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Neurophilosophical and Ethical Aspects of Virtual Reality Therapy in Neurology and Psychiatry

Published online by Cambridge University Press:  10 September 2018

PHILIPP KELLMEYER
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Abstract:

Highly immersive virtual reality (VR) systems have been introduced into the consumer market in recent years. The improved technological capabilities of these systems as well as the combination with biometric sensors, for example electroencephalography (EEG), in a closed-loop hybrid VR-EEG, opens up a range of new potential medical applications. This article first provides an overview of the past and current clinical applications of VR systems in neurology and psychiatry and introduces core concepts in neurophilosophy and VR research (such as agency, trust, presence, and others). Then, important adverse effects of highly immersive VR simulations and the ethical implications of standalone and hybrid VR systems for therapy in neurology and psychiatry are highlighted. These new forms of VR-based therapy may strengthen patients in exercising their autonomy. At the same time, however, these emerging systems present ethical challenges, for example in terms of moral and legal accountability in interactions involving “intelligent” hybrid VR systems. A user-centered approach that is informed by the target patients’ needs and capabilities could help to build beneficial systems for VR therapy.

Keywords

neuroethicsneurophilosophyvirtual realityagencyembodimenttrustneurologypsychiatry
Type
Articles
Information
Cambridge Quarterly of Healthcare Ethics , Volume 27 , Special Issue 4: Clinical Neuroethics , October 2018 , pp. 610 - 627
Copyright
Copyright © Cambridge University Press 2018 

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Footnotes

This work was (partly) supported by the German Ministry of Education and Research (BMBF) grant 13GW0053D (MOTOR-BIC) and the German Research Foundation (DFG) grant EXC 1086 BrainLinks-BrainTools to the University of Freiburg, Germany.

References

Notes

1. Spicer, R, Anglin, J, Krum, DM, Liew, S-L. REINVENT: A Low-Cost, Virtual Reality Brain-Computer Interface for Severe Stroke Upper Limb Motor Recovery—IEEE Conference Publication. Los Angeles: IEEE; 2017. doi:10.1109/VR.2017.7892338.Google Scholar

2. Pedreira da Fonseca, E, Ribeiro da Silva, NM, Pinto, EB. therapeutic effect of virtual reality on post-stroke patients: Randomized clinical trial. Journal of Stroke and Cerebrovascular Diseases 2017;26:94–100.CrossRefGoogle ScholarPubMed

3. Saposnik, G, Cohen, LG, Mamdani, M, Pooyania, S, Ploughman, M, Cheung, D, et al. Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial. The Lancet Neurology 2016;15:1019–27.CrossRefGoogle ScholarPubMed

4. Corbetta, D, Imeri, F, Gatti, R. Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: A systematic review. Journal of Physiotherapy 2015;61:117–24.CrossRefGoogle ScholarPubMed

5. Yin, CW, Sien, NY, Ying, LA, Chung, SF-CM, Tan May Leng, D. Virtual reality for upper extremity rehabilitation in early stroke: A pilot randomized controlled trial. Clinical Rehabilitation 2014;28:1107–14.CrossRefGoogle ScholarPubMed

6. Lohse, KR, Hilderman, CGE, Cheung, KL, Tatla, S, der Loos, HFMV. Virtual reality therapy for adults post-stroke: A systematic review and meta-analysis exploring virtual environments and commercial games in therapy. PLOS ONE 2014;9:e93318.CrossRefGoogle ScholarPubMed

7. Laver, K, George, S, Thomas, S, Deutsch, JE, Crotty, M. Virtual reality for stroke rehabilitation. Stroke 2012;43:e20–1.CrossRefGoogle Scholar

8. Saposnik, G, Mamdani, M, Bayley, M, Thorpe, KE, Hall, J, Cohen, LG, et al. Effectiveness of virtual reality exercises in stroke rehabilitation (EVREST): Rationale, design, and protocol of a pilot randomized clinical trial assessing the Wii gaming system. International Journal of Stroke 2010;5:47–51.CrossRefGoogle ScholarPubMed

9. Saposnik, G, Teasell, R, Mamdani, M, Hall, J, McIlroy, W, Cheung, D, et al. Effectiveness of virtual reality using wii gaming technology in stroke rehabilitation. Stroke 2010;41:1477–84.CrossRefGoogle ScholarPubMed

