Abstract
This systematic review examines the ethical landscape of electroencephalographic neurofeedback (EEG-NFB). In accordance with the PRISMA 2020 guidelines, a comprehensive search of six databases was conducted between December 2024 and February 2025, yielding 23 studies that met the predefined inclusion criteria. A qualitative thematic synthesis identified seven recurring ethical challenges: (1) concerns regarding informed consent and autonomy, shaped by uncertainty surrounding efficacy and the influence of placebo and contextual effects; (2) issues related to non-maleficence and the psychological risks associated with participation; (3) challenges pertaining to justice and equitable access to EEG-NFB interventions; (4) tensions between scientific validity and the ethical use of placebo-controlled designs; (5) questions surrounding data privacy and the governance of brain-derived data; (6) ethical vulnerabilities affecting specific populations; and (7) neuroethical concerns arising from enhancement-oriented applications. Taken together, the findings indicate that ethical analysis has not consistently kept pace with the technological expansion and commercial dissemination of EEG-NFB. Persistent limitations were identified in data governance practices, practitioner training, and regulatory oversight. The present review therefore underscores the need for standardised ethical frameworks, sustained interdisciplinary collaboration, and further empirically grounded research to support the responsible, transparent, and equitable integration of EEG-NFB into both research and practice.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12910-026-01408-4.
Keywords: EEG neurofeedback, Research ethics, Informed consent, Data privacy, Neurorights, Systematic review
Introduction
Electroencephalographic neurofeedback (EEG-NFB) is a non-invasive, closed-loop neuromodulation technique that delivers real-time feedback of ongoing brain electrical activity with the aim of facilitating self-regulation and improving cognitive, affective, or behavioural outcomes [1, 2]. The utilisation of EEG-NFB has initially been explored within clinical contexts, such as epilepsy and attention-deficit/hyperactivity disorder (ADHD). However, there has been a progressive shift towards its application in the domains of neurorehabilitation, cognitive enhancement, and consumer ‘brain-training’ markets [2, 3].
Notwithstanding the rapid proliferation of literature on the subject, the extant evidence for EEG-NFB remains heterogeneous. A considerable variation exists among studies in terms of their protocol parameters, control conditions, blinding procedures, outcome measures, and statistical power. This complicates the synthesis and inference about specific mechanisms of action [2, 4]. Methodological critiques and systematic appraisals have highlighted that many reported effects may reflect non-specific contextual factors, such as participant expectations, practitioner interaction, or task engagement, rather than reliable, learned modulation of targeted neural oscillations [5, 6]. These uncertainties do not necessarily invalidate EEG-NFB as a practice; however, they introduce epistemic ambiguity regarding efficacy claims and mechanisms of action, which has direct implications for ethical evaluation. This ambiguity has been shown to complicate the formulation of meaningful informed consent and the proportional assessment of risks and benefits [7–9].
Concurrently, EEG-NFB has undergone substantial commercialisation and a shift towards direct-to-consumer (DTC) availability. Marketing claims are often made with little or no supporting evidence, while regulatory frameworks and provider training standards are not keeping pace with innovation. In many jurisdictions, formal certification in neurofeedback (e.g., through professional bodies) is not legally required, and relatively brief training pathways may suffice to offer EEG-NFB services. The existence of this regulatory gap gives rise to an environment in which misinformation, variable professional standards and unequal access may arise [3, 9, 10]. While levels of transparency vary across commercial providers, empirical investigations of user experiences indicate a common pattern: many users perceive neurofeedback as effective or scientifically grounded even where high-quality evidence is limited. This perception is further complicated by the fact that ‘neurofeedback’ encompasses a wide variety of systems. These range from clinician-controlled platforms that allow parameters to be fine-tuned, to standardised or direct-to-consumer systems that rely on non-transparent, proprietary algorithms. In the latter case, both providers and users may have limited insight into how neural signals are processed or how feedback is generated, thereby amplifying epistemic opacity. This heterogeneity makes ethical evaluation difficult, as perceived efficacy may be influenced not only by outcomes, but also by assumptions about scientific legitimacy, despite significant differences in system transparency and controllability. This inconsistency can lead individuals to prioritise unproven interventions over established treatments, with attendant opportunity costs [8, 9].
Technological developments have further complicated the landscape. While the portability and gamification of NFB formats have been demonstrated to expand the reach of healthcare, these same characteristics have also given rise to significant governance and privacy challenges, particularly in the case of neurofeedback applications delivered at home or remotely that operate outside of traditional clinical oversight [11, 12]. Emerging closed-loop and decoded neurofeedback techniques have been shown to increase the capacity for fine-grained modulation of brain activity, thus giving rise to novel normative and practical questions concerning agency, responsibility, and the limits of acceptable neural intervention [13, 14]. The extant literature underscores concerns pertaining to the extent to which individuals can be said to exercise meaningful control over neural changes that are implicitly learned or algorithmically guided. Furthermore, questions are raised about responsibility for downstream cognitive or behavioural effects when modulation occurs without explicit awareness or intentional effort.
The extant interdisciplinary literature addressing the ethical dimensions of EEG-NFB is widely dispersed across clinical neuroscience, rehabilitation, ethics, law, and technology policy, and remains fragmented in both scope and method [9, 14]. This fragmentation is indicative of a more extensive challenge in the governance of neuroscience, where the rapid progression of technological innovation frequently outstrips the establishment of ethical and legal frameworks. This concern is echoed in foundational neuroethics literature, which calls for the introduction of new human rights protections. These are aimed at safeguarding mental privacy, cognitive liberty, and personal identity in the context of emerging neurotechnologies [15, 16]. However, ethical analyses of EEG-NFB vary considerably in the extent to which they are grounded in empirical evidence, methodological critique, or normative precaution, as reflected in both empirically informed and conceptually oriented contributions to the literature [9, 14–16]. Consequently, stakeholders – including clinicians, device developers, regulators, and users – lack a consolidated, evidence-informed framework to navigate the ethical landscape, particularly with respect to distinguishing ethical concerns that are empirically supported from those that are grounded primarily in normative or precautionary reasoning. In the absence of such a synthesis, it is challenging to derive clear policy prescriptions, training requirements, or regulatory priorities.
The present study aims to address this critical gap by conducting a systematic review that maps the ethical lacunae, potential hazards, and stakeholder obligations inherent in contemporary EEG-NFB research and practice. The present study employs a protocol that is aligned with the PRISMA 2020 guidelines, in conjunction with a rigorous 24-step methodology for evidence synthesis [17, 18]. The integration of dispersed empirical findings, methodological critiques and normative analyses is undertaken in order to achieve three primary objectives. Firstly, the most salient and recurring ethical issues within the EEG-NFB literature are to be identified and categorised. Secondly, the nature and strength of empirical support underpinning these ethical concerns are to be examined, including areas where evidence is limited or indirect. Thirdly, the respective responsibilities of key stakeholders, including practitioners, researchers, industry developers and regulators, are to be delineated and clarified. Instead of developing new ethical theories, the present review offers a synthesis oriented towards practice, which differentiates between ethical risks that are supported by empirical evidence and those that require precautionary attention. The ultimate objective is to generate a framework that is actionable and empirically attentive, with the aim of guiding ethical research translation, informing clinical best practices, and supporting the development of proportionate policy and governance structures.
Methodology
Study design
The present study employed a systematic review design to investigate the reporting and analysis of ethical considerations within empirical and conceptual research on EEG-NFB. This review integrated findings from qualitative, quantitative, and conceptual literature to map the ethical landscape comprehensively. The review was conducted in accordance with the PRISMA 2020 guidelines [18] and the 24-step methodological framework for systematic reviews in medical research proposed by Muka et al.,2020 [17], thereby ensuring transparency, reproducibility, and methodological rigor.
Eligibility criteria
The selection of studies was conducted in accordance with a predetermined set of inclusion and exclusion criteria.
Inclusion Criteria: Peer-reviewed journal articles published in English between January 2000 and February 2025 were included if they (1) addressed EEG-based neurofeedback in therapeutic, experimental, educational, or enhancement-related contexts, including both empirical studies and conceptual or ethical analyses and (2) explicitly addressed or implicitly referred to ethical considerations. The ethical considerations were identified either through direct ethical analysis or through discussion of methodological, clinical, or technological features with ethical implications. The ethical domains that were identified during the full-text analysis included informed consent, autonomy, beneficence, non-maleficence, justice, data privacy, risk-benefit assessment, the ethics of sham/placebo controls, and considerations regarding vulnerable populations. These ethical domains were identified inductively during full-text analysis, rather than being predefined as search terms. The ethical domains were identified following a full-text review of all included studies. Two reviewers independently examined the full texts and extracted ethically relevant content. Ethical issues were identified through repeated reading and comparison of the relevant literature, and were then coded and grouped into preliminary thematic categories. Any discrepancies in coding or theme assignment were resolved through discussion and consensus. The final set of ethical domains was determined on the basis of their recurrence and relevance across the included studies, reflecting how ethical concerns emerged organically within the literature rather than being imposed in advance. All empirical designs (e.g., RCTs, clinical trials, qualitative studies, mixed-methods) and conceptual/ethical analyses were included.
Exclusion Criteria: Studies were excluded if they (1) contained no reference to ethical issues; (2) focused exclusively on technical or engineering aspects without ethical reflection; (3) were not peer-reviewed full-length journal articles (e.g., preprints, conference abstracts, or non–peer-reviewed reports) (4) did not present original empirical data, systematic analysis, or substantive conceptual or ethical argumentation (e.g., brief opinion pieces or narrative commentaries without analytical depth) (5) were not published in English; or (6) lacked sufficient methodological detail for critical appraisal.
Information sources and search strategy
The search strategy employed a combination of keywords and Medical Subject Headings (MeSH) terms across two core domains:
EEG-Neurofeedback: (“EEG” OR “electroencephalography”) AND (“neurofeedback” OR “neuro-feedback” OR “neurofeedback training” OR “EEG Biofeedback” OR “brainwave feedback” OR “neural feedback”).
Ethics: (“ethic*” OR “bioethic*” OR “moral consideration” OR “ethical issues” OR “ethical principles” OR “ethical dilemmas” OR “neurorights”).
Study selection
A comprehensive search across six databases (PubMed, ScienceDirect, SpringerLink, Wiley Online Library, ProQuest, and Google Scholar) was conducted, and study selection followed PRISMA 2020 guidelines (Fig. 1). The screening process was conducted in multiple sequential stages. In the initial phase, database-specific searches were conducted using keywords related to EEG-neurofeedback, yielding a substantial number of preliminary records. These records were subsequently refined through the application of ethics-related search terms. It is important to note that a significant proportion of records were excluded at this stage because ethics-related terms were used solely to indicate procedural ethical approval (e.g., ethics committee approval statements) without engaging in ethical reflection, analysis, or normative discussion.
Fig. 1.
PRISMA 2020 Flow Diagram
The preliminary evaluation of titles and abstracts was carried out by trained members of the research team as part of a structured, supervised research group project, with each database being independently reviewed by designated reviewers. It is important to note that no artificial intelligence or automated screening tools were utilised in the study. At this stage, records that were clearly unrelated to EEG-based neurofeedback or that did not plausibly involve ethical considerations were excluded.
Following the elimination of duplicate records from the databases, the subsequent records were subjected to full-text scanning. Full-text screening was conducted through an iterative consensus-based process during regular team meetings, where borderline cases were discussed and resolved collaboratively. Cases that did not fully meet the inclusion criteria included studies addressing neurofeedback in a broad or adjacent context (e.g., fMRI-based neurofeedback) or those discussing ethical issues in related neurotechnologies. These cases were retained until full-text review to avoid premature exclusion. This iterative approach enhanced consistency in eligibility judgments over time.
