Writing from a scientifically and philosophically informed perspective, the authors provide a critical overview of the conceptual difficulties encountered in many current neuroscientific and psychological theories.

Here is a thoroughly updated edition of a classic in palliative medicine. Two new chapters have been added to the 1991 edition, along with a new preface summarizing where progress has been made and where it has not in the area of pain management. This book addresses the timely issue of doctor-patient relationships arguing that the patient, not the disease, should be the central focus of medicine. Included are a number of compelling patient narratives. Praise for the first edition "Well (...) written. . .should be read by everyone in medical practice or considering a career in medicine."---JAMA. "Memorable passages, important ideas, and critical analysis. This is a book that clinicians and educators should read."---New England Journal of Medicine. (shrink)

The position advanced in this paper is that the bedrock of emotional feelings is contained within the evolved emotional action apparatus of mammalian brains. This dual-aspect monism approach to brain–mind functions, which asserts that emotional feelings may reflect the neurodynamics of brain systems that generate instinctual emotional behaviors, saves us from various conceptual conundrums. In coarse form, primary process affective consciousness seems to be fundamentally an unconditional “gift of nature” rather than an acquired skill, even though those systems facilitate skill (...) acquisition via various felt reinforcements. Affective consciousness, being a comparatively intrinsic function of the brain, shared homologously by all mammalian species, should be the easiest variant of consciousness to study in animals. This is not to deny that some secondary processes cannot be evaluated in animals with sufficiently clever behavioral learning procedures, as with place-preference procedures and the analysis of changes in learned behaviors after one has induced re-valuation of incentives. Rather, the claim is that a direct neuroscientific study of primary process emotional/affective states is best achieved through the study of the intrinsic , albeit experientially refined, emotional action tendencies of other animals. In this view, core emotional feelings may reflect the neurodynamic attractor landscapes of a variety of extended trans-diencephalic, limbic emotional action systems—including SEEKING, FEAR, RAGE, LUST, CARE, PANIC, and PLAY. Through a study of these brain systems, the neural infrastructure of human and animal affective consciousness may be revealed. Emotional feelings are instantiated in large-scale neurodynamics that can be most effectively monitored via the ethological analysis of emotional action tendencies and the accompanying brain neurochemical/electrical changes. The intrinsic coherence of such emotional responses is demonstrated by the fact that they can be provoked by electrical and chemical stimulation of specific brain zones—effects that are affectively laden. For substantive progress in this emerging research arena, animal brain researchers need to discuss affective brain functions more openly. Secondary awareness processes, because of their more conditional, contextually situated nature, are more difficult to understand in any neuroscientific detail. In other words, the information-processing brain functions, critical for cognitive consciousness, are harder to study in other animals than the more homologous emotional/motivational affective state functions of the brain. (shrink)

The application of neuroimaging technology to the study of the injured brain has transformed how neuroscientists understand disorders of consciousness, such as the vegetative and minimally conscious states, and deepened our understanding of mechanisms of recovery. This scientific progress, and its potential clinical translation, provides an opportunity for ethical reflection. It was against this scientific backdrop that we convened a conference of leading investigators in neuroimaging, disorders of consciousness and neuroethics. Our goal was to develop an ethical frame to move (...) these investigative techniques into mature clinical tools. This paper presents the recommendations and analysis of a Working Meeting on Ethics, Neuroimaging and Limited States of Consciousness held at Stanford University during June 2007. It represents an interdisciplinary approach to the challenges posed by the emerging use of neuroimaging technologies to describe and characterize disorders of consciousness. (shrink)

A pressing issue in neuroscience is the high rate of misdiagnosis of disorders of consciousness. As new research on patients with disorders of consciousness has revealed surprising and previously unknown cognitive capacities, the need to develop better and more reliable methods of diagnosing these disorders becomes more urgent. So too the need to expand our ethical and social frameworks for thinking about these patients, to accommodate new concerns that will accompany new revelations. A recent study on trace conditioning and learning (...) in vegetative and minimally conscious patients shows promise as a potential diagnostic and prognostic tool, both for differentiating between states of diminished consciousness, and for predicting patient outcomes, but it also generates fresh concerns about quality of life in patients previously thought to be completely unaware. Optimism about progress in diagnosing and treating disorders of consciousness must be tempered by the understanding that not all progress will necessarily be good for all patients. The prognosis for most patients remains bleak, and we must remain vigilant to acute questions and concerns about welfare and quality of life. (shrink)

