Schaub 6:00
L15
THE ETHICAL DILEMMA OF VARYING LEVELS OF BRAIN-MACHINE
INTERFACE INVASIVENESS
Max Baxter (mab471@pitt.edu)
BRAIN-MACHINE INTERFACES AND THE
ETHICAL ISSUE AT HAND
Brain-machine interfaces (BMIs) have been vital in
treating neurological disorders in recent years, such as
paralysis, and are proving to be an extremely beneficial
neuroprosthetic [7]. BMIs are interfaces containing a series of
electrodes that establish a direct line of communication
between the brain and an external computing device.
When implementing a BMI, one must determine the level
of invasiveness that will be utilized; BMIs are typically
grouped into two categories regarding invasiveness: invasive
and noninvasive [7]. However, there are several different
“levels” within the patient’s head where the interface can be
placed at [7]. An ethical quandary thusly arises when
considering each level of invasiveness’s multitude of pros and
cons. The National Society of Professional Engineers’
(NSPE) and the Biomedical Engineering Society’s (BMES)
Code of Ethics aid in determining which approach is ideal, but
still leave a lot of room for question.
There are a myriad of positive and negative aspects to both
the invasive and noninvasive models of the BMI. The
noninvasive interface model applies the electrodes directly to
the scalp. This means that there is no risk of error in the
installment [5]. The typical noninvasive process is called
electroencephalography (EEG), which is a means of
monitoring electrical activity within the neurons of the brain
[5]. The main drawback of the noninvasive approach is that
the brain activity cannot be read as easily since the skull can
distort the signals [5]. Other drawbacks include the following:
“sensitivity to electromagnetic radiation, difficulty to place
and position, varying conductance, usually a limited number
of channels, and discomfort when used for a longer time.” [5].
However, the noninvasive approach of the EEG is a more
portable and cost effective device [5].
The invasive approach to the brain-machine interface has
a similar ratio of benefits and drawbacks, and involves
surgically placing the electrodes of the interface inside the
patient’s head [6]. The invasive approach of the BMI can be
viewed as more practical for an individual to utilize in
everyday life due to the fact that they are not wired [2]. The
invasive method also allows for better extraction of
information and signals due to close proximity to the brain;
however, there are several health risk factors that arise from
any neurosurgical device implantation [6]. The invasive and
noninvasive BMI have their respective pros and cons, and the
ultimate decision of which method should be used should be
determined with consideration of the patient and the benefit
to risk ratio of each specific case.
University of Pittsburgh, Swanson School of Engineering
2015-10-26
As a neural engineer, a dilemma regarding which level of
invasiveness should be used arose when treating a paralyzed
and mildly cognitively impaired patient; it was necessary to
use a brain-machine interface. The patient in question, Patient
A, is an adult of age twenty-seven, and consequently holds
full responsibility to determining what treatment, if any, will
be utilized [4]. In most situations when treating patients with
brain-machine interfaces in the past, I would simply explain
the risk factors and potential benefits of both the invasive and
noninvasive methods. However the ability of Patient A to
make an informed decision due to cognitive limitations raises
the ethical question of whether or not they have the ability to
make this decision.
Patient A is able to communicate through speech, but has
difficulty processing information and certain concepts, often
demonstrating a limited understanding. Therefore, it is
questionable that Patient A can understand the pros and cons
of different levels of invasiveness with BMIs, and
subsequently make an informed decision about his situation.
Patient A stated that he would like the most invasive BMI
possible as he would like to maximize his potential benefits
despite the risk. I, however, am uncertain if I agree with this
decision when considering all of the factors. There is no
defined minimum level of cognitive ability that delineates
whether or not a patient has the appropriate amount of mental
capacity to make an informed decision. The primary issue
then arises when considering if I, as a neural engineer, can
make the decision of what level of invasiveness should be
used. It is imperative to determine whether or not I should
favor the benefit to risk ratio of each method or the will of
Patient A. While I am confident in my decision making skills
regarding Patient A’s situation, the Code of Ethics for both
the National Society of Professional Engineers (NSPE) and
the Biomedical Engineering Society (BMES) can prohibit my
decision making ability based on individual interpretation
[1][4].
