Ethical Issues Surrounding a New Generation of Neuroprostheses for Patients With Spinal Cord Injuries

Abstract

Traumatic spinal cord injury (SCI) is a significant life event, one that often defines a fixed time point: life before SCI and life after it. However, the rise of new neuroprostheses may introduce a new point to this timeline, one that could be as precise as the injury itself: the restoration of volitional movement and perhaps even sensation. Neuroprostheses offer possibilities that may forever change physical and psychological experiences after SCI. Yet it is important to balance excitement about these possibilities with consideration of the ethical dimensions of the study and use of these technologies. Previous work on the ethical dimensions of neuroprostheses has focused largely on the broader implications of these and similar technologies once they become more widely available 1, 2. In this article, we focus on the local issues of neuroprosthetic research in its current stage of development and their effects on research participants and cli006Eic patients after SCI. We highlight 4 ethical issues with novel neuroprostheses: co-investigatorship, explantation, off-target effects, and societal responsibilities. Through introducing these issues in the context of current research, our hope is to begin a conversation regarding these new technologies and to propose methods for ongoing consideration of ethical issues as this research progresses. Acute, traumatic SCI traditionally is associated with loss. Loss of volitional movement, loss of sensation, loss of bowel/bladder control, and loss of independence may all accompany this condition 3. However, in-depth research may introduce a gain to balance this loss: the role of co-investigator. Implanted neuroprostheses, especially the many new technologies involving brain–computer interfaces (BCIs), introduce the possibility of bypassing focal impairments in the nervous or musculoskeletal systems 4. These BCIs can be used invasively 5 or noninvasively 6. In their exploratory current state, significant training is required to tune interfacing neurons to specific patterns that can then be interpreted by computer algorithms and translated into functional end effector commands. Recently, this has been accomplished in patients with SCI by using the participant's brain to control peripheral functional electrical stimulation in their own muscles 7 and also in a bidirectional manner, in experiments in which a brain-controlled robotic arm directly conveyed sensory feedback from the robot back to the somatosensory cortex 8. These applications, and the many that are still in early planning phases, require a significant investment in time and energy from the participant with the implanted device. This is needed not only to fine-tune the neuron firing patterns within the participant that are then read by the BCI but also to optimize the computer algorithms needed to decode these signals. Given this intense training and time commitment from both participant and researchers, the participant gradually may become more of a co-investigator than a passive volunteer, exploring new scientific frontiers along with the research team and making scientific contributions by providing technical insights not otherwise freely available. Many participants, and the researchers pushing the knowledge boundaries alongside them, discuss their experiences in terms of this pioneering partnership. Ian Burkhart, who was one of the first participants in an experiment to connect a BCI to the limb of a person with paralysis, says, “I really can't complain about the way my life is right now. If nothing else, I can say I was the first person ever to do something, which is an opportunity I never expected to have” 9. This novel role for the participant may provide a notable sense of self-worth and meaning but also can blur ethical boundaries. For instance, in a recent article reporting on the use of a BCI to control a robotic arm, the research participants, Tim Hemmes and Jan Scheuermann, are included in the publication as co-autho