1Neurology Department and Cyclotron Research Center, University of Lie`ge, Sart Tilman B30, 4000 Liege, Belgium 2Neurorehabilitation Medicine, Hoˆpital Caremeau, CHU Nıˆmes, 30029 Nıˆmes Cedex, France 3Department of Speech Therapy, Hospital Pitie´ Salpe´trie`re, Paris and French Association Locked in Syndrome (ALIS), 225 Bd Jean-Jaures, MBE 182, 92100 Boulogne-Billancourt, France 4Neurosciences et Syste`mes Sensoriels Unite´ Mixte de Recherche 5020, Universite´ Claude Bernard Lyon 1 – CNRS, 69007 Lyon, France 5Intensive Care Medicine, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Route de Lennik (...) 808, 1070 Brussels, Belgium 6Anesthesiology, Reanimation and Pain Clinic, CHU University Hospital, Sart Tilman B33, 4000 Liege, Belgium 7German Association Locked in Syndrome LIS e.V., Evangelischen Krankenhaus Ko¨ningin Elisabeth Herzberge gGmbh (Lehrkrankenhaus der Charite´), Haus 30, Herzbergstrasse 79, 10365 Berlin, Germany 8Intensive Care Medicine, Centre Hospitalier Re´gional de la Citadelle, Boulevard du 12e de Ligne 1, 4000 Liege, Belgium 9Biomedical PET Unit, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium.. (shrink)

In a recent contribution to this journal, Andrew Fenton and Sheri Alpert have argued that the so-called “extended mind hypothesis” allows us to understand why Brain Computer Interfaces (BCIs) have the potential to change the self of patients suffering from Locked-in syndrome (LIS) by extending their minds beyond their bodies. I deny that this can shed any light on the theoretical, or philosophical, underpinnings of BCIs as a tool for enabling communication with, or bodily action by, patients with (...) LIS: BCIs are not a case of cognitive extension. I argue that Fenton and Alpert’s claim to the contrary is the result of a widespread confusion about some related, but significantly different, approaches to cognition that all fall under the heading of “situated cognition.” I first provide a short taxonomy of various situated approaches to cognition, highlighting (some of) their important commonalities and differences, which should dissolve some of the confusions surrounding them. Then I show why the extended mind hypothesis is unsuitable as a model of BCI enhancements of LIS patients’ capacity to interact with their surroundings, and I argue that the situated approach with obvious bearings on the sort of questions that were driving Fenton and Alpert is not the idea that cognition is extended , but the idea that cognition is enacted. (shrink)

Embodied approaches in cognitive science hold that the body is crucial for cognition. What this claim amounts to, however, still remains unclear. This paper contributes to its clarification by confronting three ways of understanding embodiment—the sensorimotor approach, extended cognition and enactivism—with Locked-in syndrome. LIS is a case of severe global paralysis in which patients are unable to move and yet largely remain cognitively intact. We propose that LIS poses a challenge to embodied approaches to cognition requiring them to (...) make explicit the notion of embodiment they defend and its role for cognition. We argue that the sensorimotor and the extended functionalist approaches either fall short of accounting for cognition in LIS from an embodied perspective or do it too broadly by relegating the body only to a historical role. Enactivism conceives of the body as autonomous system and of cognition as sense-making. From this perspective embodiment is not equated with bodily movement but with forms of agency that do not disappear with body paralysis. Enactivism offers a clarifying perspective on embodiment and thus currently appears to be the framework in embodied cognition best suited to address the challenge posed by LIS. (shrink)

It has been argued that Extended Cognition (EXT), a recently much discussed framework in the philosophy of cognition, would serve as the theoretical basis to account for the impact of Brain Computer Interfaces (BCI) on the self and life of patients with Locked-in Syndrome (LIS). In this paper I will argue that this claim is unsubstantiated, EXT is not the appropriate theoretical background for understanding the role of BCI in LIS. I will critically assess what a theory of (...) the extended self would comprise and provide a list of desiderata for a theory of self that EXT fails to accommodate for. There is, however, an alternative framework in Cognitive Science, Enactivism, which entails the basis for an account of self that is able to accommodate for these desiderata. I will outline some first steps towards an Enactive approach to the self, suggesting that the self could be considered as a form of human autonomy. Understanding the self from an enactive point of view will allow to shed new light on the questions of whether and how BCIs affect or change the selves of patients with LIS. (shrink)

