Ethical gaps in closed-loop neurotechnology: a scoping review

Abstract

Closed-loop (CL) neurotechnology, which dynamically adapts to patients' neural states, offers new opportunities for treating neurological and psychiatric disorders. However, its real-time feedback mechanisms raise critical ethical challenges. This scoping review assesses whether and how clinical studies involving CL neurotechnologies address ethical concerns. We analyzed peer-reviewed research on human participants to evaluate both the presence and depth of ethical engagement. Despite the prominence of CL systems in neuroethical discourse, explicit ethical assessments remain rare. Ethical issues are typically addressed only implicitly, folded into technical or procedural discussions without structured analysis. Most notably, our findings reveal a persistent gap between regulatory compliance and meaningful ethical reflection. To address this, we propose empirically grounded, community-responsive recommendations to strengthen ethical oversight in this field. These recommendations aim to support governance frameworks that are context-sensitive, reflexive, and capable of addressing the complex ethical terrain introduced by adaptive neurotechnologies.

Fig. 1. Alluvial diagram showing existing relationships between stimulation methods and ethical considerations.

Bar thickness reflects the frequency of codes. ‘Other’ encompasses systems not categorized under responsive neurostimulation (RNS), deep brain stimulation (DBS), or vagus nerve stimulation (VNS).

Fig. 2. PRISMA Scoping literature review flow diagram.

The diagram outlines the selection process of studies included in the review, detailing the number of records identified, screened, assessed for eligibility, and ultimately included, along with the reasons for exclusion at each stage.