This article provides a conceptual and normative framework through which we may understand the potentially ethically significant roles that information generated by neurotechnologies about our brains and minds may play in our construction of our identities. Neuroethics debates currently focus disproportionately on the ways that third parties may (ab)use these kinds of information. These debates occlude interests we may have in whether and how we ourselves encounter information about our own brains and minds. This gap is not yet adequately addressed (...) by most allusions in the literature to potential identity impacts. These lack the requisite conceptual or normative foundations to explain why we should be concerned about such effects or how they might be addressed. This article seeks to fill this gap by presenting a normative account of identity as constituted by embodied self-narratives. It proposes that information generated by neurotechnologies can play significant content-supplying and interpretive roles in our construction of our self-narratives. It argues, to the extent that these roles support and detract from the coherence and inhabitability of these narratives, access to information about our brains and minds engages non-trivial identity-related interests. These claims are illustrated using examples drawn from empirical literature reporting reactions to information generated by implantable predictive BCIs and psychiatric neuroimaging. The article concludes by highlighting ways in which information generated by neurotechnologies might be governed so as to protect information subjects’ interests in developing and inhabiting their own identities. (shrink)

In a recent article, Sabine Müller, Merlin Bittlinger, and Henrik Walter launch a sweeping attack against what they call the "personal identity debate" as it relates to patients treated with deep brain stimulation (DBS). In this critique offered by Müller et al., the so-called personal identity debate is said to: (a) be metaphysical in a problematic way, (b) constitute a threat to patients, and (c) use "vague" and "contradictory" statements from patients and their families as direct evidence for metaphysical theories. (...) In this response, I critically evaluate Müller et al.'s argument, with a special focus on these three just-mentioned aspects of their discussion. My conclusion is that Müller et al.'s overall argument is problematic. It overgeneralizes criticisms that may apply to some, but certainly not to all, contributions to what they call the personal identity-debate. Moreover, it rests on a problematic conception of what much of this debate is about. Nor is Müller et al.'s overall argument fair in its assessment of the methodology used by most participants in the debate. For these reasons, we should be skeptical of Müller et al.'s claim that the "personal identity debate" is a "threat to neurosurgical patients". (shrink)

Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with (...) refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand. (shrink)

Decisions about brain surgery pose existential challenges because they are often decisions about life or death, and sometimes about possible personality changes. Therefore they require rigorous neuroethical consideration. However, we doubt whether metaphysical interpretations of ambiguous statements of patients are useful for deriving ethical and legal conclusions. Particularly, we question the application of psychological theories of personal identity on neuroethical issues for several reasons. First, even the putative “standard view” on personal identity is contentious. Second, diverse accounts of personal identity (...) have been introduced into the neuroethical debate, which are incompatible. Third, the criteria for “diagnosing” the supposed changes in “identity” are ambiguous and indeterminate. Fourth, the metaphysical theories of personal identity imply highly questionable ethical and legal revisions, namely the denial of advance directives, particularly of Ulysses contracts, and, for patients with brain cancer, even therapeutic nihilism.We discuss three examples in which ideas from the personal identity debate in metaphysics are straightforwardly applied to discuss ethical issues of neurosurgery. We discuss revisions of the current medico-legal practice that have been proposed on grounds of psychological theories of personal identity. We argue that the established status quo in law and clinical practice is beneficial to the patients concerned. Furthermore, it is metaphysically neutral, which is an important principle of liberal, democratic, pluralistic societies.We recommend a pragmatic approach: empirical research on personality changes arising from brain disorders or interventions, comprehensive information about risks of personality changes, and advance directives, particularly Ulysses contracts. (shrink)

