Soaad Q. Hossain and Syed Ishtiaque Ahmed 11institutetext: Department of
Computer and Mathematical Sciences, Department of Philosophy, University of
Toronto Scarborough, Canada
11email<EMAIL_ADDRESS>22institutetext: Department of
Computer Science, University of Toronto, Canada
22email<EMAIL_ADDRESS>
# Ethical Analysis on the Application of Neurotechnology for Human
Augmentation in Physicians and Surgeons

Soaad Q. Hossain 11 Syed Ishtiaque Ahmed 22

###### Abstract

With the shortage of physicians and surgeons and increase in demand worldwide
due to situations such as the COVID-19 pandemic, there is a growing interest
in finding solutions to help address the problem. A solution to this problem
would be to use neurotechnology to provide them augmented cognition, senses
and action for optimal diagnosis and treatment. Consequently, doing so can
negatively impact them and others. We argue that applying neurotechnology for
human enhancement in physicians and surgeons can cause injustices, and harm to
them and patients. In this paper, we will first describe the augmentations and
neurotechnologies that can be used to achieve the relevant augmentations for
physicians and surgeons. We will then review selected ethical concerns
discussed within literature, discuss the neuroengineering behind using
neurotechnology for augmentation purposes, then conclude with an analysis on
outcomes and ethical issues of implementing human augmentation via
neurotechnology in medical and surgical practice.

###### keywords:

neurotechnology, ethics, augmentation, enhancement, brain-computer interface,
physicians, surgeons, patients, harm, global, social, justice, malicious
brain-hacking, personhood, brain data, discrimination, rights, medical
practice, cognition, senses, action

##  1 Introduction

The demand for medical and healthcare professionals continue to rise as the
overall world population continues to increase. This demand is further
increased when pandemics such as the SARS-CoV-2 outbreak, also known as the
coronavirus disease COVID-19, occurs. The problem is that there is and may
always be a shortage of especially medical practitioners due to challenges and
barriers that exist to make it difficult for individuals to become physicians
or surgeons. Even if there were sufficient medical practitioners, the other
problem is the lack of resources that hospitals and institutions alike
possess. Given that resources are already a problem for hospitals, having
sufficient clinicians would only make that worse. With recent advances in
neuroscience and neurotechnology paving ways to innovative applications that
cognitively augment and enhance humans in a variety of contexts, a solution to
this would be to use neurotechnology to augment the cognition and senses of
medical practitioners to then augment their actions [13]. In doing so, this
will allow them to make optimal decisions and actions in less time, enabling
them to treat more patients. As such, this makes the solution along with the
research and discussions pertaining to it highly important as not only does
the solution impact directly impact physicians and surgeons, but it also
directly impacts patients as well. Additionally, as with any technological
intervention, it is important that not only are the technical aspects of the
intervention are analyzed and discussed, but the ethical aspects are as well.
In approaching this technological intervention, we performed an ethical
analysis on the application of neurotechnology for human augmentation in
physicians and surgeons, and found that even in the best-case scenario,
applying neurotechnology for human augmentation in physicians and surgeons has
a significant negative impact on individuals, communities and countries.

In this paper, we argue that applying neurotechnology for human augmentation
to augment physicians and surgeons, and can cause personal identity,
discrimination and financial issues for physicians and surgeons, and lead to
patients being harmed. The way that the paper is structured is as followed: we
first describe the augmentations and neurotechnologies that can be used to
achieve the relevant augmentations for physicians and surgeons, then review
selected ethical concerns discussed within literature particularly focusing on
human rights, human-computer interaction, data, brain-computer interface,
global bioethics and drug development, and discuss the neuroengineering behind
using neurotechnology for augmentation purposes. We then conclude with an
analysis on outcomes and ethical issues of implementing human augmentation via
neurotechnology in medical and surgical practice. The ethical analysis
specifically focuses on social issues, global health inequality and health
migration, and patient harm, and includes an assessment on personhood with
respect to the neurotechnology users (i.e. the physicians and surgeons). In
this paper, we assume that all neurotechnologies mentioned always succeeds in
providing a person with augmentations, but the type of augmentation provided
by a neurotechnology is based on what its capable of. The motivation behind
this assumption is to allow the paper to address a possible best-case scenario
with neurotechnology and human augmentation in physicians and surgeons, and
focus on ethical issues that arise with this scenario.

##  2 Human Augmentation and Neurotechnology

###  2.1 Types of Augmentations

Human augmentation can be formally defined as an interdisciplinary field that
addresses methods, technologies and their application for enhancing cognitive
abilities, senses and actions of humans [32]. In enhancing these leads us to
augmented cognition, augmented senses, and augmented actions. Augmented senses
focus on enhancing one’s ability to see, hear, smell, taste and touch.
Augmented cognition focuses on enhancing one’s memory (short-term and long-
term), attention, learning capabilities, awareness, and knowledge. Augmented
action can be broken down to two parts: motion augmentation and gesture
augmentation. Motion augmentation would simply be improving one’s ability to
move, enabling them to take actions that they may not normally be able to do
such as carry very heavy objects or run at a faster speed. Gesture
augmentation is similar to motion augmentation, except that it focuses more
movement and positioning of one’s hand and head. For instance, being able to
keep your hand in a specific position for a long amount of time without
fatigue and shaking would be considered augmented gesture and not motion
augmentation. The end goal of both augmentations is that the augmentation
should allow the person to perform an action optimally. From all the
augmentations mentioned, we will only focus on augmented senses (specifically
augmented vision and augmented touch), augmented cognition, and augmented
action (specifically augmented gesture). The motivation behind these
augmentations in particular is because these augmentations best allow
physicians and surgeons to better diagnose and treat diseases and disorders.