A point made repeatedly over the last few years is that the Locked-in Syndrome offers unique real-life material for revisiting and challenging certain ingrained philosophical assumptions about the nature of personhood and personal identity. Indeed, the claim has been made that a closer study of LIS will call into question some of the traditional conceptions of personhood that primarily highlight the significance of consciousness, self-consciousness and autonomy and suggest the need for a more interpersonal account of the person. (...) I am skeptical about these claims and will in the following argue that the theoretical relevance of LIS for an understanding of selfhood and personhood has been exaggerated. (shrink)

I had my accident on the rugby field on July 29, 2000 about 2.00 p.m. during a simple line - out, even before the ball was thrown in. I t just felt like another simple case of concussion , I staggered to the sideline, the coach asked me “what ’s wrong”? He said I told him I just felt sick and to put me back on the field in 10 minutes. Then I collapsed, eventually blacked out and then was rushed (...) to hospital unconscious in an ambulance with them struggling drastically to keep me alive. Af ter three days of being in there, they thought I was alright and were going to send me home. Then it star ted happening. First I nearly collapsed again tak ing a shower . For days the spe - cialists didn’t k now what was wrong with me. M y girlfriend at the time, who had rushed down from Wanak a when she had heard it had happened went mad at the specialists to do something. Af ter six days of going in and out of seizures, finally af ter what seemed like all the tests k nown to man, they said I had suffered several brain stem strokes then one massive major one, which altogether had lef t me diagnosed with the ex tremely rare and unk nown condition only k nown to a few as “ locked in syndrome”. (shrink)

The existential situation of persons who suffer from the locked-in syndrome raises manifold issues significant to medical anthropology, phenomenology, biomedical ethics, and neuroethics that have not yet been systematically explored. The present special issue of Neuroethics illustrates the joint effort of a consolidating network of scholars from various disciplines in Europe, North America and Japan to go in that direction, and to explore LIS beyond clinical studies and quality of life assessments.

In this paper, the problem of correct ascriptions of consciousness to patients in neurological intensive care medicine is explored as a special case of the general philosophical other minds problem. It is argued that although clinical ascriptions of consciousness and coma are mostly based on behavioral evidence, a behaviorist epistemology of other minds is not likely to succeed. To illustrate this, the so-called total locked-in syndrome, in which preserved consciousness is combined with a total loss of motor abilities (...) due to a lower ventral brain stem lesion, is presented as a touchstone for behaviorism. It is argued that this example of consciousness without behavioral expression does not disprove behaviorism specifically, but rather illustrates the need for a non-verificationist theory of other minds. It is further argued that a folk version of such a theory already underlies our factual ascriptions of consciousness in clinical contexts. Finally, a non-behaviorist theory of other minds for patients with total locked-in syndrome is outlined. (shrink)

There is no systematic knowledge about how individuals with Locked-in Syndrome experience their situation. A phenomenology of LIS, in the sense of a description of subjective experience as lived by the ill persons themselves, does not yet exist as an organized endeavor. The present article takes a step in that direction by reviewing various materials and making some suggestions. First-person narratives provide the most important sources, but very few have been discussed. LIS barely appears in bioethics and neuroethics. (...) Research on Quality of Life provides relevant information, one questionnaire study explores the sense of personal continuity in LIS patients, and LIS has been used as a test case of theories in “embodied cognition” and to explore issues in the phenomenology of illness and communication. A systematic phenomenology of LIS would draw on these different areas: while some deal directly with subjective experience, others throw light on its psychological, sociocultural and materials conditions. Such an undertaking can contribute to the improvement of care and QOL, and help inform philosophical questions, such as those concerning the properties that define persons, the conditions of their identity and continuity, or the dynamics of embodiment and intersubjectivity. (shrink)

