With the Known Space novels by Larry Niven, the world came in touch with brain stimulation. In his novels, Niven describes 'Wireheads'; humans who install devices onto the pleasure centre of their brains to receive electrical currents, making them feel instant gratification.
Now, approximately six decades after Niven's novels, science has made progress. Brain stimulation exists and — even better — does not necessarily require invasive procedures. The FDA approved brain stimulation to treat depression, migraines, OCD and smoking cessation (Cohen et al., 2022). Furthermore, clinics advertise brain stimulation off-label for autism, PTSD, bipolar disorder or Parkinson’s disease (Wexler et al., 2021). Outside the clinical context, the US military tested brain stimulation to enhance multitasking and learning abilities (Clark et al., 2012; Nelson et al., 2016), and fanatics already use brain stimulation at home (Jwa, 2016).
This trend is accompanied by interest from the scientific community and commercial entities, like the tech industry and its elite. So far, studies offer some evidence that brain stimulation enhances cognition — for example in relation to language learning and creative thinking — mood and even moral judgement (references to these studies can be found in the full paper that is attached to this article). This increase of interest, combined with the variety of potential applications, might imply we are approaching a situation in which brain stimulation becomes more commonplace, even among healthy people. Thus, this may be the ideal moment to look into the ethical debate about the use of brain stimulation for 'normal' people.
Why Brain Stimulation Could Be Problematic
Brain stimulation offers significant benefits. If the science holds up, people who have received brain stimulation are able to learn faster, are more creative or happy, and might even be better moral subjects. However, apart from some fear of the unknown, critics bring up four fundamental ethical points that should be considered. I will go into each of them.
Is It Even Safe?
The first point I discuss is safety, as safety is pragmatic and apriori. That is to say, if it is not safe to use brain stimulation, there are few incentives for anyone to offer or use it. To that end, it is more of a pragmatic issue than an ethical one (Hamilton et al., 2011, p. 190). Nevertheless, it is a commonly raised concern (e.g. Rossi et al., 2021).
To the best of our current knowledge, the answer to whether this technology is safe is ‘yes’. Most commonly, brain stimulation gives minor side effects such as a headache (Poreisz et al., 2007). However, there are reported cases of structural brain changes or histotoxicity (i.e., the inability to take up enough oxygen from your blood) after repeated exposure (Rossi et al., 2009). Hence, we still can’t be sure about the build-up effect of repeated exposure.
Apart from such concerns, there are three more fundamental points:
- Not everything that works in clinical practice has positive effects outside of it. Depressed patients may benefit from inhabiting emotions, but the normal population may suffer from the exact same intervention (Levasseur-Moreau et al., 2013).
- Brain areas collaborate in a zero-sum game. This means that if you stimulate one area, you mitigate another (Brem et al., 2014). This also means you may mitigate another useful or even critical function of the brain.
- We should think about whether people are still able to give informed consent, specifically when someone’s character may change because of brain stimulation (Cabrera et al., 2014, p. 9).
With this in mind, it becomes clear that even if incidental stimulation is relatively safe, there is more to consider. As a bottom line, we do need more research on safety concerns that can be linked to long-term brain stimulation.
Depressed patients may benefit from inhabiting emotions, but the normal population may suffer from the exact same intervention
What Makes Me ‘Me’?
The notion of altering creativity, moral judgement or other traits might lead to some tension. In fact, I believe some of these characteristics are part of someone’s identity and should not be altered. And I’m not alone. One study showed how mood and creativity are often seen as fundamental parts of a person's 'self', as opposed to language learning skills and the functioning of a person's memory (Riis et al., 2008).
However, even if we consider the possibility that this conviction is just false intuition, it might still be relevant to engage with the potential impact of brain stimulation on our general understanding of skills and talents. For example, language learning requires hard work and creativity is valued because of its uniqueness. Once everyone is able to access these skills, appreciation of natural giftedness and hard work may decline. This is problematic in situations where traits are only good in comparison to how common they are — such as in sports.
And even if you wouldn’t care about this, it might be reasonable to consider how brain stimulation might affect our ability to predict how traits develop and impact other aspects of life. Having a bad mood may sound inherently bad, but may also help people to develop traits such as patience, determination, empathy or feeling accomplished when a person overcomes that bad mood (Hamilton et al., 2011, p. 190). Also, it ignores the fact that someone feels bad for a reason, thus undermining the possibility to address underlying, structural reasons.