###  2.2 Augmentations Through Neurotechnology

From current technologies that are being developed, one such technology that
can be used to obtain these augmentations is neurotechnology. Neurotechnology
can be formally defined as an interdisciplinary field that combines
neuroscience, engineering and technology to create technical devices that are
interfaces with human nervous system. Within literature on neurotechnology,
there has been a considerable amount of work carried out on neurotechnologies
for cognitive enhancement, specifically focusing on brain-computer interface
(BCI), also known as neuroelectronic interface [2], applications. Based on
previous studies, neurostimulation techniques, such as transcranial electric
stimulation (tES) and transcranial magnetic stimulation (TMS), can be used to
improve performance in different cognitive domains; these cognitive domains
include perception, learning and memory, attention, and decision-making [13].
Accordingly, this can be used to accomplish augmented vision and part of
augmented cognition. Neuromodulation techniques, such as transcranial direct
current stimulation (tDCS), can also be used for memory, learning and
attention [13]. Specifically, for tDCS, studies have shown that it could
improve performance in verbal problem-solving task and other areas within
complex problem solving [13]. This allows for further enhancement of specific
cognitive domains, as desired.

To address augmented touch while also addressing augmented action, a
combination of tactile sensors and neuroprosthetics. Tactile sensors allow for
perceiving the location of the point of contact, discerns surface properties,
and detection for eventual slippage phenomena during the grasping and handling
of an object [11]. Neuroprosthetics are devices that can enhance the input and
output of a neural system [5]. Combined together, they can allow for augmented
gesture through enhancing the person’s dexterous interaction with objects by
ensuring that there is a correct application of forces between the contact
surfaces of the person’s hand and fingers and those of the object, and having
the neuroprosthetic distinguish brain activity patterns corresponding to the
intention to act from control signals of the hand itself [38]. To summarize,
the neurotechnology that can be used to accomplish the augmentations of
interest is neurostimulation, neuromodulation, tactile sensors and
neuroprosthetics. How each of these neurotechnologies accomplish augmentations
will be discussed later in the paper when We discuss how neurotechnology can
be applied in medical practice.

##  3 Ethics in Neurotechnology and Human Enhancement

###  3.1 Human Rights in Neurotechnology

While neurotechnology has the can help achieve human augmentation, it also has
the potential to impact human rights [22]. Three of the areas which
neurotechnology is said to impact is the right to mental integrity, freedom of
thought, and freedom from discrimination. The right to mental integrity is a
concern with neurotechnology due to the problem of malicious brain-hacking.
Malicious brain-hacking is defined as the neuro-criminal activities that
directly influence neural computation in the users of neurotechnological
devices in a manner that resembles how computers are hacked in computer crimes
[22]. For BCI applications, malicious brain-hacking can take place within BCI
through having the malicious agent (e.g. hacker) attack the level of
measurement or decoding and feedback of the BCI, or through the malicious
agent manipulating the person’s neural computation through the BCI
application. In such cases, the malicious agent can add noise or override the
signals sent to the neurotechnological device with the objective of reducing
or removing the control of the user over the BCI application [22].
Furthermore, the malicious agent can also hijack the BCI user’s voluntary
control. For instance, a malicious agent can override the signals sent from a
BCI user, then hijack a BCI-controlled device (e.g. smartphone) without the
BCI user’s consent [22]. Ultimately, what results from malicious brain-hacking
is both the user’s mental privacy and their brain data being at risk due from
the loss of right to mental integrity. The loss of right to mental integrity
leads to the loss of freedom of thought as when malicious brain-hacking
occurs, the BCI user is no longer able to freely think of things due to the
restraint placed by the malicious agent.

One other human rights issue with neurotechnology is one that overlaps with a
health rights issue from human enhancement. The ethical issue from human
enhancement pertains to how the ability to augment one’s physical or mental
performance raises several issues about fairness and justice regarding how
augmenting technologies, such as neurotechnologies, should be accessed or
regulated [20]. What follows from this is the question of whether they are
intended for mass consumption or restricted to humans with identifiable
impairments and disabilities. In the case where neurotechnologies are intended
for mass consumption and becomes commercialized, as with any other technology,
it will likely be expensive at the beginning [20]. Consequently, this could
generate and even exacerbate societal divisions among the population or among
inhabitants of different countries [20]. Those of a low socio-economic status
would not be able to afford to purchase neurotechnologies. Subsequently, a
digital divide is created between those that can afford neurotechnology, and
those that cannot. This leads to health right issue as the digital divide
creates an injustice to those of low socio-economic status that cannot afford
neurotechnology; they are indirectly being deprived of something that is
needed for their health and wellbeing. With the relationship between poor
mental health and the experience of poverty and deprivation being well studied
and an association between the two factors being established, communities
deprived of neurotechnology can cause those communities to experience higher
levels of deprivation and unemployment rates, leading to them experiencing
higher rates of psychiatric admissions for psychotic as well as non-psychotic
conditions and suicidal behavior [27].

###  3.2 Discrimination from Augmentation

The ongoing human rights concern regarding neurotechnology an freedom from
discrimination is that the use of neurotechnology will lead to discrimination
among individuals and groups. This concern is not only one that is valid, but
also strong evidence to support it. Throughout history, humans have shown that
existing moral code is often broken in practice, and that observable
differences between people, such as differences in race, gender, ethnicity,
religion, sexual orientation and/or ability, tend to lead to moral and social
inequalities [7]. Given that there will be a clear difference between those
that adopt augmentation technologies and those that do not and the actions
that humans have taken in the past and continue to take to this day, it is
very likely that human augmentation will lead to new, unjustified
inequalities, and may even undermined the core notion of moral equality used
in Western societies [7]. Expanding on the unjustified inequality, there is a
growing concern regarding how new human augmentation technologies can weigh
more than personal experiences and benefits [32]. Due to the cognitive
enhancement that augmentation technologies provide, those that utilize them
will have a stronger say on matters than those that rely solely on their
personal experiences and benefits. Also, there is a concern that neglecting
potential negative effects of such technologies to daily life and society can
create problematic scenarios for the future [32]. One such potential negative
side effect comes from the pressure in adopting augmentation technologies. For
a long time and even now, people frequently experience prejudice if their
bodies or brain function differently from those around them [40]. With the
integration of augmentation technologies such as neurotechnology within
society, this will lead to people feeling pressure to adopt those
technologies, and is likely to lead to change societal norms. In turn, this
will lead to issues of equitable access and generate new forms of
discrimination [40].

