Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

John Christman has argued that constitutively relational accounts of autonomy, as defended by some feminist theorists, are problematically perfectionist about the human good. I argue that autonomy is constitutively relational, but not in a way that implies perfectionism: autonomy depends on a dialogical disposition to hold oneself answerable to external, critical perspectives on one's action-guiding commitments. This type of relationality carries no substantive value commitments, yet it does answer to core feminist concerns about autonomy.

Goering and colleagues (2017) acknowledge closed-loop neural devices have the potential to undermine agency. Indeed, the authors observe that “the agent using the device may . . . sometimes doubt whether she is the author of her action, given that the device may operate in ways that are not transparent to her” (65). Still, the authors ultimately argue that closed-loop neural devices may be construed as supporting agency, especially when we view agency from a relational perspective. The reason? We often (...) manifest our agency in relation with others. For example, family and close friends sometimes step in to support us in setting and achieving our aims. In a similar way, then, the authors argue that “we can imagine [a closed-loop] device stepping in to support the user in achieving her aim” (67). Closed-loop neural devices, in other words, can be construed as supporting one’s agency in much the same way as other people can be seen as supporting one’s agency. The authors thus conclude that when we view agents from a relational perspective, closed-loop neural devices may be viewed as supporting rather than undermining agency. I largely agree with the authors’ conclusion. I also believe, however, that their discussion can be clarified by distinguishing three kinds of agency and viewing closed-loop neural devices from the perspective of each. By thinking carefully about agency, we can see more clearly the ways in which it is undermined by closed-loop neural devices, as well as the way in which these devices may support agency. (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)

The differences between critics and proponents of enhancement technologies are easily overblown. Both sides of this debate share the moral ideal of being “authentic” to oneself. They differ in how they prefer to understand authenticity, but even this difference is not as stark as it sometimes seems.

: The differences between critics and proponents of enhancement technologies are easily overblown. Both sides of this debate share the moral ideal of being "authentic" to oneself. They differ in how they prefer to understand authenticity, but even this difference is not as stark as it sometimes seems.

After a long period of neglect, the phenomenology of action has recently regained its place in the agenda of philosophers and scientists alike. The recent explosion of interest in the topic highlights its complexity. The purpose of this paper is to propose a conceptual framework allowing for a more precise characterization of the many facets of the phenomenology of agency, of how they are related and of their possible sources. The key assumption guiding this attempt is that the processes through (...) which the phenomenology of action is generated and the processes involved in the specification and control of action are strongly interconnected. I argue in favor of a three-tiered dynamic model of intention, link it to an expanded version of the internal model theory of action control and specification, and use this theoretical framework to guide an analysis of the contents, possible sources and temporal course of complementary aspects of the phenomenology of action. (shrink)

Peer commentary on: Goering, S., Klein, E., Dougherty, D. D., & Widge, A. S. (2017). Staying in the loop: Relational agency and identity in next-generation DBS for psychiatry. AJOB Neuroscience, 8(2), 59-70.

Decisions about brain surgery pose existential challenges because they are often decisions about life or death, and sometimes about possible personality changes. Therefore they require rigorous neuroethical consideration. However, we doubt whether metaphysical interpretations of ambiguous statements of patients are useful for deriving ethical and legal conclusions. Particularly, we question the application of psychological theories of personal identity on neuroethical issues for several reasons. First, even the putative “standard view” on personal identity is contentious. Second, diverse accounts of personal identity (...) have been introduced into the neuroethical debate, which are incompatible. Third, the criteria for “diagnosing” the supposed changes in “identity” are ambiguous and indeterminate. Fourth, the metaphysical theories of personal identity imply highly questionable ethical and legal revisions, namely the denial of advance directives, particularly of Ulysses contracts, and, for patients with brain cancer, even therapeutic nihilism.We discuss three examples in which ideas from the personal identity debate in metaphysics are straightforwardly applied to discuss ethical issues of neurosurgery. We discuss revisions of the current medico-legal practice that have been proposed on grounds of psychological theories of personal identity. We argue that the established status quo in law and clinical practice is beneficial to the patients concerned. Furthermore, it is metaphysically neutral, which is an important principle of liberal, democratic, pluralistic societies.We recommend a pragmatic approach: empirical research on personality changes arising from brain disorders or interventions, comprehensive information about risks of personality changes, and advance directives, particularly Ulysses contracts. (shrink)