Locked-in syndrome (LIS) is a severe neurological condition that typically leaves a patient unable to move, talk and, in many cases, initiate communication. Brain Computer Interfaces (or BCIs) promise to enable individuals with conditions like LIS to re-engage with their physical and social worlds. In this paper we will use extended mind theory to offer a way of seeing the potential of BCIs when attached to, or implanted in, individuals with LIS. In particular, we will contend that functionally (...) integrated BCIs extend the minds of individuals with LIS beyond their bodies, allowing them greater autonomy than they can typically hope for in living with their condition. This raises important philosophical questions about the implications of BCI technology, particularly the potential to change selves, and ethical questions about whether society has a responsibility to aid these individuals in re-engaging with their physical and social worlds. It also raises some important questions about when these interventions should be offered to individuals with LIS and respecting the rights of these individuals to refuse intervention. By aiding willing individuals in re-engaging with their physical and social worlds, BCIs open up avenues of opportunity taken for granted by able individuals and introduce new ways in which these individuals can be harmed. These latter considerations serve to highlight our emergent social responsibilities to those individuals who will be suitable for, and receive, BCIs. (shrink)

Extensive scholarship has described the historical and ethical imperatives shaping the emergence of the brain death criteria in the 1960s and 1970s. This essay explores the longer intellectual history that shaped theories of neurological consciousness from the late-nineteenth century to that period, and argues that a significant transformation occurred in the elaboration of those theories in the 1960s and after, the period when various disturbances of consciousness were discovered or thoroughly elaborated. Numerous historical conditions can be identified and attributed to (...) the production of the new theories that emerged from that period-on, not least in the broader social and cultural transformations that occurred with decolonialization, pro-democracy movements, and civil and disability rights advocacy, all contexts which exerted pressures on the institutions and professions of medicine. In this telling, the discovery of the locked-in patient is thus the exploration of a transformed vision of medical patients – one that moved them from a liminal indefinite space into a firmly grounded epistemological existence – in a backdrop in which medical professionals in particular and society in general was beginning to see the body differently. With this new vision, came a relational theory of consciousness to, a reading of a body and it signs, that shifted consciousness from an internally-derived state into a relationally-constructed object. The ontology of consciousness, whatever it was, thereby became entangled with the social condition of consciousness, one that bridged the worlds of close relationship with the social movements and anxieties about personhood that emanated out of that fraught period. (shrink)

New brain-computer interface and neuroimaging techniques are making differentiation less ambiguous and more accurate between unresponsive wakefulness syndrome patients and patients with higher cognitive function and awareness. As research into these areas continues to progress, new ethical issues will face physicians of patients suffering from total locked-in syndrome, characterized by complete loss of voluntary muscle control, with retention of cognitive function and awareness detectable only with neuroimaging and brain-computer interfaces. Physicians, researchers, ethicists and hospital ethics committees should (...) be aware of and prepared to handle ethical issues unique to these totally locked-in patients. Several thought experiments are discussed, to highlight potential ethical dilemmas surrounding surrogate decision-making, autonomy, end-of-life care, and pediatric care, which will be unique to total LIS patients. These, along with other ethical problems especially relevant to total LIS patients, merit further discussion among physicians, researchers, ethicists and hospital ethics committees, to facilitate consensus regarding these issues, and improve patient care. (shrink)

The locked-in syndrome is a state of profound paralysis with preserved awareness of self and environment who typically results from a brain stem stroke. Although patients in LIS have great difficulty communicating, their consciousness, cognition, and language usually remain intact. Medical decision-making by LIS patients is compromised, not by cognitive impairment, but by severe communication impairment. Former systems of communication that permitted LIS patients to make only “yes” or “no” responses to questions was sufficient to validate their consent (...) for simple medical decisions but not for consequential medical decisions such as whether to refuse further life-sustaining therapy. Emerging technologies including computer-tracking assistance of retained partial motor function and brain-computer interfaces promise to improve the communication ability of LIS patients and, when better developed, will allow them to fully exercise their right to actively participate in consequential medical decisions about their own medical care. Although so-called “covert cognition” patients clinically diagnosed as vegetative state that are shown to be aware by functional neuroimaging maybe metaphorically considered locked-in, it is nosologically more coherent not to categorize them formally as LIS. (shrink)

