Unresponsive wakefulness syndrome (UWS, previously known as vegetative state) occurs after patients survive a severe brain injury. Patients suffering from UWS have lost awareness of themselves and of the external environment and do not retain any trace of their subjective experience. Current data demonstrate that neuronal functions subtending consciousness are not completely reset in UWS; however, they are reduced below the threshold required to experience consciousness. The critical factor that determines whether patients will recover consciousness is the (...) distance of their neuronal functions from this threshold level. Recovery of consciousness occurs through functional and/or structural changes in the brain, i.e., through neuronal plasticity. Although some of these changes may occur spontaneously, a growing body of evidence indicates that rehabilitative interventions can improve functional outcome by promoting adaptive functional and structural plasticity in the brain, especially if a comprehensive neurophysiological theory of consciousness is followed. In this review we will focus on the pathophysiological mechanisms involved in UWS and on the plastic changes operating on the recovery of consciousness. (shrink)

Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on (...) conflicts in long-term care of patients in VS/UWS. A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making. (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)

For millennia self has been conjectured to be necessary for consciousness. But scant empirical evidence has been adduced to support this hypothesis. Inconsistent explications of “self” and failure to design apt experiments have impeded progress. Advocates of phenomenological psychiatry, however, have helped explicate “self,” and employed it to explain some psychopathological symptoms. In those studies, “self” is understood in a minimalist sense, sheer “for-me-ness.” Unfortunately, explication of the “minimal self” (MS) has relied on conceptual analysis, and applications to psychopathology have (...) been hermeneutic, allowing for many degrees of interpretive latitude. The result is that MS’s current scientific status is analogous to that of the “atom,” at the time when “atom” was just beginning to undergo transformation from a philosophical to a scientific concept. Fortunately, there is now an opportunity to promote a similar transformation for “MS.” Discovery of the brain’s Default Mode Network (DMN) opened the door to neuroimaging investigations of self. Taking the DMN and other forms of intrinsic activity as a starting point, an empirical foothold can be established, one that spurs experimental research and that enables extension of research into multiple phenomena. New experimental protocols that posit “MS” can help explain phenomena hitherto not thought to be related to self, thereby hastening development of a mature science of self. In particular, targeting phenomena wherein consciousness is lost and recovered, as in some cases of Unresponsive Wakefulness Syndrome (UWS), allow for design of neuroimaging probes that enable detection of MS during non-conscious states. These probes, as well as other experimental protocols applied to NREM Sleep, General Anesthesia (GA), and the waking state, provide some evidence to suggest that not only can self and consciousness dissociate, MS might be a necessary precondition for conscious experience. Finally, these findings have implications for the science of consciousness: it has been suggested that “levels of consciousness” (LoC) is not a legitimate concept for the science of consciousness. But because we have the conceptual and methodological tools with which to refine investigations of MS, we have the means to identify a possible foundation—a bifurcation point—for consciousness, as well as the means by which to measure degrees of distance from that foundation. These neuroimaging investigations of MS position us to better assess whether LoC has a role to play in a mature science of consciousness. (shrink)

Understanding loss of consciousness after brain injury poses a practical test for the field of consciousness research, with both clinical and ethical implications. We here discuss three major pathological disorders of consciousness; coma, the unresponsive wakefulness syndrome and the minimally conscious state, which together represent a lesion model for the investigation of human awareness. We review the anatomical and neurophysiological correlates of each condition, and discuss the current findings in context of several theoretical frameworks of consciousness.

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)

Disorders of consciousness (DoC)—that is, unresponsive wakefulness syndrome/vegetative state and minimally conscious state—are debilitating conditions for which no reliable markers of consciousness recovery have yet been identified. Evidence points to the GABAergic system being altered in DoC, making it a potential target as such a marker.

Unresponsive wakefulness syndrome is a disorder of consciousness wherein a patient is awake, but completely non-responsive at the bedside. However, research has shown that a minority of these patients remain aware, and can demonstrate their awareness via functional neuroimaging; these patients are referred to as having ‘cognitive motor dissociation’. Unfortunately, we have little insight into the subjective experiences of these patients, making it difficult to determine how best to promote their well-being. In this paper, I argue that (...) the capacity to experience pain or pleasure is a key component of well-being for these patients. While patients with unresponsive wakefulness syndrome are believed to be incapable of experiencing pain or pleasure, I argue that there is evidence to support the notion that CMD patients likely can experience pain and pleasure. I analyze current neuroscientific research into the mechanisms of pain experience in patients with disorders of consciousness, and provide an explanation for why CMD patients likely can experience physical pain. I then do the same for physical pleasure. I conclude that providing these patients with pleasurable experiences, and avoiding subjecting them to pain, are viable means of promoting their well-being. (shrink)