10. Yang, Y-R, Tsai, M-P, Chuang, T-Y, Sung, W-H, Wang, R-Y. Virtual reality-based training improves community ambulation in individuals with stroke: A randomized controlled trial. Gait & Posture 2008;28:201–6.CrossRefGoogle ScholarPubMed

11. Henderson, A, Korner-Bitensky, N, Levin, M. Virtual reality in stroke rehabilitation: A systematic review of its effectiveness for upper limb motor recovery. Topics in Stroke Rehabilitation 2007;14:52–61.CrossRefGoogle ScholarPubMed

12. Le May, S, Paquin, D, Fortin, J-S, Khadra, C. DREAM project: Using virtual reality to decrease pain and anxiety of children with burns during treatments. In: Proceedings of the 2016 Virtual Reality International Conference, New York: Association for Computing Machinery; 2016:24:1–24:4.Google Scholar

13. Malloy, KM, Milling, LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clinical Psychology Review 2010;30:1011–8.CrossRefGoogle ScholarPubMed

14. Das, DA, Grimmer, KA, Sparnon, AL, McRae, SE, Thomas, BH. The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: A randomized controlled trial [ISRCTN87413556]. BMC Pediatrics 2005;5:1.CrossRefGoogle Scholar

15. Chiarovano, E, Wang, W, Rogers, SJ, MacDougall, HG, Curthoys, IS, de Waele, C. Balance in virtual reality: Effect of age and bilateral vestibular loss. Frontiers in Neurology 2017;8:5.CrossRefGoogle ScholarPubMed

16. Tjernström, F, Zur OJahn, K. Current concepts and future approaches to vestibular rehabilitation. Journal of Neurology 2016;263:65–70.CrossRefGoogle ScholarPubMed

17. Whitney, SL, Alghadir, AH, Anwer, S. Recent evidence about the effectiveness of vestibular rehabilitation. Current Treatment Options in Neurology 2016;18:13.CrossRefGoogle ScholarPubMed

18. Hsu, S-Y, Fang, T-Y, Yeh, S-C, Su, M-C, Wang, P-C, Wang, VY. Three-dimensional, virtual reality vestibular rehabilitation for chronic imbalance problem caused by Ménière’s disease: A pilot study. Disability and Rehabilitation 2017;39:1601–6.CrossRefGoogle ScholarPubMed

19. Meldrum, D, Herdman, S, Moloney, R, Murray, D, Duffy, D, Malone, K, et al. Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: A randomised controlled trial. BMC Ear, Nose and Throat Disorders 2012;12:3.CrossRefGoogle ScholarPubMed

20. Liao, Y-Y, Yang, Y-R, Cheng, S-J, Wu, Y-R, Fuh, J-L, Wang, R-Y. Virtual reality-based training to improve obstacle-crossing performance and dynamic balance in patients with Parkinson’s disease. Neurorehabilitation and Neural Repair 2015;29:658–67.CrossRefGoogle ScholarPubMed

21. Mendes, FA dos, S, Pompeu, JE, Lobo, AM, da Silva, KG, Oliveira, T de P, Zomignani, AP, et al. Motor learning, retention and transfer after virtual-reality-based training in Parkinson’s disease—effect of motor and cognitive demands of games: A longitudinal, controlled clinical study. Physiotherapy 2012;98:217–23.CrossRefGoogle Scholar

22. Mirelman, A, Maidan, I, Herman, T, Deutsch, JE, Giladi, N, Hausdorff, JM. Virtual reality for gait training: Can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson’s disease? The Journals of Gerontology: Series A 2011;66A:234–40.CrossRefGoogle Scholar

23. Ma, H-I, Hwang, W-J, Fang, J-J, Kuo, J-K, Wang, C-Y, Leong, I-F, et al. Effects of virtual reality training on functional reaching movements in people with Parkinson’s disease: A randomized controlled pilot trial. Clinical Rehabilitation 2011;25:892–902.CrossRefGoogle ScholarPubMed

24. Yen, C-Y, Lin, K-H, Hu, M-H, Wu, R-M, Lu, T-W, Lin, C-H. Effects of virtual reality-augmented balance training on sensory organization and attentional demand for postural control in people with Parkinson disease: A randomized controlled trial. Physical Therapy 2011;91:862–74.CrossRefGoogle ScholarPubMed

25. Moyle, W, Jones, C, Dwan, T, Petrovich, T. Effectiveness of a virtual reality forest on people with dementia: A mixed methods pilot study. The Gerontologist 2017 [epub ahead of print].Google Scholar