The final set of included studies was determined following comprehensive full-text evaluation and the exclusion of duplicate, overlapping, or methodologically insufficient publications. The rationale behind each stage of exclusion is documented in the PRISMA flow diagram (Fig. 1).
Data extraction
A standardised and pilot-tested data extraction form was utilised to ensure consistent data collection. The extraction form was initially piloted on a subset of the included studies and subsequently refined through discussion to ensure clarity, consistency, and relevance to the study objectives. The following variables were extracted:
Bibliographic details (authors, publication year, journal).
Study characteristics (design, objectives, population/sample size).
Neurofeedback protocol (targeted frequency bands, number of sessions, equipment).
Ethical dimensions (e.g., informed consent, autonomy, risk–benefit balance, use of sham/placebo, data privacy, vulnerable populations).
Key findings and conclusions related to ethical issues.
Type of ethical contribution (empirical evidence, methodological critique, normative argument, or policy-oriented analysis).
The process of data extraction was conducted independently by two reviewers using a finalised data extraction form. The aforementioned reviewers were tasked with the identification, coding and synthesis of ethically relevant content. The extracted data were then compared to ensure consistency, and any discrepancies were discussed in consensus meetings. In instances where uncertainties prevailed, resolution was attained through discourse with the broader research team. The process was designed to enhance analytic rigour and minimise interpretative bias.
Data synthesis and analysis
In view of the heterogeneity that characterised the study designs, populations, and ethical foci, a qualitative thematic synthesis was undertaken. This approach was selected to accommodate the integration of diverse evidence types—including empirical data and normative arguments—into a coherent analysis of recurring ethical challenges. During the synthesis process, ethical concerns were first identified and coded inductively through repeated reading of the included studies. These codes were then compared, refined, and clustered into higher-order themes through an iterative consensus-based process. It is important to note that particular attention was paid to distinguishing ethical concerns that were directly supported by empirical findings (e.g. reported psychological risks or consent practices) from those grounded primarily in normative, conceptual, or precautionary reasoning. This distinction was employed in an analytical manner to elucidate the evidentiary basis of disparate ethical claims, rather than to exclude any category of concern from the synthesis. The findings are presented according to the recurrent themes identified, with illustrative examples drawn from the included studies to support these themes. A theme–source evidence matrix is provided in Supplementary File 2, while the detailed search strategy and screening log are available in Supplementary File 1.
Ethics and transparency
As this review synthesised data from previously published studies, ethical approval was not required. All extracted datasets, search strings, and coding materials are available as supplementary files to promote transparency and reproducibility.
Results
Study selection
The database search conducted between 1 December 2024 and 10 February 2025 identified a total of 1,028,333 records across six major databases (PubMed, ScienceDirect, SpringerLink, Wiley Online Library, ProQuest, and Google Scholar). The initial screening process was conducted in a staged and manual manner, in accordance with predefined eligibility criteria, without the utilisation of automated or artificial intelligence–based tools. Following the processes of automated and manual de-duplication, a total of 674,079 records were removed, leaving 354,254 records for the subsequent stages of title and abstract screening. At this stage, records were excluded if they were clearly unrelated to EEG-based neurofeedback or if ethics-related terminology was used solely to indicate procedural ethical approval (e.g., ethics committee statements) without substantive ethical discussion. Of these, 354,182 records were excluded on the basis of relevance, and 72 full-text articles were assessed for eligibility. The full-text assessment was conducted through an iterative, consensus-based process involving senior members of the research team. The group engaged in deliberations on borderline cases, encompassing studies that addressed neurofeedback in associated domains or ethical concerns pertinent to related neurotechnologies. Through collective discussion and deliberation, a consensus was ultimately established. Following a thorough examination of the full texts, 49 articles were excluded on various grounds, including inappropriate population (n = 18), absence of ethical analysis (n = 14), non-peer-reviewed format (n = 7), inadequate methodological detail (n = 5), and inaccessible full text (n = 5). Disagreements were resolved through discussion or adjudication by a third reviewer.
Ultimately, 23 studies were included in the final synthesis. The study selection process is illustrated in Fig. 1 (PRISMA 2020 flow diagram). The substantial reduction from over one million initial records to 23 included studies is indicative of the specificity of EEG-NFB as an intervention, the relative scarcity of studies that engage substantively with its ethical dimensions and the pronounced heterogeneity of the literature with respect to study designs, disciplinary focus and depth of ethical analysis. The subsequent thematic analysis was based on these 23 studies.
Study characteristics
The 23 studies included in the review were published between 2010 and 2025, with the majority appearing in the last decade, reflecting a growing scholarly interest in the ethics of EEG-based neurofeedback. The geographical distribution of the studies encompassed a diverse array of regions, with contributions from Europe (France, the United Kingdom, Belgium, and the Netherlands), North America (the United States and Canada), Asia (China, Hong Kong, Japan, India), South America (Chile), and the Middle East (Turkey and Saudi Arabia).
The study designs were found to be heterogeneous, with analytically grounded conceptual/theoretical papers forming the largest group (n = 12), followed by reviews (systematic or narrative; n = 5), and empirical investigations (n = 6). The latter category included qualitative interview studies, randomised controlled trials (RCTs), a mixed-methods field experiment, an fMRI experimental study, and a Delphi expert survey. The samples exhibited significant variation, encompassing children and adolescents diagnosed with ADHD (n = 100 in one RCT) and adult clinical populations, students, counsellors, and expert panels.
The ethical foci most frequently addressed were informed consent and autonomy, psychological risks and non-maleficence, and justice in access to treatment. A number of studies have been conducted that have examined a variety of topics. These include questions regarding the scientific validity of claims regarding the efficacy of EEG-NFB and the ethical implications of placebo-controlled designs. Other areas that have been explored include data governance and neurorights, vulnerabilities in specific populations, and neuroethical debates around enhancement and transhumanism. Table 1 provides a detailed overview of the included studies.
Table 1.
Characteristics of included studies
| Author (Year) | Country | Aim | Design | Data Collection | Sample | Summary |
|---|---|---|---|---|---|---|
| Micoulaud-Franchi et al. (2013) | France | To propose the concept of ‘Cyborg Psychiatry’ combining rTMS and neurofeedback, focusing on agency and autonomy in mental disorders | Conceptual/theoretical ethics paper | Literature-based conceptual synthesis | Not applicable (no empirical participants) | Explores autonomy and agency in mental disorders through neuromodulation. |
| Ferreri et al. (2019) | France | To review how new technologies can improve prediction, assessment, and intervention in OCD | Systematic review | PubMed search | Not applicable (review) | Reviews digital tools for OCD and ethical implications. |
| Ferreri et al. (2018) | France | To provide an overview of new technologies in addictive behaviors and discuss related ethical issues | Narrative review | Keyword-based synthesis | Not applicable (review) | Discusses ethical concerns in digital addiction interventions. |
| Kalokairinou et al. (2022) | USA | To empirically assess ethical concerns and attitudes of EEG neurofeedback users | Qualitative empirical ethics study | Telephone interviews | 36 participants | Identifies ethical risks and user perspectives in neurofeedback. |
| Holt & McLean (2019) | Australia | To explore ethical and evidence-informed practices in trauma therapies incorporating neuroscience | Narrative review | Literature synthesis and case examples | Not applicable | Analyzes ethics in trauma therapies including neurofeedback. |
| Jap et al. (2025) | China & Hong Kong | To investigate EEG experimental conditions and psychological well-being | Quantitative empirical ethics study | PANAS questionnaire | 166 participants | Examines affective impact of EEG experiments. |
| Jiang et al. (2022) | USA | To review EEG neurofeedback paradigms for improving working memory | Systematic review | Literature review | Not applicable | Identifies effective neurofeedback protocols and challenges. |
| Kalokairinou et al. (2022) | USA | To explore ethical implications of neurofeedback for ADHD when efficacy may be placebo | Conceptual/theoretical ethics paper | Literature-based ethical analysis | Not applicable | Discusses deception and placebo ethics in ADHD neurofeedback. |
| Lindebaum et al. (2018) | UK | To assess ethical and scientific validity of EEG neurofeedback in leadership development | Conceptual/theoretical ethics paper | Literature-based analysis | Not applicable | Critiques neurofeedback use in corporate leadership. |
| Antle & McLaren (2024) | Canada | To assess feasibility of mobile neurofeedback games for marginalized children | Mixed-methods field experiment | Surveys, logs, observations | 28 children | Evaluates neurofeedback games for attention regulation. |
| Cohen Kadosh et al. (2016) | UK | To assess feasibility and neural effects of real-time fMRI neurofeedback | Experimental fMRI study | fMRI, questionnaires | 17 children/adolescents | Explores emotion regulation via fMRI neurofeedback. |
| Nakazawa et al. (2016) | Japan | To explore ethical implications of decoded neurofeedback | Conceptual/theoretical ethics paper | Literature-based analysis | Not applicable | Analyzes ethics of decoded neurofeedback in enhancement. |
| Jerrin & Bhuvaneswari (2024) | India | To explore ethical implications of neurofeedback and AI in transhumanist art | Conceptual/theoretical transdisciplinary paper | Philosophical and ethical analysis | Not applicable | Discusses neurofeedback ethics in transhumanist creativity. |
| Focquaert (2014) | Belgium | To explore permissibility of mandatory neurotechnological treatments | Conceptual/theoretical ethics paper | Legal and ethical analysis | Not applicable | Examines ethics of mandated neurofeedback for offenders. |
| Nagappan et al. (2021) | USA | To examine ethical and legal issues in alternative neurotherapies | Conceptual/theoretical ethics and policy paper | Literature-based analysis | Not applicable | Reviews ethics and regulation of alternative neurotherapies. |
| Horstkötter (2016) | Netherlands | To critique ethical assumptions in decoded neurofeedback research | Conceptual/theoretical ethics commentary | Normative analysis | Not applicable | Challenges moral values in decoded neurofeedback studies. |
| Nakazawa et al. (2022) | Japan | To identify key neuroethical challenges in Japan | Conceptual/theoretical review | Thematic synthesis | Not applicable | Maps neuroethical issues in Japanese context. |
| Ruiz et al. (2024) | Chile | To analyze implications of constitutional neurorights legislation | Conceptual/theoretical legal-ethical analysis | Interdisciplinary review | Not applicable | Explores neurorights and political ethics in Chile. |
| Golshan et al. (2024) | Canada | To evaluate neurofeedback mindfulness for chronic migraine | RCT protocol | EEG + questionnaires | Planned N = 180 | Designs trial for wearable EEG neurofeedback in migraines. |
| Logemann et al. (2010) | Netherlands | To assess neurofeedback’s effect on attention and impulsivity | RCT (sham-controlled) | EEG + behavioral tasks | N = 26 students | Tests neurofeedback efficacy with sham control. |
| Ölçüoğlu et al. (2023) | Turkey | To assess ILF neurofeedback’s impact on cognitive abilities in ADHD children | RCT (sham-controlled) | WISC-R + QEEG | N = 100 children | Evaluates ILF neurofeedback in ADHD treatment. |
| Spears et al. (2024) | USA | To identify neurofeedback training competencies for counselors | Delphi study | Expert panel survey | N = 17 experts | Defines core competencies for neurofeedback education. |
| Jangwan et al. (2022) | India & Saudi Arabia | To review brain augmentation technologies and ethics | Narrative review | Literature synthesis | Not applicable | Surveys brain augmentation and ethical challenges. |
Thematic analysis of the included studies revealed seven core ethical challenges. Table 2 provides a summary of these analytic themes, along with their descriptive sub-themes and illustrative quotations from the source literature, offering a concise overview prior to the detailed synthesis.