All people are vulnerable to having their self-concepts shaped by others. This article investigates that vulnerability using a theory of narrative self-constitution. According to narrative self-constitution, people depend on others to develop and maintain skills of self-narration and they are vulnerable to having the content of their self-narratives co-authored by others. This theoretical framework highlights how vulnerability to co-authoring is essential to developing a self-narrative and, thus, the possibility of autonomy. However, this vulnerability equally entails that co-authors can undermine autonomy (...) by contributing disvalued content to the agent’s self-narrative and undermining her authorial skills. I illustrate these processes with the first-hand reports of several women who survived sexual abuse as children. Their narratives of survival and healing reveal the challenges involved in developing the skills required to manage vulnerability to co-authoring and how others can help in this process. Finally, I discuss some of the implications of co-authoring for the healthcare professional and the therapeutic relationship. (shrink)

The profound changes in personality, mood, and other features of the self that neural interventions can induce can be disconcerting to patients, their families, and caregivers. In the neuroethical debate, these concerns are often addressed in the context of possible threats to the narrative self. In this paper, I argue that it is necessary to consider a dimension of impacts on the narrative self which has so far been neglected: neural interventions can lead to a loss of meaning of actions, (...) feelings, beliefs, and other intentional elements of our self-narratives. To uphold the coherence of the self-narrative, the changes induced by neural interventions need to be accounted for through explanations in intentional or biochemical terms. However, only an explanation including intentional states delivers the content to directly ascribe personal meaning, i.e., subjective value to events. Neural interventions can deprive events of meaning because they may favor a predominantly biochemical account. A loss of meaning is not inherently negative but it can be problematic, particularly if events are affected one was not prepared or willing to have stripped of meaning. The paper further examines what it is about neural interventions that impacts meaning by analyzing different methods. To which degree the pull towards a biochemical view occurs depends on the characteristics of the neural intervention. By comparing Deep Brain Stimulation, Prozac, Ritalin, psychedelics, and psychotherapy, the paper identifies some main factors: the rate of change, the transparency of the causal chain, the involvement of the patient, and the presence of an acute phenomenological experience. (shrink)

The potential of memory modification techniques (MMTs) has raised concerns and sparked a debate in neuroethics, particularly in the context of identity and authenticity. This paper addresses the question whether and how MMTs influence authenticity. I proceed by drawing two distinctions within the received views on authenticity. From this, I conclude that an analysis of MMTs based on a dual-basis, process view of authenticity is warranted, which implies that the influence of MMTs on authenticity crucially depends on the specifics of (...) how memory modification would eventually work. Therefore, I continue with a systematic analysis of possible properties of MMTs in which I distinguish between the dimensions of memories and the kinds of experiences that can be modified as well as the properties of the process of memory modification. The impact of MMTs on authenticity is analyzed regarding the possible properties of MMTs and based on a narrative approach to authenticity which fulfills the requirements of a dual-basis, process view of authenticity. Lastly, I explore the potential of MMTs to shift the balance between self-discovery and self-creation within authenticity and thereby alter the concept itself as well as the value of authenticity. (shrink)

Not too long ago, neurotechnology was the purview of the clinic and research. In 2011, researchers at Brown University succeeded for the first time in using an implanted sensor in the brain of a pa...

While deep brain stimulation (DBS) for patients with Parkinson's disease has typically raised ethical questions about autonomy, accountability and personal identity, recent research indicates that we need to begin taking into account issues surrounding the patients’ feelings of authenticity and alienation as well. In order to bring out the relevance of this dimension to ethical considerations of DBS, I analyse a recent case study of a Dutch patient who, as a result of DBS, faced a dilemma between autonomy and authenticity. (...) This case study is meant to point out the normatively meaningful tension patients under DBS experience between authenticity and autonomy. (shrink)

Medical devices are often referred to as being invasive or non-invasive. Though invasiveness is relevant, and central, to how devices are understood and regarded in medicine and bioethics, a consensus concept or definition of invasiveness is lacking. To begin to address this problem, this essay explores four possible descriptive meanings of invasiveness: how devices are introduced to the body, where they are located in the body, whether they are foreign to the body, and how they change the body. An argument (...) is offered that invasiveness is not purely descriptive, but implicates normative concepts of danger, intrusion, and disruption. In light of this, a proposal is offered for how to understand use of the concept of invasiveness in discussions of medical devices. (shrink)