To describe the forms of discrimination, we refer to self-identity, industry
practice, and history. In self-identity, moral and social importance plays a
crucial role in how one people feel about themselves, and it plays a strong
role in determining people’s intentions, attitudes and behaviors [7].
Consequently, a poorly developed self-concept could bring about low self-
esteem, level of confidence, purpose and reason to live, and level of
motivation. With groups and communities determining collectively how one is
treated by others, poorly formed self-concept could make one subject to
discrimination. Within industries, the discrimination can take place as
earlier as the job application process to later while the person is employed
with the company. In industry practice, it is common for companies to hire the
person that they think are best for the position. With neurotechnology
providing its users with augmentations, a complaint regarding this is that
this provides those people with an unfair advantage that will allow them to
secure jobs more easily, and that those that are augmented may view those that
are not augmented as inferior. This unfair advantage can lead to
discrimination within industries through employment.

The unfair advantage from augmentations can have serious implications in the
workplace especially once employers, administrators and decision-makers
realize that those with augmentation perform better than those without them
[10]. The realization will likely lead to them having a preference for those
with augmentations and a bias against those that do not have any
augmentations, leading to things such as them inquiring beforehand (or on the
job for current employees) whether an applicant has undergone an augmentation
or utilizes neurotechnology, and making decisions simply based on this
information along with selected other pieces of information from the applicant
(or employee). This can lead to prejudice, resulting in non-augmented people
being discriminated against, creating justice and equity issues. Note that
this type of discrimination is not limited to employment settings, and extends
as far as in areas such as families and academic institutions. Between
children, parents will give preference to the child that performs best
academically and professionally. Similarly, with academic institutions, the
institutions will prefer and reward those that perform best academically, and
treat those that perform best academically better than those that perform
worse regardless of whether they have undergone any sort of augmentation or
not. We know this as in many academic institutions, if students do not perform
well enough academically, they are either removed from their program,
suspended or both, and those that perform well academically are rewarded
awards, research and other opportunities, and scholarships. As a result, in
the long-term and possibly even in the short-term, the implications from the
unfair advantage from augmentations can lead to a collapse in the social
process of education, care, interactions, relationships and more as
impartiality, open-mindedness, nondiscrimination, acceptance, and unbiasedness
would be minimized or lost completely in some groups and societies.

With neurotechnology and human enhancement possibly being enjoyed by the
already privileged, if this possibility is realized, then this will lead to a
failure of distributive justice [18]. Of all communities, marginalized
communities will suffer the most from this failure. A major challenge
experienced by underprivileged communities comes from the fact that not only
are they are often excluded from opportunities, health services, development
programs, resources and more, but they often struggle to raise their voice in
public discussions due to the lack of access and autonomy [4]. As a result,
underprivileged communities, including women, LGBTQ groups, refugees, people
with physical or mental disabilities, people of low socio-economic status, and
those that are less educated are often ignored, deprived, or discriminated
[4]. Among them, marginalized groups in those communities are even more
deprived, which this deprivation are sometimes due to their physical or
economic vulnerabilities, or various social and cultural practices [4]. For
example, in multiple places in the Indian subcontinent, women are not allowed
to use mobile phones due to social and cultural reasons [4]. Consequently,
this deprivation prevents them from obtaining the benefits from it - one of
them being that it can be used to cope with everyday stress [28]. In the case
where the group of Indian women were members of the LGBTQ group, this
deprivation of technological device can further negatively impact their mental
health. LGBTQ people have and continue to experience various forms of
oppression and discrimination worldwide [21]. The oppression is in the form of
harassment and violence while the discrimination is experienced in areas such
as employment, housing, access to education and human services, and the law.
This oppressions and discrimination along with rejection, violence and
harassment have been shown to have negative physical and mental health effects
on both LGBTQ people [21]. Combining the primary societal stressors that many
LGBT people experience, that lead to “minority stress” [21], with deprivation
of mobile phones leads to those Indian women having less effective coping
mechanism options which are needed to deal with both everyday stress and
minority stress. Consequently, this results to there being major mental health
disparities between those Indian women within the LGBTQ population and other
individuals. From just the transgender individuals alone, the mental health
disparities can be severe enough to the point where the difference is that
those individuals have higher odds of depression symptoms and attempted
suicides [39]. What the failure of distributive justice will likely do is
aggravate the everyday stress and minority stress experienced by this
marginalized group and others to an extent where the majority of of the
marginalized population will show depression symptoms, and a substantial
amount of them may even commit suicide. As such, the already marginalized
communities will suffer more than they already are. The repercussions of this
will have negative impacts on both a local and global level.

###  3.3 Autonomy and Brain Data

Neurotechnology not only has the potential to impact human rights, but is can
also impact autonomy, confidentiality and protection. Note that it is possible
to obtain information through BCIs that can be extracted to reveal security
breaches [26]. Neurotechnology such as BCI relies on multiple types of
probabilistic inference to be operationalized, for one to use any sort of
probabilistic inference requires a large amount of data [19]. This data,
consisting of neural information, is of high value to companies and
individuals as neurotechnology produces raw data in a way that enables a more
direct detection pathway of the neural correlates of mental processes, such as
interests, intentions, mood and preferences [23]. Additionally, the neural
data includes rich and personally identifiable sources of information that
could be aggregated by data handlers to apprehend or predict parts of health
status, preferences and behavior [23]. An example of where neural information
would be very useful is marketing and advertising. The field of marketing has
been interested in BCI research as they are interested in utilizing a
neuromarketing-based approach to marketing and advertising [3]. Algorithms
that are designed and used to target advertising can better calculate things
like insurance premiums through using neural information [40]. Accordingly,
investment in neural data (and computer scientists) is something that
marketing firms are striving to acquire, heavily investing time, effort and
money to obtain it.