Table 2.
Summary of analytic and descriptive themes derived from the study
| Author (Year) | Analytic themes (7 main) | Descriptive themes | Example quotations |
|---|---|---|---|
| Ferreri et al. (2019) | Informed consent & autonomy | Tools must be explained and tailored; self-administration can risk weaker alliance and coping adjustments. | For them to be used, these tools must be properly explained and tailored to individual physician and patient profiles… The question of self-administration of a treatment is also a significant risk. |
| Non-maleficence & psychological risks | False positives/negatives, VR side effects (dizziness, nausea, eyestrain), digital stress/anxious counter-reactions; hacking risk. | Side effects (dizziness, nausea, headache, eyestrain) are not enough evaluated… data security, data storage, privacy, and hacking risk have yet to be resolved. | |
| Justice & equitable access | Telemedicine can reduce barriers to care; interaction with a professional supports adherence and adaptation. | Telemedicine… provides solutions to the difficulties of access to care. Interaction with a health professional reduces the risk of poor compliance and allows better therapeutic adaptation. | |
| Scientific validity & ethics of placebo effects | Evaluation is heterogeneous with few randomized studies; some assessment apps unvalidated (e.g., Y-BOCS). | Our systematic review shows… the number of randomized studies available is low… No study has so far validated assessment apps for OCD, and the use of Y-BOCS apps is not yet supported. | |
| Data privacy & rights of the brain | Unresolved issues of data security, storage, privacy, and hacking risk in e-mental-health tools. | Many ethical issues, data security, data storage, privacy, and hacking risk have yet to be resolved. | |
| Vulnerabilities in special populations | Severe cases often excluded; pediatric protocols and VR tolerance insufficiently defined. | Few data are available on the severe forms… the optimal therapeutic protocol is not yet clearly defined… or the use in children. | |
| Neuroethical concerns related to enhancement | New technologies enable new therapies (biofeedback, VR) and prediction/personalization; benefits must be balanced with risks. | These new technologies are enabling the development of new therapies, including biofeedback and VR… severity or treatment success can be predicted with a good degree of accuracy. | |
| Ferreri et al. (2018) | Informed consent & autonomy | Effective use requires explanation and adaptation to clinicians’/patients’ profiles; co-design with patients and caregivers. | If they are to be used effectively, these tools must be explained and adapted to the different profiles of physicians and patients. The involvement of patients, caregivers and other health professionals is essential. |
| Non-maleficence & psychological risks | Dangerous recommendations from commercial apps; liability for malfunctions; hacking; false positives/negatives. | Users may thus be exposed to dangerous recommendations… liability in the case of malfunction… security (hacking of data)… potential errors in false-positives and false-negatives. | |
| Justice & equitable access | Unclear cost-effectiveness, lack of reimbursement; digital divide for low income/limited literacy users. | There is a dearth of information regarding the cost-effectiveness… The lack of reimbursement schemes is equally problematic… may be out of the reach of people with low incomes and/or limited computer literacy. | |
| Scientific validity & ethics of placebo effects | Lack of randomized trials; small samples and short follow-ups; many commercial apps not truly efficient; ‘a like is not a statistical difference’. | There is a lack of randomized controlled trials… most apps are commercial and not truly efficient… A like is not a statistical difference. | |
| Data privacy & rights of the brain | Protection, ownership, confidentiality and transparency of personal/health data are central; few willing to share with private companies. | The most important probably being the protection and ownership of personal and health data… Very few patients are currently willing for their data to be shared with private companies. | |
| Vulnerabilities in special populations | Compliance varies by substance; cannabis users least compliant; passive data may mitigate anosognosia biases. | Compliance is variable… cannabis users are the least compliant… Most authors advocate the use of passive rather than active data in disorders with anosognosia. | |
| Neuroethical concerns related to enhancement | Promise of prediction/personalization and therapies (biofeedback/VR) to learn coping skills—must be clinically validated. | New technologies are enabling… biofeedback and virtual reality, which focus on the learning of coping skills. | |
| Micoulaud-Franchi et al. (2013) | Informed consent & autonomy | Autonomy and agency hinge on first-person embodiment of neuromodulation devices. | Agency and autonomy depend on the capacity of all these techniques to be embodied by the patients. |
| Non-maleficence & psychological risks | Closed-loop systems may trigger unforeseeable ‘resonance’ effects—safety and predictability required. | A closed loop feedback system… could lead to unforeseeable ‘resonance’ effects in the brain. | |
| Neuroethical concerns related to enhancement | Neuromodulation framed as restoring or enhancing agency and autonomy via self-engaged interaction (cyborg psychiatry). | How can we ensure that all these techniques restore or enhance a person’s agency and autonomy? | |
| Kalokairinou et al. (2022) | Informed consent & autonomy | Perceived understanding is high, yet discussions of risks/benefits and alternatives are inconsistent; users often believe NF is scientifically established. | Only half recalled having a conversation about therapeutic alternatives with their neurofeedback provider… Many participants considered EEG neurofeedback to be a scientifically well-established treatment. |
| Non-maleficence & psychological risks | Unwanted effects (e.g., headaches, nausea, anxiety) were commonly reported but usually minor/temporary; a few severe cases noted. | The majority… reported experiencing various unwanted effects… overall, adult users considered unwanted effects to be minor and temporary; however, in one case a participant reported experiencing severe anxiety for a prolonged period of time. | |
| Justice & equitable access | Most users paid out-of-pocket; session/device costs substantial; insurance coverage uncommon. | Most participants (72.7%) paid for neurofeedback treatment out-of-pocket… session costs ranged from $60 to $299; device rental $600 to $1,000 per month. | |
| Scientific validity & ethics of placebo effects | Disconnect between evidence and user beliefs: many reject placebo explanations and consider NF established despite mixed RCTs. | Many participants (57.6%) considered neurofeedback to be a scientifically well-established treatment… most did not believe that benefits were based on placebo effects. | |
| Vulnerabilities in special populations | Children frequently receive NF; diminished autonomy underscores need for pediatric oversight. | Half stated that their child was less than 12 years old… consult a pediatric or other healthcare provider to ensure appropriateness. | |
| Holt & McLean (2019) | Informed consent & autonomy | Ethical practice requires informed consent with disclosure of efficacy and safety; beware the ‘seductive allure’ of neuroscience. | Recommendations include careful consideration of informed consent… disclosure of efficacy and safety… people without expertise are more likely to judge explanations including neuroscience as more satisfying. |
| Non-maleficence & psychological risks | Psychotherapy can harm; monitor adverse events; estimates suggest 3–10% may worsen. | Potential harms of psychotherapy include… estimates of 3–10% of patients worsening after psychotherapy… systematic monitoring of untoward events is recommended. | |
| Scientific validity & ethics of placebo effects | Evidence base for NFB/SE still developing; call for sham-controlled trials and replication, especially for ADHD criticisms. | Further research with an active control condition, preferably a well-devised sham NFB condition… is yet to occur. | |
| Vulnerabilities in special populations | Use with refugees, prisoners, toddlers, and complex trauma—contexts requiring enhanced safeguards and cultural sensitivity. | In Australia, NFB has been used alongside psychotherapy assisting refugees impacted by torture and trauma… Toddler trauma: Somatic Experiencing with disrupted attachment (five sessions). | |
| Jap et al. (2025) | Informed consent & autonomy | EEG research burdens (time, monotony, confined spaces) should be reflected in risk assessment and informed consent. | Our study can… contribute to discussions about risk assessment and enhancement of informed consent reliability in EEG experimental settings. |
| Non-maleficence & psychological risks | EEG experiments can reduce positive affect; longer sessions predict larger reductions; pre-session discomfort moderates risk. | Participants experienced significant reduction in positive affect across the group… For each minute increase in experiment duration, the predicted positive affect difference increased by 0.02. | |
| Jiang et al. (2022) | Informed consent & autonomy | Advocates clearer disclosure about placebo/expectancy, double-blind challenges, and participant burden (multi-week training). | We review various neurofeedback reward strategies and outcome measures… training typically takes multiple weeks… strong individual differences; placebo effects and BCI ‘insensitivity’ warrant attention. |
| Non-maleficence & psychological risks | Notes risk of non-responders and expectancy/nocebo dynamics; calls for ethical placebo designs and careful controls. | A deficiency was the lack of placebo/double-blind methodology… placebo/expectancy effects complicate interpretation; up to 15–30% show BCI inefficiency. | |
| Justice & equitable access | Protocols are time-intensive (5–20 weeks, 2–3 sessions/week), potentially limiting access for older adults; suggests efficient paradigms and home/portable systems. | Most training studies typically take multiple weeks (e.g., 5–20 weeks) with 2–3 sessions per week… portable wireless neurofeedback systems reported in some studies. | |
| Scientific validity & ethics of placebo effects | Synthesizes mixed efficacy with many successes but stresses need for double-blind, sham, and long-term follow-up; discusses ‘BCI insensitivity’. | Further studies, particularly double-blind, are needed… a well-known issue is that some people simply do not respond to neurofeedback (‘BCI insensitivity’). | |
| Data privacy & rights of the brain | Implicit BCI/EEG data collection across sessions; not a primary focus but highlights registries/trials and biomarkers use implying data governance needs. | ClinicalTrials.gov listings and biomarker integration indicate accumulation of sensitive EEG/ERP data across sessions; ethical governance implied. | |
| Vulnerabilities in special populations | Focus on older adults/MCI/AD—calls for tailored protocols and safeguards; follow-up retention concerns. | There is hope for older adults with MCI, but few double-blind studies and limited follow-up; recommend individualized approaches. | |
| Neuroethical concerns related to enhancement | Explores enhancement in healthy aging and young adults; recommends ERP/gamma/sleep-based features and individual-based approaches. | Our review brings overall good news… suggests ERP and sleep EEG as future directions; individualized ‘neural modulation sensitivity’. | |
| Kalokairinou et al. (2022) | Informed consent & autonomy | Argues providers have enhanced disclosure duties where benefits likely due to placebo; otherwise risks unintentional deception about mechanism. | Providers should inform clients about the mechanism of action and the possibility of placebo effect… practice may constitute **unintentional deception** regarding mechanism. |
| Scientific validity & ethics of placebo effects | Reviews RCTs showing NF not superior to sham in ADHD; frames NF as potentially placebo-mediated and calls for non-deceptive provision. | The highly anticipated trial showed neurofeedback was **not superior** to control… effects ‘best explained by other factors’ besides contingent reinforcement. | |
| Justice & equitable access | Highlights high out-of-pocket costs and need to balance low risk with honest claims to avoid exploitation. | It has been reported that total cost of up to 40 sessions may be $4,000–$10,000 and is seldom covered by insurance. | |
| Lindebaum et al. (2018) | Informed consent & autonomy | Warns of scientistic over-claiming in organizational NF, urging neuro-literacy and transparency about limits with participants and employees. | We call for a **pro tem vote of no confidence** and **neuro-literacy**, discouraging premature triumphalism and urging transparency in leader development. |
| Non-maleficence & psychological risks | Notes risk of bad management practice from invalid data; organizational misuse can harm careers and wellbeing. | Unreliable data can yield **bad management practice**… organizational clients may seek ‘scores’ impacting promotion/firing despite questionable validity. | |
| Justice & equitable access | Raises fairness concerns if NF scores drive HR decisions; potential erosion of organizational justice and bias against those with ‘non-ideal’ brain signals. | Organizational justice is compromised by a **reification and fetishization of brain signals** assumed more relevant than actual performance. | |