BackgroundFunctional neurodiagnostics could allow researchers and clinicians to distinguish more accurately between the unresponsive wakefulness syndrome and the minimally conscious state. It remains unclear how it informs surrogate decision-making.ObjectiveTo explore how the next of kin of patients with disorders of consciousness interpret the results of a functional neurodiagnostics measure and how/why their interpretations influence their attitudes towards medical decisions.Methods and SampleWe conducted problem-centered interviews with seven next of kin of patients with DOC who had undergone a functional (...) HD-EEG examination at a neurological rehabilitation center in Germany. The examination included an auditory oddball paradigm and a motor imagery task to detect hidden awareness. We analyzed the interview transcripts using structuring qualitative content analysis.ResultsRegardless of the diagnostic results, all participants were optimistic of the patients’ meaningful recovery. We hypothesize, that participants deal with the results of examinations according to their belief system. Thus, an unfavorable evaluation of the patient’s state had the potential to destabilize the participant’s belief system. To re-stabilize or to prevent the destabilization of their belief system, participants used different strategies. Participants accepted a “positive” HD-EEG result since it stabilized their belief system.ConclusionWe hypothesize, that a group of next of kin of patients with DOC deals with functional neurodiagnostics results on the basis of the result’s value and their high hope that the patient will recover meaningfully. A psychological mechanism seems to moderate the impact of functional neurodiagnostics on surrogate treatment decisions. (shrink)

意識是如此不可捉摸又抽象的概念，「測量」意識簡直就像科幻小說情節。科學家近年來在這方面已大有進展，藉由各項腦造影技術和實驗手法，能夠分析不同意識狀態下的大腦活動型態。.

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/uws) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal (...) of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/uws more respondents agreed with treatment withdrawal when they considered that VS/uws patients did not feel pain (77%) as compared to those who thought VS/uws did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

The intriguing issue of pain and suffering in patients with disorders of consciousness (DOCs), particularly in Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS), is assessed from a theoretical point of view, through an overview of recent neuroscientific literature, in order to sketch an ethical analysis. In conclusion, from a legal and ethical point of view, formal guidelines and a situationist ethics are proposed in order to best manage the critical scientific uncertainty about pain and (...) suffering in DOCs and ensure the best possible care for the patient. (shrink)

Modelling and simulations have gained a leading position in contemporary attempts to describe, explain, and quantitatively predict the human brain's operations. Computer models are highly sophisticated tools developed to achieve an integrated knowledge of the brain with the aim of overcoming the actual fragmentation resulting from different neuroscientific approaches. In this paper we investigate plausibility of simulation technologies for emulation of consciousness and the potential clinical impact of large-scale brain simulation on the assessment and care of disorders of consciousness, e.g. (...) Coma, Vegetative State/Unresponsive Wakefulness Syndrome, Minimally Conscious State.Notwithstanding their technical limitations, we suggest that simulation technologies may offer new solutions to old practical problems, particularly in clinical contexts. We take DOCs as an illustrative case, arguing that the simulation of neural correlates of consciousness is potentially useful for improving treatments of patients with DOCs. (shrink)

Human consciousness is widely understood to be underpinned by rich and diverse functional networks, whose breakdown results in unconsciousness. Candidate neural correlates of anesthetic-induced unconsciousness include: (1) disrupted frontoparietal functional connectivity; (2) disrupted brain network hubs; and (3) reduced spatiotemporal complexity. However, emerging counterexamples have revealed that these markers may appear outside of the state they are associated with, challenging both their inclusion as markers of conscious level, and the theories of consciousness that rely on their evidence. In this study, (...) we present a case series of three individuals in disorders of consciousness (DOC) who exhibit paradoxical brain responses to exposure to anesthesia. High-density electroencephalographic data were recorded from three patients with unresponsive wakefulness syndrome (UWS) while they underwent a protocol of propofol anesthesia with a targeted effect site concentration of 2 μg/ml. Network hubs and directionality of functional connectivity in the alpha frequency band (8–13 Hz), were estimated using the weighted phase lag index (wPLI) and directed phase lag index (dPLI). The spatiotemporal signal complexity was estimated using three types of Lempel-Ziv complexity (LZC). Our results illustrate that exposure to propofol anesthesia can paradoxically result in: (1) increased frontoparietal feedback-dominant connectivity; (2) posterior network hubs; and (3) increased spatiotemporal complexity. The case examples presented in this paper challenge the role of functional connectivity and spatiotemporal complexity in theories of consciousness and for the clinical evaluation of levels of human consciousness. (shrink)