CONSIDERING THE CODE OF ETHICS
The Code of Ethics for the NSPE is key to making the
appropriate decision in this particular BMI dilemma. While
personal interpretation of the codes is a factor, they still
provide clarification towards determining the ideal approach.
One professional obligation stated in the NSPE Code of
Ethics directly applies to the safety of Patient A: “Engineers
shall advise their clients or employees when they believe a
project will not be successful.” [1]. This statement gives the
engineer more influence in the final decision as the engineer
should advise the client on what is considered to be the most
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successful “project” (where each project has a different
degree of invasiveness). The Code of Ethics also states that
engineers are not to be influenced by any “conflicting
interests” when making a profession decision [1]. The
conflicting interests that should be avoided can be interpreted
to include the opinions of the patient and his family since both
are not experts with this particular innovation. Therefore the
patient’s opinion on which level of invasiveness should be
utilized should not be a factor in the final verdict based on this
section of the code. The engineer’s influence is especially
important and should be considered to a perhaps even greater
extent due to the fact that this decision may end up being a
life or death decision.
The BMES Code of Ethics is also a paramount resource
that needs to be considered when making this decision. One
particular section of the code concerns one of the most
important responsibilities of a biomedical engineer:
“[Biomedical engineers involved in health care activities
shall] regard responsibility toward and rights of patients… as
their primary concern.” [4]. This particular statement provides
reason for choosing the safest implementation of the
interface; the overall health and well-being of the patient is
what is most important. This means that any risk for the
patient should be reduced even if it means a potentially less
effective result. The BMES Code of Ethics also states that the
larger consequences of a biomedical engineer’s work must be
considered [4]. This also provides reason for choosing the
safest approach for the brain-machine interface since the loss
of a life is a very large potential consequence that should be
avoided. Based on this statement in the BMES code of ethics,
it is not worth the risk of a patient death, especially since
Patient A is not in potentially fatal trouble in his current
situation.
Statements in the Code of Ethics for both the NSPE and
BMES provide different reasoning for different approaches
regarding this particular ethical dilemma. Overall, it seems
that the BMES Code of Ethics generally promotes more
consideration for the patient in comparison to the NSPE code
[1] [3]. The BMES code tends to favor keeping the patient’s
safety as the primary concern, which means that any risk
should be eliminated [3]. On the other hand, the NSPE
advocates for the empowerment of the engineer’s opinion as
it recognizes that engineers are the most well informed
individuals when deciding when and to what extent a
particular innovation should be applied [1]. The Code of
Ethics for each society is somewhat useful when deciding
which level of invasiveness is the most practical and to what
extent an engineer would be able to override a patient’s
decision if necessary due to lack of cognitive ability;
however, the statements of both codes are contradictory in
multiple instances. When faced with an ethical dilemma, the
Code of Ethics for both the NSPE and BMES significantly
assist in reaching a decision.
APPLYING OUTSIDE SOURCES TO THE
DILEMMA
During various ethical dilemmas throughout my life, I
have turned to various outside sources for guidance. My
father has always been a prominent figure in my life, and a lot
of the morals and ethics that I practice resulted from his
leadership. Since he has been extremely significant in
defining who I am today, I often call or visit him when faced
with a tough life challenge. Even if I do not receive a direct
answer regarding what I should do in the dilemma, simply
talking out my thoughts on the issue with someone whom I
respect has proven to be very effective for me, and my father
has always been the most helpful individual to turn to in these
situations. Faced with the situation of the level of
invasiveness should be used in the case of Patient A, I called
my father to discuss the matter [9]. Essentially what he told
me was that I should be careful with my approach, but overall
I should trust my personal judgement and what I feel would
be ideal for Patient A [9]. He stated that I need to remember
that Patient A knows that I want to make the best decision for
him, and that, even if some risk is involved, I should do what
I feel would be the most beneficial for the patient [9].
