This comment responds to a remark made by Meloni et al concerning brain implants and brain-gene transferthat we ought to give primacy to ethical issues inherent to medical utility rather than speculating on issues of potential misuse. It foregrounds the benefits, burdens and risks as well as how to validate consent to the use of such novel and uncertain techniques. It asks how legal claims would be handled in the absence of historical casuistryconstructs of responsibility and culpability for resultant harms. Finally, it confronts the practical question of how decisions about who receives state-of-the-art treatments are addressed, deliberated and articulated. Are we looking at a new boutique neurology or widely accessible applications requiring substantive changes in the health-economic infrastructure and better preparedness in practice and policy?