Notwithstanding fundamental methodological advancements, scientific information about disorders of consciousness (DOCs)—e.g. Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) and Minimally Conscious State (MCS)—is incomplete. The possibility to discriminate between different levels of consciousness in DOC states entails treatment strategies and ethical concerns. Here we attempted to investigate Italian clinicians’ and basic scientists’ opinions regarding some issues emerging from the care and the research on patients with DOCs. From our survey emerged that Italian physicians working with patients with DOCs give (...) a central role to ethics. Current Italian regulation regarding basic research conducted in patients with DOCs apparently risks to be inadequate to support scientific advancement, and would deserve a different assessment compared to ordinary treatments. We think the results of our survey deserve attention from an international audience because they exemplify the difficulty to define a shared approach to the issues related to patients with DOCs and the necessity to better assess both the ordinary and experimental treatment of patients with DOCs at the ethical and legal level. (shrink)

When an individual is comatose while parts of her brain remain functional, the question arises as to whether any mental characteristics are still associated with this brain, that is, whether the person still exists. Settling this uncertainty requires that one becomes clear about two issues: the type of functional loss that is associated with the respective profile of brain damage and the persistence conditions of persons. Medical case studies can answer the former question, but they are not concerned with the (...) latter. Conversely, in the philosophical literature, various accounts of personal identity are discussed, but usually detached from any empirical basis. Only uniting the two debates and interpreting the real-life configurations of brain damage through the lens of the philosophical concepts enables one to make an informed judgment regarding the persistence of comatose persons. Especially challenging are cases in which three mental characteristics that normally occur together—wakefulness, awareness and memory storage—come apart. These shall be the focus of this paper. (shrink)

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal (...) of artificial nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

Fifty years have passed since brain death was first proposed as a criterion of death. Its advocates believe that with the destruction of the brain, integrated functioning ceases irreversibly, somatic unity dissolves, and the organism turns into a corpse. In this article, I put forward two objections against this assertion. First, I draw parallels between brain death and other pathological conditions and argue that whenever one regards the absence or the artificial replacement of a certain function in these pathological conditions (...) as compatible with organismic unity, then one equally ought to tolerate that function’s loss or replacement in brain death. Second, I show that the neurological criterion faces an additional problem that is only coming to light as life-supporting technology improves: the growing sophistication of the latter gives rise to a dangerous decoupling of the actual performance of a vital function from the retention of neurological control over it. Half a century after its introduction, the neurological criterion is facing the same fate as its cardiopulmonary predecessor. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC can (...) survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

Neural correlates of consciousness (for brevity NCC) are foundational to the scientific study of consciousness. Chalmers (2000) has provided the most informative and influential definition of NCC, according to which neural correlates are minimally sufficient for consciousness. However, the sense of sufficiency needs further clarification since there are several relevant senses with different entailments. In section one of this article, we give an overview of the desiderata for a good definition of NCC and Chalmers’s definition. The second section analyses the (...) merit of understanding the sufficiency of neural correlates for corresponding consciousness according to three relevant types of sufficiency: logical, metaphysical, and physical. In section three, a theoretical approach to consciousness studies is suggested in light of the sense in which NCC are sufficient for consciousness. Section four addresses a concern some might have about this approach. By the end, it will become apparent that our conception of NCC has important implications for research methodology, neuroethics, and the vitality of the search for NCC. (shrink)

It has been argued that complex subjective sense of self is linked to the brain default-mode network (DMN). Recent discovery of heterogeneity between distinct subnets (or operational modules - OMs) of the DMN leads to a reconceptualization of its role for the experiential sense of self. Considering the recent proposition that the frontal DMN OM is responsible for the first-person perspective and the sense of agency, while the posterior DMN OMs are linked to the continuity of ‘I’ experience (including autobiographical (...) memories) through embodiment and localization within bodily space, we have tested in this study the hypothesis that heterogeneity in the operational synchrony strength within the frontal DMN OM among patients who are in a vegetative state (VS) could inform about a stable self-consciousness recovery later in the course of disease (up to six years post-injury). Using EEG operational synchrony analysis we have demonstrated that among the three OMs of the DMN only the frontal OM showed important heterogeneity in VS patients as a function of later stable clinical outcome. We also found that the frontal DMN OM was characterized by the process of active uncoupling (stronger in persistent VS) of operations performed by the involved neuronal assemblies. (shrink)