Having a bad mood may sound inherently bad, but may help you to develop traits such as patience, determination, empathy or feeling accomplished when you overcome that bad mood
The latter can be linked to the concept of 'techno-solutionism', which refers to the idea that social problems can be solved by innovative, technological solutions. From that perspective, media reporting might be inclined to present brain enhancement as an easy intervention, while ignoring other potential solutions and the complex effects of brain stimulation. This leads to two effects that need to be considered. One, it takes attention away from other — possibly more advantageous and human-centred — interventions. Two, it alters the expectations people have of this technology (Gardner & Warren, 2019). The reality is that brain enhancement is anything but discrete and well-bounded, with some accounts mentioning contradicting effects (e.g. Schüpbach et al., 2006) and change of character (Bell et al., 2011). For example in this doctor's account: "You know this is a man who previously hiked and enjoyed sort of peaceful serenity in the outdoors and now wanted to drive an all-terrain vehicle through the woods” (Bell et al., 2011).
Is It Fair?
Some groups of people might not be able to use this technology because they don’t have resources or access, while others might have practical or fundamental reasons to not use it. This can give one group an unfair advantage at the expense of another group. This then widens gaps, for example between poor and rich.
The appreciation of your talent is almost always dependent on how talented others are
If that argument sounds familiar, you are right. Similar arguments can be brought up for access to healthy food or a silent study place. It is hard to see why exactly we think some means are okay for people to use in order to gain an advantage, while other means are not. On top of that, the price for some brain stimulation technology is comparable to a smartphone, and thus relatively cheap and accessible anyway (Cabrera et al., 2014, p. 11-12).
Yet, we can go one step further. Especially where technology is commercialised, existing concerns may become more prominent. Recently, Neuralink — a company owned by Elon Musk that aims to develop brain implants for general use — has received FDA approval for its first clinical trials (Paul & Singh, 2023). At this point, it is not only a concern of who is able to use the technology but also who owns it. Neuralink is under investigation for animal abuse and mishandling of bio-hazardous materials across state lines. Furthermore, there are concerns about sloppy test data, in addition to Musk's track record of mishandling user data (Paul & Singh, 2023). If brain stimulation will be in the hands of a few actors, we should wonder whether these actors can be trusted. Having few actors with the capacity to commercialise this technology increases the power of those actors. Eventually, this might lead to a situation in which there are few alternatives. The end result might be characterized by, for example, more privacy violations — as dominant actors will experience less pressure to create safeguards, and hackers or malicious governments can target fewer actors —, consumer exclusion by raised prices, and lack of trust or accessibility limitations. However, most of these potential issues rely on assumptions regarding how tech elites will behave in this hypothetical future context.
Other leading individuals from the tech industry, such as Bryan Johnson and Mark Zuckerberg, have also expressed an interest in developing a similar technology (Marsh, 2018). The power over the technology, and consequent data, is a debate similar to other big tech debates. However, the technology we are talking about here is more invasive than ever seen before and, therefore, the need for fair distribution and appropriate consumer protection becomes more important.
Are We Really Free To Choose?
Normalising technology can also produce the danger of coercing people into using it. For example, in a case where you are required to use brain stimulation in order to get a job in the military (Lapenta et al., 2014, p. 177-178).
Even when coercion is not that explicit, you may still be implicitly coerced to use brain stimulation in order to keep up with the competition. If opting out leads to a situation in which you are unable to memorise or focus to the same degree as your peers, you don’t really have the opportunity to say ‘no’. Or at least, your rejection then comes at a heavy price.
We can already see comparable cases in the real world. On some campuses, up to 25% of students use prescription stimulants (e.g. Ritalin) to become more focused (Greely et al., 2008). If too many people participate in this practice, this influences what we deem normal and what we expect from students. Brain stimulation could function in similar ways.
If the only opt-out option is a situation in which you are unable to memorise or focus to the same degree as peers, you don’t really have an opportunity to say ‘no’
Does Any Of This Matter?
More profoundly, we may look at these concerns and think ‘Why is this any different than clinical treatment?’. A treatment of a disease can confront an individual with the same concerns as enhancement, with the only difference being that intuitively we feel that enhancement and treatment are not the same thing. If we agree that treating diseases is a good thing, we must either accept enhancement is inherently good as well or differentiate the two. Since I feel uncomfortable with the first option, I will attempt the second one.
The Fine Line Between Treatment And Enhancement
The obvious and unhelpful answer to this difference is that treatment is repairing something broken or remedying a dysfunction (Sandberg, 2014) or, more simply, becoming healthy. But treating someone in order to become healthy still requires an answer to the question ‘What is healthy?’.
The WHO has answered this question and defines health as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). This definition explicitly refers to more than simply having no disease but uses the concept of 'complete well-being'. Well-being, according to the WHO (n.d., p. 30), includes: coping with life, realising one's abilities, learning and working well and contributing to one's community. It is unclear to what extent this holds. Living up to your maximum potential sounds nice, but may be problematic if that maximum potential includes your access to brain stimulation. According to the WHO definition, there can't even be a concept of 'enhancement', and brain stimulation can never be wrong as long as it raises your potential.
