This article provides an ethical analysis of the U.S. practice guideline update on disorders of consciousness. Our analysis focuses on the guideline’s recommendations regarding the use of investigational neuroimaging methods to assess brain‐injured patients. Complex and multifaceted ethical issues have emerged because these methods alter the clinical understanding of consciousness. We address issues of false hope, patient suffering, and cost. We argue that, in spite of these concerns, there is significant benefit to using neuroimaging to assess brain‐injured patients in most (...) cases. (shrink)

Rapid technological advances have produced a variety of novel techniques that allow a comprehensive assessment of brain function to be combined with detailed information about brain structure and connectivity. Any assessment that is based on exhibited behavior after brain injury will be prone to error for a number of reasons. These questions are explored in the context of recent studies in both healthy populations and brain injured patients that have sought to investigate covert awareness through the use of functional neuroimaging. (...) Those circumstances in which functional magnetic resonance imaging data can be used to infer awareness in the absence of a behavioral response are contrasted with those circumstances in which it cannot. This distinction is fundamental for understanding and interpreting patterns of brain activity following acute brain injury and has implications for clinical care, diagnosis, prognosis, and medicolegal decision-making after serious brain injury. (shrink)

Idiopathic Parkinson’s disease impairs working memory, but the exact nature of this deficit in terms of the underlying cognitive mechanisms is not well understood. In this study patients with mild clinical symptoms of PD were compared with matched healthy control subjects on a computerized battery of tests designed to assess spatial working memory and verbal working memory. In the spatial working memory task, subjects were required to recall a sequence of four locations. The verbal working memory task was methodologically identical (...) except for the modality of the stimuli used, requiring subjects to orally recall a sequence of six digits. In either case, half of the sequences were structured in a way that allowed ‘chunking’, while others were unstructured. This manipulation was designed to dissociate the strategic component of task performance from the memory-load component. Mild medicated patients with PD were impaired only on the structured versions of the verbal working memory tasks. The analogous deficit in the spatial working memory was less pronounced. These findings are in agreement with the hypothesis that working memory deficits in PD reflect mainly the executive component of the tasks and that the deficits may be at least partly modality-independent. (shrink)

BackgroundSevere brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope.MethodsTo examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who were (...) enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study.ResultsTwelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results.ConclusionThis study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. (shrink)

Which systems/organisms are conscious? New tests for consciousness (‘C-tests’) are urgently needed. There is persisting uncertainty about when consciousness arises in human development, when it is lost due to neurological disorders and brain injury, and how it is distributed in nonhuman species. This need is amplified by recent and rapid developments in artificial intelligence (AI), neural organoids, and xenobot technology. Although a number of C-tests have been proposed in recent years, most are of limited use, and currently we have no (...) C-tests for many of the populations for which they are most critical. Here, we identify challenges facing any attempt to develop C-tests, propose a multidimensional classification of such tests, and identify strategies that might be used to validate them. (shrink)

:Recent neuroimaging research on disorders of consciousness provides direct evidence of covert consciousness otherwise not detected clinically in a subset of severely brain-injured patients. These findings have motivated strategic development of binary communication paradigms, from which researchers interpret voluntary modulations in brain activity to glean information about patients’ residual cognitive functions and emotions. The discovery of such responsiveness raises ethical and legal issues concerning the exercise of autonomy and capacity for decisionmaking on matters such as healthcare, involvement in research, and (...) end of life. These advances have generated demands for access to the technology against a complex background of continued scientific advancement, questions about just allocation of healthcare resources, and unresolved legal issues. Interviews with professionals whose work is relevant to patients with disorders of consciousness reveal priorities concerning further basic research, legal and policy issues, and clinical considerations. (shrink)

