Who Uses Direct-to-Consumer Brain Stimulation Products, and Why? A Study of Home Users of tDCS Devices

Transcutaneous and transcranial electrical stimulation for enhancing military performance: an update and systematic review

Introduction

Electrical stimulation (ES), including transcranial electrical stimulation (tES) and transcutaneous vagus nerve stimulation (tVNS), has shown potential for cognitive enhancement in military contexts. Various types of ES, such as transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), modulate neuronal membrane potentials and cortical excitability, potentially improving cognitive functions relevant to military training and operations.

Methods

This systematic review updates previous findings by examining studies published between 2019 and 2024 that investigated electrical stimulation effects on cognitive performance in military personnel and tasks. We focused on whether the studies addressed key questions about the generalizability of lab findings to military tasks, the frequency and intensity of adverse effects, the impact of repeated ES administration, and the ethical and regulatory considerations for its use in potentially vulnerable military populations.

Results

Eleven studies met the inclusion criteria; most demonstrated overall low to some concerns, however, two of these had overall high risk of bias. While tES and tVNS showed some promise for enhancing multitasking and visual search performance, the results were mixed, with no reliable effects on vigilance tasks.

Discussion

The reviewed studies highlight the need for a better understanding of ES mechanisms, optimal stimulation parameters, and individual differences in response to ES. They also highlight the importance of conducting high-powered research in military settings to evaluate the efficacy, safety, and ethical implications of ES. Future research should address the generalizability of lab-based results to real-world military tasks, monitor the frequency and intensity of adverse effects, and explore the long-term impacts of repeated administration. Furthermore, ethical and regulatory considerations are crucial for the responsible application of ES in military contexts, and a series of outstanding questions is posed to guide continuing research in this domain.

Ethical issues in direct-to-consumer healthcare: A scoping review

An increasing number of health products and services are being offered on a direct-to-consumer (DTC) basis. To date, however, scholarship on DTC healthcare products and services has largely proceeded in a domain-specific fashion, with discussions of relevant ethical challenges occurring within specific medical specialties. The present study therefore aimed to provide a scoping review of ethical issues raised in the academic literature across types of DTC healthcare products and services. A systematic search for relevant publications between 2011-2021 was conducted on PubMed and Google Scholar using iteratively developed search terms. The final sample included 86 publications that discussed ethical issues related to DTC healthcare products and services. All publications were coded for ethical issues mentioned, primary DTC product or service discussed, type of study, year of publication, and geographical context. We found that the types of DTC healthcare products and services mentioned in our sample spanned six categories: neurotechnology (34%), testing (20%), in-person services (17%), digital health tools (14%), telemedicine (13%), and physical interventions (2%). Ethical arguments in favor of DTC healthcare included improved access (e.g., financial, geographical; 31%), increased autonomy (29%), and enhanced convenience (16%). Commonly raised ethical concerns included insufficient regulation (72%), questionable efficacy and quality (70%), safety and physical harms (66%), misleading advertising claims (56%), and privacy (34%). Other frequently occurring ethical concerns pertained to financial costs, targeting vulnerable groups, informed consent, and potential burdens on healthcare providers, the healthcare system, and society. Our findings offer insights into the cross-cutting ethical issues associated with DTC healthcare and underscore the need for increased interdisciplinary communication to address the challenges they raise.

Advocating for neurodata privacy and neurotechnology regulation

The ability to record and alter brain activity by using implantable and nonimplantable neural devices, while poised to have significant scientific and clinical benefits, also raises complex ethical concerns. In this Perspective, we raise awareness of the ability of artificial intelligence algorithms and data-aggregation tools to decode and analyze data containing highly sensitive information, jeopardizing personal neuroprivacy. Voids in existing regulatory frameworks, in fact, allow unrestricted decoding and commerce of neurodata. We advocate for the implementation of proposed ethical and human rights guidelines, alongside technical options such as data encryption, differential privacy and federated learning to ensure the protection of neurodata privacy. We further encourage regulatory bodies to consider taking a position of responsibility by categorizing all brain-derived data as sensitive health data and apply existing medical regulations to all data gathered via pre-registered neural devices. Lastly, we propose that a technocratic oath may instill a deontology for neurotechnology practitioners akin to what the Hippocratic oath represents in medicine. A conscientious societal position that thoroughly rejects the misuse of neurodata would provide the moral compass for the future development of the neurotechnology field.