Different sort of people are interested in personal identity. Philosophers frequently ask what it takes to remain oneself. Caregivers imagine their patients’ experience. But both philosophers and caregivers think from the armchair: they can only make assumptions about what it would be like to wake up with massive bodily changes. Patients with a locked-in syndrome suffer a full body paralysis without cognitive impairment. They can tell us what it is like. Forty-four chronic LIS patients and 20 age-matched healthy (...) medical professionals answered a 15-items questionnaire targeting: global evaluation of identity, body representation and experienced meaning in life. In patients, self-reported identity was correlated with B and C. Patients differed with controls in C. These results suggest that the paralyzed body remains a strong component of patients’ experienced identity, that patients can adjust to objectives changes perceived as meaningful and that caregivers fail in predicting patients’ experience. (shrink)

Personhood is ascribed on others, such that someone who is recognized to be a person is bestowed with certain civil rights and the right to decision making. A rising question is how severely brain-injured patients who regain consciousness can also regain their personhood. The case of patients with locked-in syndrome is illustrative in this matter. Upon restoration of consciousness, patients with LIS find themselves in a state of profound demolition of their bodily functions. From the third-person perspective, it (...) can be expected that LIS patients might experience a differential personal identity and may lose their status as persons. However, from the patients’ perspective, it is uncontested that they retain their personal identity and that they consider themselves to be persons. We here include results from a survey with patients with LIS aimed at identifying the primary expectations of patients for their care by non-medical professionals. Based on these first-hand reports, we argue that personhood in LIS is progressively regained as the widening circle of others recognizes them as persons. (shrink)

Personhood is ascribed on others, such that someone who is recognized to be a person is bestowed with certain civil rights and the right to decision making. A rising question is how severely brain-injured patients who regain consciousness can also regain their personhood. The case of patients with locked-in syndrome is illustrative in this matter. Upon restoration of consciousness, patients with LIS find themselves in a state of profound demolition of their bodily functions. From the third-person perspective, it (...) can be expected that LIS patients might experience a differential personal identity and may lose their status as persons. However, from the patients’ perspective, it is uncontested that they retain their personal identity and that they consider themselves to be persons. We here include results from a survey with patients with LIS aimed at identifying the primary expectations of patients for their care by non-medical professionals. Based on these first-hand reports, we argue that personhood in LIS is progressively regained as the widening circle of others recognizes them as persons. (shrink)

The history of brain-computer interfaces developed from a mere idea in the days of early digital technology to today’s highly sophisticated approaches for signal detection, recording, and analysis. In the 1960s, electroencephalography was tied to the laboratory due to equipment and recording requirements. Today, amplifiers exist that are built in the electrode cap and are so resistant to movement artefacts that data collection in the field is no longer a critical issue. Within 60 years, the field has moved from simple (...) and artefact-sensitive EEG recording to making real the vision of brain-computer communication. In the last 40 years, direct brain-computer interaction went from simple communication programs to sophisticated BCI-controlled applications. In the past two decades, much research was conducted with locked-in individuals, and since the 2010s, independent home use by exemplary patients has been demonstrated. In these patients with locked-in syndrome, BCI were installed at their home and long-term usage was established, resulting in increased quality of life. Maintaining communication in disorders leading to LIS contributes significantly to the patients’ sense of being full persons. BCI as an assistive technology will likely be perceived as integral part of the self: insofar as it can prevent total loss of communication and the ensuing social isolation, it enables essential conditions for the subjective and intersubjective experience of personhood. (shrink)

Locked-in syndrome (LIS) is one of the most dramatic neurological outcomes and has a profound impact on patients and their families. Most patients have intact cognition and intellectual ability and perception. Communication is possible with eyelid and/or eyeball movement. According to the literature, the wish to die is not an important issue in acute and chronic LIS. This study describes and analyses the ethical decision-making process in two opposite cases of LIS in the intensive care unit. One patient (...) expressed the wish to prolong her life for as long as possible; the other patient asked for deliberate termination of life. Both wishes were honoured. In conclusion, most patients with LIS are competent and intellectually intact. In The Netherlands the autonomy of the patient is respected by law. In respecting this autonomy, medical choices can be different in comparable patients. (shrink)

Marie-Aure´lie Bruno,1 Jan L Bernheim,2 Didier Ledoux,1 Fre´de´ric Pellas.