Fortunately, the WHO definition is not our only option. For example, the biostatistical theory (BST) gives us a different popular approach to health. BST only knows statistical normality. Everything that is beyond average is an enhancement; everything below it is treatment.
Although this sounds intuitive, it does not consider which traits are enhanced. I think it does matter whether we are enhancing creativity or language learning skills. I also think it matters how we accomplish enhancement — through hard work or brain stimulation. If you agree, BST is unhelpful in answering why a person might believe it is morally wrong to use brain enhancement. On top of this, the average also changes based on how many people enhance themselves.
Other approaches to health — such as positive health or Nordenfelt’s vital goals (Huber et al., 2011; Nordenfelt, 2007) — define health as the extent to which you can fulfil your societal function (i.e. are you able to do what you should be able to do?). Note how this makes health dependent on the societal context, expectations and infrastructure. If brain stimulation becomes more common, this means that just because it is common you can only be healthy by using it.
Living up to your maximum potential sounds nice, but may be problematic if that maximum potential includes your access to brain stimulation
In general, these health definitions are unfit to render our discomfort intelligible. They either raise new questions, or make the definition dependent on the societal context. This transforms the question into a popularity contest. In this popularity contest, the question of whether brain stimulation is something for the normal population changes depending on how many people agree, disregarding the various reasons that might underly a person's decision to use brain stimulation.
What Is Wrong With A Popularity Contest?
The consequence of this thinking is that it is not grounded at all, but constantly changing. This changes our approach towards normality in two ways.
- Humans have similar preferences and are likely to enhance in similar patterns (Kamm, 2005). Exactly the variety in humans we appreciate may be undermined if everyone complies with the same standard. This makes 'normal' even less variable and broad than our current understanding of it.
- Enhancement may result in differences between enhanced and unenhanced people, creating division. If you are unenhanced, it is hard to keep up and you are given fewer opportunities to interact with enhanced groups (Anomaly, 2020).
I hoped to end this article with a more satisfying answer. Even though we can see multiple issues with the broad implementation of brain stimulation, these issues are grounded in assumptions that don’t hold. This is what we should think about.
They beg the question or make the definition dependent on the societal context. This transforms the question into a popularity contest
Anomaly, J. (2020). Creating Future People: The Ethics of Genetic Enhancement (1st ed.). Routledge.
Bell, E., Maxwell, B., McAndrews, M. P., Sadikot, A. F., & Racine, E. (2011). A review of social and relational aspects of deep brain stimulation in parkinson’s disease informed by healthcare provider experiences. Parkinson’s Disease. https://doi.org/10.4061/2011/871874
Brem, A. K., Fried, P. J., Horvath, J. C., Robertson, E. M., & Pascual-Leone, A. (2014). Is neuroenhancement by noninvasive brain stimulation a net zero-sum proposition? NeuroImage, 85, 1058–1068. https://doi.org/10.1016/j.neuroimage.2013.07.038
Cabrera, L. Y., Evans, E. L., & Hamilton, R. H. (2014). Ethics of the electrified mind: Defining issues and perspectives on the principled use of brain stimulation in medical research and clinical care. Brain Topography, 27(1), 33–45. https://doi.org/10.1007/s10548-013-0296-8
Clark, V. P., Coffman, B. A., Mayer, A. R., Weisend, M. P., Lane, T. D. R., Calhoun, V. D., Raybourn, E. M., Garcia, C. M., & Wassermann, E. M. (2012). TDCS guided using fMRI significantly accelerates learning to identify concealed objects. NeuroImage, 59(1), 117–128. https://doi.org/10.1016/j.neuroimage.2010.11.036
Cohen, S. L., Bikson, M., Badran, B. W., & George, M. S. (2022). A visual and narrative timeline of US FDA milestones for Transcranial Magnetic Stimulation (TMS) devices. Brain Stimulation, 15(1), 73–75. https://doi.org/10.1016/j.brs.2021.11.010