Neurofeedback on twitter: Evaluation of the scientific credibility and communication about the technique

Neurofeedback is a popular technique to induce neuroplasticity with a controversial reputation. The public discourse on neurofeedback, as a therapeutic and neuroenhancement technique, encompasses scientific communication, therapeutic expectations and outcomes, as well as complementary and alternative practices. We investigated twitter publications from 2010 to 2022 on the keyword "neurofeedback". A total of over 138 k tweets were obtained, which originated from over 42 k different users. The communication flow in the neurofeedback community is mainly unidirectional and non-interactive. Analysis of hashtags revealed application fields, therapy provider and neuroenhancement to be the most popular contents in neurofeedback communication. A group of 1221 productive users was identified, in which clinicians, entrepreneurs, broadcasters, and scientists contribute. We identified reactions to critical publications in the twitter traffic and an increase in the number of tweets by academic users which suggest an increase in the interest on the scientific credibility of neurofeedback. More intense scientific communication on neurofeedback in twitter may contribute to promote a more realistic view on challenges and advances regarding good scientific practice of neurofeedback.

Transcranial Direct Current Stimulation in Nicotine Use: Nursing Implications for Patient Outcomes

ABSTRACT

Tobacco use is a leading cause of cancer, cardiovascular and respiratory disease, and preventable death in the United States. The brains of individuals with nicotine dependence are characterized by damaged mesolimbic pathways in the medial portion of the limbic and frontal lobes, creating positive reinforcing mechanisms. Transcranial direct current stimulation (tDCS) targets this neuroadaptation to improve smokers' nicotine-related outcomes, such as craving and smoking behavior, by depolarizing or hyperpolarizing the neurons of the brain. Recent literature reported promising outcomes in smokers after tDCS treatment interventions. tDCS has great potential for clinical nursing research for tobacco control given its multiple methodological advantages and few disadvantages. Nurse researchers can consider individualized and home-based tDCS interventions for community-based tobacco control research and may need to consider objective outcome measures (e.g., cotinine in urine) and addiction-related cognitive variables (e.g., self-regulation). Users of electronic nicotine delivery systems also need to be considered as participants in tDCS interventions. Additional considerations for nursing research are discussed.

Transcranial Direct Current Stimulation (tDCS) in Pediatric Populations—– Voices from Typically Developing Children and Adolescents and their Parents

Background

Transcranial direct current stimulation (tDCS) is a brain stimulation technique currently being researched as an alternative or complimentary treatment for various neurological disorders. There is little knowledge about experiences of the participants of tDCS clinical research, especially from pediatric studies.

Methods

An interview study with typically developing minors (n = 19, mean age 13,66 years) participating in a tDCS study, and their parents (n = 18) was conducted to explore their views and experiences and inform the ethical analysis.

Results

Children (10–13 years old) and adolescents (14–18 years old) reported good experiences with the stimulation. Next to financial incentives, main motives to participate in the study were curiosity and the possibility to help develop treatments for children affected by neurological disorders. They could also see a potential of using tDCS in a non-medical setting, especially regarding the provision of equal opportunity, e.g. in education. Parents also presented a positive attitude towards tDCS and their children participation in the basic research study. Nevertheless, their understanding of tDCS was rather poor. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Parents were also cautious about using tDCS for non-medical/enhancement purposes.

Conclusions

The study findings show a need for more transparent information about the state of the art of tDCS, its function and what it might be able to offer, especially considering the good acceptability of tDCS.