| Scientific validity & ethics of placebo effects | Synthesizes critiques (Thibault & Raz): lack of double-blind sham; likely placebo-driven effects; warns against using NF as evidence-based enhancement. | Recent reviews largely dismissed EEG-NF effects as ‘**placebo-driven**’… only **one** double-blind sham study showed superiority. | |
| Data privacy & rights of the brain | Notes commercialization and data capture (e.g., Nasdaq neurotech index); warns about employers accessing NF ‘results’ and using them in HR. | Organizations paying for retreats will expect **full access** to ‘results’ and ‘scores’, using data in performance management despite contestable meaning. | |
| Vulnerabilities in special populations | Targets healthy employees as ‘enhancement’ subjects without clinical safeguards; power imbalances and consent pressures at work. | Neuroscience at work raises questions of **power and access**; employees may be viewed as ‘neurological subjects’, risking coercive enhancement norms. | |
| Neuroethical concerns related to enhancement | Critiques enhancement teleology; calls for alternatives (psychological interventions) and emphasis on **phronesis** (practical wisdom). | Forms of leadership training that ignore **practical wisdom (phronesis)** are ethically problematic; advocate psychologically driven interventions. | |
| Antle & McLaren (2024) | Informed consent & autonomy | Details assent/consent for 5–8 y/o marginalized children; explains non-blind teacher/parent ratings and waitlist rationale to avoid placebo harms/inequity. | Children and caregivers provided consent/assent; used a waitlist (ethical reasons) and avoided placebo due to negative impacts on agency and social-justice concerns; teachers/parents best suited to assess transfer. |
| Non-maleficence & psychological risks | Reports headset discomfort, Bluetooth drops; facilitator mitigations; stresses avoiding stigma, managing pull-out sessions, and safeguarding children’s agency. | Observed issues: headset discomfort and connectivity; facilitator reframed glitches, emphasized practice over winning; addressed stigma of pull-outs and provided supports. | |
| Justice & equitable access | Motivation is reaching underserved children in low-SES schools with low-cost, portable NF (consumer EEG + tablet) run by novice social worker. | Aim: accessible, in-situ intervention for disadvantaged communities; used $99 consumer EEG and school delivery by trained but novice facilitator. | |
| Scientific validity & ethics of placebo effects | Field RCT with waitlist; small n; mixed ANOVA; within-group gains and 2-month maintenance; openly notes consumer-EEG limits and indicative (not definitive) claims. | Within-group teacher & parent gains maintained at follow-up; headset precision limited; avoided placebo as it can depress performance; results treated as indicative. | |
| Data privacy & rights of the brain | Handles school-based data under REB/school district rules; no data sharing; discusses admin burden and role separation for safeguarding. | Ethics approvals (University & School District); no permission to share data; emphasize admin/role separation to protect participants. | |
| Vulnerabilities in special populations | Targets marginalized 5–8-year-olds with attentional challenges; highlights need to prevent stigma, ensure benefits, and manage withdrawals. | All 28 children completed 18 sessions; authors discuss stigma from pull-outs, parental concerns, and continued community engagement. | |
| Neuroethical concerns related to enhancement | Frames NF as behavioral support (not enhancement), combining psychoeducation + NF; warns against over-claiming with consumer EEG. | Intervention pairs coaching + NF games; recommends transfer/maintenance measures and cautions about headset accuracy. | |
| Cohen Kadosh et al. (2016) | Informed consent & autonomy | Paediatric rtfMRI NF protocol with assent/consent; avoids sham in minors due to ethical concern about misleading feedback during plastic windows. | Children (7–16) provided assent/consent; authors rejected sham in paediatric samples citing ethical/scientific problems of incoherent feedback during development. |
| Non-maleficence & psychological risks | Monitors motion/fatigue; notes task difficulty and individual variability; warns about unknown longevity/specificity and need for larger samples. | Some participants failed late runs (fatigue); longevity/sustainability of effects unknown; need larger cohorts and puberty measures. | |
| Justice & equitable access | Demonstrates feasibility in youth but acknowledges scanner resource intensity vs. EEG; motivates timing interventions at sensitive periods. | rtfMRI NF feasible in 7–16 y/o; targets sensitive developmental windows but requires MRI resources, unlike cheaper EEG. | |
| Scientific validity & ethics of placebo effects | Shows bilateral insula up-regulation and network-level changes (GCA); argues against sham in children; calls for transfer tests and follow-up. | Significant up-regulation (right insula all sessions) and altered Granger flows; proposes authentic feedback + baseline rather than sham for minors. | |
| Data privacy & rights of the brain | Handles paediatric imaging data under ethics approvals; acknowledges lack of pubertal/hormonal data as limitation (data minimisation trade-off). | Local ethics approved; did not collect puberty measures, raising open questions for future data collection. | |
| Vulnerabilities in special populations | Focuses on adolescents’ plastic ER networks; highlights risk/benefit of influencing developing systems; simple ‘think happy’ instructions used. | Feasibility proven but intervening in developing networks demands caution; simple strategies guided training. | |
| Neuroethical concerns related to enhancement | Positions NF as potential developmental intervention shaping ER networks, not generic enhancement; stresses need for transfer to behaviour. | Suggests combining NF with cognitive training; urges measuring behavioural transfer and persistence. | |
| Nakazawa et al. (2016) | Informed consent & autonomy | For first-in-human decoded NF: disclose limited preclinical evidence, black-box mechanisms, uncertain reversibility; involve patients/families in risk–benefit. | Guidelines: emphasise non-established status, lack of mechanism clarity, possible worsening; include compensation & after-care details. |
| Non-maleficence & psychological risks | Notes FDA adverse event report for NF; warns decoded NF effects may persist months; unknown reversibility could threaten autonomy if harms occur. | Adverse effects reported in NF; decoded NF connectivity changes lasted ≥ 2 months; reversibility/ safety uncertain. | |
| Justice & equitable access | Decoder construction increases session burden/cost; tailored protocols may limit scalability; recommends careful first-in-human thresholds. | Decoded NF may need extra sessions and is resource-intensive compared with ROI rtfMRI; balance costs/benefits in early trials. | |
| Scientific validity & ethics of placebo effects | Highlights shortage of reliable preclinical data and difficulty of efficacy assessment; animal models weak; personalization complicates standard endpoints. | Efficacy hard to estimate in advance; DMN heterogeneity complicates outcomes; standard statistics ill-suited for personalized endpoints. | |
| Data privacy & rights of the brain | Decoded NF uses voxel-based patterns and DMN states—fine-grained neural fingerprints—raising governance concerns though not the focus here. | Voxel-based decoders and DMN patterning imply sensitive neural state data; calls for careful steps to avoid hype/fear. | |
| Vulnerabilities in special populations | Warns about applying decoded NF to mental disorders (autism, depression) without robust evidence; potential to worsen symptoms with lasting effects. | Therapeutic use termed ‘precision medicine’ with variable DMN; deterioration could persist; involve advocates in decisions. | |
| Neuroethical concerns related to enhancement | Argues decoded NF could enable ‘moral neuroenhancement’ without uniformity but raises reversibility/efficacy concerns and threats to freedom if irreversible. | Decoded NF may tailor moral states, avoiding uniformity critique, yet unknown reversibility threatens moral development freedom. | |
| Jerrin & Bhuvaneswari (2024) | Informed consent & autonomy | Highlights need for consent and control over neural data in BCI/neurofeedback art making; stresses user control over how neural data are stored/used. | BCI/neurofeedback require safeguarding privacy and ownership of neural data; artists should control how neural data are mined, stored, generated. |
| Non-maleficence & psychological risks | Warns about manipulation of artistic expression via BCIs/AI; calls for protections against violations of autonomy and bias in creative algorithms. | BCI–AI collaboration must not violate personal autonomy or manipulate expression; address algorithmic bias and fairness. | |
| Justice & equitable access | Notes risk of digital divide and income disparities from AI/BCI; urges accessibility, affordability and inclusion to reduce inequities. | Integration of AI/BCI can widen gaps; recommend accessibility, affordability, inclusivity and upskilling to prevent disparities. | |
| Scientific validity & ethics of placebo effects | Primarily a conceptual review; frames computational creativity/BCI as augmentative; does not present clinical efficacy claims; flags need for transparency and originality/authenticity debates. | Discusses originality, authorship, transparency; stresses responsible AI use, not evidentiary claims of NF efficacy. | |
| Data privacy & rights of the brain | Explicitly argues for neural data privacy, ownership, consent for BCIs/neurofeedback, and storage controls. | Safeguard privacy and neural-data ownership; artists should authorize how neural data are handled. | |
| Vulnerabilities in special populations | Points to accessibility for people with disabilities via BCIs; but warns about exploitation if consent/controls are weak. | BCIs can enable creative expression for individuals with impairments; ensure protections and consent. | |
| Neuroethical concerns related to enhancement | Frames BCIs/neurofeedback as transhumanist enhancement of creativity; urges balancing augmentation with authenticity and human agency. | Transhumanist scope: AI/BCI extend creativity; maintain human agency and authenticity. | |
| Focquaert (2014) | Informed consent & autonomy | Proposes conditions for offering neurotechnological treatment as probation/parole option: status quo not cruel, option not cruel, in best interests, and informed consent. | Ethically offer effective, non-invasive neurotech only if (1) status quo not cruel/inhuman, (2) option not cruel/inhuman, (3) in offender’s best interests, (4) offender gives informed consent. |
| Non-maleficence & psychological risks | Argues invasive options (e.g., DBS) with moderate-severe side-effects are unethical in quasi-coercive judicial contexts; highlights ineffectiveness of forced treatment for psychopathy. | Mandating invasive neurotech is ethically/practically problematic; forced interventions often ineffective for psychopathy; prefer non-invasive NF if any. | |
| Justice & equitable access | Situates neurotech as alternative sanction balancing public safety and offender rights; emphasizes victims’ closure and statutory reparations alongside treatment offers. | Alternative sanctions should include legal provisions for victim reparations and societal concerns, not only treatment. | |
| Scientific validity & ethics of placebo effects | Notes limited evidence for adult psychopathy treatments; NF and rtfMRI under investigation; cautions about overclaiming efficacy and structural deficits limiting response. | Small studies suggest NF promise; deep brain targets may lack substrate; psychotherapy meta-analyses show limited adult efficacy; proceed cautiously. | |
| Data privacy & rights of the brain | Not central; focuses on consent/coercion; implies respect for bodily privacy vs. incarceration when assessing intrusiveness of ‘internal punishments’. | Compares bodily privacy invasions to incarceration; bodily intrusions generally unfair even for offenders. | |
| Vulnerabilities in special populations | Offenders with psychopathy as a vulnerable group in quasi-coercive judicial settings; consent can be compromised; need safeguards. | Consent under threat of incarceration is quasi-coercive; ensure voluntariness where possible and avoid irreversible options. | |
| Neuroethical concerns related to enhancement | Considers neurotech as behaviour-modification in justice system; stresses autonomy restoration as justification for offering (not mandating) non-invasive options. | Non-invasive NF might be ethically offerable to restore autonomy; mandated invasive ‘enhancement’ unacceptable. | |
| Nagappan, Kalokairinou & Wexler (2021) | Informed consent & autonomy | Calls for truthful representation of evidence; many provider websites exaggerate benefits; disclose experimental status and alternatives. | Neurofeedback/SPECT/TMS marketed with misleading claims; providers should clearly explain evidence levels and experimental nature. |
| Non-maleficence & psychological risks | Physical risks generally low (e.g., TMS headaches/seizure risk; tDCS burns; SPECT radiation); highlights psychological harms from misdiagnosis, opportunity costs, and financial harms. | Catalogues side-effects and emphasizes misdiagnosis/opportunity cost/financial harms for alternative neurotherapies. | |