26. Teo, W-P, Muthalib, M, Yamin, S, Hendy, AM, Bramstedt, K, Kotsopoulos, E, et al. Does a combination of virtual reality, neuromodulation and neuroimaging provide a comprehensive platform for neurorehabilitation?—A narrative review of the literature. Frontiers in Human Neuroscience 2016;10:284.CrossRefGoogle ScholarPubMed

27. Cushman, LA, Stein, K, Duffy, CJ. Detecting navigational deficits in cognitive aging and Alzheimer disease using virtual reality. Neurology 2008;71:888–95.CrossRefGoogle ScholarPubMed

28. Anderson, PL, Edwards, SM, Goodnight, JR. Virtual reality and exposure group therapy for social anxiety disorder: Results from a 4–6 year follow-up. Cognitive Therapy and Research 2017;41:230–6.CrossRefGoogle Scholar

29. Bouchard, S, Dumoulin, S, Robillard, G, Guitard, T, Klinger, É, Forget, H, et al. Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: a three-arm randomised controlled trial. The British Journal of Psychiatry 2017;210:276–83.CrossRefGoogle ScholarPubMed

30. Gebara, CM, Barros-Neto, TP de, Gertsenchtein, L, Lotufo-Neto, F, Gebara, CM, Barros-Neto, TP de, et al. Virtual reality exposure using three-dimensional images for the treatment of social phobia. Revista Brasileira de Psiquiatria 2016;38:24–9.CrossRefGoogle ScholarPubMed

31. Miloff, A, Lindner, P, Hamilton, W, Reuterskiöld, L, Andersson, G, Carlbring, P. Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy : A randomized-controlled trial. Trials 2016;17:60.CrossRefGoogle Scholar

32. Meyerbröker, K, Emmelkamp, PMG. Virtual reality exposure therapy in anxiety disorders: a systematic review of process-and-outcome studies. Depression and Anxiety 2010;27:933–44.CrossRefGoogle ScholarPubMed

33. Lindner, P, Miloff, A, Hamilton, W, Reuterskiöld, L, Andersson, G, Powers, MB, et al. Creating state of the art, next-generation Virtual Reality exposure therapies for anxiety disorders using consumer hardware platforms: Design considerations and future directions. Cognitive Behaviour Therapy 2017;46:404–20.CrossRefGoogle ScholarPubMed

34. Mölbert, SC, Thaler, A, Mohler, BJ, Streuber, S, Romero, J, Black, MJ, et al. Assessing body image in anorexia nervosa using biometric self-avatars in virtual reality: Attitudinal components rather than visual body size estimation are distorted. Psychological Medicine 2018;48:642–53.CrossRefGoogle ScholarPubMed

35. Keizer, A, Elburg A van, Helms R, Dijkerman HC. A virtual reality full body illusion improves body image disturbance in anorexia nervosa. PLOS ONE 2016;11:e0163921.CrossRefGoogle Scholar

36. Yang, YJD, Allen, T, Abdullahi, SM, Pelphrey, KA, Volkmar, FR, Chapman, SB. Brain responses to biological motion predict treatment outcome in young adults with autism receiving Virtual Reality Social Cognition Training: Preliminary findings. Behaviour Research and Therapy 2017;93:55–66.CrossRefGoogle ScholarPubMed

37. Didehbani, N, Allen, T, Kandalaft, M, Krawczyk D Chapman S. Virtual Reality Social Cognition Training for children with high functioning autism. Computers in Human Behavior 2016;62:703–11.CrossRefGoogle Scholar

38. Ip, HHS, Wong, SWL, Chan, DFY, Byrne, J, Li, C, Yuan, VSN, et al. Virtual reality enabled training for social adaptation in inclusive education settings for school-aged children with autism spectrum disorder (ASD). In: Blended Learning: Aligning Theory with Practices. Cham: Springer; 2016:94–102.Google Scholar

39. Dehn, LB, Kater, L, Piefke, M, Botsch, M, Driessen, M, Beblo, T. Training in a comprehensive everyday-like virtual reality environment compared to computerized cognitive training for patients with depression. Computers in Human Behavior 2018;79:40–52.CrossRefGoogle Scholar

40. Falconer, CJ, Rovira, A, King, JA, Gilbert, P, Antley, A, Fearon, P, et al. Embodying self-compassion within virtual reality and its effects on patients with depression. BJPsych Open 2016;2:74–80.CrossRefGoogle ScholarPubMed