Mapping the Landscape of Do-it-Yourself Medicine

The practice of medicine is typically conceptualized as remaining within the boundaries of a hospital or clinic. However, in recent years, patients have been able to gain access to information about medical research as it is ongoing. As a result, there has been a rise in do-it-yourself (DIY) medicine, where individuals treat themselves for medical conditions outside of clinical settings, often mimicking experimental therapies that remain inaccessible to the wider public. For example, in DIY brain stimulation, individuals suffering from depression build at-home electrical headsets using nine-volt batteries, mimicking an experimental neuroscience technique used in scientific laboratories. In DIY fecal transplantation, those with intestinal disorders like C. Difficile and inflammatory bowel disease transplant stool from donors into themselves with the aid of blenders and enemas. In the open Artificial Pancreas System movement, diabetes patients hacked together an artificial pancreas system from their glucose monitors and insulin pumps, years before such a system was approved by the United States Food and Drug Administration (US FDA). To date, scholarship on DIY medicine has largely been relegated to specific medical domains (e.g., neurology, gastroenterology, infectious disease). In this paper, however, I recognize DIY medicine as a cross-cutting phenomenon that has emerged independently across medical domains but shares common features. I map the varieties of DIY medicine across these domains and suggest that four key factors lead to their creation, growth, and uptake. In doing so, this essay sheds light on an understudied area of biomedical citizen science that is likely to grow substantially in the coming decades.

Public attitudes towards neurotechnology: Findings from two experiments concerning Brain Stimulation Devices (BSDs) and Brain-Computer Interfaces (BCIs)

This study contributes to the emerging literature on public perceptions of neurotechnological devices (NTDs) in their medical and non-medical applications, depending on their invasiveness, framing effects, and interindividual differences related to personal needs and values. We conducted two web-based between-subject experiments (2×2×2) using a representative, nation-wide sample of the adult population in Germany. Using vignettes describing how two NTDs, brain stimulation devices (BSDs; NExperiment 1 = 1,090) and brain-computer interfaces (BCIs; NExperiment 2 = 1,089), function, we randomly varied the purpose (treatment vs. enhancement) and invasiveness (noninvasive vs. invasive) of the NTD, and assessed framing effects (variable order of assessing moral acceptability first vs. willingness to use first). We found a moderate moral acceptance and willingness to use BSDs and BCIs. Respondents preferred treatment over enhancement purposes and noninvasive over invasive devices. We also found a framing effect and explored the role of personal characteristics as indicators of personal needs and values (e.g., stress, religiosity, and gender). Our results suggest that the future demand for BSDs or BCIs may depend on the purpose, invasiveness, and personal needs and values. These insights can inform technology developers about the public's needs and concerns, and enrich legal and ethical debates.

Intelligenzsteigerung durch Neuroenhancement?

Zusammenfassung. Die menschliche Intelligenz gehört zu den bestuntersuchten psychologischen Merkmalen, in denen interindividuelle Differenzen bestehen. Die mehr als 100jährige Forschungsgeschichte hat einen hoch belastbaren Wissensstand hervorgebracht; dieser umfasst die Definition, die Psychometrie, die (ontogenetische) Entwicklung, die Struktur, die Vorhersagekraft für real-life-Variablen, das Wissen über elementar-kognitive, verhaltensgenetische und neurobiologische Grundlagen der Intelligenz, u.v.m. Jüngst steht zudem die Frage des ‚enhancements‘ der Intelligenz im Fokus, eine Frage, die nicht zuletzt durch die aktuelle philosophische Strömung des Transhumanismus stark an Bedeutung gewinnt. Der Transhumanismus nimmt eine substanzielle Erhöhung (enhancement) von Fähigkeiten und anderen (auch) psychologischen Eigenschaften des Menschen ins Zentrum und postuliert, dass ein soziokultureller Fortschritt – und letztlich das Überlegen des Homo Sapiens und unseres Planeten – erst durch technologischen Fortschritt ermöglicht werde. Viele Transhumanisten stellen eine substanzielle Steigerung der Intelligenz in den Vordergrund, die primär durch (neuro–)‌technologische und pharmakologische Maßnahmen zu bewerkstelligen seien. Diese Debatten sind jedoch oft gekennzeichnet durch übertrieben optimistische Annahmen der Möglichkeiten moderner neurowissenschaftlicher Methoden bei gleichzeitiger Vernachlässigung der potenziellen negativen Folgen für das Individuum, für die Gesellschaften und insgesamt für unsere Spezies. Im gegenständlichen Überblicksbeitrag werden behaviorale, neuroelektrische und pharmakologische Methoden im Hinblick auf ihr aktuelles Potenzial einer Steigerung der individuellen Intelligenz analysiert. Die zwischenzeitlich zu diesen Fragen vorliegenden experimentellen Studien, sowie verfügbare Metaanalysen lassen allerdings den Schluss zu, dass bislang keine der gegenwärtig verfügbaren Methoden das Potenzial haben, die individuelle Intelligenz substanziell zu steigern. Und selbst falls solche möglicherweise in absehbarer Zeit zur Verfügung stünden, müssen zuvor sowohl individuelle als auch gesellschaftliche (negative) Konsequenzen einer kritischen Analyse unterzogen werden. Diese sind Gegenstand einer abschließenden Diskussion.