Gardner, J., & Warren, N. (2019). Learning from deep brain stimulation: the fallacy of techno-solutionism and the need for ‘regimes of care.’ Medicine, Health Care and Philosophy, 22(3), 363–374. https://doi.org/10.1007/s11019-018-9858-6
Greely, H., Sahakian, B., Harris, J., Kessler, R. C., Gazzaniga, M., Campbell, P., & Farah, M. J. (2008). Towards responsible use of cognitive-enhancing drugs by the healthy. Nature, 456, 702–705. https://doi.org/10.1038/456702a
Hamilton, R., Messing, S., & Chatterjee, A. (2011). Rethinking the thinking cap: Ethics of neural enhancement using noninvasive brain stimulation. Neurology, 76(2), 187–193. https://doi.org/10.1212/WNL.0b013e318205d50d
Huber, M., André Knottnerus, J., Green, L., van der Horst, H., Jadad, A. R., Kromhout, D., Leonard, B., Lorig, K., Loureiro, M. I., van der Meer, J. W. M., Schnabel, P., Smith, R., van Weel, C., & Smid, H. (2011). How should we define health? BMJ, 343(d4163). https://doi.org/10.1136/bmj.d4163
Jwa, A. (2016). Early adopters of the magical thinking cap: A study on do-it-yourself (DIY) transcranial direct current stimulation (tDCS) user community. Journal of Law and the Biosciences, 2(3), 292–335. https://doi.org/10.1093/jlb/lsv017
Kamm, F. M. (2005). Is there a problem with enhancement? American Journal of Bioethics, 5(3), 5–14. https://doi.org/10.1080/15265160590945101
Lapenta, O. M., Valasek, C. A., Brunoni, A. R., & Boggio, P. S. (2014). An ethical discussion of the use of transcranial direct current stimulation for cognitive enhancement in healthy individuals: A fictional case study. Psychology and Neuroscience, 7(2), 175–180. https://doi.org/10.3922/j.psns.2014.010
Levasseur-Moreau, J., Brunelin, J., & Fecteau, S. (2013). Non-invasive brain stimulation can induce paradoxical facilitation. Are these neuroenhancements transferable and meaningful to security services? Frontiers in Human Neuroscience, 7(449). https://doi.org/10.3389/fnhum.2013.00449
Nelson, J., McKinley, R. A., Phillips, C., McIntire, U., Goodyear, C., Kreiner, A., & Montorton, L. (2016). The Effects of Transcranial Direct Current Stimulation (tDCS) on Multitasking Throughput Capacity. Frontiers in Human Neuroscience, 10(589). https://doi.org/10.3389/fnhum.2016.00589
Nordenfelt, L. (2007). The concepts of health and illness revisited. Medicine, Health Care and Philosophy, 10(1), 5–10. https://doi.org/10.1007/s11019-006-9017-3
Poreisz, C., Boros, K., Antal, A., & Paulus, W. (2007). Safety aspects of transcranial direct current stimulation concerning healthy subjects and patients. Brain Research Bulletin, 72(4–6), 208–214. https://doi.org/10.1016/j.brainresbull.2007.01.004
Riis, J., Simmons, J. P., & Goodwin, G. P. (2008). Preferences for Enhancement Pharmaceuticals: The Reluctance to Enhance Fundamental. Journal of Consumer Research, 35(3), 495–508. https://doi.org/10.1086/588746
Rossi, S., Hallett, M., Rossini, P. M., Pascual-Leone, A., Avanzini, G., Bestmann, S., Berardelli, A., Brewer, C., Canli, T., Cantello, R., Chen, R., Classen, J., Demitrack, M., di Lazzaro, V., Epstein, C. M., George, M. S., Fregni, F., Ilmoniemi, R., Jalinous, R., … Ziemann, U. (2009). Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology, 120(12), 2008–2039. https://doi.org/10.1016/j.clinph.2009.08.016
Rossi, S., Antal, A., Bestmann, S., Bikson, M., Brewer, C., Brockmöller, J., Carpenter, L. L., Cincotta, M., Chen, R., Daskalakis, J. D., di Lazzaro, V., Fox, M. D., George, M. S., Gilbert, D., Kimiskidis, V. K., Koch, G., Ilmoniemi, R. J., Pascal Lefaucheur, J., Leocani, L., … Hallett, M. (2021). Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 132, 269–306. https://doi.org/10.1016/j.clinph.2020.10.003
Sandberg, A. (2014). Cognition Enhancement: Upgrading the Brain. In J. Savulescu, R. ter Meulen, & G. Kahane (Eds.), Enhancing Human Capacities (p. 69–91). Blackwell Publishing Ltd. https://doi.org/10.1002/9781444393552.ch5
Schüpbach, M., Gargiulo, M., Welter, M.L., Mallet, L., Behar, C., Houeto, J.L., Maltete, D., Mesnage, V., & Agid, Y. 2006. Neuro-surgery in Parkinson Disease: A Distressed Mind in a Repaired Body? Neurology 66(12), 1811–1816. https ://doi.org/10.1212/01.wnl.00002 34880.51322 .16.
Wexler, A., Nagappan, A., Kopyto, D., Santarnecchi, E., & Pascual-Leone, A. (2021). Off-Label Promotion of Transcranial Magnetic Stimulation on Provider Websites. In Brain Stimulation (Vol. 14, Issue 3, p. 723–724). Elsevier Inc. https://doi.org/10.1016/j.brs.2021.04.013
WHO. (1948). Constitution of the World Health Organization. American Journal of Public Health, 36(11), 1315–1323. https://doi.org/10.2105/AJPH.36.11.131