41. Rus-Calafell, M, Garety, P, Sason, E, Craig, TJK, Valmaggia, LR. Virtual reality in the assessment and treatment of psychosis: A systematic review of its utility, acceptability and effectiveness. Psychological Medicine 2018;48:362–91.CrossRefGoogle ScholarPubMed

42. Veling, W, Pot-Kolder, R, Counotte, J, van Os, J, van der Gaag, M. Environmental social stress, paranoia and psychosis liability: A virtual reality study. Schizophrenia Bulletin 2016;42:1363–71.CrossRefGoogle ScholarPubMed

43. Veling, W, Moritz, S, van der Gaag, M. Brave new worlds—Review and update on virtual reality assessment and treatment in psychosis. Schizophrenia Bulletin 2014;40:1194–7.CrossRefGoogle ScholarPubMed

44. Beidel, DC, Frueh, BC, Neer, SM, Bowers, CA, Trachik, B, Uhde, TW, et al. Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial. Journal of Anxiety Disorders 2017 [epub ahead of print].Google ScholarPubMed

45. Gahm, G, Reger, G, Ingram, MV, Reger, M, Rizzo, A. A Multisite, Randomized Clinical Trial of Virtual Reality and Prolonged Exposure Therapy for Active Duty Soldiers with PTSD. Tacoma WA: Geneva Foundation; 2015.CrossRefGoogle Scholar

46. Thompson, E, Varela, FJ. Radical embodiment: neural dynamics and consciousness. Trends in Cognitive Sciences 2001;5:418–25.CrossRefGoogle ScholarPubMed

47. Gallagher, S, Allen, M. Active inference, enactivism and the hermeneutics of social cognition. Synthese 2016;1–22.Google ScholarPubMed

48. Clark, A, Chalmers, D. The extended mind. Analysis 1998;58:7–19.CrossRefGoogle Scholar

49. Sterelny, K. Minds: Extended or scaffolded? Phenomenology and the Cognitive Sciences 2010;9:465–81.CrossRefGoogle Scholar

50. Sutton, J, Harris, CB, Keil, PG, Barnier, AJ. The psychology of memory, extended cognition, and socially distributed remembering. Phenomenology and the Cognitive Sciences 2010;9:521–60.CrossRefGoogle Scholar

51. Menary, R. Introduction to the special issue on 4E cognition. Phenomenology and the Cognitive Sciences 2010;9:459–63.CrossRefGoogle Scholar

52. Pereplyotchik, D. Cognitivism and nominalism in the philosophy of linguistics. In: Psychosyntax. Cham: Springer; 2017:19–44.CrossRefGoogle Scholar

53. Adams, F, Aizawa, K. The value of cognitivism in thinking about extended cognition. Phenomenology and the Cognitive Sciences 2010;9:579–603.CrossRefGoogle Scholar

54. Kalckert, A, Ehrsson, HH. The moving rubber hand illusion revisited: Comparing movements and visuotactile stimulation to induce illusory ownership. Consciousness and Cognition 2014;26:117–32.CrossRefGoogle ScholarPubMed

55. Alimardani, M, Nishio, S, Ishiguro, H. Removal of proprioception by BCI raises a stronger body ownership illusion in control of a humanlike robot. Scientific Reports 2016;6:33,514.CrossRefGoogle ScholarPubMed

56. Blumberg, MS, Dooley, JC. Phantom limbs, neuroprosthetics, and the developmental origins of embodiment. Trends in Neurosciences 2017;40:603–12.CrossRefGoogle ScholarPubMed

57. Gallagher, S. Philosophical conceptions of the self: Implications for cognitive science. Trends in Cognitive Sciences 2000;4:14–21.CrossRefGoogle ScholarPubMed

58. Moore, JW, Fletcher, PC. Sense of agency in health and disease: A review of cue integration approaches. Consciousness and Cognition 2012;21:59–68.CrossRefGoogle ScholarPubMed

59. Gentsch, A, Weber, A, Synofzik, M, Vosgerau, G, Schütz-Bosbach, S. Towards a common framework of grounded action cognition: Relating motor control, perception and cognition. Cognition 2016;146:81–9.CrossRefGoogle ScholarPubMed