Implantable brain–computer interface technology is an expanding area of engineering research now moving into clinical application. Ensuring meaningful informed consent in implantable BCI research is an ethical imperative. The emerging and rapidly evolving nature of implantable BCI research makes identification of risks, a critical component of informed consent, a challenge. In this paper, 6 core risk domains relevant to implantable BCI research are identified—short and long term safety, cognitive and communicative impairment, inappropriate expectations, involuntariness, affective impairment, and privacy and security. (...) Work in deep brain stimulation provides a useful starting point for understanding this core set of risks in implantable BCI. Three further risk domains—risks pertaining to identity, agency, and stigma—are identified. These risks are not typically part of formalized consent processes. It is important as informed consent practices are further developed for implantable BCI research that attention be paid not just to disclosing core research risks but exploring the meaning of BCI research with potential participants. (shrink)

Do neurosurgical procedures ever result in the patient prior to the procedure not being identical with the individual who wakes up postsurgery in the hospital bed? We address this question by offering an analysis of the persistence of persons that emphasizes narrative, rather than numerical, identity. We argue that a narrative analysis carries the advantage of highlighting what matters to patients in their ordinary lives, explaining the varying degrees of persistence of personal identity, and enhancing our understanding of patients' experiences. (...) We illustrate these points in cases involving temporal lobectomy for treatment of refractory epilepsy and deep brain stimulation for refractory Parkinson's disease. (shrink)

The debate about how neurotechnologies impact authenticity has focused on two inter-related dimensions: self-discovery and self-creation. In this paper, we develop a broader framework that includes the experimental and relational dimensions of authenticity, both understood as decisive for shaping one’s narrative identity. In our view, neurointerventions that alter someone’s personality traits will also impact her very own self-understanding across time. We argue that experimental authenticity only needs a minimum conception of narrative coherence of the self and that reversibility should remain (...) a key feature in the ethical assessment of neurotechnologies. The relational dimension of authenticity derives from the fact that a process of self-constitution is never a solitary business. The significant others act not just as subsequent judges of one’s life decisions, but as real co-authors of one’s self. We discuss relevant cases in which others are actively contributing to the meaning-making process, as to the direction one’s life is taking. We also claim that the experimental and the relational dimensions of authenticity should aim to correct each other. The relational dimension introduces socially approved standards as well as limitations to the array of available possibilities of self-fashioning or human enhancement. The experimental side enables us to avoid confusing one’s personal identity with a social and narrative construct that only bears the mark of social pressure and conformism. (shrink)

Purpose – The purpose of this study is to think ahead into the year 2035 and reflect on the ethical implications of brain-to-brain linking. Design/methodology/approach – Philosophical argument. Findings – It is quite likely that the direction of technological research today is heading toward a closer integration of mind and machine in 2035. What is interesting is that the integration also makes mind-mind or brain-brain integration possible too. There is nothing in principle that would prevent hooking up more than one (...) brain to a machine, or connecting two or more brains together to harness their processing power to tackle a very complicated task. If that happens, the whole notion of what it is to be an individual and a self will have to be rethought. I have offered a way in which that can be done: Instead of viewing the self as being contained in a closed space traditionally defined by the skin, the self can expand outside of the skin and merge temporarily with other selves too. This also has profound implications on the notion of privacy, especially on how it is conceptualized and justified. Research limitations/implications – This research is limited to theoretical argumentation only. It relies on the current empirical and scientific investigations that are going on at the moment and provide ethical reflections on them. Practical implications – We need to anticipate technological innovations to be more proactive in deliberating and formulating policy and ethical guidelines; otherwise, ethicists will just muse after the fact, implying that there is nothing further to be done. Social implications – Brain-to-brain linking has tremendous social implications, so is the ethical reflection on the issue. Originality/value – Argument purporting to show the specific content in ethical guidelines on brain-to-brain interlinking based on the metaphysics of the self that is directly implicated by the technology has not been done before, according to the author’s best knowledge. (shrink)