| Justice & equitable access | Notes marketing to vulnerable populations (parents of autistic/ADHD children); recommends safeguards against exploitation and conflicts of interest. | Providers often target vulnerable families; need protections, accurate claims, and manage conflicts (e.g., provider-researcher ties). | |
| Scientific validity & ethics of placebo effects | Evidence base often weak/contested; double-blind/sham NF trials show similar outcomes; cautions about placebo and need for rigorous trials. | Many NF studies lack blinding; sham-controlled trials show similar effects → placebo concerns; call for rigour. | |
| Data privacy & rights of the brain | Focus on legal landscape: licensing, scope of practice, CAM statutes; less on privacy; however warns about marketing practices and device oversight gaps. | State licensure/scope-of-practice govern services; device oversight gaps fuel proliferation; ensure truthful marketing and compliance. | |
| Vulnerabilities in special populations | Emphasizes children with autism/ADHD and desperate families; allure of ‘neuroscience’ explanations may bias decisions. | Vulnerable users may be swayed by neuroscience images/explanations; need protections in advertising and consent. | |
| Neuroethical concerns related to enhancement | Situates NF/TMS/SPECT within CAM ‘non-normative scientific enterprises’; warns about ‘neuro-placebo’ and commercialization ahead of evidence. | Alternative neurotherapies appeal to neuroscience yet depart from accepted practice; commercialization outpaces evidence; caution urged. | |
| Horstkötter (2016) | Informed consent & autonomy | Argues DNF should be considered under research ethics, not therapy, until safety/efficacy are established; requires independent review and registration (Helsinki/Emanuel et al.). | Treat DNF as research only; ensure scientific value, valid design, aftercare/compensation, independent review, and register single-case studies. |
| Non-maleficence & psychological risks | Warns against premature therapeutic use; risk-benefit calculus differs between research vs. care; avoid harm and publication bias. | Premature ‘therapeutic use’ of DNF is ethically problematic; risks must be handled under research safeguards; register all cases to avoid bias. | |
| Justice & equitable access | Implicitly calls for transparent registration to prevent selective reporting and to build fair evidence base. | Central trial register for individualized DNF cases to reduce bias and support fair evidence accumulation. | |
| Scientific validity & ethics of placebo effects | Critiques leap from possibility to therapy; separates research from treatment and insists on rigorous design and social/scientific value. | Do not intermingle treatment rhetoric with research uncertainty; adhere to Declaration of Helsinki criteria for validity/value. | |
| Data privacy & rights of the brain | Not a main focus; emphasizes governance (independent review, trial registration) rather than privacy per se. | Primary emphasis on research governance vs. privacy; still relevant to ‘rights of the brain’ via oversight. | |
| Vulnerabilities in special populations | Notes moral enhancement claims risk ignoring value content (e.g., ‘enhancing’ racism); cautions about targets of intervention. | Value content matters: enhancement could entrench immoral traits; procedural focus alone is insufficient. | |
| Neuroethical concerns related to enhancement | Challenges DNF for moral enhancement unless value judgments are explicit; irreversibility is problematic when outcomes are morally bad. | ME analysis must include moral values, not only self-control/procedural risks; irreversibility only bad if content is morally worse. | |
| Nakazawa et al. (2022) | Informed consent & autonomy | Highlights consent challenges in psychiatric research; calls for patient–public involvement and capacity assessment standards in Japan. | Advance consent frameworks (incl. dynamic consent), capacity assessment, and stakeholder engagement in psychiatric neuroscience. |
| Non-maleficence & psychological risks | Addresses stigma risks from neuroscientific framings and returning results; urges careful communication and handling of incidental/secondary findings. | Biomedical framings can increase stigma; manage return of results and incidental findings with caution and physician screening. | |
| Justice & equitable access | Calls for rules enabling international data/sample sharing, sustainable brain banks, and fairness in data governance. | Build interoperable biobanks, align with GDPR adequacy, and ensure fair access/industry use with social consensus. | |
| Scientific validity & ethics of placebo effects | Promotes methodological clarity: systematic reviews for neuroethics, rigorous evaluation of NF/TMS/tDCS and optogenetics. | Advocate systematic, mixed-methods reviews and continuous monitoring of intervention tech efficacy/safety. | |
| Data privacy & rights of the brain | Focus on data sharing regimes, dynamic consent, and governance for big-data neuroscience; national law updates aligning with GDPR. | Investigate legal harmonization, dynamic consent practicality, and ethics of AI/big-data in neuroscience. | |
| Vulnerabilities in special populations | Discusses inclusion of persons with impaired consent capacity; co-production with caregivers (e.g., 22q11.2 deletion). | Develop frameworks to include vulnerable groups with protections; expand PPI/co-production. | |
| Neuroethical concerns related to enhancement | Addresses regulation of neuromodulation, DIY neurotech, and public-health uses (nudges); urges realistic rules for enhancement/social fairness. | Rules for neuroenhancement & DIY use are urgent; examine dual-use, military links, and inequality impacts. | |
| Ruiz, Valera, Ramos & Sitaram (2024) | Informed consent & autonomy | Charts Chile’s neurorights path (2021 constitutional reform) and draft law requiring specific informed consent for commercial neurotech uses; different regimes for therapeutic/research vs. commercial. | Law recognizes medical, research, and commercial uses; commercial uses require written, specific prior consent; IPS registration and potential restrictions. |
| Non-maleficence & psychological risks | Warns that over-protective rules may inadvertently harm patients by suppressing research; cites Chilean precedents where well-meant patient-rights laws curtailed trials. | Over-regulation can reduce clinical studies (e.g., 2012 & 2015 laws), limiting benefits; caution to avoid chilling effects on BCI/NF progress. | |
| Justice & equitable access | Notes constitutional call for science to serve people with safeguards for cerebral activity; cautions that excessive limits could restrict patient access to beneficial neurotech. | Balance protection (mental integrity, privacy) with equitable access to research/therapies; avoid over-inclusive bans. | |
| Scientific validity & ethics of placebo effects | Urges epistemic humility and realistic predictions; critiques neurohype/neuroexceptionalism as weak grounds for urgent legislation. | Base rules on proven evidence; beware ‘neurohype’ and mereological fallacies; separate neuromodulation vs. neuroimaging impacts. | |
| Data privacy & rights of the brain | Describes Chile’s framework: protects mental integrity, mental privacy and regulates neurodata handling; Supreme Court case against DTC BCI firm for ‘private neuronal data’. | Constitutional reform + draft law set safeguards for cerebral activity/data; 2023 Supreme Court protected user vs. DTC BCI over neurodata. | |
| Vulnerabilities in special populations | Highlights tension where strict consent rules could exclude unconscious/locked-in patients from BCI benefits; calls for narrowly-tailored exceptions. | ALS locked-in patients need BCIs but can’t consent traditionally; avoid rules that block their inclusion in research/care. | |
| Neuroethical concerns related to enhancement | Questions creating new rights vs. strengthening existing human rights; warns of ‘rights inflation’; recommends careful, minimal, precise legislation. | Prefer refining existing rights/guidelines over proliferating new ‘neurorights’; legislate narrowly to avoid harming innovation. | |
| Golshan et al. (2024) | Informed consent & autonomy | Participants were informed and consented; generic coded emails used to protect identity; mindfulness-naive adults recruited. | The participants will receive an invitation letter with a description of their task, the PDF form of their consent, and the contact information of the researcher in charge of the device delivery. |
| Non-maleficence & psychological risks | Protocol includes safeguards for device issues, dropout, and adverse effects; participants allowed to keep device even if they withdraw. | Since chronic migraine is lifelong, it is important to take measures for both respecting their choice of withdrawal, as well as reinforcing participants’ adherence throughout the study. | |
| Justice & equitable access | Use of low-cost portable EEG headband (MUSE) enables home-based access and telemonitoring. | This device is known as a low-cost EEG device (less than 500 CAD)… enables a more convenient remote access to participants’ practices. | |
| Scientific validity & ethics of placebo effects | RCT includes waitlist and attention control groups; belief in treatment assessed; placebo expectancy effects considered. | Previous literature is suggestive of an interaction between the expectancy and belief in treatments with the reports of improvements by headache sufferers. | |
| Data privacy & rights of the brain | Participants used generic emails; researchers monitored via MUSE Connect; no personal identifiable data shared. | Plans should be made to ensure that no personal identifiable details are shared on the app. | |
| Vulnerabilities in special populations | Adults with chronic migraine targeted; protocol designed for high dropout risk and long-term adherence. | Due to the high demanding nature of chronic migraine… a high rate of attrition is expected. | |
| Neuroethical concerns related to enhancement | Mindfulness and neurofeedback framed as self-regulation tools to reduce medication dependence and improve agency. | We need to explore how the suggested alternatives could improve headache sufferers’ pain tolerance and ability to withhold or decrease the overuse of medicine. | |
| Logemann et al. (2010) | Informed consent & autonomy | Double-blind sham-controlled design used; participants were blinded to group assignment. | Participants were blind with respect to group inclusion… Inclusion in group did not significantly influence guessing. |
| Non-maleficence & psychological risks | No behavioral improvements observed; study ceased early per ethical guidelines to avoid unnecessary burden. | The experiment was ceased after 16 sessions (since no trend towards an effect of neurofeedback on behavior was evident, and ethical guidelines were to cease the experiment). | |
| Scientific validity & ethics of placebo effects | Sham-controlled design used to test neurofeedback efficacy; no significant behavioral effects found. | The present findings suggest that neurofeedback may have no effect on behavior when accounting for unspecific factors. | |
| Justice & equitable access | Healthy university students recruited; no clinical ADHD population studied. | The sample consisted of academic students… the results cannot be generalized to the clinical ADHD population. | |
| Data privacy & rights of the brain | EEG data collected and analyzed using standard protocols; no specific privacy concerns discussed. | Eyes closed EEGs recorded at baseline and interim, were analyzed in Brain Vision Analyzer. | |
| Vulnerabilities in special populations | Subclinical impulsivity studied; not generalizable to ADHD population with greater vulnerability. | Subclinical impulsivity does not correlate positively with decreased motor inhibition… results cannot be generalized to the clinical ADHD population. | |
| Neuroethical concerns related to enhancement | Neurofeedback effects may be diminished by double-blind design; awareness may be necessary for efficacy. | Awareness of feedback may be necessary for neurofeedback to have an effect. | |
| Ölçüoğlu et al. (2023) | Informed consent & autonomy | Single-blind randomized design; informed consent obtained from parents; sham group later offered active NFB. | Participants assigned to the control group were subsequently administered the active NFB protocol upon completion of the entire study. |
| Non-maleficence & psychological risks | Sham group used to control for placebo; ILF-NFB considered non-invasive and safe; no adverse effects reported. | With advancing technology… NFB can be considered an effective, non-invasive, drug-free, and painless treatment opportunity. | |
| Justice & equitable access | Study conducted in special education center; low-cost EEG system used; access for non-medicated children. | All participants were newly diagnosed, had never used medication previously, or were from families who preferred not to use medication. | |
| Scientific validity & ethics of placebo effects | Sham-controlled design used; significant improvements in performance IQ observed in NFB group. | Significant improvements in performance scores of WISC-R were observed in the experimental group… when compared to the sham-NFB control group. | |
| Data privacy & rights of the brain | QEEG data collected and analyzed; standard protocols followed; no specific privacy risks discussed. | Quantitative EEG data were stored on a computer for offline analysis, and each recording was visually inspected to check for artifacts. | |
| Vulnerabilities in special populations | Children aged 8–12 with ADHD studied; no IQ restrictions; special education setting used. | No specific IQ score restrictions were imposed as exclusion criteria… children diagnosed with ADHD by a specialized clinical psychologist. | |
