Neuromodulation and brain-computer interface technologies present patients, caregivers, clinicians, engineers, and regulators with significant ethical challenges surrounding patient autonomy and self-determination. Existing frameworks address autonomy and self-determination narrowly, typically focusing on the restoration of some physical deficit lost to disease, and cannot account for the trade-offs these therapeutics impose across multiple dimensions of a patient’s life. We propose a need-based framework that reconceives autonomy as a graded configuration of self-determination consisting of two procedural capacities: decisional and executional autonomy. Each of these domains is shaped by three influence dimensions consisting of mental, relational, and physical autonomy. This structure captures how neurotechnological design and deployment can simultaneously enhance and erode self-determination. We offer a candidate formalization of our framework and apply it to a well-documented case of a Dutch Parkinson’s disease patient who accepted cognitive side effects in exchange for restored motor function and demonstrate that our framework reveals trade-offs in autonomy that existing approaches cannot capture. We further show that poorly considered neurotechnology implementation can erode mental, relational, or physical autonomy independently of decisional capacity. Finally, applied to current and emerging neurotechnology, the framework unifies disparate ethical concerns of implant abandonment, neural data governance, and closed-loop neural control, under a single criterion: net impact on patient self-determination.
D, physical most on E. The weights are
not universal — they shift by clinical population and decision context. For example, a physical deficit from
blindness loads heavily on the decisional row (it shapes the
option set), whereas a lower-limb amputation loads more on the executional row.