Over the last few decades, neuroimaging techniques have transformed our understanding of the brain and the effect of neurological conditions on brain function. More recently, light-based modalities such as functional near-infrared spectroscopy have gained popularity as tools to study brain function at the bedside. A recent application is to assess residual awareness in patients with disorders of consciousness, as some patients retain awareness albeit lacking all behavioural response to commands. Functional near-infrared spectroscopy can play a vital role in identifying these (...) patients by assessing command-driven brain activity. The goal of this review is to summarise the studies reported on this topic, to discuss the technical and ethical challenges of working with patients with disorders of consciousness, and to outline promising future directions in this field. (shrink)

Functional MRI shows promise as a candidate prognostication method in acutely comatose patients following severe brain injury. However, further research is needed before this technique becomes appropriate for clinical practice. Drawing on a clinical case, we investigate the process of obtaining informed consent for this kind of research and identify four ethical issues. After describing each issue, we propose potential solutions which would make a patient’s participation in research compatible with her rights and interests. First, we defend the need for (...) traditional proxy consent against two alternative approaches. Second, we examine the impact of the intensive care unit environment on the informed consent process. Third, we discuss the therapeutic misconception and its potential influence on informed consent. Finally, we deal with issues of timing in recruiting participants and related factors which may affect the risks of participation. (shrink)

This paper critically examines whether patients with severe brain injury, who can only communicate through assistive neuroimaging technologies, may permissibly participate in medical decisions. We examine this issue in the context of a unique case study from the Brain and Mind Institute at the University of Western Ontario. First, we describe how the standard approach to medical decision making might problematically exclude patients with communication impairments secondary to severe brain injury. Second, we present a modified approach to medical decision making. (...) We argue that this approach might warrant the inclusion of some patients with severe brain injury in low-stakes decisions, or to express preferences. Third, we present a model of supported decision making to address recalcitrant uncertainty. We conclude by suggesting that the modified approach to decision making and supported decision making might allow a patient with severe brain injury to participate in some medical decisions. Our analysis is provisional and has not yet been implemented in practice. Our discussion is intended to generate further debate on approaches to enhancing autonomy in patients with profound motor and cognitive impairments. (shrink)

Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques (...) are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to “yes” or “no” answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients. (shrink)

After severe brain injury, one of the key challenges for medical doctors is to determine the patient’s prognosis. Who will do well? Who will not do well? Physicians need to know this, and families need to do this too, to address choices regarding the continuation of life supporting therapies. However, current prognostication methods are insufficient to provide a reliable prognosis. -/- Functional Magnetic Resonance Imaging (MRI) holds considerable promise for improving the accuracy of prognosis in acute brain injury patients. Nonetheless, (...) research on functional MRI in the intensive care unit context is ethically challenging. These studies raise several ethical issues that have not been addressed so far. In this article, Prof. Charles Weijer and his co-workers provide a framework for researchers and ethics committees to design and review these studies in an ethically sound way. (shrink)

This white paper outlines the plans of the History Philosophy Culture Working Group of the Next Generation Event Horizon Telescope Collaboration.

The Humean conception of the self consists in the belief-desire model of motivation and the utility-maximizing model of rationality. This conception has dominated Western thought in philosophy and the social sciences ever since Hobbes’ initial formulation in Leviathan and Hume’s elaboration in the Treatise of Human Nature. Bentham, Freud, Ramsey, Skinner, Allais, von Neumann and Morgenstern and others have added further refinements that have brought it to a high degree of formal sophistication. Late twentieth century moral philosophers such as Rawls, (...) Brandt, Frankfurt, Nagel and Williams have taken it for granted, and have made use of it to supply metaethical foundations for a wide variety of normative moral theories. But the Humean conception of the self also leads to seemingly insoluble problems about moral motivation, rational final ends, and moral justification. Can it be made to work? (shrink)