Given the value of neural information, these motivate malicious agents,
companies and corporations to perform malicious brain-hacking, or retrieve,
aggregate disseminate and use the information of the neurotechnology users
without their informed consent. In the case of malicious brain-hacking, after
a malicious agent has successfully hacked a device, rather than changing
signals or taking control, they can instead extract the data from the device,
then abuse to them to as they desire. Similarly, for companies and
corporations behind a neurotechnological application, they can either take the
data collected from the neurotechnology users as hostage of the users or sell
the data to another entity or individual, with the purpose of making more
money. This has several consequences, including loss of ownership of one’s own
data, loss of privacy, increase in level of distrust, data used against them
(e.g. for insurance purposes), Furthermore, with the malicious hacker or
entities not getting the consent from the users to take and sell their data,
the autonomy of the users is not respected.

###  3.4 Global Bioethics and Drug Development

The aftermath from a situation of malicious brain-hacking, neural data
hostage, or neural data sharing does not just impact an individual, but it
impacts society altogether. However, of the three, We will focus on neural
data sharing, continuing the discussion from the point where what can occur
after an individual, corporation, or organization has obtained neural data as
this is one of the biggest concerns expressed within literature due to the
impact that neural data sharing has on society at large. What a person or
entity will do with the neural data is difficult to determine. However, it is
easier for us to get a sense on what some individuals and companies will do
with the data compared to others. With the advances in artificial intelligence
and machine learning, when combining learning algorithms with brain data
obtained through BCI or other neurotechnologies, they can lead to fruitful
results for things such as drug development. However, using BCI for drug
development is not a simple task. Contemporary drug discovery strategies rely
on the identification of molecular targets associated with a specific pathway
and subsequently probe the role of a given gene product in disease progression
[6]. Subsequent to the identification of a relevant bioactive compound,
further compound screening can be achieved through phenotypic screens. With
phenotypic screens, they are capable of capturing complex cellular level
behaviors that are physiologically relevant and central to a pathology without
relying on the identification of a specific drug target or a corresponding
hypothesis concerning its pathological role [6]. For that reason, phenotypic
screens are gradually becoming more utilized in drug discovery as using a
phenotypic approach can generate novel treatments for diseases and disorders
which have either complex or unknown mechanisms [6]. When using a phenotypic
approach onto a nervous system, it provides a way to find compounds and genes
active in a nervous system without assumptions about relevant molecular
targets, which can possibly lead to new therapeutic targets, new disease
biology, and new compounds or genes [14]. The challenge is that phenotypic
screens require a quantifiable phenotypic alteration, such as neuronal
survival or changes in fluorescently tagged protein expression in order to
generate a usable output [14]. Conveniently, BCIs can provide brain data
containing neuronal survival [2]. With BCIs being able to extract quantifiable
phenotypic alteration and classification algorithms being able to understand
BCI’s messages, we can conclude that pharmaceutical companies that purchased
neural data will most likely use it with a phenotypic approach to discover,
develop and patent new generic drugs. The problems that follow this are
societal and global health issues.

In the past, pharmaceutical companies have consistently argued that high
prices and multilateral patent protection afforded by Trade-Related Aspects of
Intellectual Property Rights are reasonable rewards for highly expensive and
often fruitless research and development of pharmaceutical products, which are
ultimately of benefit to society [9]. Furthermore, with pharmaceutical
research and development costs being substantial and given the low success
rates, pharmaceutical companies argued that profits from the few successful
products are essential [9]. Consequently, the problem with pharmaceutical
companies researching and developing drugs using neural data and phenotypic
approach is that it will likely be very expensive as not only will the
companies have to pay a price for conducting and developing the drug, but they
also have to pay a price for neural data based on the price set by the third
party. For them to generate the data can be even more costly for them as on
top of cost associated with conducting data collection, hardware costs from
neurotechnologies and costs associated with data preprocessing and
augmentation will need to be included in the total cost. Furthermore, with
patented drugs preventing others from making or using the generic drug without
obtaining a license from the patent holder, most pharmaceutical companies
refuse to grant licenses so they can benefit from having a limited monopoly on
the drug [33]. As a result, not only will they likely enforce their patents on
those generic drugs, but there is a chance that they will also charge a hefty
amount for those interested in purchasing the license for it for therapeutic
purposes. In turn, this will lead to affordability, accessibility and health
issues experienced by the portion of the population unable to afford the
drugs. On a global level, with the pharmaceutical companies enforcing their
patents, this will prevent developing countries from manufacturing the generic
versions of those drugs, creating affordability, accessibility and health
issues experienced by those countries [8].

While it was easy to attempt to determine how pharmaceutical companies will
neural data, in the case of the military, for example, is not as obvious. The
US Department of Defense, for instance, is currently exploring the use of
neurotechnologies and neural data [26]. It is said that in pursuing
neurotechnology, they are using it with the goal of restoring function
following trauma from war and to develop programs involving improving human
training and performance [26]. From a first glance, it seems that they are
doing it to help better those within the military recover or become a better
version of themselves. However, from a closer look, this can be seen as the
military trying to get an advantage over other countries [26]. To make
neurotechnologies’ use more extreme, yet more effective for the military and
even politicians and corporations such as those that sell firearms,
exploration of neurotechnologies such as brain implants by the military can be
used in a way that create a potential for terrorism [32], leading to
beneficence issues. This is an issue as this indirectly promotes warfare
between countries, which the consequences from any sort of warfare which
neurotechnology contributed to includes an increase in casualties,
environmental damage, loss of resources and infrastructure, psychological and
neurological disorder cases, loss of talent, and more. These casualties and
other losses are a major injustice to the innocent civilians caught in the
middle of the warfare [31].

