Ethical aspects of highly immersive virtual reality systems in neurology and psychiatry Philipp Kellmeyer1,2, Oliver Müller2,3 1 – Translational Neurotechnology Lab, Department of Neurosurgery, University of Freiburg – Medical Center, Germany 2 – Cluster of Excellence BrainLinks-BrainTools, University of Freiburg, Germany 3 – Department of Philosophy, University of Freiburg, Germany
Introduction Recently, several companies have released high-performance virtual reality (VR) systems for the consumer market (see Fig. 1). These systems, like the Oculus Rift or the HTC Vive, are characterized by high-resolution and seamless rendering, minimal “lag” and other technical advances that generally increase the immersiveness of the user experience in the virtual environment. Despite their obvious commercial appeal for the entertainment market, these systems also enable a variety of new clinical applications for highly immersive VR (Dascal et al. 2017). In neurology, VR therapy, for example, has already shown the potential for providing auxiliary benefits and improving outcomes in motor rehabilitation for patients with stroke or spinal cord injury (Lohse et al. 2014; Villiger et al. 2013). In psychiatry, previous research with VR systems has already demonstrated some therapeutic effect in psychosis, eating disorders, social anxiety disorder and other contexts (Bouchard et al. 2017; Freeman et al. 2016; Astur et al. 2016). Many clinical researchers expect, that the increased immersiveness of the new generation of VR systems will further improve these applications; we may therefore expect a wave of clinical studies on VR therapy in neurology and psychiatry.
Ethical aspects of highly immersive VR Ethics of VR-therapy in neurology and psychiatry For neurological and psychiatric patients, VR systems may, on the one hand, provide a safe environment for exploring therapeutic options in otherwise highly stressful (or stigmatized) contexts, for example, in exposure therapy in social anxiety disorder. On the other hand, patients may become dependent on the assistive or therapeutic effects of advanced VR technology which could worsen their vulnerability and/or negatively affect their autonomy, self, agency or body ownership. For psychiatrists (as well as many other therapy providers), the technology also opens the possibility for immersive cyber (group) therapy that includes participants in remote locations that might not otherwise have access to such provisions. However, the “seductive allure” of this immersive technology may also negatively affect the relationship between professionals and patients. Therefore, we advocate for increasing the systematic empirical study of interaction of humans and VR (and human/human in VR) with a special focus on dependability and the effects on human autonomy, the “active self”, agency and body ownership. Using VR to investigate moral decision-making The immersiveness of modern consumer-directed VR systems may be leveraged to study moral decision-making under various conditions, e.g. w/ or wo/ time pressure (Fig. 3). Having better tools for research—experimental ethics, if you will—would certainly be of interest to expand empirical knowledge on the issue. At the same time, however, we suggest to carefully navigate the concomitant use of multivariate analysis of (neuro)physiological data, e.g. with “deep learning”, to avoid overly reductionist accounts of moral decision-making, akin to the importance of the responsible use (and interpretation) of neuroimaging Fig. 3 “Trolley Problem” in VR in searching for brain-based explanations of moral behavior.
Screenshot from: https://www.youtube.com/watch?v=ebdU3HhhYs8; Ref.: Patil et al., 2013; see also: https://www.wsj.com/articles/how-newtechnology-is-illuminating-a-classic-ethical-dilemma-1465395082
Fig. 1 – History of VR
Advanced VR systems for medical and neuroscience research Closed-loop VR-EEG systems
With the increasing power of advanced machine learning, especially “deep learning”, we will soon have clinical and consumer-directed systems for real-time closed-loop interaction in VR based on online analysis of multivariate data from (neuro)physiological sensors, motion tracking and other sources (see Fig. 2).
closedloop VR/EEG
Fig. 2 – Illustration of a closed-loop VR-EEG system
Points for discussion & summary VR is a promising tool for therapy in neurology and psychiatry However, more empirical research is needed to assess the precise benefits and risks for different patient groups with the new generation of highly immersive VR systems. Highly immersive VR may adversely affect the sense of agency, body ownership and other action- or embodiment related aspects We advocate for increasing empirical research on these issues and to include the study of theses factors as a regular part of clinical VR research. Should highly immersive VR-Systems used for clinical research and therapy be considered medical devices? We advocate for investigating this question and to open the debate on whether highly immersive VR systems that are adapted for clinical therapy should undergo medical device regulatory approval. Summary While the new VR systems open promising avenues for new therapeutic approaches in neurology and psychiatry – more empirical research on their benefits and risks is necessary. We also advocate for a careful and proactive ethical deliberation process that integrates perspectives from potential (or actual) end-users, philosophers, developers as well as the medical professionals and clinical researchers (as intermediaries). Selected references
This work was supported by BrainLinks-BrainTools Cluster of Excellence funded by the German Research Foundation (DFG, grant number EXC 1086) and grant 13GW0053D (MOTOR-BIC) by the German Ministry of Education and Research (BMBF)
(Full list of references may be provided upon request)
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Contact Dr med Philipp Kellmeyer, MPhil Translational Neurotechnology Lab, University Medical Center Freiburg Engelbergerstr. 21, 79106 Freiburg www.tnt.uni-freiburg.de
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