I wish to defend the claim that given the content and structure of any moral theory we are likely to find palatable, there is no way of uniquely breaking down that theory into either consequentialist or deontological elements. Indeed, once we examine the actual structure of any such theory more closely, we see that it can be classified in either way arbitrarily. Hence if we ignore the metaethical pronouncements often made by adherents of the consequentialist-deontological distinction, we are quickly led (...) to the conclusion that this distinction contributes nothing of consequence to an understanding of moral theory. I will try to show that there are basically two reasons for this. First, what we mean by the terms endemic to the consequentialist-deontological distinction have no unique references to particular states of affairs in actual cases of moral decision making. Hence we may justify any such concrete moral decision by reference to typically consequentialist or deontological reasoning indifferently. Second, scrutiny of actual and viable moral theories reveals a much finer-grained structure than the consequentialist-deontological taxonomy can capture. And it is this structure, rather than simple attention to consequences or principles, that determines practical moral decision making. We would thus do better to develop the richer vocabulary of causes and constituents, goals and effects, states and events (mental, social, or physical). So in the end, the consequentialist-deontological distinction is irrelevant at the normative level of actual moral reasoning, whereas at the metaethical level it crudely schematizes two opposing types of dummy theory, neither of which is convincing, upon reflection, to any practicing moral philosopher. (shrink)

We need modal imagination in order to extend our conception of reality - and, in particular, of human beings - beyond our immediate experience in the indexical present; and we need to do this in order to preserve the significance of human interaction. To make this leap of imagination successfully is to achieve not only insight but also an impartial perspective on our own and others' inner states. This perspective is a necessary condition of experiencing compassion for others. This is (...) the primary thesis I will try to defend in this discussion. (shrink)

Most moral theories share certain features in common with other theories. They consist of a set of propositions that are universal, general, and hence impartial. The propositions that constitute a typical moral theory are (1) universal, in that they apply to all subjects designated as within their scope. They are (2) general, in that they include no proper names or definite descriptions. They are therefore (3) impartial, in that they accord no special privilege to any particular agent's situation which cannot (...) be justified under (2) and (3). These three features do not distinguish moral theories from other theories, nor indeed from most general categorical propositions we assert. Yet, in recent years, these features of moral theories have been the target of a certain concerted and sustained criticism, namely, that to be committed to such a moral theory, or to aspire to act in accordance with its requirements, results in what has come to be known as moral alienation. Moral alienation, according to this criticism, consists in (i) viewing one's ground projects from an impersonal, "moral point of view" engendered by one's acceptance of the theory; (ii) being prepared to sacrifice these projects to the requirements of moral principle; and (iii) making such a sacrifice specifically and self-consciously in order to conform to these requirements. Moral alienation is said to manifest itself in one (or both) of two ways, depending on the nature of the project thus susceptible to sacrifice. One may be alienated from oneself, if the project consists of tastes, convictions, or aspirations that are centrally definitive of one's self. In this case one's commitment to the project can be at best conditional on its congruence with one's moral theory. It is claimed that this must make for a rather tepid and unenthusiastic commitment indeed. Alternatively, one may be alienated from others, if the project is an interpersonal relationship such as a friendship, marriage, or collegial relationship. In this case one's responses to the other are motivated by one's awareness of what one's moral theory requires. It is claimed that this obstructs a genuine and unmediated emotional response to the other as such. My aim here will be to argue that this very compelling criticism - call it the moral-alienation criticism - is nevertheless misdirected. The real culprit is not any particular moral theory, but rather a certain familiar personality type that may or may not adopt it. (shrink)