Using Remotely Supervised At-Home TES for Enhancing Mental Resilience

We are in the midst of a mental health crisis with major depressive disorder being the most prevalent among mental health disorders and up to 30% of patients not responding to first-line treatments. Noninvasive Brain Stimulation (NIBS) techniques have proven to be effective in treating depression. However, there is a fundamental problem of scale. Currently, any type of NIBS treatment requires patients to repeatedly visit a clinic to receive brain stimulation by trained personnel. This is an often-insurmountable barrier to both patients and healthcare providers in terms of time and cost. In this perspective, we assess to what extent Transcranial Electrical Stimulation (TES) might be administered with remote supervision in order to address this scaling problem and enable neuroenhancement of mental resilience at home. Social, ethical, and technical challenges relating to hardware- and software-based solutions are discussed alongside the risks of stimulation under- or over-use. Solutions to provide users with a safe and transparent ongoing assessment of aptitude, tolerability, compliance, and/or misuse are proposed, including standardized training, eligibility screening, as well as compliance and side effects monitoring. Looking into the future, such neuroenhancement could be linked to prevention systems which combine home-use TES with digital sensor and mental monitoring technology to index decline in mental wellbeing and avoid relapse. Despite the described social, ethical legal, and technical challenges, the combination of remotely supervised, at-home TES setups with dedicated artificial intelligence systems could be a powerful weapon to combat the mental health crisis by bringing personalized medicine into people’s homes.

Non-invasive brain stimulation and neuroenhancement

Attempts to enhance human memory and learning ability have a long tradition in science. This topic has recently gained substantial attention because of the increasing percentage of older individuals worldwide and the predicted rise of age-associated cognitive decline in brain functions. Transcranial brain stimulation methods, such as transcranial magnetic (TMS) and transcranial electric (tES) stimulation, have been extensively used in an effort to improve cognitive functions in humans. Here we summarize the available data on low-intensity tES for this purpose, in comparison to repetitive TMS and some pharmacological agents, such as caffeine and nicotine. There is no single area in the brain stimulation field in which only positive outcomes have been reported. For self-directed tES devices, how to restrict variability with regard to efficacy is an essential aspect of device design and function. As with any technique, reproducible outcomes depend on the equipment and how well this is matched to the experience and skill of the operator. For self-administered non-invasive brain stimulation, this requires device designs that rigorously incorporate human operator factors. The wide parameter space of non-invasive brain stimulation, including dose (e.g., duration, intensity (current density), number of repetitions), inclusion/exclusion (e.g., subject's age), and homeostatic effects, administration of tasks before and during stimulation, and, most importantly, placebo or nocebo effects, have to be taken into account. The outcomes of stimulation are expected to depend on these parameters and should be strictly controlled. The consensus among experts is that low-intensity tES is safe as long as tested and accepted protocols (including, for example, dose, inclusion/exclusion) are followed and devices are used which follow established engineering risk-management procedures. Devices and protocols that allow stimulation outside these parameters cannot claim to be "safe" where they are applying stimulation beyond that examined in published studies that also investigated potential side effects. Brain stimulation devices marketed for consumer use are distinct from medical devices because they do not make medical claims and are therefore not necessarily subject to the same level of regulation as medical devices (i.e., by government agencies tasked with regulating medical devices). Manufacturers must follow ethical and best practices in marketing tES stimulators, including not misleading users by referencing effects from human trials using devices and protocols not similar to theirs.