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those (...) feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness. (shrink)

Recent studies indicate that patients who are diagnosed with vegetative states may retain more awareness than their clinical assessments suggest. Disorders of consciousness traditionally have been diagnosed on the basis of outwardly observable behaviors alone, but new functional imaging studies have shown surprising levels of brain activity in some patients, indicating that even higher-level cognitive functions like language processing and visual imagery may be preserved. For example, one recently developed method purports to detect voluntary mental imagery solely on the basis (...) of neural response patterns observed with functional magnetic resonance imaging. This line of research has already led to some widely reported cases of patients who were discovered to have more brain activity than expected. In November 2009, Rom Houben, a Belgian man who was thought to be in a coma for 23 years, was diagnosed with locked-in syndrome through the use of neuroimaging; however, that assessment was later overturned by further testing. (shrink)

The application of neuroimaging technology to the study of the injured brain has transformed how neuroscientists understand disorders of consciousness, such as the vegetative and minimally conscious states, and deepened our understanding of mechanisms of recovery. This scientific progress, and its potential clinical translation, provides an opportunity for ethical reflection. It was against this scientific backdrop that we convened a conference of leading investigators in neuroimaging, disorders of consciousness and neuroethics. Our goal was to develop an ethical frame to move (...) these investigative techniques into mature clinical tools. This paper presents the recommendations and analysis of a Working Meeting on Ethics, Neuroimaging and Limited States of Consciousness held at Stanford University during June 2007. It represents an interdisciplinary approach to the challenges posed by the emerging use of neuroimaging technologies to describe and characterize disorders of consciousness. (shrink)

If ever I summon before me my highest ideals of men and medicine, I find them sprung from the spirit of Osler. —Wilder Penfield, M.D. Neuroethics is a recently coined term that is shaping our cultu...

In lieu of an abstract, here is a brief excerpt of the content:Convention for Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Biomedicine: Convention on Human Rights and BiomedicineCouncil of EuropePreambleThe Member States of the Council of Europe, the other States and the European Community signatories hereto,Bearing in mind the Universal Declaration of Human Rights proclaimed by the General Assembly of the United Nations on 10 December 1948;Bearing in mind the (...) Convention for the Protection of Human Rights and Fundamental Freedoms of 4 November 1950;Bearing in mind the European Social Charter of 18 October 1961;Bearing in mind the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights of 16 December 1966;Bearing in mind the Convention for the Protection of Individuals with Regard to Automatic Processing of Personal Data of 28 January 1981;Bearing also in mind the Convention on the Rights of the Child of 20 November 1989;Considering that the aim of the Council of Europe is the achievement of a greater unity between its members and that one of the methods by which that aim is to be pursued is the maintenance and further realisation of human rights and fundamental freedoms;Conscious of the accelerating developments in biology and medicine;Convinced of the need to respect the human being both as an individual and as a member of the human species and recognising the importance of ensuring the dignity of the human being; [End Page 277]Conscious that the misuse of biology and medicine may lead to acts endangering human dignity;Affirming that progress in biology and medicine should be used for the benefit of present and future generations;Stressing the need for international co-operation so that all humanity may enjoy the benefits of biology and medicine;Recognising the importance of promoting a public debate on the questions posed by the application of biology and medicine and the responses to be given thereto;Wishing to remind all members of society of their rights and responsibilities;Taking account of the work of the Parliamentary Assembly in this field, including Recommendation 1160 (1991) on the preparation of a Convention on bioethics;Resolving to take such measures as are necessary to safeguard human dignity and the fundamental rights and freedoms of the individual with regard to the application of biology and medicine;Have agreed as follows:Chapter IGeneral provisionsArticle 1. (Purpose and object)Parties to this Convention shall protect the dignity and identity of all human beings and guarantee everyone, without discrimination, respect for their integrity and other rights and fundamental freedoms with regard to the application of biology and medicine.Each Party shall take in its internal law the necessary measures to give effect to the provisions of this Convention.Article 2. (Primacy of the human being)The interests and welfare of the human being shall prevail over the sole interest of society or science.Article 3. (Equitable access to health care)Parties, taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to health care of appropriate quality. [End Page 278]Article 4. (Professional standards)Any intervention in the health field, including research, must be carried out in accordance with relevant professional obligations and standards.Chapter IIConsentArticle 5. (General rule)An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it.This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks.The person concerned may freely withdraw consent at any time.Article 6. (Protection of persons not able to consent)1. Subject to Articles 17 and 20 below, an intervention may only be carried out on a person who does not have the capacity to consent, for his or her direct benefit.2. Where, according to law, a minor does not have the capacity to consent to an intervention, the intervention may only be carried out with the authorisation of his or her representative or an authority or a person or... (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