The proliferation of mitochondrial DNA (mtDNA) with deletion mutations has been linked to aging and age related neurodegenerative conditions. In this study we model the effect of mtDNA half-life on mtDNA competition and selection. It has been proposed that mutation deletions (mtDNAdel\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{del}$$\end{document}) have a replicative advantage over wild-type (mtDNAwild\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{wild}$$\end{document}) and that this is detrimental to the host cell, especially in post-mitotic (...) cells. An individual cell can be viewed as forming a closed ecosystem containing a large population of independently replicating mtDNA. Within this enclosed environment a selfishly replicating mtDNAdel\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{del}$$\end{document} would compete with the mtDNAwild\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{wild}$$\end{document} for space and resources to the detriment of the host cell. In this paper, we use a computer simulation to model cell survival in an environment where mtDNAwild\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{wild}$$\end{document} compete with mtDNAdel\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{del}$$\end{document} such that the cell expires upon mtDNAwild\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{wild}$$\end{document} extinction. We focus on the survival time for long lived post-mitotic cells, such as neurons. We confirm previous observations that mtDNAdel\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{del}$$\end{document} do have a replicative advantage over mtDNAwild\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{wild}$$\end{document}. As expected, cell survival times diminished with increased mutation probabilities, however, the relationship between survival time and mutation rate was non-linear, that is, a ten-fold increase in mutation probability only halved the survival time. The results of our model also showed that a modest increase in half-life had a profound affect on extending cell survival time, thereby, mitigating the replicative advantage of mtDNAdel\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\text {mtDNA}_{del}$$\end{document}. Given the relevance of mitochondrial dysfunction to various neurodegenerative conditions, we propose that therapies to increase mtDNA half-life could significantly delay their onset. (shrink)

In our dealings with young children, we often get them to do or think things by arranging their environments in certain ways; by dissembling, simplifying, or ambiguating the facts in answer to their queries; by carefully selecting the states of affairs, behavior of others, and utterances to which they shall be privy. We rightly justify these practices by pointing out a child's malleability, and the necessity of paying close attention to formative influences during its years of growth. This filtering of (...) influences is necessary, we point out, if children are ever to reach a degree of maturity and inner stability that will enable them to understand and cope adequately with the complexities, contradictions, and difficulties of the world from which we now seek to shield them. Thus a child's eventual state of competence, maturity, and autonomy adequately justifies our current practices of manipulation and selection of his environment: such practices are rightly held to be ultimately in the child's best interests as an adult. There is no future state of things with reference to which the Utilitarian night justify his policy of secrecy and manipulation, and in light of which this policy night eventually be dispensed with and commonly validated, in retrospect, as a means to the worthwhile goal of moral maturity. That is, there is no point at which the attitude of the Utilitarian to the rest of the community can develop past the analogous attitude of the parent towards the child; no point at which the Utilitarian might eventually bear to others a relationship of mutual acknowledgement and respect as mature, autonomous, moral adults. The consistent Utilitarian, then, largely regards himself as if he were the only adult in a community of children. (shrink)

This discussion treats a set of familiar social derelictions as consequences of the perversion of a universalistic moral theory in the service of an ill-considered or insufficiently examined personal agenda.The set includes racism, sexism, anti-Semitism, homophobia, and class elitism, among other similar pathologies, under the general heading of discrimination. The perversion of moral theory from which these derelictions arise, I argue, involves restricting its scope of application to some preferred subgroup of the moral community of human beings. -/- The following (...) analysis of higher-order discrimination suggests that we often select the individuals who constitute such subgroups for reasons that we ourselves would reject on moral grounds were we to examine them carefully, but that we choose instead to put our rational resources in the service of avoiding any such examination at all costs. The implication is that arguments that truncate the scope of moral theory in fact justify bestowing the gift of moral treatment on a select few who deserve it no more than the many from whom we withhold it. Therefore, it would be precipitous to conclude that universalistic moral theory can be legitimately restricted in its practical scope of application in any way at all. (shrink)

I want to argue that self-deception is a species of a more general phenomenon, which I shall call pseudorationality, which in turn is necessitated by what I shall describe as our highest-order disposition to literal self-preservation. By "literal self-preservation," I mean preservation of the rational intelligibility of the self, in the face of recalcitrant facts that invariably threaten it.