The 'Beethoven syndrome' is the inclination of listeners to hear music as the projection of a composer's inner self. This was a radically new way of listening that emerged after Beethoven's death. Beethoven's music was a catalyst for this change, but only in retrospect, for it was not until after his death that listeners began to hear composers--and not just Beethoven--in their works, particularly in their instrumental music. The Beethoven syndrome: hearing music as autobiography traces the rise, fall, (...) and persistence of this mode of listening from the middle of the eighteenth century to the present. Prior to 1830, composers and audiences alike operated within a framework of rhetoric in which the burden of intelligibility lay squarely on the composer, whose task it was to move listeners in a calculated way. But through a confluence of musical, philosophical, social, and economic changes, the paradigm of expressive objectivity gave way to one of subjectivity in the years around 1830. The framework of rhetoric thus yielded to a framework of hermeneutics: concert-goers no longer perceived composers as orators but as oracles to be deciphered. In the wake of World War I, however, the aesthetics of 'new objectivity' marked a return not only to certain stylistic features of eighteenth-century music but also to the earlier concept of expression itself. Objectivity would become the cornerstone of the high modernist aesthetic that dominated the century's middle decades. Masterfully citing a broad array of source material from composers, critics, theorists, and philosophers, Mark Evan Bonds's engaging study reveals how perceptions of subjective expression have endured, leading to the present era of mixed and often conflicting paradigms of listening"--Dust jacket flap. (shrink)

Postnatal parent-infant physiological regulatory effects described in the previous paper (Part I) are viewed here as being biologically contiguous with events that occur prenatally, preparing and sensitizing the fetus to the average microenvironment into which the infant is expected, based on its evolutionary past, to be born. Following McKenna (1986), evidence (some of which is circumstantial) is presented concerning fetal hearing and fetal amniotic liquid breathing as they are affected both by maternal cardiovascular blood flow sounds in the uterus and (...) by fluctuating maternal blood sugar levels. These data are linked in turn to the infant’s postulated postnatal responsivity to parental sensory cues, including auditory and vestibular respiratory cues that may assist infants as they “learn” to breathe and, for some, to resist a SIDS event. Data on the respiratory and vocalizing behavior of normal and hearing-impaired persons are used to show that not all forms of human breathing are innate; some forms develop with experience. These data reveal how human infants learn, for example, to coordinate higher and lower brain respiratory nuclei in the context of learning initially to cry with intent and purpose and later to speak. Voluntary, cortex-based breathing emerges at the same time that infants are most likely to die from SIDS, between 2 and 4 months of age. This switch between voluntary and involuntary breathing during both sleep (while dreaming) and wake cycles, which depends on the integration of higher cortical and lower brain stem nuclei, is complex and is possibly the basis of the human species’ unique susceptibility to SIDS—a syndrome as yet unrecognized in other species. These human infant vulnerabilities, including delayed maturity, can explain in part why natural selection ought to favor increased infant sensitivity to parental sensory cues provided by a caregiver—stimuli available in the evolving parental care environment that included parent-infant co-sleeping for more than 4–5 million years of human evolution. (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)