In this paper, we review recent neuroimaging investigations of disorders of consciousness and different disciplines' understanding of consciousness itself. We consider potential tests of consciousness, their legal significance, and how they map onto broader themes in U.S. statutory law pertaining to advance directives and surrogate decision-making. In the process, we outline a taxonomy of themes to illustrate and clarify the variance in state-law definitions of consciousness. Finally, we discuss broader scientific, ethical, and legal issues associated with the advent of neuroimaging (...) for disorders of consciousness and conclude with policy recommendations that could help to mitigate confusion in this realm. (shrink)

Writing from a scientifically and philosophically informed perspective, the authors provide a critical overview of the conceptual difficulties encountered in many current neuroscientific and psychological theories.

William Uttal is concerned that in an effort to prove itself a hard science, psychology may have thrown away one of its most important methodological tools—a critical analysis of the fundamental assumptions that underlie day-to-day empirical research. In this book Uttal addresses the question of localization: whether psychological processes can be defined and isolated in a way that permits them to be associated with particular brain regions. New, noninvasive imaging technologies allow us to observe the brain while it is actively (...) engaged in mental activities. Uttal cautions, however, that the excitement of these new research tools can lead to a neuroreductionist wild goose chase. With more and more cognitive neuroscientific data forthcoming, it becomes critical to question their limitations as well as their potential. Uttal reviews the history of localization theory, presents the difficulties of defining cognitive processes, and examines the conceptual and technical difficulties that should make us cautious about falling victim to what may be a "neo-phrenological" fad. (shrink)

In "The Quest for Consciousness," Caltech neuroscientist Christof Koch explores the biological basis of consciousness.

While philosophers have, for centuries, pondered upon the relation between mind and brain, neuroscientists have only recently been able to explore the connection analytically — to peer inside the black box. This ability stems from recent advances in technology and emerging neuroimaging modalities. It is now possible not only to produce remarkably detailed images of the brain’s structure (i.e. anatomical imaging) but also to capture images of the physiology associated with mental processes (i.e. functional imaging). We are able to see (...) how specific regions of the brain ‘light up’ when activities such as reading this book are performed, and how our neurons and their elaborate cast of supporting cells organize and coordinate their tasks. As demonstrated in the other chapters of this book, the mapping of the human mind (mostly by measuring regional changes in blood flow, initially by positron emission tomography (PET) and recently by functional magnetic resonance imaging or (fMRI)) has provided insight into the functional neuroanatomy of neuropsychiatric diseases. Amazingly, the idea that regional cerebral blood flow (rCBF) is related intimately to brain function goes back more than a century. As is often the case in science, this idea was initially the result of unexpected observations. The Italian physiologist Angelo Mosso first expressed the idea while studying pulsations of the living human brain that keep pace with the heartbeat (Mosso, 1881). These brain pulsations can be observed on the surface of the fontanelles in newborn children. Mosso believed that they reflected blood flow to the brain. He observed similar pulsations in an adult with a post-traumatic skull defect over the frontal lobes. While studying this subject, a peasant named Bertino, Mosso observed a sudden increase in the magnitude of the ‘brain’s heart-beats’ when the church bells signalled 12 o’clock, the time for a required prayer. The changes in brain pulsations occurred independently of any change in pulsations in the forearm.. (shrink)