##  4 Augmentation of Physicians and Surgeons

###  4.1 Neuroengineering for Augmentations

Before moving onto how neurotechnology can be applied to medical practice, it
is important to have a foundational understanding of how the neurotechnologies
that were mentioned earlier accomplish their respective augmentations. How
neurostimulation techniques accomplishes enhancing perception, learning and
memory, attention, and decision-making within a person is by using invasive or
non-invasive electrical stimulation systems on the person [17], to then apply
electricity to affect the person’s central nervous system [37]. Similarly, how
neuromodulation accomplishes enhancing memory, learning, attention and complex
problem solving within a person is by sending electrical or pharmaceutical
agents to a target area of the person’s brain to alter nerve activities [24].
While there are several types of tactile sensors, the tactile sensor that
would be best for achieving augmented touch and augmented action is a tactile
sensor using CNT-based nanocomposites because not only are they mechanically
flexible, robust and chemically resistant needed to achieve the flexibility of
human skin, but they also require lower conductive phase concentration, which
leads to better mechanical properties of the composite [12]. The tactile
sensors would be placed onto a sensor glove, then worn by the user.

The way they work in achieving augmented touch is through optimizing the use
volume changes in sensitive materials to detect pressure [12], in a way that
allows the tactile sensors to be capable of [11]: (1) evaluating mechanical
compliance and surface texture properties of objects; (2) sensing an applied
force by evaluating the magnitude and direction; (3) spatially discriminating
the point of application of a force; and (4) Emulating the dynamic behavior of
human mechanoreceptors while tracking tactile stimuli overtime. Furthermore,
the design criteria for the tactile sensors must consider spatial resolution
and range of applied force in order to properly achieve augmented touch [12].
Accordingly, neuroprosthetics accomplishes augmented gesture and augmented
touch by utilizing tactile sensors with the BCI to receive relevant sensory
information concurrently with letting the user directly control the output
behavior of the prosthesis (e.g. artificial arm movement); in doing so, this
recreates the control-feedback loop [1]. The signals produced by the loop
provide output for controlled muscle contractions, input and feedback from
sensory organs (e.g. position), creating a bidirectional pathway through which
we explore and manipulate our environment [1], enabling for augmented gesture
and augmented touch to take place. Figure 1 illustrates the process of
augmented gesture. The approach used in the figure incorporates the
neurofeedback approach – an approach that is promising for enhancing the
performance of the brain [3].

Figure 1: Diagram displaying the steps taken to obtain augmented gesture.
First, the tactile sensors that are places on the hands or fingers of the
surgeon. Once measurements are obtained, then they are sent to a controller
(e.g. BCI) that evaluates, refines and translates the measurements into
stimulations that neurons can react to. Upon receiving the stimulations, the
neural circuits within the neurons reorganize themselves in a way that allows
the surgeon’s brain to update itself on how to better perform the gesture. The
gesture is then realized through neuroprosthetics combined with either a
prosthetic or the surgeon’s hand.

###  4.2 Augmentations in Surgery

Knowing how neurotechnology can realize augmentations within humans enables us
to address how such technology and augmentations will impact medical practice.
For this section, we will specifically focus on the practice of surgery. In
this case, the users of the neurotechnology are surgeons. Within surgical
settings, augmented vision, augmented touch and augmented gesture will enable
surgeons to perform surgeries with a higher level of precision and accuracy by
allowing them to see details more clearly, utilize surgical tools and methods
better, and perform surgical procedures and operations better. As a result,
the success rate of surgeries performed by surgeons utilizing neurotechnology
will increase, which is good for multiple reasons; the main reason being that
successful surgery will enable the patient to live longer and healthier life,
which is helpful for the individual, their family and society. Augmented
cognition for surgeons enables surgeons to be able to learn new surgical
procedures that are less invasive, shorten operative times, lessens costs and
reduce the likelihood of complications. Furthermore, it will allow surgeons to
be more knowledgeable in surgical techniques and competent in the ability to
recognize the limits of their professional competence [36]. The benefits of
these can best be understood through a bioethics perspective, with
specifically using the principle of beneficence, non-maleficence and justice,
In terms of beneficence, in neurotechnology and the augmentations empowering
surgeons, they enable surgeons to take actions, make suitable surgical
judgements to assess the risks, burdens and benefits, and approach surgeries
in a way that that respects and is in the best the interest of their patients.
In addition, their improved cognitive abilities will allow them to stay up to
date with activities and update their knowledgebase as required.

With having surgeons keeping themselves professionally and educationally
advanced, this will help ensure that they will provide the highest standards
of patient care and the lowest rates of complications [36]. This leads to non-
maleficence as higher standards of patient care is accompanied with better
communication and improvement in the type of care being offered (e.g.
palliative care), and lower rates of complications leads to a decrease in the
likelihood of a medical error occurring and minimization of harm caused to the
patient. Lastly, with the surgeons being able to perform tasks better, this
will decrease the time needed for surgeries, and can decrease the time of the
patient’s stay in the hospital. From a justice standpoint, this is crucial as
just as much as health burden is an issue for patients, so is economic burden.
With surgeons successfully performing surgeries on their patients, patients
will not need to stay in the hospital for long, enabling them to be able to
live back their normal life and do their regular activities, such as working
and spending time with their family.

###  4.3 Augmentations in Medical Practice

For this section, we will focus on medical practice that do not involve
surgery. In this case, the users of the neurotechnology would be physicians.
Within non-surgical settings, augmented vision and augmented cognition will
allow physicians to better perform diagnoses. For instance, given that the
physician will have enhanced vision and cognitive abilities, analysis of scans
from diagnostic radiology exams such as computed tomography (CT) and
fluoroscopy would be better performed as physician will be able to see details
more clearly and better spot indicators on the scans. As such, this will allow
physicians to make more accurate diagnoses, which can result in better
understanding assessment, planning and execution of treatment, communication
between the physician and the patient, maintain of the physicians’ fidelity
and responsibilities, and care for the patient. These help with achieving non-
maleficence as effective diagnosis and communication significantly reduces the
amount of harm within patients on both a physical and mental level. Good
diagnosis helps with increasing the chances that a correct treatment will be
used, and prevents moral distress in patients and their family. Additionally,
and most importantly, with neurotechnology, augmented vision and augmented
cognition enhancing physicians’ diagnoses performance, this leads to a major
step towards justice. Specifically, improvement in diagnosis will lead to
reduction in discrimination, misclassification and prejudice experienced by
patients, and better provide freedom from misdiagnosis to patients.