Exploring the frontiers in reality-enhanced service communication: from augmented and virtual reality to neuro-enhanced reality

Purpose

The authors explore neuro-enhanced reality (NeR) as a novel approach for enhancing service communication between customers, frontline employees, and service organizations that extends beyond current state-of-the-art approaches based on augmented reality (AR) and virtual reality (VR) technologies.

Design/methodology/approach

The authors first take stock of research on reality-enhanced service communication with AR and VR, then complement these insights with emerging neuroscientific research to conceptualize how NeR enables innovative forms of service communication. On this basis, the authors develop a research agenda to guide the future study and managerial exploitation of NeR.

Findings

AR and VR already offer unique affordances for digital-to-physical communication, but these can be extended with NeR. Specifically, NeR supports neuro-to-digital and digital-to-neuro communication based on neuroimaging (e.g. controlling digital content through thought) and neurostimulation (e.g. eliciting brain responses based on digital content). This provides a basis for outlining possible applications of NeR across service settings.

Originality/value

The authors advance knowledge on reality-enhanced service communication with AR and VR, whilst also demonstrating how neuroscientific research can be extended from understanding brain activity to generating novel service interactions.

Transcranial direct-current stimulation and pediatric attention deficit hyperactivity disorder (ADHD)-Findings from an interview ethics study with children, adolescents, and their parents

INTRODUCTION

Transcranial direct current stimulation (tDCS) is a brain stimulation technique for an alternative or complementary treatment for various neurological disorders, including pediatric ADHD. However, little is known about the experiences of participants undergoing tDCS treatments in clinical trials. Exploration of their views on the matter is an important contribution to the societal debate on ethical issues of tDCS, allowing for a responsible translation into clinical practice and timely identification of potential challenges.

METHODS

in-depth interviews study with children with ADHD undertaking tDCS and their parents (n=32).

RESULTS

Children reported overall good experiences with the stimulation, although they found participation in the clinical study very tiring and time consuming. Their responses to the actual effects of the stimulation were mixed. Parents were very keen for their children to participate in the study as they saw it as a promising and safe alternative to medication. Even though many of them understood the techniques, they often did not see the link between the (current) lack of side effects and an absence of longitudinal studies. Unlike children, interviewed parents were cautious about using tDCS for non-medical/enhancement purposes.

DISCUSSION

There is a need for more transparent information about the state of the art of tDCS, its function and what it actually might be able to offer. It is especially important in order to prevent unrealistic hopes and to make sure that future pediatric patients and their carers are more aware of the potential side-effects and long-term effects of tDCS.

Recommendations for Responsible Development and Application of Neurotechnologies

Advancements in novel neurotechnologies, such as brain computer interfaces (BCI) and neuromodulatory devices such as deep brain stimulators (DBS), will have profound implications for society and human rights. While these technologies are improving the diagnosis and treatment of mental and neurological diseases, they can also alter individual agency and estrange those using neurotechnologies from their sense of self, challenging basic notions of what it means to be human. As an international coalition of interdisciplinary scholars and practitioners, we examine these challenges and make recommendations to mitigate negative consequences that could arise from the unregulated development or application of novel neurotechnologies. We explore potential ethical challenges in four key areas: identity and agency, privacy, bias, and enhancement. To address them, we propose (1) democratic and inclusive summits to establish globally-coordinated ethical and societal guidelines for neurotechnology development and application, (2) new measures, including "Neurorights," for data privacy, security, and consent to empower neurotechnology users' control over their data, (3) new methods of identifying and preventing bias, and (4) the adoption of public guidelines for safe and equitable distribution of neurotechnological devices.

