Identity Following

It has frequently been argued that "the mind is the seat of our personhood, and of consciousness, freedom and responsibility" [38, p. 224]. Since DBS directly interferes with the functioning of the mind, this technology potentially forms a threat to our personhood and personal identity. Indeed, feelings of alienation have been reported following DBS in Parkinson's disease patients [40]. This finding underlines the ability of DBS to interfere with, or pose a threat to, our sense of self. While feelings of alienation are considered as adverse effects of DBS for Parkinson's disease, when DBS is used to alter (aggressive or violent) behavior or other affective states, a change identity seems to be the intended goal of the treatment [41].

While changes in mood, cognition and behavior are in some instances (such as the treatment of psychiatric disorders) considered as positive effects of DBS, others claim that this treatment is a threat to personal identity, since identity is "a constellation of characteristics, values and the experiential sense of who one fundamentally is as a person" [42, p.

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487]. Since the main goal of DBS for pathological aggression is to alter aggressive behavior, and its corresponding motives and urges, one could argue that this is a type of identity-changing DBS. However, the attenuating of aggressive behavior by DBS could potentially still result in feelings of alienation if aggression is strongly integrated in one's identity, if affective states, other than aggression, are altered, or if individuals feel as if they are controlled by the DBS device (a subjective loss of free will).

The ability of DBS to induce self-estrangement in patients has spurred the moral debate on identity changes in response to DBS. Consequently, personal identity has become a central concept in the ethical debate on DBS and has, by some authors, also been linked to autonomy. The central question in this debate relates to whether and when DBS poses a threat to personal identity. Naturally, whether DBS indeed poses a threat to personal identity depends on which concept of identity is applied: numerical, narrative, relational identity or the synchronic notion of identity. Numerical, narrative, relational and synchronic notion of identity Authors seem to agree that numerical identity, which is "the continuous sense of biological self that persists over time that is independent of experience" [43, p. 2], is not threatened by DBS [31,43,44].

Although DBS does not pose a threat to numerical identity at the moment, it has been suggested that this may well be the case in the future [43]. For example, DBS of patients with schizophrenia or dementia, which are disorders associated with alternations in the "subjective sense of self-continuity", might result in distortions of numerical identity [43, p. 2]. However, currently, DBS for aggressive behavior does not seem to pose a threat to numerical identity. Rather than numerical identity, DBS for aggressive behavior is more likely to pose a threat to narrative identity. Narrative identity is the sense of self that is constructed by the 'stories we tell about ourselves', which are shaped by our self-understanding, values, social role and personal characteristics [42,45-47].

However, it has been argued that abrupt (DBS-induced) changes in our narrative identity are not necessarily problematic; negative (or positive) life events often have a similar effect on our identity and these experiences are not considered a threat to our identity [47]. Furthermore, it has been suggested that individuals often experience negative identity changes as burdensome, while positive identity changes are more likely to be accepted and internalized [48]. Subsequently, it could be argued that the attenuation of aggression by DBS would generally be experienced as a positive identity change, and would not be considered troublesome by the majority of the affected individuals. Some authors argue that the concept of narrative identity is perhaps too individualistic and disregards the role that close relations play in the shaping of one's identity: "the self, the I, the person is more than the brain and its functions" [43,49, p. 3]. A change in identity following DBS does not only affect the patient himself, but also affects their spouse, family members or other close relations [50,51].