| Neuroethical concerns related to enhancement | ILF-NFB framed as cognitive enhancement; improvements in spatial and performance IQ observed. | Children demonstrated development in spatial skills through NFB training, leading to a significant increase in their performance scores. | |
| Spears et al. (2024) | Informed consent & autonomy | Emphasizes ethical/legal standards, scope of practice, and alignment with ACA/AMHCA; competencies include communicating purpose and scope of neurofeedback; consent and client understanding embedded in training | Possess knowledge of ethical and legal standards and considerations … Communicate the purpose and scope of neurofeedback as a treatment approach. |
| Non-maleficence & psychological risks | Competencies require recognizing adverse effects, side effects, contraindications, and safe thresholds; supervision/mentoring and hygiene/device safety are mandated | Understand potential consequences of neurofeedback training … Understand common side effects … Receive supervision and mentorship from a credentialed neurofeedback professional. | |
| Justice & equitable access | Points to program design and standardization for equitable counselor training; calls out multicultural considerations and inclusion limits in panel | The list of competency statements … complements standardized training … Limitations include limited racial and ethnic diversity in the present study. | |
| Scientific validity & ethics of placebo effects | Requires knowledge of evidence base, protocol efficacy, outcome tracking, and qEEG assessment; stresses research literacy and empirically based protocols | Have awareness of current empirically based neurofeedback protocols and their efficacy … Track client’s amplitude and symptoms progress across sessions. | |
| Data privacy & rights of the brain | Competencies include documentation standards, data handling in qEEG/EEG, communication with medical teams; implies safeguarding client neurodata | Effectively record, process, and analyze qEEG recordings … Articulate outcomes to the medical community. | |
| Vulnerabilities in special populations | Highlights counselor identity, trauma awareness, and adaptation to client characteristics; integrates wellness model and trauma-informed practice | Be knowledgeable of signs and symptoms relating to trauma and attachment styles … Understand that neurofeedback is a therapeutic tool integrated into counseling. | |
| Neuroethical concerns related to enhancement | Frames neurofeedback as specialized tool requiring competencies to avoid scope drift and overclaiming; addresses resistance or hype in field | Be prepared to engage with those against or wary of neurofeedback as a treatment modality … Pursue BCIA certification to promote competency. | |
| Jangwan et al. (2022) | Informed consent & autonomy | Reviews consent challenges for neuromodulation/BCI incl. risk disclosure, agency, accountability, and user understanding | Ethical concerns regarding agency, accountability, and liability … tracking ethical implications is vital, especially in mind reading and privacy. |
| Non-maleficence & psychological risks | Details safety risks of TMS/tES (seizures, burns), surgery risks for DBS, DIY-tDCS hazards; emphasizes placebo control challenges | No brain stimulation technology is without side effects … risks of seizures from TMS and tCS, and scalp burns from tCS. | |
| Justice & equitable access | Raises equity issues: high costs benefiting wealthy, ‘arms race’ of enhancement, potential social divide | Cognitive augmentations may benefit primarily the wealthy … may result in an ‘arms race’ of enhancement. | |
| Scientific validity & ethics of placebo effects | Questions robustness/variability of tDCS/TMS effects, need for sham controls, inter/intra-subject variability and parameter sensitivities | Enhancement claims … inter- and intra-subject variability … challenges of proper placebo control for non-invasive brain stimulation. | |
| Data privacy & rights of the brain | Highlights mind reading, privacy, decoding mental states, brain-to-brain links; calls for governance for neurodata | Mind reading and privacy … ability of neuroimaging to ‘assess’ thoughts raises problems about free will and privacy. | |
| Vulnerabilities in special populations | Notes pediatric/adolescent uses and sensitivities; warns of maladaptive plasticity and need for dose-finding safety in children | Non-invasive stimulation to children may provide benefits … this same ‘sensitivity’ may cause maladaptive brain plasticity. | |
| Neuroethical concerns related to enhancement | Broadly surveys enhancement ethics: hype-disappointment cycles, DIY practices, obligation-to-enhance, scope creep toward ‘superhuman’ function | Technological augmentation … transhumanist literature … ethical and policy consequences of augmenting technology are also an issue. |
Synthesized findings
Informed consent and autonomy
Concerns pertaining to the principles of informed consent and autonomy were addressed in the majority of the studies. Empirical trials, including those conducted by Logemann [4] and Ölçüoğlu et al. [19], utilised sham-controlled designs in conjunction with explicit consent procedures. This emphasises the ethical significance of autonomy in paediatric and adolescent contexts. In a similar vein, Golshan [20] emphasised the necessity for safeguards in remote neurofeedback mindfulness trials, including the anonymisation of participation and the strengthening of consent protocols. Conceptual analyses [12, 14, 21] have noted that digital phenotyping and remote interventions complicate transparency and patient involvement. Ferreri et al. [22] further highlighted how digital tools such as EMA and VR reshape the clinician–patient dynamic, requiring new models of consent. In their 2013 paper, Micoulaud-Franchi et al. proposed the concept of “Cyborg Psychiatry,” which emphasises patient autonomy and engagement in the process of neuromodulation.
A review of the extant literature reveals that the concept of informed consent in EEG-NFB is frequently invoked, albeit with significant variation in its operationalisation, particularly in the context of digital, paediatric, and remote settings.
Non-maleficence and psychological risks
It is evident that all 23 studies addressed the risks or harms associated with EEG-NFB. Empirical trials [4, 19] have emphasised the importance of careful protocol design and the use of sham controls to minimise harm to children. In their 2024 publication, Spears et al. [23] delineated a set of competencies that are essential for counsellors, including the ability to supervise and recognise artefacts. The primary objective of these competencies is to avert adverse outcomes. Conceptual papers have highlighted broader risks, including digital stress, false positives, and unintended effects from VR and biofeedback [12, 22, 24]. As Micoulaud-Franchi et al. [25] have previously indicated, there exists the possibility of resonance effects occurring in closed-loop systems. The necessity for algorithmic safeguards has been called for in order to mitigate this potential issue.
As is evident from a perusal of the extant literature, the question of psychological risk mitigation has been discussed in relation to protocol design, practitioner competencies, and technological safeguards.
Justice and equitable access
A range of studies, grounded in empirical evidence and theoretical conceptualisations, have explored the themes of justice and access. Portable electroencephalography (EEG) devices have been proposed as a cost-effective solution for underserved populations [20], while Ölçüoğlu et al. [19] emphasised the inclusion of children whose families opted out of medication. Antle [11] and Nakazawa [21] emphasised the democratisation of access to neurotechnologies, while Spears et al. [23] advocated for the integration of neurofeedback into standardised training programmes to ensure equitable dissemination. Concurrently, Ferreri et al. [12, 22] sounded a note of caution regarding digital divides and the exclusion of low-income groups from emerging interventions. In their 2013 publication, Micoulaud-Franchi et al. [25] advanced the concept of inclusive neuromodulation, a theoretical framework grounded in a biopsychosocial paradigm.
A synthesis of the reviewed studies indicates that access to EEG-NFB remains disparate across populations and settings. While this finding is robust within the included sample, it should be noted that access-related inequities have also been discussed in other literature on neurofeedback and related neurotechnologies. This suggests that the scope of disparity may extend beyond analyses framed explicitly in terms of ethics.
Scientific validity and placebo ethics
The themes of scientific rigour and placebo ethics were recurring themes. As demonstrated in the research by Logemann [4], Ölçüoğlu et al. [19] and Golshan [20], randomised controlled trials (RCTs) with sham controls and trial protocols highlighted the importance of employing rigorous designs to differentiate between specific and non-specific effects. Spears et al. [23] emphasised the necessity of training counsellors in methodological rigour. Conceptual analyses have indicated limitations in current enhancement claims and reliability concerns in neurotechnology research [12, 22, 24]. Micoulaud-Franchi et al. [25] emphasised the significance of EEG-contingent rTMS protocols in enhancing precision.
A review of the extant literature reveals persistent tensions between therapeutic claims and methodological uncertainty, thus rendering placebo ethics a central challenge for EEG-NFB research. This concern has been echoed in recent critical reviews, which highlight limitations in blinding, sham design, and interpretability of neurofeedback outcomes [26].
Data privacy and rights of the brain
The issue of data privacy has emerged as a significant ethical concern, particularly in the context of remote and digital interventions. In the 2024 study by Golshan [20], the subject of data safeguards in remote EEG monitoring was addressed, while Spears et al. [23] identified data security as a core professional competency. Conceptual contributions [12, 22, 24] have raised concerns regarding ownership, hacking, algorithmic opacity, and the risks of unregulated data flows. In a seminal study, Micoulaud-Franchi et al. [25] advanced the notion that embodied neuromodulation devices challenge established principles concerning brain data and personal identity.
As is apparent from a review of the extant literature, there is a recurrent theme of concern regarding the necessity for secure governance frameworks to address the risks associated with brain-related data.
Vulnerable populations
The protection of vulnerable groups was a recurring theme. In the context of neurofeedback trials, the necessity for special safeguards for paediatric and adolescent participants has been emphasised [4, 19]. Spears et al. [23] underlined the competencies required of counsellors when working with populations that have been affected by trauma and exhibit developmental diversity. A plethora of other studies have indicated that underserved groups may include adults afflicted with chronic migraine [20] or those encumbered by psychiatric comorbidities and inadequate digital literacy [12, 22]. As posited by Micoulaud-Franchi et al. [25], the issue of BCI illiteracy, alongside difficulties in modifying neural dynamics, has been identified among patients suffering from mental disorders.
A review of the extant literature reveals a consistent theme of concerns regarding the protection of vulnerable populations in relation to developmental status, clinical complexity, and capacity to engage with neurofeedback technologies.
Neuroethical concerns on enhancement
Finally, several studies explored enhancement beyond therapeutic applications. In a recent study, Ölçüoğlu et al. [19] reported significant cognitive improvements in children receiving ILF neurofeedback, thereby raising questions about the distinction between treatment and enhancement. This distinction has been addressed within various training models, as evidenced by the work of Spears et al. [23], while Jangwan et al. [24] have conducted a comprehensive analysis of the moral risks associated with enhancement technologies, encompassing issues such as irreversibility and inequality. Ferreri et al. [12, 22] cautioned against the utilisation of unregulated commercial tools that promise enhancement without validation. Micoulaud-Franchi et al. [25] engaged directly with the concept of enhancement ethics through the medium of their “cyborg” model, thereby giving rise to questions concerning identity and agency.
A synthesis of the reviewed studies reveals persistent ethical dilemmas surrounding the boundary between therapeutic use and enhancement in EEG-NFB applications.
Discussion
The present systematic review synthesised the ethical discourse surrounding EEG-based neurofeedback (EEG-NFB) and identified seven core thematic challenges. When considered as a whole, the findings indicate a field at a critical developmental juncture, in which technological and commercial advances risk outpacing ethical oversight, while the existing literature remains fragmented and unevenly distributed across disciplines [9, 14]. To the best of our knowledge, this is the first systematic review to focus explicitly on the ethics of EEG-NFB. Previous contributions have largely consisted of conceptual analyses [27, 28] or broader neuroethics overviews [29], without a systematic integration of empirical and theoretical dimensions.