In this paper, I discuss whether it is ever morally permissible to diminish the cognitive abilities or capacities of some cognitively gifted offenders whose ability to commit their crimes successfully relies on them possessing these abilities or capacities. I suggest that, given such cognitive diminishments may prevent such offenders from re-offending and causing others considerable harm, this provides us with at least one good moral reason in favour of employing them. After setting out more clearly what cognitive diminishment may consist (...) of, I then critically discuss variations of four plausible arguments against a proposal of using them on cognitive gifted offenders related to autonomy, harm, narrative identity, and a right to mental self-determination. I argue that none of these concerns should have us reject the use of cognitive diminishments. (shrink)

In "Neurotechnologies, Relational Autonomy, and Authenticity," Mary Walker and Catriona Mackenzie engage with discourses surrounding the morality of neurotechnologies, arguing that these debates have been largely mistaken in their focus on worries about the effects of emerging technologies on human authenticity. They offer an alternative, autonomy-centered approach that problematizes concerns about authenticity as necessarily "essentialist or existentialist views of the self" that "transcends socialization". Instead, they suggest that, although authenticity is a condition for self-governance, autonomy itself is the more helpful (...) way to frame current debates about neurotechnologies.The goals of their... (shrink)

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

Advancements in novel neurotechnologies, such as brain computer interfaces and neuromodulatory devices such as deep brain stimulators, 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 democratic and inclusive summits to establish globally-coordinated ethical and societal guidelines for neurotechnology development and application, new measures, including “Neurorights,” for data privacy, security, and consent to empower neurotechnology users’ control over their data, new methods of identifying and preventing bias, and the adoption of public guidelines for safe and equitable distribution of neurotechnological devices. (shrink)

Novel neurotechnologies, like deep brain stimulation and brain‐computer interface, offer great hope for treating, curing, and preventing disease, but raise important questions about effects these devices may have on human identity, authenticity, and autonomy. After briefly assessing recent narrative work in these areas, we show that agency is a phenomenon key to all three goods and highlight the ways in which neural devices can help to draw attention to the relational nature of our agency. Drawing on insights from disability theory, (...) we argue that neural devices provide a kind of agential assistance, similar to that provided by caregivers, family, and others. As such, users and devices participate in a kind of co‐agency. We conclude by suggesting the need for developing relational agency‐competencies—skills for reflecting on the influence of devices on agency, for adapting to novel circumstances ushered in by devices, and for incorporating the feedback of loved ones and others about device effects on agency. (shrink)

Bioethics has already had a rich interaction with the relatively new field of neurotechnology. Scholars have wondered whether neurotechnological interventions, such as deep brain stimulation, are threats to personal identity, lead to alienation or create dilemmas between authenticity and autonomy, impact autonomy, detract from agency, or lead to self-estrangement. Many of these ethical investigations are concerned not with the targeted health benefits of neurotechnology but with whether and how they fit into users' lives in more personal and profound ways.In some (...) ways, this focus on general bioethical issues... (shrink)

Timothy Brown's piece "Building Intricate Partnerships with Neurotechnology" makes a valuable contribution to ethical discussion of questions about human identity and agency raised by Deep Brain Stimulation. The paper brings together a number of relational approaches to narrative identity and autonomy, drawing on first-personal empirical accounts, to extend a relational account of agency to include neurostimulators. In doing so, it builds on the contributions relational approaches have made to making sense of changes to aspects of selfhood following neurological intervention while (...) also helpfully reframing concerns away from the threat that DBS may pose to aspects of self-hood. This approach directs... (shrink)

This paper explores the impacts of neurological intervention on selfhood with reference to recipients’ claims about changes to their self-understanding following Deep Brain Stimulation for treatment of Parkinson’s Disease. In the neuroethics literature, patients’ claims such as: “I don’t feel like myself anymore” and “I feel like a machine”, are often understood as expressing threats to identity. In this paper I argue that framing debates in terms of a possible threat to identity—whether for or against the proposition, is mistaken and (...) occludes what is ethically salient in changes from DBS. Rather, by adopting a relational narrative approach to identity and autonomy, I show that the ethically salient issue from DBS is impacts on autonomous agency—whether one’s actions and beliefs are one’s own, and how DBS may hinder, or foster, embodied, relational autonomy competences. This approach recognizes that if sufficiently significant, impacts on autonomy competences may pose a threat to one’s ability to contribute to the process of authoring one’s own life and so pose a threat to identity formation. I argue this approach resolves the confusion in the literature about whether and how DBS threatens identity and provides a complex picture of how DBS may affect selfhood by disrupting narrative identity formation and revision, distorting agency and/or undermining autonomy. (shrink)