Ethical and Legal Considerations of Alternative Neurotherapies

Neurotherapies for diagnostics and treatment-such as electroencephalography (EEG) neurofeedback, single-photon emission computerized tomography (SPECT) imaging for neuropsychiatric evaluation, and off-label/experimental uses of brain stimulation-are continuously being offered to the public outside mainstream healthcare settings. Because these neurotherapies share many key features of complementary and alternative medicine (CAM) techniques-and meet the definition of CAM as set out in Kaptchuk and Eisenberg-here we refer to them as "alternative neurotherapies." By explicitly linking these alternative neurotherapy practices under a common conceptual framework, this paper draws attention to, and critically considers, the cross-cutting ethical and legal issues related to the provision of these services. The first section of this paper provides an updated empirical overview of uses of SPECT neuropsychiatric evaluations, EEG neurofeedback, and experimental/off-label forms of brain stimulation. Next, drawing on CAM bioethics scholarship, we highlight the pertinent ethical issues in the alternative neurotherapy context, including the truthful representation of evidence base, marketing to vulnerable populations, potential harms, provider competency, and conflicts of interest. Finally, we consider the principal legal issues at stake for the provision of alternative neurotherapies in the U.S., namely those related to licensing and scope-of-practice considerations. We conclude with recommendations for future research in this domain.

Effects of a five-day HD-tDCS application to the right IFG depend on current intensity: A study in children and adolescents with ADHD

Impaired executive functions in ADHD are associated with hypoactivity of the right inferior frontal gyrus (IFG). This region was targeted via repetitive applications of anodal, high-definition transcranial direct current simulation (HD-tDCS) on five consecutive days in 33 ADHD patients (10-17years) and in a healthy control group (n=13, only sham). Patients received either sham (n=13) or verum tDCS with 0.5mA (n=9) or 0.25mA (n=11) depending on individual cutaneous sensitivity. During stimulation, participants performed a combined working memory and response inhibition paradigm (n-back/nogo). At baseline, post, and a 4-month follow up, electroencephalography was recorded during this task. Moreover, interference control (flanker task) and spatial working memory (spanboard task) were assessed to explore possible transfer effects. Omission errors and reaction time variability in all tasks served as measures of attention. In the 0.25mA group increased nogo commission errors indicated a detrimental tDCS effect on response inhibition. After the 5-day stimulation, attentional improvements in the 0.5mA group were indicated by reduced omission errors and reaction time variability. Variability improvements were still evident at follow up. In all groups, nogo P3 amplitudes were reduced post-stimulation, but in the 0.5mA group this reduction was smaller than in the 0.25mA group. Results of the current study suggest distinct effects of tDCS with different current intensities demonstrating the importance of a deeper understanding on the impact of stimulation parameters and repeated tDCS applications to develop effective tDCS-based therapy approaches in ADHD.

Neurostimulation, doping, and the spirit of sport

There is increasing interest in using neuro-stimulation devices to achieve an ergogenic effect in elite athletes. Although the World Anti-Doping Authority (WADA) does not currently prohibit neuro-stimulation techniques, a number of researchers have called on WADA to consider its position on this issue. Focusing on trans-cranial direct current stimulation (tDCS) as a case study of an imminent so-called ‘neuro-doping’ intervention, we argue that the emerging evidence suggests that tDCS may meet WADA’s own criteria (pertaining to safety, performance-enhancing effect, and incompatibility with the ‘spirit of sport’) for a method’s inclusion on its list of prohibited substances and methods. We begin by surveying WADA’s general approach to doping, and highlight important limitations to the current evidence base regarding the performance-enhancing effect of pharmacological doping substances. We then review the current evidence base for the safety and efficacy of tDCS, and argue that despite significant shortcomings, there may be sufficient evidence for WADA to consider prohibiting tDCS, in light of the comparable flaws in the evidence base for pharmacological doping substances. In the second half of the paper, we argue that the question of whether WADA ought to ban tDCS turns significantly on the question of whether it is compatible with the ‘spirit of sport’ criterion. We critique some of the previously published positions on this, and advocate our own sport-specific and application-specific approach. Despite these arguments, we finally conclude by suggesting that tDCS ought to be monitored rather than prohibited due to compelling non-ideal considerations.

