attend to the specifics of similarities and differences
between humans and other species and evaluating the model system may
involve considerable philosophical work. In some cases, the
dissimilarities may not warrant animal experiments.



Other issues to which neuroethics also must be attentive to involve
social justice. As neuroscience promises to offer treatments and
enhancements, it must attend to issues of distributive justice, and
play a role in ensuring that the fruits of neuroscientific research do
not go only to those who enjoy the best our society has to offer.
Moreover, a growing understanding that poverty and socioeconomic
status more generally have long-lasting cognitive effects raises moral
questions about the social policy and the structure of our society,
and the growing gap between rich and poor (Farah, 2017). It seems that
the social and neuroscientific realities may reveal the American Dream
to be largely hollow, and these findings may undercut some popular
political ideologies. There are also global issues to consider (Stein
and Singh, 2020). Justice may demand more involvement of
neuroethicists in policy decisions.



Finally, neuroethics stretches seamlessly into the law (see, e.g.
Vincent, 2013; Morse and Roskies, 2013; Jones et al., 2014).
Neuroethical issues arise in criminal law, in particular with the
issue of criminal responsibility (see, e.g. Birks & Douglas,
2018). For example, the recognition that a large percentage of prison
inmates have some history of head trauma or other abnormality raises
the question of where to draw the line between the bad and the mad.
Neuroethics has bearing on issues of addiction and juvenile
responsibility, as well as on some other areas of law, such as in tort
law, employment law, and health care law.


## 3. The Neuroscience of Ethics



Neuroscience, or more broadly the cognitive and neural sciences, have
made significant inroads into understanding the neural basis of
ethical thought and social behavior. In the last decades, these fields
have begun to flesh out the neural machinery underlying human
capacities for moral judgment, altruistic action, and the moral
emotions (Liao, 2016). The field of social neuroscience, nonexistent
two decades ago, is thriving, and our understanding of the circuitry,
the neurochemistry, and the modulatory influences underlying some of
our most complex and nuanced interpersonal behaviors is growing
rapidly. Neuroethics recognizes that the heightened understanding of
the biological bases of social and moral behaviors can itself have
effects on how we conceptualize ourselves as social and moral agents,
and foresees the importance of the interplay between our scientific
conception of ourselves and our ethical views and theories (Roskies,
2002). The interplay and its effects provide reason to view the
neuroscience of ethics (or more broadly, of sociality) as part of the
domain of neuroethics.



Perhaps the most well-known and controversial example of such an
interplay marks the beginning of this kind of exploration. In 2001,
Joshua Greene scanned people while they made a series of moral and
nonmoral decisions in different scenarios, including dilemmas modeled
on the philosophical "Trolley Problem" (Thomson, 1985). He
noted systematic differences in the engagement of brain regions
associated with moral processing in "personal" as opposed
to "impersonal" moral dilemmas and hypothesized that
emotional interference was behind the differential reaction times in
judgments of permissibility in the footbridge case. In later work, he
proposed a dual-process model of moral judgment, where relatively
automatic emotion-based reactions and high-level cognitive control
jointly determined responses to moral dilemmas, and he related his
findings to philosophical moral theories (Greene, 2004, 2008). Most
controversially, he suggested that there are reasons to be suspicious
of our deontological judgments, and interpreted his work as lending
credence to utilitarian theories (Greene 2013). Greene's work is
thus a clear example of how neuroscience might affect our ethical
theorizing. Claims regarding the import of neuroscience studies for
philosophical questions have sparked a heated debate in philosophy and
beyond, and prompted critiques and replies from scholars both within
and outside of philosophy (see, e.g. Berker, 2009; Kahane, 2011;
Christensen, 2014). One effect of these exchanges is to highlight a
problematic tendency for scientists and some philosophers to think
they can draw normative conclusions from purely descriptive data;
another is to illuminate the ways in which descriptive data might
itself masquerade as normative (Roskies, forthcoming).



Greene's early studies demonstrated that neuroscience can be
used in the service of examining extremely high-level behaviors and
capacities, and have served as an inspiration for numerous other
experiments investigating the neural basis of social and moral
behavior and competences (May et al., forthcoming). Neuroethics has
already turned its attention to phenomena such as altruism, empathy,
well-being, and theory of mind, as well as to disorders such as autism
and psychopathy. The relevant works range from imaging studies using a
variety of imaging techniques, to manipulation of hormones and
neurochemicals, to purely behavioral studies, and the use of virtual
reality. In addition, interest in moral and social neuroscience has
collided synergistically with the growth of neuroeconomics, which has
flourished in large part independently. A recent bibliography has
collected almost 400 references to works in the neuroscience of ethics
since 2002 (Darragh et al., 2015). We can safely assume that many more
advances will be made in the years to come, and that neuroethicists
will be called upon to advance, evaluate, expound upon, or deflate
claims for the purported ethical implications of our new
knowledge.


## 4. Looking forward: New neurotechnologies



The examples discussed above included pharmaceuticals that are already
approved for use, existing brain imaging techniques and invasive
neurotherapies. But practical neuroethical concerns, and some
theoretical concerns, are highly dependent upon the details of
technologies. For example, adaptive DBS or aDBS, which "closes
the loop" by concurrently stimulating and recording from neural
tissue, and automatically adjusting stimulation based on the state of
the brain, raises more pressing and somewhat different concerns about
agency and autonomy than does regular DBS (see, e.g. Goering et al.,
2017). Several technologies are already on the horizon that are bound
to raise some new neuroethical questions, or old questions in new
guises. One of the most powerful new tools in the research
neuroscientist's arsenal is "optogenetics", a method
of transfecting brain cells with genetically engineered proteins that
make the cell responsive to light of specific wavelengths (Diesseroth,
2011). The cells can then be activated or silenced by shining light
upon them, allowing for cell-specific external control. Optogenetics
has been successfully used in many model organisms, including rats,
and work is underway to use optogenetics in monkeys. One may presume
it is only a matter of time before it will be developed for use in
humans. The method promises to provide precise control of specific
neural populations and relatively noninvasive targeted treatments for
diseases. It promises to raise the kind of neuroethical issues raised
by many mechanisms that intervene on brain function: Questions of
harm, of authenticity, and the prospect of brain cells being
controlled by someone other than the agent himself (Gilbert, 2014;
Adamczyk & Zawadzki, 2020). A second technique, CRISPR, allows
powerful targeted gene editing. Although not strictly a
neuroscientific technique, it can be used on neural cells to effect
brain changes at the genetic level (Canli, 2015). Genetic engineering
might make possible neural gene therapies and designer babies, making
real consequences of the genetic revolution thus far only
imagined.



These and other technologies were not even imagined a few decades ago,
and is likely that other future technologies will emerge which we
cannot currently conceive of. If many neuroethical issues are closely
tied to the capabilities of neurotechnologies, as I have argued, then
we will likely be unlikely to anticipate future technologies in enough
detail to predict the constellation of neuroethical issues that they
may give rise to. Neuroethics will have to grow as neuroscience does,
adapting to novel ethical and technological challenges.