Although being generally safe, the use of Deep Brain Stimulation has been associated with a significant number of patients experiencing postoperative psychological and neurological harm within experimental trials. A proportion of these postoperative severe adverse effects have lead to the decision to medically prescribe device deactivation or removal. However, there is little debate in the literature as to what is in the patient’s best interest when device removal has been prescribed; in particular, what should be the conceptual approach to ethically (...) guide the decision to remove or maintain implants. The purpose of this article is to examine the ethical issues raised when patients refuse brain device explantation despite medical prescription. In order to illustrate these issues, we report and discuss a clinical case involving a patient suffering from treatment resistant depression who experienced forms of postoperative self-estrangement, as well as suicidal attempts, but who resists giving consent to device explantation. (shrink)

The phenomenological effects of deep brain stimulation (DBS) on the self of the patient remains poorly understood and under described in the literature, despite growing evidence that a significant number of patients experience postoperative neuropsychiatric changes. To address this lack of phenomenological evidence, we conducted in-depth, semistructured interviews with 17 patients with Parkinson's disease who had undergone DBS. Exploring the subjective character specific to patients' experience of being implanted gives empirical and conceptual understanding of the potential phenomenon of DBS-induced self-estrangement. (...) Our study concluded that (1) the more patients preoperatively felt alienated by their illness, the more they experienced postoperative self-estrangement, and (2) the notion of self-estrangement seems to exist in association with certain common qualitative characters, namely, loss of control, which reflects a deteriorative estrangement, and distorted perception of capacities, which reveals a restorative estrangement. These findings indicate that subjective self-reports help us to understand some aspects of the potential phenomenon of DBS-induced self-estrangement. (shrink)

The idea that deep brain stimulation (DBS) induces changes to personality, identity, agency, authenticity, autonomy and self (PIAAAS) is so deeply entrenched within neuroethics discourses that it has become an unchallenged narrative. In this article, we critically assess evidence about putative effects of DBS on PIAAAS. We conducted a literature review of more than 1535 articles to investigate the prevalence of scientific evidence regarding these potential DBS-induced changes. While we observed an increase in the number of publications in theoretical neuroethics (...) that mention putative DBS-induced changes to patients’ postoperative PIAAAS, we found a critical lack of primary empirical studies corroborating these claims. Our findings strongly suggest that the theoretical neuroethics debate on putative effects of DBS relies on very limited empirical evidence and is, instead, reliant on unsubstantiated speculative assumptions probablyin lieuof robust evidence. As such, this may reflect the likelihood of a speculative neuroethics bubble that may need to be deflated. Nevertheless, despite the low number of first-hand primary studies and large number of marginal and single case reports, potential postoperative DBS changes experienced by patients remain a critical ethical concern. We recommend further empirical research in order to enhance theoretical neuroethics work in the area. In particular, we call for the development of better instruments capable of capturing potential postoperative variations of PIAAAS. (shrink)

Owing to an oversight, we noted that the acknowledgement section was missing from the original published version of this paper.

The article Deflating the "DBS causes personality changes" bubble, written by Frederic Gilbert, J. N. M. Viaña and C. Ineichen, was originally published electronically on the publisher’s internet portal on 19 June 2018 without open access.