This review directly addresses the previously noted fragmentation of the ethical discourse on EEG-NFB by systematically identifying and synthesising 23 relevant studies. In doing so, it provides a consolidated map of the ethical landscape that integrates empirical findings with conceptual and normative analyses, rather than treating these domains in isolation. The seven core themes identified — namely, informed consent and autonomy, non-maleficence, justice, scientific validity, data privacy, vulnerability, and enhancement — offer stakeholders a structured overview of the recurring ethical tensions discussed in the literature. The objective of the review is to facilitate the development of practice, research, and policy deliberations without the introduction of novel ethical theories.
The issue of informed consent and the concept of autonomy
The present findings corroborate the concerns articulated in the introduction regarding the accelerated commercialisation of EEG-NFB. The synthesis indicates that the evidence base for many applications remains heterogeneous and often inconclusive, failing to keep pace with market claims. As has been discussed in the context of scientific validity and the concept of informed consent, this discrepancy has been theorised in the extant literature as engendering conditions under which users may develop inflated expectations regarding the efficacy of the product, with concomitant opportunity costs.
A comprehensive review of the extant literature reveals that the process of informed consent in EEG-NFB is one that is frequently contested and inconsistently operationalised, rather than being uniformly compromised. These challenges stem from uncertainties regarding mechanistic efficacy, the influential—and often insufficiently disclosed—role of placebo and contextual effects [4, 6], and the persistent risk of therapeutic misconception. These dynamics are particularly pronounced in direct-to-consumer (DTC) contexts, where marketing narratives have been shown to simplify the evidence base and obscure limitations and risks [3, 9]. These consent-related challenges are further complicated by substantial inter-individual variability in learning and response to EEG-NFB, including documented phenomena of non-responders or ‘BCI illiteracy’, thereby limiting the predictability of individual benefit.
This constellation of factors corresponds to what Kalokairinou et al. (2022) describe as “unintentional deception”, wherein practitioners or developers – acting without deceptive intent – may nonetheless convey overly optimistic representations of efficacy due to sincere belief in the intervention [8]. The ethical concern here lies not in deliberate misconduct, but in the cumulative effects of epistemic uncertainty, expectation management, and commercial framing. These may collectively undermine autonomous decision-making and generate substantial opportunity costs.
In view of these findings, a number of considerations pertaining to practice, research and policy have come to light.
Practice: Both clinicians and developers could benefit from moving beyond generic consent forms and adopting standardised, plain-language templates. These templates should transparently communicate evidentiary uncertainty (for example, by describing many applications as investigational), explicitly acknowledge the potential contribution of placebo effects and outline available, evidence-based alternatives.
Research: Future studies could empirically assess the effectiveness of different consent models, such as layered consent processes or interactive digital aids, in supporting comprehension and autonomous decision-making, particularly among vulnerable populations. Further investigation into the prevalence and impact of unintentional deception may also clarify how consent practices influence expectations and treatment choices.
Policy: Ethics committees and regulatory bodies may consider requiring explicit documentation of how uncertainties, evidentiary limitations and alternative options are communicated to participants and consumers. In DTC contexts, greater scrutiny of marketing claims may be necessary to ensure they are aligned with the strength of the available evidence.
Overall, the reviewed literature suggests that unresolved challenges in informed consent risk undermining respect for individuals by limiting the circumstances in which autonomous decisions regarding EEG-NFB can be meaningfully made.
The notion of non-maleficence in the context of experimental risks
The principle of non-maleficence is challenged by an incomplete understanding of the risk profile associated with EEG-NFB. The findings of the present review suggest that monitoring and reporting of potential harms remain uneven across studies. The documented harms associated with this practice extend beyond physical adverse events, encompassing psychological burdens such as frustration, anxiety, and documented reductions in positive affect [30]. Furthermore, opportunity costs are incurred when patients forgo established treatments in favour of unproven neurofeedback interventions [8].
As demonstrated by Holt and McLean [31], trauma-focused psychotherapeutic interventions that incorporate neuroscientific techniques require ethics-informed safeguards, particularly when applied to vulnerable populations. Within the EEG-NFB literatüre [30], analogous concerns emerge in relation to emotional discomfort, experimental burden, and the possibility of misdirection, thereby underscoring the notion that the concept of harm extends beyond immediate physiological risk. These findings are consistent with broader discourses in digital health ethics, wherein harm is progressively recognised to encompass psychological, social, and opportunity-related dimensions [32].
The collective analysis of the extant studies suggests that the ethical evaluation of EEG-NFB should encompass both psychological harms and opportunity-related risks, rather than focusing exclusively on physical safety.
In view of these findings, a number of considerations pertaining to practice, research and policy have come to light.
Practice: Standardised adverse-event monitoring protocols may facilitate a more systematic identification of harm, particularly if they incorporate psychological metrics alongside documentation of opportunity costs and financial burden.
Research: Longitudinal safety studies and prospective registration of EEG-NFB trials have the potential to enhance transparency and facilitate comprehensive tracking of outcomes, including null or negative effects.
Policy: Institutional Review Boards (IRBs) may consider the requirement of risk-monitoring plans that are proportionate to both protocol novelty and participant vulnerability, in accordance with the Declaration of Helsinki’s principle of “reasonable risk and burden”.
A comprehensive review of the extant literature indicates that the expansion of the scope of harm assessment is central to ethically robust risk-benefit analysis in EEG-NFB research and practice.
The ethical principles of equality and justice
The adoption of EEG-NFB has the potential to compound existing disparities in health and social well-being. The findings of this review indicate disparities in access, attributable to high costs [9], and the risk of marginalising vulnerable populations who may be disproportionately targeted by DTC marketing or excluded from therapeutic benefits [11]. A review of the extant literature reveals a persistent concern regarding the allocation of access to EEG-NFB, with the observation that this is influenced to a greater extent by socioeconomic factors than by clinical need. This has been termed “neuro-elitism” [24].
It is important to note that additional concerns related to justice emerge in organisational and enhancement-oriented contexts. The use of neurofeedback for the purposes of performance optimisation or leadership development may enable discriminatory practices if deployed for the evaluation or selection of employees. This would consequently challenge the principles of organisational justice [3]. These concerns are consistent with broader findings in the ethics of artificial intelligence-based mental health technologies, where innovation has been shown to risk amplifying existing inequalities in the absence of explicit equity safeguards [33].
A synthesis of the reviewed studies indicates that equity considerations in EEG-NFB are often of secondary importance rather than being intrinsic to implementation and dissemination strategies.
In view of these findings, a number of considerations pertaining to practice, research and policy have come to light.
Practice: The design and evaluation of low-cost, evidence-based delivery models, such as group-based interventions or teleneurofeedback, may support broader access for underserved populations, particularly if accompanied by explicit equity metrics in outcome evaluation. Recent research on supervised home-based and remote neurofeedback further illustrates both the access-enhancing potential and the accompanying ethical challenges of decentralised delivery models [34, 35].
Research: Empirical investigation into the socioeconomic characteristics of current EEG-NFB users could clarify the extent and drivers of access disparities and support comparative analyses of cost-effectiveness relative to standard care.
Policy: It is recommended that policymakers and insurers give due consideration to equity impact alongside efficacy criteria. In this regard, ongoing efforts by professional organisations to establish reimbursement pathways for neurofeedback underscore the importance of aligning coverage decisions with both evidence and access considerations. The discourse on policy is further informed by ongoing initiatives led by professional organisations, such as the Association for Applied Psychophysiology and Biofeedback (AAPB) [36] and the International Society for Neuroregulation and Research (ISNR) [37], which are actively pursuing reimbursement pathways for neurofeedback interventions. Furthermore, the implementation of safeguards to prevent the use of data derived from neurofeedback for discriminatory or exclusionary purposes may be required.
A comprehensive review of the extant literature indicates that attention to equitable access is central to the ethically responsible development and deployment of EEG-NFB.
The relationship between scientific validity and placebo ethics
The present review identifies scientific validity as a central ethical concern in EEG-based neurofeedback (EEG-NFB), particularly in relation to the use of sham controls and the interpretation of treatment effects. In the context of digital and neuromodulatory interventions, methodological rigour is of critical importance in ensuring both scientific integrity and ethical standards. In circumstances where the efficacy of a given procedure remains ambiguous, challenges arise not only for the purposes of scientific inference but also for ethical practices such as the provision of informed consent and the undertaking of fair risk-benefit assessments. A significant proportion of the reviewed literature raises methodological concerns regarding inadequate blinding, poorly designed sham conditions, and limited statistical power [2, 4, 19]. Methodological discussions of EEG-NFB trials frequently point to difficulties in implementing credible sham controls and blinding, which may constrain how strongly efficacy claims – and their ethical implications – can be interpreted. These limitations render efforts to distinguish specific neurophysiological effects from placebo responses, contextual influences, or participant expectations ethically problematic, given the implications for transparency and consent [5, 6]. In this regard, the phenomenon of so-called “BCI insensitivity” or non-responsiveness further complicates the ethical evaluation of EEG-NFB by reducing the predictability of benefit at the individual level [2].
The collective analysis of the reviewed studies indicates that methodological uncertainty can engender ethical vulnerability, particularly in instances where claims of efficacy exceed the robustness of the supporting evidence. Rather than constituting deliberate deception, these dynamics reflect structural limitations in current research practices, which nevertheless have ethical consequences for participants, patients and consumers.
In view of these findings, a number of considerations pertaining to practice, research and policy are apparent.
Practice: In circumstances where this is possible, the incorporation of meticulously formulated sham control conditions and efficacious blinding procedures may facilitate a more reliable interpretation of outcomes. Transparent disclosure of evidentiary limitations is also central to ethically sound communication with participants and users.
Research: Future research could prioritise adequately powered, preregistered randomised controlled trials incorporating active sham controls and open data practices. Further investigation into predictors of response may assist in the refinement of participant selection, thereby reducing unnecessary exposure to ineffective interventions.
Policy: It is recommended that regulatory bodies consider articulating explicit evidentiary thresholds, such as replicated findings from sham-controlled trials, when evaluating clinical claims or reimbursement decisions related to EEG-NFB.
The extant literature suggests that sustained attention to scientific validity is foundational to ethically responsible EEG-NFB research and application, particularly in contexts where placebo effects and contextual influences are difficult to disentangle.
The nexus between data privacy and neurorights
The increasing prevalence of portable EEG devices and consumer neurotechnology has given rise to concerns surrounding data privacy in EEG-based neurofeedback (EEG-NFB). The synthesis indicates that the collection and processing of neural data introduce distinctive risks, including re-identification, unauthorised secondary use, and potential infringements of mental privacy [20, 21, 38]. These risks appear particularly salient in mobile applications and DTC platforms, which frequently operate outside the robust data governance frameworks typical of clinical settings [11, 12].
A recurring theme in the reviewed literature is the sensitivity of neural data, which is frequently cited as a rationale for calls to strengthen existing privacy protections. In this context, proposals for constitutional or statutory “neurorights,” such as those advanced in Chile [16], have emerged alongside broader academic debates concerning the extension of established rights (e.g., freedom of thought) or the articulation of new legal protections specific to brain data [39, 40]. Concurrently, the neurorights discourse itself has been subject to critique, particularly with respect to concerns about neuro-exceptionalism and the lack of clear epistemological boundaries distinguishing neural data from other forms of sensitive health information [16, 21].
When considered as a whole, these discussions indicate that while neurorights frameworks highlight authentic governance discrepancies, their ethical and regulatory value is contingent on their translation into pragmatic, proportionate safeguards as opposed to exclusively symbolic legal innovation.