Some philosophers have criticized the use of psychopharmaceuticals on the grounds that even if these drugs enhance the person using them, they threaten their authenticity. Others have replied by pointing out that the conception of authenticity upon which this argument rests is contestable; on a rival conception, psychopharmaceuticals might be used to enhance our authenticity. Since, however, it is difficult to decide between these competing conceptions of authenticity, the debate seems to end in a stalemate. I suggest that we need (...) not resolve this debate to end the stalemate. New technologies which alter the self can be understood within the framework of the first conception of authenticity, I suggest, not as threatening the authentic self, but rather as bringing the outward appearance of the self into line with its deepest essence. Since psychopharmaceutical use can plausibly be understood on this model, it can be seen as enhancing our authenticity on either conception. (shrink)

Deep brain stimulation is a well-accepted treatment for movement disorders and is currently explored as a treatment option for various neurological and psychiatric disorders. Several case studies suggest that DBS may, in some patients, influence mental states critical to personality to such an extent that it affects an individual’s personal identity, i.e. the experience of psychological continuity, of persisting through time as the same person. Without questioning the usefulness of DBS as a treatment option for various serious and treatment refractory (...) conditions, the potential of disruptions of psychological continuity raises a number of ethical and legal questions. An important question is that of legal responsibility if DBS induced changes in a patient’s personality result in damage caused by undesirable or even deviant behavior. Disruptions in psychological continuity can in some cases also have an effect on an individual’s mental competence. This capacity is necessary in order to obtain informed consent to start, continue or stop treatment, and it is therefore not only important from an ethical point of view but also has legal consequences. Taking the existing literature and the Dutch legal system as a starting point, the present paper discusses the implications of DBS induced disruptions in psychological continuity for a patient’s responsibility for action and competence of decision and raises a number of questions that need further research. (shrink)

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

The phenomenological effects of deep brain stimulation (DBS) on the self of the patient remains poorly understood and under described in the literature, despite growing evidence that a significant number of patients experience postoperative neuropsychiatric changes. To address this lack of phenomenological evidence, we conducted in-depth, semistructured interviews with 17 patients with Parkinson's disease who had undergone DBS. Exploring the subjective character specific to patients' experience of being implanted gives empirical and conceptual understanding of the potential phenomenon of DBS-induced self-estrangement. (...) Our study concluded that (1) the more patients preoperatively felt alienated by their illness, the more they experienced postoperative self-estrangement, and (2) the notion of self-estrangement seems to exist in association with certain common qualitative characters, namely, loss of control, which reflects a deteriorative estrangement, and distorted perception of capacities, which reveals a restorative estrangement. These findings indicate that subjective self-reports help us to understand some aspects of the potential phenomenon of DBS-induced self-estrangement. (shrink)

The idea that deep brain stimulation (DBS) induces changes to personality, identity, agency, authenticity, autonomy and self (PIAAAS) is so deeply entrenched within neuroethics discourses that it has become an unchallenged narrative. In this article, we critically assess evidence about putative effects of DBS on PIAAAS. We conducted a literature review of more than 1535 articles to investigate the prevalence of scientific evidence regarding these potential DBS-induced changes. While we observed an increase in the number of publications in theoretical neuroethics (...) that mention putative DBS-induced changes to patients’ postoperative PIAAAS, we found a critical lack of primary empirical studies corroborating these claims. Our findings strongly suggest that the theoretical neuroethics debate on putative effects of DBS relies on very limited empirical evidence and is, instead, reliant on unsubstantiated speculative assumptions probablyin lieuof robust evidence. As such, this may reflect the likelihood of a speculative neuroethics bubble that may need to be deflated. Nevertheless, despite the low number of first-hand primary studies and large number of marginal and single case reports, potential postoperative DBS changes experienced by patients remain a critical ethical concern. We recommend further empirical research in order to enhance theoretical neuroethics work in the area. In particular, we call for the development of better instruments capable of capturing potential postoperative variations of PIAAAS. (shrink)

This is a book about how we see: the environment around us (its surfaces, their layout, and their colors and textures); where we are in the environment; whether or not we are moving and, if we are, where we are going; what things are good for; how to do things (to thread a needle or drive an automobile); or why things look as they do.The basic assumption is that vision depends on the eye which is connected to the brain. The (...) author suggests that natural vision depends on the eyes in the head on a body supported by the ground, the brain being only the central organ of a complete visual system. When no constraints are put on the visual system, people look around, walk up to something interesting and move around it so as to see it from all sides, and go from one vista to another. That is natural vision—and what this book is about. (shrink)

Questions about the nature of self and self-consciousness are closely aligned with questions about the nature of autonomy. These concepts have deep roots in traditional philosophical discussions that concern metaphysics, epistemology and ethics. They also have direct relevance to practical considerations about informed consent in medical contexts. In this paper, with reference to understanding specific side effects of deep brain stimulation treatment in cases of, for example, Parkinson’s Disease, Obsessive Compulsive Disorder, and Major Depressive Disorder, I’ll argue that it is (...) best to frame discussions of informed consent in terms of relational autonomy and a pattern theory of self. (shrink)

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

The article proposes a theoretical model to account for changes in self due to Deep Brain Stimulation. First, we argue that most existing models postulate a very narrow conception of self, and thus fail to capture the full range of potentially relevant DBS-induced changes. Second, building on previous work by Shaun Gallagher, we propose a modified ‘pattern-theory of self’, which provides a richer picture of the possible consequences of DBS treatment.

