Ethical challenges of adaptive deep brain stimulation: a multidimensional analysis through the lens of control

Adaptive deep brain stimulation (aDBS) is a neuromodulation technology that enables real-time monitoring and automatic adjustment of stimulation parameters. While enhancing treatment precision, this technology also introduces more intricate ethical challenges than conventional DBS (cDBS). Current discussions of autonomy in aDBS often appeal to different definitions of autonomy, making it difficult to fully capture the distinctive problems posed by aDBS. To address this gap, this article proposes a multidimensional analytical framework centred on control, derived from aDBS's two distinctive features: 'automatic unperceived operation' and 'patient-device shared control of neural activity'. Within this framework, control is categorised along two dimensions: source and perception. Using this framework, the study identifies three categories of ethical challenges: (1) unperceived external control by third parties (such as hacking) constitutes a potential manipulation of individual autonomy; (2) unperceived external control arising from system autonomy may become conflated with patients' internal control, blurring human-machine boundaries and creating dilemmas of self-identity and responsibility attribution; and (3) perceived external control may foster patient dependence or even addiction to the technology, undermining individual capacities for internal control. This mapping provides a more explanatory conceptual toolkit for ethical assessment and policy-making around aDBS, aiming to ensure that technological innovation promotes human well-being while safeguarding individual dignity and autonomy.