Neuroenhancement for sale: assessing the website claims of neurofeedback providers in the United States

Although electroencephalographic (EEG) neurofeedback is a technique that has been in existence for many decades, it has remained controversial, largely due to questions about efficacy. Yet neurofeedback is being widely offered to the public, often at great expense. To date, however, there has not been empirical data on which providers are utilizing neurofeedback, what they are offering it for, and how they are advertising the technique. The present study aimed to fill that gap by systematically analyzing the websites of neurofeedback practitioners in the United States. To that end, we obtained data from four directories of neurofeedback providers, extracting practitioner names, geographical locations, professional training, and website URLs. Only websites offering neurofeedback services (N=371) were included in the next step, wherein two coders independently coded the websites based on a codebook developed from preliminary analyses. We found that nearly all websites (97.0%) contained claims about at least one clinical indication, most commonly anxiety, ADHD/ADD, and depression; however, only 36.0% of providers had either a medical degree (MD) or a doctoral-level degree in psychology. The majority of websites advertised neurofeedback for cognitive (90.0%) or performance (67.9%) enhancement, and roughly three-quarters utilized language related to complementary and alternative medicine (CAM). In sum, there is a considerable divergence between the scientific literature on neurofeedback and the marketing of neurofeedback services to the general public, raising concerns regarding the misrepresentation of services and misleading advertising claims.

Understanding the Scope of Do-It-Yourself Fecal Microbiota Transplant

OBJECTIVES

Fecal microbiota transplantation (FMT) has emerged as an effective treatment option for Clostridioides difficile infection (CDI) and is considered an investigational therapy for a number of other diseases. Social media has facilitated widespread exposure of the public to the gut microbiome and FMT, ultimately acting as a catalyst for the Do-It-Yourself (DIY)-FMT movement. The aims of this study were to identify factors that influenced willingness to pursue DIY-FMT including common indications, screening processes, sample preparation, and self-reported efficacy and safety outcomes.

METHODS

A twenty-five-point cross-sectional survey was posted online through the websites and social media pages of the Peggy Lillis Foundation, The Fecal Transplant Foundation, and The Power of Poop. Responses were cataloged through the Research Electronic Data Capture tool, and descriptive analyses were performed.

RESULTS

Eighty-four respondents completed the survey between January 2018 and February 2019. The majority were female (71%) and white (92%). Most (80%) reported performing FMT on themselves; 87% used Internet resources to assist in the process, and 92% knew their stool donor. Inflammatory bowel disease (35%) and irritable bowel syndrome (29%) were the 2 most common conditions that respondents attempted to treat. Only 12% reported adverse events, whereas 82% reported improvement in their condition.

DISCUSSION

DIY-FMT is being used for many indications, including those for which there is little evidence. There was a high self-reported success rate among respondents with few adverse events. There is a need for increased awareness around DIY-FMT and research around this phenomenon, which may impact public health.

Ethical Challenges of Risk, Informed Consent, and Posttrial Responsibilities in Human Research With Neural Devices: A Review

Importance

Developing more and better diagnostic and therapeutic tools for central nervous system disorders is an ethical imperative. Human research with neural devices is important to this effort and a critical focus of the National Institutes of Health Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative. Despite regulations and standard practices for conducting ethical research, researchers and others seek more guidance on how to ethically conduct neural device studies. This article draws on, reviews, specifies, and interprets existing ethical frameworks, literature, and subject matter expertise to address 3 specific ethical challenges in neural devices research: analysis of risk, informed consent, and posttrial responsibilities to research participants.