Augmented cognition, augmented gesture and augmented touch from
neurotechnology will allow physicians to perform treatments and therapy in a
more efficient and effective manner. The benefits of performing successful
treatments and therapy are similar to those of performing a successful surgery
or diagnosis. Just as in performing a successful surgery provides justice to
the patient by allowing them to leave the hospital and get back to their
routinely activities, performing a successful treatment is no different.
However, given the difference in nature of surgeries and treatments in terms
of activities and procedures, there are particular benefits that
neurotechnology and augmentations provides that applies more for physicians
than for surgeons. One of these benefits is how they help physicians with
meeting their fiduciary duty to their patients during treatment through
enabling physicians to properly implement precision medicine within the
treatment itself. What makes precision medicine desirable for treatments is
that its approach consists of utilizing the patient’s genes, environment, and
lifestyle. This is especially of interest for patients as they would much
rather have a treatment that is personalized for them than a one-size-fits-all
treatment.

##  5 Ethical Analysis

###  5.1 Personhood Assessment

In the ethical evaluation of technological interventions, integrity and
dignity of a person are the most relevant criteria [29]. Within philosophical
literature, a portion of ethical questions raised in regard to neurotechnology
are associated with what we call our “self” or “Soul”, which the debate itself
usually draws on the concept of personhood as a modern notion that includes
core aspects that we typically ascribe to our self or soul; these aspects
include planning of the individual future and responsibility [29]. The concept
of personhood always has normative implications due to the fact that we
describe certain attributes and capabilities of a person, and want to have
that person recognized, acknowledged and guaranteed [29]. Just as patients
must consciously authorize a neurotechnological intervention before it is
conducted, physicians and surgeons must also consciously provide authorization
as well. As such, the concept of a person can provide an ethical benchmark
applicable to persons such as physicians and surgeons, assuming that we do not
want to impair the personal capabilities, such as autonomy and responsibility
interventions in the brain [29]. With that being said, neurotechnological
interventions are ethically unacceptable if remaining a person is at risk.

This statement poses major problems for neurotechnology and human augmentation
for physicians and surgeons for two reasons. To best understand those reasons,
we will provide two cases. Note that the concept of personal identity refers
to the query to which degree and under which circumstances a person remains
the same over time, above and beyond physical identity [29]. In investigating
and evaluating for the “sameness” for a person, we need to consider both the
interaction that the person has with others and the appreciation of moral
capabilities, such as the ability to make a promise and keep it [29]. This,
especially, is important for the physicians and surgeons as both of them have
a fiduciary responsibility to their patients. Consider the simple case where
all physicians and surgeons provide authorization for augmentation via
neurotechnology and neurotechnology successfully accomplishes its
augmentations on them without any interference (i.e. no hackers or third
parties involved). An undesired outcome that can be produced from this comes
from the augmented cognition. The increase in knowledge does not guaranteed
consistency or improvement in morality within a person. As such, there is a
chance that the cognitive enhancement that they have undergone changes the way
that they appreciate moral capabilities. A physician with increase in
knowledge on the importance of using a specific biomedical approach to
treating patients with a specific condition can reinforce their current belief
that biomedical approaches are better than holistic approaches. In turn, this
can lead to a lack of openness for alternative approaches such as a holistic
approach, and empathy needed to understand why approaches like the holistic
approach is needed for the treatment of those kinds of patients. This will
lead to disputes and disagreements between the physician or surgeon and other
physicians and surgeons, and with medical practitioners such as nurses and
clinical social workers. Overtime, this will lead to the interaction that they
have with each other as well as with those medical professionals to change. By
the end of it, at the cost of wanting to improve their cognitive abilities for
the sake of their patients, the physician or surgeon will have lost their
personal identity. This possible loss of personal identity makes it
problematic for neurotechnological interventions as the physician or surgeon
is at risk of not remaining the person that he or she was prior to the
augmentation.

For the second case, consider the instance where simple case where all
physicians and surgeons provide authorization for augmentation via
neurotechnology and neurotechnology successfully accomplishes its
augmentations on them, but an interference by a third party, by say a
malicious brain-hacker, occurs later. After such an instance occurs, assuming
that the negotiation with the malicious brain-hacker was successful resulting
in no changes made to the BCI and brain of the physician or surgeon, it is
pretty much guaranteed that the physician or surgeon will not remain after the
incident. The physician or surgeon will likely suffer from sort of paranoia,
trust issues, and/or psychological trauma. This is not surprising as often
when an individual’s mental integrity and dignity has been compromised, they
end up suffering mentally from it to some degree. Furthermore, with the
advancement of technologies and areas within computer science, specifically
artificial intelligence, machine learning and quantum computing, it is
justified for them to have fears and worries as there is no guarantee that the
same issue will not be experienced again. What that degree is heavily depends
on the person’s mental strength, willpower and self-control, the amount of
support provided to them after the incident has occurred, and the environment
where the person is situated after the occurrence of the incident. Regardless,
their interaction with physicians, surgeons and others will likely change and
their appreciation of moral capabilities will be altered as their view on them
will be called into question. In worst case scenario, they become diagnosed
with a psychological or neurological disorder as an aftermath or have their
brain altered by the malicious brain-hacker, guaranteeing that their
interaction with others and their appreciation of moral capabilities will
change. This unintentional or intentional loss of personal identity makes it
problematic for neurotechnological interventions as the physician or surgeon
is at risk of becoming a new person that he or she was not prior to the
augmentation.