My father was not the only outside source that I
considered; I often turn to deep personal thought in nature
when faced with a challenging situation. Ever since I was I
child, I have always integrated nature into my life whether it
be for recreational sports or hiking with friends and family. In
order to help resolve this current dilemma, I took a day hike
alone along a state trail so I could weigh my options away
from the strong, conflicting emotions of others [10]. The
seclusion, along with being surrounded with the serenity of
nature, allowed me to make a better informed decision for
Patient A’s situation [10]. Utilizing both my father and nature
significantly aided in the determination of my approach
towards the issue at hand.
Several other engineers and academics have published
articles on ethical issues regarding invasiveness. Dr. Walter
Glannon of the University of Calgary published an article
detailing his own views on the ethics of BMIs, which involves
his opinion on the benefits and risks of the invasive versus the
noninvasive method [3]. After stating the known pros and
cons of degree of invasiveness, Glannon reached a conclusion
on what he believes to be the most ideal level of invasiveness
[3]. He finished his ethical analysis by favoring the invasive
approach on the grounds that “[a more invasive BMI] does
not imply an unacceptable degree of risk” [3]. Glannon
believes that the potential advantages of the invasive BMI
outweigh the safer approach of the noninvasive interface [3].
Dr. Mary Jane Schneider of the University of North
Dakota et al. published a paper that also discussed the ethics
of brain-machine interfaces [8]. After examining multiple
cases where BMIs were used as treatment, the group
determined that while the invasive method is more helpful,
the technology has not developed enough to use them in
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clinical cases with humans [8]. Despite favoring the
noninvasive method currently, Schneider and her associates
recognize that the invasive approach will be the best option in
the future [8]. It is important to consider the perspective of
other engineers or academics to perhaps view the issue in a
manner that was not previously apparent.
this device. The noninvasive approach is also not going to be
as effective as the invasive, and there is a lot more room for
error [5]. Therefore, the partially invasive brain-machine
interface, which would be implanted within the skull, but
outside the brain itself, is the ideal treatment for Patient A.
The partially invasive BMI has the most ideal benefit to risk
ratio as it is more practical and still offers a long term viable
solution. A partially invasive brain-machine interface is ideal
for Patient A when considering his situation, the Code of
Ethics for both the BMES and NSPE, and my moral
obligations as a neural engineer.
REACHING THE FINAL VERDICT
When faced with any ethical impasse such as the one with
Patient A, all professional engineers should use similar key
tactics to reach the final decision regarding how the problem
will be handled. Consulting any engineering society or
organization’s Code of Ethics is principal to determining the
approach. The Codes of Ethics are often very applicable in
these scenarios, and even if certain statements seemingly
contradict others, understanding which aspects of a situation
are the most important is crucial for a successful decision.
Utilizing the Code of Ethics maximizes professional integrity
due to the fact that they help engineers focus in on the nuances
of the situation; this allows for careful assessments of the
problem at hand.
Regardless of the societally accepted ethics in the medical
field at hand, it is also essential that the engineer is confident
with their decisions. Therefore, the engineer is consequently
the most qualified to make the decision to approach the ethical
dilemma. This confidence will significantly aid in making the
best decision as it will allow the engineer to analyze the
different options more thoroughly. It is also important to
consider the perspective of other experts in a given scenario
since they can help shed light on a different means of
approaching a problem that might not have been previously
recognizable. One final tactic for engineers to implement
when facing a challenging ethical situation is to take
advantage of any outside sources that you have whether it be
talking with a family member or friend, or consulting a certain
religion or faith. Everyone involved in the situation
recognizes that the engineer understands the innovation or
technology involved the best. Using these outside sources can
help clear an engineer’s mind and consequently allow them to
determine the ideal decision.