The article proposes a theoretical model to account for changes in self due to Deep Brain Stimulation. First, we argue that most existing models postulate a very narrow conception of self, and thus fail to capture the full range of potentially relevant DBS-induced changes. Second, building on previous work by Shaun Gallagher, we propose a modified ‘pattern-theory of self’, which provides a richer picture of the possible consequences of DBS treatment.

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are implanted. (...) It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

The phenomenology of agency has, until recently, been rather neglected, overlooked by both philosophers of action and philosophers of consciousness alike. Thankfully, all that has changed, and of late there has been an explosion of interest in what it is like to be an agent. 1 This burgeoning field crosses the traditional boundaries between disciplines: philosophers of psychopathology are speculating about the role that unusual experiences of agency might play in accounting for disorders of thought and action; cognitive scientists are (...) developing models of how the phenomenology of agency is generated; and philosophers of mind are drawing connections between the phenomenology of agency and the nature of introspection, phenomenal character, and agency itself. My aim in this paper is not to provide an exhaustive survey of this recent literature, but to provide a.. (shrink)

This article explores the notion of the dislocated self following deep brain stimulation (DBS) and concludes that when personal identity is understood in dynamic, narrative, and relational terms, the claim that DBS is a threat to personal identity is deeply problematic. While DBS may result in profound changes in behaviour, mood and cognition (characteristics closely linked to personality), it is not helpful to characterize DBS as threatening to personal identity insofar as this claim is either false, misdirected or trivially true. (...) The claim is false insofar as it misunderstands the dynamic nature of identity formation. The claim is misdirected at DBS insofar as the real threat to personal identity is the discriminatory attitudes of others towards persons with motor and other disabilities. The claim is trivially true insofar as any dramatic event or experience integrated into one’s identity-constituting narrative could then potentially be described as threatening. From the perspective of relational personal identity, when DBS dramatically disrupts the narrative flow, this disruption is best examined through the lens of agency. For illustrative purposes, the focus is on DBS for the treatment of Parkinson’s disease. (shrink)

Recent work on consciousness has featured a number of debates on the existence and character of controversial types of phenomenal experience. Perhaps the best-known is the debate over the existence of a sui generis, irreducible cognitive phenomenology – a phenomenology proper to thought. Another concerns the existence of a sui generis phenomenology of agency. Such debates bring up a more general question: how many types of sui generis, irreducible, basic, primitive phenomenology do we have to posit to just be able (...) to describe the stream of consciousness? This book offers a first general attempt to answer this question in contemporary philosophy. It develops a unified framework for systematically addressing this question and applies it to six controversial types of phenomenal experience, namely, those associated with thought and judgment, will and agency, pure apprehension, emotion, moral thought and experience, and the experience of freedom. (shrink)

Ethical concepts are, or purport to be, normative. They make claims on us: they command, oblige, recommend, or guide. Or at least when we invoke them, we make claims on one another; but where does their authority over us - or ours over one another - come from? Christine Korsgaard identifies four accounts of the source of normativity that have been advocated by modern moral philosophers: voluntarism, realism, reflective endorsement, and the appeal to autonomy. She traces their history, showing how (...) each developed in response to the prior one and comparing their early versions with those on the contemporary philosophical scene. Kant's theory that normativity springs from our own autonomy emerges as a synthesis of the other three, and Korsgaard concludes with her own version of the Kantian account. Her discussion is followed by commentary from G. A. Cohen, Raymond Geuss, Thomas Nagel, and Bernard Williams, and a reply by Korsgaard. (shrink)

When philosophers address personal identity, they usually explore numerical identity: what are the criteria for a person's continuing existence? When non-philosophers address personal identity, they often have in mind narrative identity: Which characteristics of a particular person are salient to her self-conception? This book develops accounts of both senses of identity, arguing that both are normatively important, and is unique in its exploration of a range of issues in bioethics through the lens of identity. Defending a biological view of our (...) numerical identity and a framework for understanding narrative identity, DeGrazia investigates various issues for which considerations of identity prove critical: the definition of death; the authority of advance directives in cases of severe dementia; the use of enhancement technologies; prenatal genetic interventions; and certain types of reproductive choices. He demonstrates the power of personal identity theory to illuminate issues in bioethics as they bring philosophical theory to life. (shrink)