60. Synofzik, M, Vosgerau, G, Lindner, A. The experience of free will and the experience of agency: an error-prone, reconstructive process. In: Glannon, W, ed. Free Will and the Brain: Neuroscientific, Philosophical, and Legal Perspectives. New York: Cambridge University Press; 2015.66–79.CrossRefGoogle Scholar

61. Ma, K, Hommel, B. The role of agency for perceived ownership in the virtual hand illusion. Consciousness and Cognition 2015;36:277–88.CrossRefGoogle ScholarPubMed

62. Wegner, DM, Sparrow, B, Winerman, L. Vicarious agency: Experiencing control over the movements of others. Journal of Personality and Social Psychology 2004;86:838–48.CrossRefGoogle Scholar

63. Bowman, DA, McMahan, RP. Virtual reality: How much immersion is enough? Computer 2007;40:36–43.CrossRefGoogle Scholar

64. Witmer, BG, Singer, MJ. Measuring presence in virtual environments: A presence questionnaire. Presence: Teleoperators and Virtual Environments 1998;7:225–40.CrossRefGoogle Scholar

65. Salanitri, D, Lawson, G, Waterfield, B. The relationship between presence and trust in virtual reality. In Proceedings of the European Conference on Cognitive Ergonomics , New York: Association for Computing Machinery; 2016:16:1–16:4.Google Scholar

66. Poeschl, S, Doering, N. Measuring co-presence and social presence in virtual environments - psychometric construction of a German scale for a fear of public speaking scenario. Studies in Health Technology and Informatics 2015;219:58–63.Google ScholarPubMed

67. Waltemate, T, Gall, D, Roth, D, Botsch, M, Latoschik, ME. The impact of avatar personalization and immersion on virtual body ownership, presence, and emotional response. IEEE Transactions on Visualization and Computer Graphics 2018;24:1643–52.CrossRefGoogle ScholarPubMed

68. Pavone, EF, Tieri, G, Rizza, G, Tidoni, E, Grisoni, L, Aglioti, SM. Embodying others in immersive virtual reality: Electro-cortical signatures of monitoring the errors in the actions of an avatar seen from a first-person perspective. The Journal of Neuroscience 2016;36:268–79.CrossRefGoogle ScholarPubMed

69. Serino, S, Pedroli, E, Keizer, A, Triberti, S, Dakanalis, A, Pallavicini, F, et al. Virtual reality body swapping: A tool for modifying the allocentric memory of the body. Cyberpsychology, Behavior, and Social Networking 2015;19:127–33.CrossRefGoogle Scholar

70. Slater, M, Spanlang, B, Sanchez-Vives, MV, Blanke, O. First person experience of body transfer in virtual reality. PLOS ONE 2010;5:e10564.CrossRefGoogle ScholarPubMed

71. Smurrayinchester. An SVG Version of Image:Moriuncannyvalley.gif. 2007; available at https://commons.wikimedia.org/wiki/File:Mori_Uncanny_Valley.svg. (last accessed 2 Feb 2018).Google Scholar

72. Saygin, AP, Chaminade, T, Ishiguro, H, Driver, J, Frith, C. The thing that should not be: predictive coding and the uncanny valley in perceiving human and humanoid robot actions. Social Cognitive and Affective Neuroscience 2012;7:413–22.CrossRefGoogle Scholar

73. Tinwell, A, Grimshaw, M, Nabi DAWilliams, A. Facial expression of emotion and perception of the Uncanny Valley in virtual characters. Computers in Human Behavior 2011;27:741–9.CrossRefGoogle Scholar

74. Salanitri, D, Hare, C, Borsci, S, Lawson, G, Sharples, S, Waterfield, B. Relationship between trust and usability in virtual environments: An ongoing study. In Human-Computer Interaction: Design and Evaluation. Cham: Springer; 2015:49–59.CrossRefGoogle Scholar

75. See note 65, Salanitri et al. 2016.

76. Rehfeld, S, Latoschik, ME, Tramberend, H. Estimating latency and concurrency of asynchronous real-time interactive systems using model checking. In: Virtual Reality (VR). Greenville, SC: IEEE;2016:57–66.Google Scholar

77. Davis, S, Nesbitt, K, Nalivaiko, E. A systematic review of cybersickness. In: Proceedings of the 2014 Conference on Interactive Entertainment, New York: Association for Computing Machinery; 2014:8:1–8:9.Google Scholar