Observations

Research with humans proceeds after careful assessment of the risks and benefits. In assessing whether risks are justified by potential benefits in both invasive and noninvasive neural device research, the following categories of potential risks should be considered: those related to surgery, hardware, stimulation, research itself, privacy and security, and financial burdens. All 3 of the standard pillars of informed consent-disclosure, capacity, and voluntariness-raise challenges in neural device research. Among these challenges are the need to plan for appropriate disclosure of information about atypical and emerging risks of neural devices, a structured evaluation of capacity when that is in doubt, and preventing patients from feeling unduly pressured to participate. Researchers and funders should anticipate participants' posttrial needs linked to study participation and take reasonable steps to facilitate continued access to neural devices that benefit participants. Possible mechanisms for doing so are explored here. Depending on the study, researchers and funders may have further posttrial responsibilities.

Conclusions and Relevance

This ethical analysis and points to consider may assist researchers, institutional review boards, funders, and others engaged in human neural device research.

Oversight of direct-to-consumer neurotechnologies

Efficacy of products is far from clear

Unmet Needs in Children With Attention Deficit Hyperactivity Disorder-Can Transcranial Direct Current Stimulation Fill the Gap? Promises and Ethical Challenges

Attention deficit hyperactivity disorder (ADHD) is a disorder most frequently diagnosed in children and adolescents. Although ADHD can be effectively treated with psychostimulants, a significant proportion of patients discontinue treatment because of adverse events or insufficient improvement of symptoms. In addition, cognitive abilities that are frequently impaired in ADHD are not directly targeted by medication. Therefore, additional treatment options, especially to improve cognitive abilities, are needed. Because of its relatively easy application, well-established safety, and low cost, transcranial direct current stimulation (tDCS) is a promising additional treatment option. Further research is needed to establish efficacy and to integrate this treatment into the clinical routine. In particular, limited evidence regarding the use of tDCS in children, lack of clear translational guidelines, and general challenges in conducting research with vulnerable populations pose a number of practical and ethical challenges to tDCS intervention studies. In this paper, we identify and discuss ethical issues related to research on tDCS and its potential therapeutic use for ADHD in children and adolescents. Relevant ethical issues in the tDCS research for pediatric ADHD center on safety, risk/benefit ratio, information and consent, labeling problems, and nonmedical use. Following an analysis of these issues, we developed a list of recommendations that can guide clinicians and researchers in conducting ethically sound research on tDCS in pediatric ADHD.

Moral attitudes and willingness to enhance and repair cognition with brain stimulation

BACKGROUND

The availability of technological means to enhance and repair human cognitive function raises questions about the perceived morality of their use. However, we have limited knowledge about the public's intuitive attitudes toward uses of brain stimulation. Studies that enlighten us about the public's willingness to endorse specific uses of brain stimulation on themselves and others could provide a basis to understand the moral psychology guiding intuitions about neuromodulation and opportunities to inform public education and public policy.

OBJECTIVE

Hypothesis: We expected that subjects would be less willing to enhance or repair cognitive functions perceived as more "core" to "authentic" self-identity, prioritize brain stimulation uses for themselves, and more willing to enhance "core" functions in others. Across specific hypothetical uses, we expected the moral acceptability of specific uses to be associated with subjects' willingness to endorse them.

METHODS

We administered two surveys to the public in which subjects were asked to report how willing they would be to enhance or repair specific cognitive abilities using a hypothetical brain stimulation device called "Ceremode".

RESULTS

Among 894 subjects, we found that subjects were more willing to use technologies to repair other people than themselves. They were most inclined to repair core functions in others. Subjects' ratings of the moral acceptability of specific uses was related to their reported willingness to use brain stimulation.

CONCLUSION

Moral acceptability is related to the public's willingness to use brain stimulation. These findings suggest that the public endorses a generous approach to applying brain stimulation for cognitive gains in others. Further, this study establishes a basis to guide moral psychological studies of cognitive modification and social processes that guide attitudes toward and uses of brain stimulation.