Upon considering the Code of Ethics for both the BMES
and NSPE, I have concluded that Patient A should be treated
with a partially invasive brain-machine interface. Patient A
originally stated that he would like to implant the interface
within the grey matter of the brain, in order to maximize
potential benefits [2]. This would have been the most invasive
implantation available.
After consulting the codes and additional sources, I, as the
neural engineer, have determined that the prospective
advantages do not outweigh the risks. I am responsible for
maintaining the patient’s health, and do not want to risk
harming his welfare [4]. I had considered recommending the
noninvasive BMI; however, it is simply impractical for a man
of his young age to be able to function in everyday life with
REFERENCES
[1] National Society of Professional Engineers. (2015).
“NSPE Code of Ethics for Engineers.” Journal of the
National Society of Professional Engineers. (Online Article).
http://www.nspe.org/sites/default/files/resources/pdfs/Ethics/
CodeofEthics/Code-2007-July.pdf
[2] J. Lahr. (2015). “Invasive brain-machine interfaces.”
University of Freiburg Journal of Neural Engineering.
(Online Article).
http://material.bccn.uni-freiburg.de/publicationsbccn/2015/Lahr15_1.pdf
[3] W. Glannon. (2014). “Ethical issues with brain-computer
interfaces.” Frontiers in Systems Neuroscience. (Online
Article).
http://journal.frontiersin.org/article/10.3389/fnsys.2014.0013
6/full
[4] Biomedical Engineering Society. (2014). “Biomedical
Engineering Society Code of Ethics.” Journal of the
Biomedical Engineering Society. (Online Article)
http://bmes.org/files/2004%20Approved%20%20Code%20o
f%20Ethics(2).pdf
[5] F. Cincotti, D. Mattia, F. Aloise, et al. (2011). “Noninvasive brain-computer: Towards its application as assistive
technology.” Brain Research Bulletin. (Online Article).
http://www.springer.com/cda/content/document/cda_downlo
addocument/9783642020902-c1.pdf?SGWID=0-0-451015086-p173959822.
[6] G. Baranauskas. (2014). “What limits the performance of
current invasive machine interfaces?.” Frontiers in Systems
Neuroscience.
(Online
Article).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010778/
[7] B. Graimann. (2011). “Brain-Computer Interfaces: A
gentle Introduction.” The Frontiers Collection. (Online
Article).
http://www.springer.com/cda/content/document/cda_downlo
addocument/9783642020902-c1.pdf?SGWID=0-0-451015086-p173959822.
[8] M. Schneider, D. Steines, D. Szibbo, et al. (2012).
“Ethical Issues in Brain-Computer Interface Research,
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Development, and Dissemination.” Journal of Neurologic
Physical Therapy. (Online Article).
http://journals.lww.com/jnpt/Abstract/2012/06000/Ethical_Is
sues_in_Brain_Computer_Interface.8.aspx
[9] D. Baxter. (2015). “Personal Interview.”
[10] M. Baxter. (2015). “Personal Interview.”
ADDITIONAL SOURCES
P. Anderson. (2015). “Paralyzed Patient Uses BrainComputer Interface to Walk.” Medscape. (Website).
http://www.medscape.com/viewarticle/852053
P. Ifft. (2013). “Brain-Machine Interface Enables Bimanual
Arm Movements in Monkeys.” Science Translational
Medicine.
(Website).
http://europepmc.org/articles/pmc3967722
S. Silvoni, M. Cavinato, C. Volpato, et al. (2013). “Kinematic
and neurophysiological consequences of an assisted-forcefeedback brain-machine interface training: a case study.”
Frontiers
in
Neurology.
(Website).
http://journal.frontiersin.org/article/10.3389/fneur.2013.0017
3/full
ACKNOWLEDGMENTS
I would like to thank the following individuals: my writing
instructor, Dan McMillan, for the helpful advice in crafting
the paper, my friends for discussing my ideas with me.
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