Donation after cardiac death (DCD) traditionally occurs in two patient populations: (1) those who do not meet neurological death criteria but who have suffered severe neurological damage, and (2) those who are fully alert and awake but are dependent on machines. This case highlights the unique dilemma when a patient falls between these two populations—conscious and cognitively intact, but completely paralyzed except for limited eye movement, afflicted by what the medical community refers to as locked-in syndrome. Prompted by (...) the treatment team’s discomfort, an ethics consultant examined whether the team was obligated to discuss a decision to donate with the patient, who was a registered organ donor. This article shows how, in determining whether or not to talk to the patient or family during end-of-life decision making, the weight assigned to the various ethical concerns in the case— the patient’s condition, the decision to be made, and the family’s agreement or disagreement regarding the patient’s wishes—can “swing the pendulum” of ethical analysis in different ways. The comfort of the patient must be accorded the highest priority, as well as the needs of the patient’s family. This case study highlights the nuanced contextual factors necessary to guide a treatment team’s approach to DCD for a patient with uncertain decision-making capacity. (shrink)

Alstin, Zac Results of a Belgian study have revealed that a large number of people suffering from Locked-In Syndrome are happy. Disability is foremost a challenge to one's values, not to our happiness.

An Essay Concerning Human Understanding is a work by John Locke concerning the foundation of human knowledge and understanding. It first appeared in 1689 (although dated 1690) with the printed title An Essay Concerning Humane Understanding. He describes the mind at birth as a blank slate (tabula rasa, although he did not use those actual words) filled later through experience. The essay was one of the principal sources of empiricism in modern philosophy, and influenced many enlightenment philosophers, such as David (...) Hume and George Berkeley. (shrink)

Ever since humankind raised its head toward the heavens in search of universal understanding and spiritual fulfilment, wars, pogroms, persecution, prejudice, and contempt have been the means of resolving the many and varied disagreements that have arisen over matters religious. In his Letter Concerning Toleration, Locke offers a compelling plea for freedom of conscience and religious expression. He outlines the limits of social and political incursion into the realm of personal belief or non-belief, discusses the dangers of mixing church and (...) state, and strikes hard at those who would use the power of the state to fulfil religious or political goals. Rational persuasion is always to be encouraged in the hope that wayward souls may find a moral direction in life, but the use of force in such matters is unwarranted and unacceptable. Locke also addresses the question of denominational infighting and relations among the major religions. Talk of heresy and schism should be set aside in favour of understanding and co-operation to achieve mutually desirable social ends. (shrink)

Locke lived at a time of heightened religious sensibility, and religious motives and theological beliefs were fundamental to his philosophical outlook. Here, Victor Nuovo brings together the first comprehensive collection of Locke's writings on religion and theology. These writings illustrate the deep religious motivation in Locke's thought.

This book brings together a comprehensive collection of the writings of one of the greatest philosophers in the Western tradition. Along with five of John Locke's major essays, seventy shorter essays are included that stand outside the canonical works that Locke published during his lifetime. For the first time students will be able to fully explore the evolution of Locke's ideas concerning the philosophical foundations of morality and sociability, the boundary of church and state, the shaping of constitutions, and the (...) conduct of government and public policy. (shrink)

This book brings together a comprehensive collection of the writings of one of the greatest philosophers in the Western tradition. Along with five of John Locke's major essays, seventy shorter essays are included that stand outside the canonical works that Locke published during his lifetime. For the first time students will be able to fully explore the evolution of Locke's ideas concerning the philosophical foundations of morality and sociability, the boundary of church and state, the shaping of constitutions, and the (...) conduct of government and public policy. (shrink)

This is a reproduction of the original artefact. Generally these books are created from careful scans of the original. This allows us to preserve the book accurately and present it in the way the author intended. Since the original versions are generally quite old, there may occasionally be certain imperfections within these reproductions. We're happy to make these classics available again for future generations to enjoy!

Bundel opstellen over de belangrijkste stromingen in en auteurs over politieke filosofie, waarin thema's als het zoeken naar waarheid en rechtvaardigheid centraal staan.