Adrian Piper argues that the Humean conception can be made to work only if it is placed in the context of a wider and genuinely universal conception of the self, whose origins are to be found in Kant’s Critique of Pure Reason. This conception comprises the basic canons of classical logic, which provide both a model of motivation and a model of rationality. These supply necessary conditions both for the coherence and integrity of the self and also for unified (...) agency. The Kantian conception solves certain intractable problems in decision theory by integrating it into classical predicate logic, and provides answers to longstanding controversies in metaethics concerning moral motivation, rational final ends, and moral justification that the Humean conception engenders. In addition, it sheds light on certain kinds of moral behavior – for example, the whistleblower – that the Humean conception is at a loss to explain. (shrink)

The purpose of this discussion is twofold. First, I want to shed some light on Kant's concept of personhood as rational agency, by situating it in the context of the first Critique's conception of the self as defined by its rational dispositions. I hope to suggest that this concept of personhood cannot be simply grafted onto an essentially Humean conception of the self that is inherently inimical to it, as I believe Rawls, Gewirth, and others have tried to do. Instead (...) I will try to show how deeply embedded this concept of personhood is in Kant's conception of the self as rationally unified consciousness. Second, I want to deploy this embedded concept of personhood as the basis for an analysis of the phenomenon of xenophobia. (shrink)

Most published discussions in contemporary metaethics include some textual exegesis of the relevant contemporary authors, but little or none of the historical authors who provide the underpinnings of their general approach. The latter is usually relegated to the historical, or dismissed as expository. Sometimes this can be a useful division of labor. But it can also lead to grave confusion about the views under discussion, and even about whose views are, in fact, under discussion. Elijah Millgram’s article, “Does the Categorical (...) Imperative Give Rise to a Contradiction in the Will?” is a case in point. In it, he takes the New Kantians to task for various flaws in their interpretation of Kant’s moral theory, to be detailed shortly. He concludes with a question and a suggestion. In order to properly dissect the first, “universal law” formulation of the Categorical Imperative, he argues, we first need to understand “why an agent wills the universalization of his maxim” (549). He also suggests that in order to answer this question, we must recur to what Kant himself actually says (550). His question is a good one, and his advice on how to go about answering it is sound. But to take Millgram’s advice is to call this division of labor into question, at least for this case. For it demands close and sustained exegesis, not only of his argument against the New Kantians, but also – in order to assess whether and where they go wrong – of Kant’s text itself. (shrink)

In an era of transition and tension in American health care, Dorothy M. Owens offers a model of empathic communication that benefits both patients and physicians. Drawing from concepts in the domains of psychology and theology, she constructs a model of empathy that is ethical and reciprocal. An integrated model of empathy recognizes the physical, psychological, spiritual, and social nature of human beings. Empathy is a clinically useful, time-effective communication skill that can be taught in medical and pastoral education. Dr. (...) Owens's unique approach to empathy is applicable to other professional and personal relationships as well. (shrink)

Kant identifies what are in fact Free Riders as the most noxious species of polemicists. Kant thinks polemic reduces the stature and authority of reason to a method of squabbling that destabilizes social equilibrium and portends disintegration into the Hobessian state of nature. In the first Critique, Kant proposes two textually related solutions to the Free Rider problem.

My intellectual journey in philosophy proceeded along two mountainous paths that coincided at their base, but forked less than halfway up the incline. The first is that of my philosophical development, a steep but steady and continuous ascent. It began in my family, and accelerated in high school, art school, college, and graduate school. Those foundations propelled my philosophical research into the nature of rationality and its relation to the structure of the self, a long-term project focused on the Kantian (...) and Humean metaethical traditions in Anglo-American analytic philosophy. It would have been impossible to bring this project to completion without the anchor, compass, and conceptual mapping provided by my prior, longstanding involvement in the practice and theory of Vedic philosophy. The second path is that of my professional route through the field of academic philosophy, which branched onto a rocky detour in graduate school, followed by a short but steep ascent, followed next by a much steeper, sustained descent off that road, into the ravine, down in flames, and out of the profession. In order to reach the summit of the first path, I had to reach the nadir of the second. It was the right decision. My yoga practice cushioned my landing. (shrink)