###  5.2 Social Issues

What can be noticed in the previous section is a third reason, or case as we
can call it, which is the case where some physicians and surgeons decides to
either not provide authorization to the neurotechnological intervention
altogether or to provide authorization to the neurotechnological intervention
but not to undergo at least one type of augmentation. The types of groups and
a possible distribution of these groups is shown in Figure 2. This case leads
to one of the previously raised concerns stemming from the consequence of
human augmentation. As discussed earlier, there is a chance that augmentations
can lead to a divide between humans, where the population of humans with
augmentations will feel that they are more superior to those without
augmentation, leading to different types of social issues. In our case with
the physician or surgeon not

Figure 2:  Diagram displaying the types of groups that would exist in the case
where undergo types of augmentations for physicians and surgeons are optional,
and a possible distribution of each group. To avoid providing false
information, population percentages were omitted.

providing authorization to neurotechnological intervention, this divide can
occur in three different divides:

  1. 1.

Division among physicians and surgeons domestically.

  2. 2.

Division between physicians and surgeons, and healthcare professionals.

  3. 3.

Division between physicians, surgeons and healthcare professionals.

  4. 4.

Division among physicians and surgeons internationally.

For our case, we will only mainly focus on (1) and (4) as (2) and (3) are more
distant to the scope of the paper. However, those are areas that can and
should be further investigated. With there being four different groups, there
is the change that those that physicians and surgeons that are fully augmented
(i.e. have successfully undergone all augmentation via neurotechnology)
mistreat those that do not have the augmentations that they have. This
possibility is not farfetched and is very likely to happen. In every industry,
including healthcare and medicine, we see prejudice and workers being
mistreated due to their title, lack of experience or the lack of knowledge
that (at least according to the administration or management within their
organization). With those physicians and surgeons that do not have a
particular augmentation, such as and especially augmented vision, cognition
and touch, fully and semi augmented physicians and surgeons can take advantage
of that to enforce their agendas and ideologies and bypassing arguments and
statements made by them on the grounds that given their inferiors cognitive
abilities or senses, what they say and their opinions should not be weighted
equally to those that are fully augmented, or things along those lines. As
such, augmentations increase the chance of prejudice and mistreatment
occurring among physicians and surgeons, reinforcing existing beneficence,
non-maleficence and justice issues within healthcare and medicine. Overtime,
this can lead to alteration of personality among physicians and surgeons.
Furthermore, this can lead to moral distress, trust issues, and other
psychological issues experienced by those doctors that are mistreated,
resulting in a loss of personal identity. This is dangerous as this shift in
personality and personal identity will not only impact the performance of
those physicians and surgeons and the lives of patients, but can create or
further contribute to suicidal thoughts within them. Depending on the profile,
involvements, commitments and types of patients that the doctor was treating,
the impact that their suicide can have can be one that is negatively impacts
individuals on a one-to-one, domestic, and/or international level.

The other way in which physicians or surgeons can be discriminated is in an
instance where either malicious brain-hacking or a data hostage leading, with
either of them leading to data sharing occurs. What makes doctors neural data
valuable is that the doctors are known for being very well off financially.
With proper preprocessing of the neural data and correct use of data mining
and machine learning algorithms, health status, preferences and behavior of
physicians and surgeons, physicians and surgeons can be exploited financially
by companies such as insurance companies. Note that data records are stored
electronically, which the highly personalized nature of neural data – much
like genomic data – may increase the identifiability of individuals [25]. With
that being said, the neural data obtained from malicious brain-hacking or data
sharing could be used for discrimination purposes against a particular
physician or surgeon, or to blackmail them into doing something. The severity
of the consequences from the blackmail will depend on what is being asked and
whether the doctor carries out the act. Regardless of what is produced from
this scenario, as the risk of psychological harms depends directly on the
presence of other risks [16], it is guaranteed that the doctor will experience
distress, anxiety and other psychological issues, which can lead decreased
performance in completing medical and non-medical tasks. This decrease in
performance increases the chances that they harm the patient.

###  5.3 Global Health Inequality and Health Migration

Given that there are major economical, technological, and infrastructural
disparities among countries, it is inevitable that some countries will not be
able to provide their physicians and surgeons with the neurotechnological
interventions needed to obtain augmentations. As computing technologies can
greatly contribute to the growth and development of countries [4], countries
such as the United States, Germany and China that have the manpower,
infrastructure and resources to realize computing technologies for economic,
social and medical development will be able to provide their doctors with the
augmentations quicker and with guarantees compared to countries that are
struggling due to poverty, warfare and humanitarian crises such as Libya,
Syria and Myanmar. Consequently, if only doctors in developed countries are
augmented, then this will create a global health inequality. Patients in
countries with augmented physicians and surgeons will receive better treatment
than those with regular physicians and surgeons. Furthermore, in times where
doctors from different countries have to collaborate together on medical and
healthcare issues, conflicts will likely arise between augmented doctors from
one country (i.e. developed country) versus regular doctors from another (i.e.
underdeveloped country). With augmented doctors possibly having a lack of
openness for alternative approaches and empathy towards patients from
different countries, this will lead to disputes and disagreements between the
doctors from the different countries. The disputes and disagreements can lead
to physicians and surgeons experiencing distress, anxiety and other
psychological issues, resulting in decreased performance in completing medical
and non-medical tasks. This decrease in performance increases the chances that
they harm their patients and patients internationally depending on the case.

With developed and high-income countries being able to provide not just
augmentations to physicians and surgeons but also better employment
opportunities, education, safety and security for them and their families,
these will push physicians and surgeons to migrate to those countries [34].
Their migration will further contribute to the current disparity in the health
workforce between high- and low/middle-income countries [35]. In Serour’s
work, which was done back in 2009, she stated that Africa needs 1 million
health workers, which includes physicians and surgeons, for Sub-Saharan Africa
alone. This number has likely increased due to the SARS-CoV-2 outbreak that
has and continues to take place in 2020. With countries like the United
States, United Kingdom, Canada and Australia already benefitting considerably
from the migration of nurses and doctors [30], the implementation of
neurotechnology for human augmentation will further benefit those countries as
well as other developed countries, leaving the underdeveloped countries to
suffer more. What results from this is an increase in harm experienced by the
patients and an increase in mortalities in the underdeveloped countries’
population.