Questions about the nature of self and self-consciousness are closely aligned with questions about the nature of autonomy. These concepts have deep roots in traditional philosophical discussions that concern metaphysics, epistemology and ethics. They also have direct relevance to practical considerations about informed consent in medical contexts. In this paper, with reference to understanding specific side effects of deep brain stimulation treatment in cases of, for example, Parkinson’s Disease, Obsessive Compulsive Disorder, and Major Depressive Disorder, I’ll argue that it is (...) best to frame discussions of informed consent in terms of relational autonomy and a pattern theory of self. (shrink)

Neuromodulation and narrative identity: the importance of relational autonomyIn this paper, I discuss the impact of psychological and relational changes after neuromodulation for movement- and psychiatric disorders and the need to adequately address the possibility of such changes in clinical contexts. Based on ), ) and ), I outline a relational narrative identity perspective that can inform and support medical-ethical decisions. The narrative identity theory by Marya Schechtman in combination with a focus on the relational aspects that impact and constitute (...) our identity, highlights the need to identify post-interventional identity changes both from the perspective of the patient, his or her family and loved ones and the medical team. I argue that a thorough informed consent process pre- and post-intervention and adequate psychological counseling allows for such identification and a step by step monitoring and guiding of the patient in this process. From a relational narrative perspective, neuromodulation does not by default pose a threat to our identity. However, this perspective highlights the need to take the relational autonomy of patients seriously and provide a substantial informed consent procedure and adequate psychological counseling. (shrink)

Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease can lead to the development of neuropsychiatric symptoms. These can include harmful changes in mood and behaviour that alienate family members and raise ethical questions about personal responsibility for actions committed under stimulation-dependent mental states. Qualitative interviews were conducted with twenty participants following subthalamic DBS at a movement disorders centre, in order to explore the meaning and significance of stimulation-related neuropsychiatric symptoms amongst a purposive sample of persons (...) with PD and their spousal caregivers. Interview transcripts underwent inductive thematic analysis. Clinical and experiential aspects of post-DBS neuropsychiatric symptoms were identified. Caregivers were highly burdened by these symptoms and both patients and caregivers felt unprepared for their consequences, despite having received information prior to DBS, desiring greater family and peer engagement prior to neurosurgery. Participants held conflicting opinions as to whether emergent symptoms were attributable to neurostimulation. Many felt that they reflected aspects of the person’s “real” or “younger” personality. Those participants who perceived a close relationship between stimulation changes and changes in mental state were more likely to view these symptoms as inauthentic and uncontrollable. Unexpected and troublesome neuropsychiatric symptoms occurred despite a pre-operative education programme that was delivered to all participants. This suggests that such symptoms are difficult to predict and manage even if best practice guidelines are followed by experienced centres. Further research aimed at predicting these complications may improve the capacity of clinicians to tailor the consent process. (shrink)

The article proposes a theoretical model to account for changes in self due to Deep Brain Stimulation. First, we argue that most existing models postulate a very narrow conception of self, and thus fail to capture the full range of potentially relevant DBS-induced changes. Second, building on previous work by Shaun Gallagher, we propose a modified ‘pattern-theory of self’, which provides a richer picture of the possible consequences of DBS treatment.

The article proposes a theoretical model to account for changes in self due to Deep Brain Stimulation. First, we argue that most existing models postulate a very narrow conception of self, and thus fail to capture the full range of potentially relevant DBS-induced changes. Second, building on previous work by Shaun Gallagher, we propose a modified ‘pattern-theory of self’, which provides a richer picture of the possible consequences of DBS treatment.

We whole-heartedly agree with Mecacci and Haselager(2014) on the need to investigate the psychosocial effects of deep brain stimulation (DBS), and particularly to find out how to prevent adverse psychosocial effects. We also agree with the authors on the value of an embodied, embedded, enactive approach (EEC) to the self and the mind–brain problem. However, we do not think this value primarily lies in dissolving a so-called “maladaptation” of patients to their DBS device. In this comment, we challenge three central (...) claims of the authors on the basis of our direct experience with psychosocial effects of DBS in 45 obsessive- compulsive disorder (OCD) patients treated at the AMC in Amsterdam, The Netherlands, and our indepth qualitative interviews with 18 of them (de Haan et al. 2013). We end our comment by sketching out our perspective on the practical merits of an EEC approach to DBS. (shrink)