Agency and identity -- Necessitation -- Acts and actions -- Aristotle and Kant -- Agency and practical identity -- The metaphysics of normativity -- Constitutive standards -- The constitution of life -- In defense of teleology -- The paradox of self-constitution -- Formal and substantive principles of reason -- Formal versus substantive -- Testing versus weighing -- Maximizing and prudence -- Practical reason and the unity of the will -- The empiricist account of normativity -- The rationalist account of normativity (...) -- Kant on the hypothetical imperative -- Against particularistic willing -- Deciding and predicting -- Autonomy and efficacy -- The function of action -- The possibility of agency -- Non-rational action -- Action -- Attribution -- The psychology of action -- Expulsion from the garden : the transition to humanity -- Instinct, emotion, intelligence, and reason -- The parts of the soul -- Inside or outside -- Pull yourself together -- The constitutional model -- Models of the soul -- The city and the soul -- Platonic virtues -- Justice : substantive, procedural, and platonic -- Kant and the constitutional model -- Defective action -- The problem of bad action -- Being governed by the wrong law -- Or five bad constitutions -- Conceptions of evil -- Degrees of action -- Integrity and interaction -- Deciding to be bad -- The ordinary cases -- Dealing with the disunified -- Kant's theory of interaction -- My reasons -- Deciding to treat someone as an end in himself -- Interacting with yourself -- How to be a person -- What's left of me? (shrink)

This important new book develops a new concept of autonomy. The notion of autonomy has emerged as central to contemporary moral and political philosophy, particularly in the area of applied ethics. professor Dworkin examines the nature and value of autonomy and uses the concept to analyse various practical moral issues such as proxy consent in the medical context, paternalism, and entrapment by law enforcement officials.

Does DBS change a patient’s personality? This is one of the central questions in the debate on the ethics of treatment with Deep Brain Stimulation (DBS). At the moment, however, this important debate is hampered by the fact that there is relatively little data available concerning what patients actually experience following DBS treatment. There are a few qualitative studies with patients with Parkinson’s disease and Primary Dystonia and some case reports, but there has been no qualitative study yet with patients (...) suffering from psychiatric disorders. In this paper, we present the experiences of 18 patients with Obsessive-Compulsive Disorder (OCD) who are undergoing treatment with DBS. We will also discuss the inherent difficulties of how to define and assess changes in personality, in particular for patients with psychiatric disorders. We end with a discussion of the data and how these shed new light on the conceptual debate about how to define personality. (shrink)

The now growing literature on the content and sources of the phenomenology of first-person agency highlights the multi-faceted character of the phenomenology of agency and makes it clear that the experience of agency includes many other experiences as components. This paper examines the possible relations between these components of our experience of acting and the processes involved in action specification and action control. After a brief discussion of our awareness of our goals and means of action, it will focus on (...) the sense of agency for a given action, understood as the sense the agent has that he or she is the author of that action. I argue that the sense of agency can be analyzed as a compound of more basic experiences, including the experience of intentional causation, the sense of initiation and the sense of control. I further argue that the sense of control may itself be analysed into a number of more specific, partially dissociable experiences. (shrink)

Deep Brain Stimulation (DBS) is a relatively new, experimental treatment for patients suffering from treatment-refractory Obsessive Compulsive Disorder (OCD). The effects of treatment are typically assessed with psychopathological scales that measure the amount of symptoms. However, clinical experience indicates that the effects of DBS are not limited to symptoms only: patients for instance report changes in perception, feeling stronger and more confident, and doing things unreflectively. Our aim is to get a better overview of the whole variety of changes that (...) OCD patients experience during DBS treatment. For that purpose we conducted in-depth, semi-structured interviews with 18 OCD patients. In this paper, we present the results from this qualitative study.We list the changes grouped in four domains: with regard to (a) person, (b) (social) world, (c)characteristics of person-world interactions, and (d) existential stance. We subsequently provide an interpretation of these results. In particular, we suggest that many of these changes can be seen as different expressions of the same process; namely that the experience of anxiety and tension gives way to an increased basic trust and increased reliance on one’s abilities. We then discuss the clinical implications of our findings, especially with regard to properly informing patients of what they can expect from treatment, the usefulness of including CBT in treatment, and the limitations of current measures of treatment success. We end by making several concrete suggestions for further research. (shrink)