###  5.4 Patient Harm

Whether it is data hostage situation of the data from a TMS or malicious
brain-hacking of a neuroprosthetic, given the risks associated with physicians
and surgeons using neurotechnology for augmentations along with the impact
that augmentation has on people in general, there is no doubt that there is a
chance that the change in self-concept, personal identity or the
discrimination, psychological and other issues experienced by physicians and
surgeons will influence doctor-patient relationships. One of the reasons for
why the relationship will likely become worse is because the voices of the
patients will either be ignored or be of less value to their physicians and
surgeons. For fully or semi augmented physicians and surgeons, especially
those with augmented cognition, there is a higher chance that they will think
that whatever decision they make will be the right decision for the patient.
Consequently, when patients of theirs voice their concern to them, they will
either ignore or listen only selected parts of the concern. In turn, this will
make the patient feel as if their doctor does not care for them, leading to
feelings of sadness, distress, and pain. This is problematic because even in
the case where the patient is successfully treated, they would leave the
hospital or clinic feeling mentally hurt. While the degree in which the mental
pain from the experienced differs from one patient to the other, it is still a
problem because the physician or surgeon did not accomplish non-maleficence.
During times when they could have prevented the patient from experiencing
mental harm, they did not prevent it. As a result, the physician or surgeon
did not ensure to inflict the least amount of harm possible to reach a
beneficial outcome. Rather, they inflicted an amount of harm onto the patient
that either they were not aware of or did not care about enough to reach a
beneficial outcome.

The other reason for why doctor-patient relationships will likely worsen is
because of the side effects experienced by physicians and surgeons from either
undergoing all augmentations or selected few augmentations, and/or from being
mistreated and discriminated by their colleagues [15]. For fully or semi
augmented physicians and surgeons, in the case where they lose their personal
identity, this can make it difficult for patients to communicate their
concerns as the new personality developed by their physician or surgeon can be
one that makes it difficult to communicate with them, and vice-versa.
Consequently, in the physician or surgeon having difficulty communicating with
their patients, this increases the chances of and eventually lead them harm
their patients either by accident or on purpose. In the case of harm occurring
due to an accident, this accident could be due to the physician or surgeon
making a wrong assumption based on the limited information verbally provided
by their patients. Alternatively, this can also be due to after using tES to
increase the physician or surgeon memory, rather than the memory being used
for remembering details about the patients, the memory retrieval within the
physician or surgeon’s brain retrieves unrelated information or even
problematic information such as details of a traumatic event; in retrieving
the wrong information, the physician or surgeon’s attention is not adequately
concentrated on the patient, making it difficult for them to communicate with
the patient, and eventually leading to them accidentally harming the patient.
In the case of harm occurring on purpose, this could be due to first the
personal identity change resulting in the physician or surgeon not being able
to properly control their anger, then the patient criticizing the physician or
surgeon, infuriating the doctor in a way that made them feel that the patient
is attacking their expertise, experiences and augmentations.

The problem of the voices of patients being ignored extends to issues of
justice. What results from the patient’s voice being partially or fully
ignored is unequal and unfair treatment by the fully or semi augmented
physicians and surgeons to their patients. The way that they approached the
medical intervention was not the same across all of their patients. Some
received more care from the physicians or surgeons while others received less.
Consequently, this unequal level of care is unfair to those that do not
receive the same amount of care from the physicians or surgeons. This unequal
treatment to patients can not only be experienced while undergoing the medical
intervention, but it can be experienced prior to it as well. Especially with
augmented cognition, augmented vision and BCIs, those make it possible for
physicians and surgeons to easily take advantage of their patients during the
diagnosis and consent phase prior to the treatment. With tDCS providing
physicians and surgeons the ability to better solve complex problems, they can
find ways to trick patients into providing their “informed” consent to
treatments that are either costly, ineffective, harmful or all three combined.
Consequently, this will lead to the patient further suffering from the disease
and any complications that arise during the medical intervention, financial
loss, and increased levels of distress from spending a larger than expected
time in the hospital and from the worry of either dying or possibly not being
able to live a regular life again or anytime soon.

##  6 Conclusion

A limitation with our work is that there were no medical professionals that
directly contributed to the paper. As such, there are some notable ethical
issues that were not included in this paper. Additionally, as our work did not
include any discussions on health policy and cyber security, we were not able
to discuss solutions that could be used to address the ethical and health
issues. Future work can ethically analyze the impact of neurotechnology for
human augmentation on physicians and surgeons with respect to the division
between physicians, surgeons and healthcare professionals, and should focus on
health policy and cyber security needed to address those ethical and health
issues. Even with the best-case scenario where neurotechnology always succeeds
in providing people with augmentations, in applying it on physicians and
surgeons to augment them, there are high risk associated with it. This makes
it challenging when it comes to doing a cost benefit analysis of it,
especially because when doing such an analysis, we cannot make the big
assumption that we made in this paper. A way to reduce the risks associated
with the neuroengineering component of augmenting physicians and surgeons is
to design and program the tactile sensors and neuroprosthetics so that in a
worse case where a malicious brain-hacker takes over a surgeon’s BCI and tries
to make the surgeon harm their patient, the neuroprosthetic detects the
abnormality then communicates with the tactile sensors, activating the
emergency magnet mechanism in the glove, forcing the gloves to tighten
together like handcuffs. This will prevent the surgeon from harming the
patient and medical practitioners in the room, and give the surgical team time
to figure out what to do next. It is important that such safety mechanisms
like these and others are rigorously tested prior to using them in clinical
settings, and have them ready for use once they are ready to be used.
Furthermore, after augmentations have been embedded within physicians and
surgeons, have a designated medical and bioethics combined team dedicated to
supporting them mentally to ensure that the transition is smooth and the
physicians and surgeons’ personal identity and other crucial aspects of them
are preserved. In doing so, this can help reduce and prevent the occurences of
harm and ethical, medical, and personhood issues experienced by physicians,
surgeons and patients.

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