In view of these findings, a number of considerations for practice, research and policy can be identified.
Practice: It is important to acknowledge the heightened sensitivity of neural data, which may provide a foundation for the treatment of EEG-derived information as particularly confidential health data. It is submitted that data minimisation, strong encryption, and explicit consent for secondary data use may contribute to ethically robust data handling practices.
Research: Further investigation into the technical risks of re-identification in EEG datasets has the potential to inform the development of anonymisation and privacy-preserving techniques that are tailored to neural data. This, in turn, could support responsible data sharing without unduly constraining scientific progress.
Policy: It is recommended that policymakers consider ways to strengthen legal protections for mental privacy and cognitive liberty. In doing so, they should ensure that device certification and regulatory standards incorporate baseline data security and privacy requirements. It is imperative to calibrate such measures meticulously in order to circumvent the potential for regulatory overreach, which could result in the unwarranted hindrance of legitimate research and clinical innovation.
A comprehensive review of the extant literature indicates that proactive yet proportionate attention to data privacy is central to maintaining public trust and supporting the ethically responsible development of EEG-NFB.
The ethical implications for vulnerable populations
The extant literature consistently indicates that vulnerable groups – including children, individuals with cognitive impairments, and psychiatric populations – are both frequent subjects of EEG-based neurofeedback (EEG-NFB) research and particularly susceptible to ethical challenges. A plethora of studies have expressed concerns regarding the capacity for meaningful assent or consent, the heightened potential for subtle forms of coercion, and the uncertainties surrounding long-term developmental or psychological effects [19, 41]. These issues are especially salient in light of evidence that such populations are often targeted by marketing for alternative or adjunctive interventions [9].
In this particular context, the results of the present review are consistent with broader critiques in the fields of digital health and artificial intelligence ethics. These critiques have drawn attention to systematic shortcomings in the protection of children and marginalised groups in rapidly evolving technological domains [33]. The extant literature suggests that vulnerability in EEG-NFB is not incidental but structurally embedded in both research and commercial practices, particularly in paediatric applications and interventions involving individuals with limited capacity to give consent [19, 23].
In view of these findings, a number of considerations for practice, research and policy can be identified.
Practice: The implementation of additional safeguards, including age-appropriate assent procedures, dual caregiver consent, and, where appropriate, the involvement of independent patient advocates, may contribute to the enhancement of protections for highly vulnerable participants.
Research: It is recommended that future studies incorporate outcome measures that have been explicitly tailored to vulnerability-related risks. Furthermore, such studies should ensure sufficient statistical power to detect adverse or unintended effects within these groups. It is imperative to meticulously formulate the protocol to mitigate the risk of participants experiencing feelings of failure, stigma, or self-blame when anticipated benefits are not realised.
Policy: Regulatory approaches may consider the implementation of more stringent restrictions on DTC marketing directed at vulnerable populations, as well as the requirement of clinical oversight for EEG-NFB interventions involving these groups. In contexts where neurotechnological interventions are proposed as mandatory or quasi-mandatory, it may be necessary to establish exceptionally high ethical thresholds in order to guard against coercion.
The extant literature suggests that the ethical integrity of EEG-NFB research and practice is contingent on attention to vulnerable populations.
The relationship between neuroethics and transhumanism
The present review elucidates the novel normative questions raised by emerging neurofeedback techniques, with a particular focus on decoded neurofeedback (dNFB), a form of neurofeedback in which feedback signals are derived from multivariate decoding of neural activity patterns rather than explicit conscious strategies, and enhancement-oriented applications [13]. A review of the extant literature reveals that these developments challenge established conceptions of agency, identity, and moral responsibility. Instead of representing incremental extensions of therapeutic practice, enhancement-oriented uses of EEG-NFB raise qualitatively distinct ethical concerns, especially where interventions move beyond the restoration of function towards optimisation or augmentation.
Empirical work, for instance that of Cohen Kadosh et al. [42] illustrates this blurring of boundaries between therapy and augmentation by demonstrating modulation of effective connectivity within emotion-regulation networks in adolescents. Although such studies are generally conducted under strict ethical oversight, their findings nevertheless highlight unresolved questions concerning fairness, personal identity, and the moral status of enhancement, particularly when applied to developing or vulnerable populations.
When considered as a whole, the reviewed studies indicate that as applications of EEG-NFB transition from therapeutic contexts to cognitive or affective enhancement [24] and as techniques such as dNFB evolve [13], ethical scrutiny must extend beyond conventional clinical frameworks [38]. In particular, dNFB has been associated with concerns regarding irreversibility, diminished transparency of intervention mechanisms, and the potential manipulation of identity-relevant neural processes, including in speculative discussions of moral enhancement [13]. These concerns emphasise the necessity of approaching enhancement-related applications with sensitivity to moral pluralism and societal diversity, rather than assuming consensus regarding the desirability or acceptability of such interventions [29].
In view of these findings, a number of considerations for practice, research and policy can be identified.
Practice: It is recommended that enhancement-oriented neurofeedback projects benefit from multidisciplinary ethical review processes that include expertise from ethics, social sciences, and patient or public representatives. The implementation of such review mechanisms could facilitate critical reflection on the value-laden goals and assumptions that underpin enhancement claims.
Research: It is recommended that future research engage proactively with the societal implications of enhancement narratives. This engagement should be facilitated through the utilisation of foresight methodologies, scenario analysis, and structured public engagement. A critical examination of optimistic or promotional claims surrounding neurotechnological enhancement may also facilitate the contextualisation of scientific findings within broader social and ethical debates [24].
Policy: Regulatory approaches may consider maintaining clear distinctions between therapeutic and enhancement-oriented uses of EEG-NFB, with the latter subject to heightened ethical scrutiny. Concurrently, ongoing debates surrounding neurorights necessitate meticulous calibration to circumvent overly broad or rigid legal frameworks that could inadvertently constrain legitimate research and clinical innovation.
The extant literature suggests that engagement with questions of enhancement and transhumanism is integral to the responsible development of EEG-NFB, requiring sustained philosophical reflection alongside empirical and regulatory analysis.
Limitations
It is important to acknowledge the limitations of the present systematic review. Firstly, the included studies exhibited considerable heterogeneity with respect to study design, neurofeedback protocols, ethical frameworks, and sample characteristics. This variability limited the capacity for direct comparison across studies and precluded quantitative meta-analysis. Accordingly, a narrative thematic synthesis was adopted in order to integrate this diverse body of evidence. While this approach facilitated a structured synthesis of heterogeneous sources, it is important to note that the findings should be interpreted as reflecting patterns within a diverse literature rather than conclusions derived from methodologically homogeneous studies. Despite efforts to mitigate these challenges through systematic classification and extraction of key variables, methodological and conceptual variability may have influenced the synthesis and the generalisability of the findings.
Secondly, the scope of the review was restricted to English-language, peer-reviewed publications. This may have resulted in the exclusion of relevant studies published in other languages or disseminated as grey literature. Furthermore, limited Access to certain specialised databases may have resulted in the omission of region-specific or emerging contributions. Consequently, the review may not fully capture the global diversity of ethical perspectives on EEG-based neurofeedback. Furthermore, the search strategy employed ethics-related keywords to identify relevant literature. Consequently, a proportion of studies that engage substantively with ethical issues – such as informed consent, risk-benefit considerations, or justice – without explicitly using ethics-related terminology may not have been captured. This limitation reflects a broader challenge in systematically identifying ethically relevant content in biomedical and neurotechnological research, where ethical discussion is often embedded implicitly within methodological or clinical discourse rather than labelled as such.
Thirdly, the relatively limited number of studies explicitly addressing ethical issues, in conjunction with the potential for publication bias, may have influenced the extant evidence base. It is evident that ethical discussions are more likely to be reported in studies presenting positive or confirmatory findings. Conversely, ethical challenges arising in null or negative trials may remain underreported. This imbalance may have influenced the balance of themes identified in the synthesis.
Finally, both EEG-NFB technologies and neuroethical frameworks are undergoing rapid evolution. As novel applications, delivery formats, and user populations emerge, ethical considerations and risk profiles may shift. Consequently, it is possible that some of the ethical challenges identified in this review may be addressed or reframed by more recent or forthcoming research not yet represented in the literature.
The development of future systematic reviews could be enhanced by the implementation of standardised methodological approaches, transparent reporting of ethical dimensions, and longitudinal perspectives that capture the evolution of ethical challenges over time. Greater integration of interdisciplinary perspectives—including neuroscience, bioethics, clinical practice, and regulatory policy—may further strengthen the comparability, reproducibility, and applicability of future findings.
Conclusion
This systematic review highlights that ethical considerations in EEG-based neurofeedback, while widely recognised as important, remain unevenly examined and inconsistently addressed within the existing literature. The thematic synthesis process resulted in the identification of seven core ethical challenges, which exposed persistent empirical gaps and normative uncertainties, particularly with regard to data governance, equitable access, scientific validity, and the protection of vulnerable populations.
The findings, when considered as a whole, indicate that in order to address these challenges, there is a necessity for ongoing interdisciplinary engagement among neuroscientists, ethicists, clinicians, researchers, industry stakeholders, and policymakers. The development of transparent reporting standards, proportionate risk-management strategies, and context-sensitive approaches to informed consent may contribute to more ethically robust research and practice. As neurofeedback technologies evolve and extend beyond conventional clinical environments, it is likely that attention to equity and governance considerations will become increasingly important.
The extant literature suggests that the incorporation of ethical reflection as a core component of EEG-NFB research and application, rather than as an ancillary or marginal component, has the potential to enhance methodological rigour, foster public trust, and guide the responsible and socially responsive development of this evolving field.
Supplementary Information
Acknowledgements
The authors would like to extend their sincere gratitude to Setareh Bitaraf, Batu Ekeyilmaz, Nehir Okay, Mikail Barbaros Ozkan, Sara Shokrikia, and Begüm Vergül for their invaluable assistance in the systematic literature screening and data organisation phases of this review. The preliminary thematic findings, derived from the full-text analysis, were presented in abstract form by the student working group at the XXVI Başkent University Student Symposium (May 28–30, 2025) as part of an academic training activity. The project’s successful completion was contingent on the diligent and meticulous efforts of the team.
Clinical trial number
Not applicable.
Abbreviations
- EEG
Electroencephalography
- EEG-NFB
Electroencephalographic Neurofeedback
- NFB
Neurofeedback
- dNFB
Decoded Neurofeedback
- ILF-NFB
Infra-Low Frequency Neurofeedback
- qEEG
Quantitative Electroencephalography
- fMRI
Functional Magnetic Resonance Imaging
- rtfMRI
Real-time Functional Magnetic Resonance Imaging
- BCI
Brain–Computer Interface
- DTC
Direct-to-Consumer
- RCT
Randomised Controlled Trial
- PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- IRB
Institutional Review Board
Authors’ contributions
R.Ö. and R.V.Y. jointly conceptualized and designed the study. R.Ö. conducted the database search, screening, and data extraction. Both authors contributed to the thematic analysis. R.Ö. drafted the manuscript, and R.V.Y. provided critical revisions and theoretical framing. All authors reviewed and approved the final version of the manuscript.
Funding
The present study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.No specific funding.
Data availability
All data generated or analysed during this study are included in this published article and its supplementary information files, including the search strategy, screening log, and thematic source matrix.
Declarations
Ethics approval and consent to participate
Not applicable. This study is based exclusively on the analysis of previously published literature and did not involve human participants or animals.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data generated or analysed during this study are included in this published article and its supplementary information files, including the search strategy, screening log, and thematic source matrix.