78. Pot-Kolder, R, VelingW, Counotte J, van der Gaag, M. Anxiety partially mediates cybersickness symptoms in immersive virtual reality environments. Cyberpsychology, Behavior, and Social Networking 2018; 21:187–93.CrossRefGoogle ScholarPubMed

79. Arafat, IM, Ferdous, SMS, Quarles, J. The effects of cybersickness on persons with multiple sclerosis. In: Proceedings of the 22nd Association for Computing Machinery Conference on Virtual Reality Software and Technology, New York: Association for Computing Machinery; 2016:51–9.Google Scholar

80. Kim, YY, Kim, HJ, Kim, EN, Ko, HD, Kim, HT. Characteristic changes in the physiological components of cybersickness. Psychophysiology 2005;42:616–25.Google ScholarPubMed

81. Petry, NM, Rehbein, F, Gentile, DA, Lemmens, JS, Rumpf, H-J, Mößle, T, et al. An international consensus for assessing internet gaming disorder using the new DSM-5 approach. Addiction 2014;109:1399–406.CrossRefGoogle ScholarPubMed

82. Weinstein, A, Livny, A, Weizman, A. New developments in brain research of internet and gaming disorder. Neuroscience & Biobehavioral Reviews 2017;75:314–30.CrossRefGoogle ScholarPubMed

83. Holmes, NP, Snijders, HJ, Spence, C. Reaching with alien limbs: Visual exposure to prosthetic hands in a mirror biases proprioception without accompanying illusions of ownership. Perception & Psychophysics 2006;68:685–701.CrossRefGoogle Scholar

84. Spanlang, B, Normand, J-M, Borland, D, Kilteni, K, Giannopoulos, E, Pomés, A, et al. How to build an embodiment lab: Achieving body representation illusions in virtual reality. Frontiers in Robotics and AI 2014;1. See also note 67, Waltmate et al. 2018; note 70, Slater et al. 2010.Google Scholar

85. Gonzalez-Franco, M, Lanier, J. Model of illusions and virtual reality. Frontiers in Psychology 2017;8:1125. See also note 35, Keizer et al. 2016.CrossRefGoogle ScholarPubMed

86. Kellmeyer, P, Cochrane, T, Müller, O, Mitchell, C, Ball, T, Fins, JJ, et al. The effects of closed-loop medical devices on the autonomy and accountability of persons and systems. Cambridge Quarterly of Healthcare Ethics 2016;25:623–33.CrossRefGoogle ScholarPubMed

87. Goering, S, Klein, E, Dougherty, DD, Widge, AS. Staying in the loop: Relational agency and identity in next-generation DBS for psychiatry. AJOB Neuroscience 2017;8;59–70.CrossRefGoogle Scholar

88. Beauchamp, TL, Childress, JF. Principles of Biomedical Ethics. New York: Oxford University Press; 2001.Google Scholar

89. Walter, JK, Ross, LF. Relational autonomy: Moving beyond the limits of isolated individualism. Pediatrics 2014;133:S16–23.CrossRefGoogle ScholarPubMed

90. Gilbert, F, O’Brien, T, Cook, M. The effects of closed-loop brain implants on autonomy and deliberation: What are the risks of being kept in the loop? Cambridge Quarterly of Healthcare Ethics 2018;27:316–25.CrossRefGoogle Scholar See also note 86, Kellmeyer et al., 2016; note 87, Goering et al. 2017.

91. See note 85, Gonzalez-Franco, Lanier 2017; See also note 35, Keizer et al. 2016.

92. Robertson, A. How virtual reality developers are surviving the hype cycle. The Verge 2017; available at https://www.theverge.com/2017/10/11/16458806/oculus-rift-htc-vive-vr-hype-game-developers (last accessed 2 Feb 2018).Google Scholar

93. Yang, G-Z, Cambias, J, Cleary, K, Daimler, E, Drake, J, Dupont, PE, et al. Medical robotics—Regulatory, ethical, and legal considerations for increasing levels of autonomy. Science Robotics 2017;2:1–2.CrossRefGoogle Scholar

94. Yuste, R, Goering, S, Arcas, BA, Bi, G, Carmena, JM, Carter, A, et al. Four ethical priorities for neurotechnologies and AI. Nature News 2017;551:159.CrossRefGoogle ScholarPubMed

95. Elenko, E, Speier, A, Zohar, D. A regulatory framework emerges for digital medicine. Nature Biotechnology 2015;33:697–702.CrossRefGoogle ScholarPubMed