This is a new revised version of Dr. Laslett's standard edition of Two Treatises. First published in 1960, and based on an analysis of the whole body of Locke's publications, writings, and papers. The Introduction and text have been revised to incorporate references to recent scholarship since the second edition and the bibliography has been updated.

This volume is the first of three which will contain all of Locke's extant writings on philosophy which relate to An Essay Concerning Human Understanding, other than those contained in volumes of the Clarendon Edition of John Locke such as the Correspondence. The book contains the two earliest known drafts of the Essay, both written in 1671, and provides for the first time an accurate version of Locke's text together with a record of virtually all his changes, in notes at (...) the foot of each page. (shrink)

According to a number of recent philosophers, knowledge has an intimate relationship with rationality. Some philosophers hold, in particular, that rational agents do things for good motivating reasons, and that p can be one’s motivating reason for -ing (acting/believing/fearing/etc.) only if one knows that p. This paper argues against this view and in favor of the view that p cannot be one’s motivating reason for -ing—in the relevant sense—unless there is an appropriate explanatory connection between the fact that p and (...) one’s -ing. I argue that this view offers a better account of the cases alleged to support the knowledge view. (shrink)

This work has been selected by scholars as being culturally important, and is part of the knowledge base of civilization as we know it. This work was reproduced from the original artifact, and remains as true to the original work as possible. Therefore, you will see the original copyright references, library stamps (as most of these works have been housed in our most important libraries around the world), and other notations in the work. This work is in the public domain (...) in the United States of America, and possibly other nations. Within the United States, you may freely copy and distribute this work, as no entity (individual or corporate) has a copyright on the body of the work. As a reproduction of a historical artifact, this work may contain missing or blurred pages, poor pictures, errant marks, etc. Scholars believe, and we concur, that this work is important enough to be preserved, reproduced, and made generally available to the public. We appreciate your support of the preservation process, and thank you for being an important part of keeping this knowledge alive and relevant. (shrink)

What is known? And how do we come to know it? These are the primary points of focus for metaphysics and epistemology, respectively. Here, in one of the classic works of early-modern empiricist philosophy, John Locke (1632-1704) attempts to answer these basic human questions by moving away from the rationalist notion of innate ideas to establish the concept of the tabula rasa in which the mind is initially impressed with ideas through perception of the external world of substance. The formation (...) of basic ideas through the perception of primary and secondary qualities, and the more sophisticated development of concepts, is discussed as Locke departs from a purely mental view of knowledge to ground what we know in the firmer soil of empirical observation and in the mind's ability to interrelate ideas from perception. The careful reasoning of Locke's Essay has made it an enduring part of the history of of Western philosophy. (shrink)

In recent years, global corporations and national governments have been enacting a growing number of codes of conduct and public regulations to combat dangerous and degrading work conditions in global supply chains. At the receiving end of this activity, local producers must contend with multiple regulatory regimes, but it is unclear how these regimes interact and what results, if any, they produce. This article examines this dynamic in the sugar sector in Brazil. It finds that although private and public agents (...) rarely communicate, let alone coordinate with one another, they nevertheless reinforce each other’s actions. Public regulators use their legal powers to outlaw extreme forms of outsourcing. Private auditors use the trust they command as company insiders to instigate a process of workplace transformation that facilitates compliance. Together, their parallel actions block the low road and guide targeted firms to a higher road in which improved labor standards are not only possible but even desirable. (shrink)

This paper offers a novel conversational implicature account of the pragmatic sensitivity of knowledge attributions. Developing an account I first suggested elsewhere and independently proposed by Lutz, this paper explores the idea that the relevant implicatures are generated by a constitutive relationship between believing a proposition and a disposition to treat that proposition as true in practical deliberation. I argue that while this view has a certain advantage over standard implicature accounts of pragmatic sensitivity, it comes with a significant concession (...) to proponents of pragmatic encroachment. On the account offered here, knowledge attributions have locally-pragmatically-sensitive implicatures because they have non-locally-pragmatically-sensitive entailments. The view thus represents a unique and powerful hybrid of these two approaches to the pragmatic sensitivity of knowledge attributions. (shrink)