There is growing interest in examining dark personality traits, to better explain malevolent and self-serving behaviour patterns commonly observed in clinical and non-clinical settings. Recently, taxonomies of dark personalities have been developed, along with psychometric tools to measure and delineate between traits including psychopathy, Machiavellianism and narcissism. The extent to which these constructs are distinct or overlapping remains controversial. Psychophysiological research can improve understanding of biological mechanisms contributing to personality that may help to evaluate taxonomies. This study investigated diurnal variations (...) in salivary cortisol (on waking, cortisol awakening response, and at bedtime, over two days) and their relationship to personality traits (Short Dark Triad Scale and IPIP Mini), psychopathology (Depression, Anxiety and Stress Scale; DASS) and quality of life (WHOQOL-BREF) in a non-clinical sample (N=45, 26 females, 19 males, 18-59 years). Dark personality traits correlated with low bedtime cortisol, reduced sleep, depression and poorer quality of life. Hierarchical linear regressions analyses indicated that bedtime cortisol levels significantly accounted for variance in Psychopathy (F(1,39)=5.55, p=.02, R=.52, B=-1.81, 95% CI [-3.37-(-.26)], β=-.33, sr2=.10) and reduced sleep uniquely accounted for variance Machiavellianism (F(2,40)=5.99, p=.01, R=.48, B=1.01, 95% CI [.16-2.02], β=.34, sr2=.11). These data provide preliminary evidence that supports the cortisol hypoarousal hypothesis of Psychopathy and has identified a link between Machiavellianism, sleep-wake cycles, and chronotype. The hypoarousal hypothesis of Psychopathy contends that the hypothalamic-pituitary-adrenal axis is unresponsive to the stress of social engagement. Machiavellianism was predicted by longer days with evidence for an evening chronotype. These findings indicated that the Dark Triad traits have different underlying biological mechanisms that require further exploration. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Post-Traumatic Hermeneutics: Melancholia in the Wake of TraumaAngelika Rauch (bio)1Classical Analysis: Problems for Trauma TherapyAccording to the Journal of the American Psychoanalytical Association, American ego psychology has taken a leading role in debunking what it considers antiquated Freudian approaches to the study of trauma. As neutral observers and students of the facts, ego psychologists have purportedly reclaimed the study of trauma as the search for an objectifiable traumatic event (...) in the past, one that can be accessed as recovered memory, as a specimen of pathogenic development, or as cognitive and behavioral effects that point to an inaccessible implied memory buried in the psyche. Central to this revision of psychoanalytical trauma therapy is the dismissal of Nachträglichkeit as an antiquated and irrelevant concept. Harold P. Blum, for instance, writes in a recent article of JAPA that “‘deferred action’ is an ambiguous concept, a dubious, antiquated, theoretical legacy.” According to Blum, “deferred action overlooks the immediate and potentially powerful effects of preoedipal trauma and is dissociated from considerations of cumulative trauma and developmental disturbance.” [1155]. With respect to Freud’s case of the Wolf-Man, Blum states that “[d]eferred action emphasized traumatic events and memory rather than cumulative developmental effects of shock and strain trauma, and pathogenic object relationships.” Key to Blum’s view, then, is the assertion that “the concept of deferred action deterred consideration of real infantile experience and the complex overdetermination of pathogenesis through development” [1156]. Blum apparently takes the side of those who like to argue that trauma is more real than imagined. Whereas oedipal trauma is an imaginary or illusory trauma, preoedipal trauma is comprehensible as real shock and, as such, is empirically true. This is an idea that is very compatible with “recovered memory” therapy, a subject that has become controversial in recent debates about child abuse and recovered memory syndrome.In contrast, Arnold H. Modell in Other Times, Other Realities points out that “[t]he concept of Nachträglichkeit is virtually unknown among American psychoanalysts. This may be due in part to Strachey’s faulty translation; but this idea is also inconsistent with the belief in an orderly hierarchical psychic development such as that envisioned by ego psychologists.” [3]. In other words, Freudian Nachträglichkeit violates the principles of space and time assumed by empirical scientists whose conceptions are founded on the causality of such principles as stimulus/response. It is here, of course, that ego psychology’s treatment of trauma would come into conflict not only with Freudian analysis, including its French Freudian variants, but with the kind of trauma studies being conducted by the contributors to Cathy Caruth’s Trauma: Explorations in Memory. They include Bessel [End Page 111] van der Kolk, Onno van der Hart, Shoshana Felman, Dori Laub, Robert Lifton, and, of course, Cathy Caruth herself.Emphasis on the reality of traumatic shock (as abuse, stress, accident, and so on), however important it may be, loses sight of a hermeneutical dimension of psychoanalytic therapy that Caruth and her contributors emphasize: the question of how meanings are associated or bound to the understanding of life’s events. My own clinical approach to psychoanalysis favors the introduction of an even stronger hermeneutical perspective that is sensitive to the kinds of issues raised by philosophers like Dilthey, Heidegger, Benjamin, and Gadamer, for whom the question of experience is not reducible to restricted understandings of stimulus/response, nor—as in the case of Caruth (for example, in Unclaimed Experience)—to the privileging of language as a formal (that is, literary) construct. Rather, I am interested in emphasizing a hermeneutics of the therapeutic encounter within which questions of language, culture, history, and behavior are situated. With respect to trauma therapy, I will introduce a number of well-known analytical contributions even as I take the following statement of Arnold Modell’s as my point of departure:The analyst or therapist becomes an unwitting collaborator in the recreation of the past, while still retaining a proximity to present time. The therapist becomes the person with whom one can reexperience trauma within a new context or experience for the first time what has been absent in the past. Affects belonging to... (shrink)

Although medicolegal challenges to the use of neurologic criteria to declare death in the USA have been well-described, the management of court cases in the United Kingdom about objections to the use of neurologic criteria to declare death has not been explored in the bioethics or medical literature. This article (1) reviews conceptual, medical and legal differences between death by neurologic criteria (DNC) in the United Kingdom and the rest of the world to contextualize medicolegal challenges to DNC; (2) summarizes (...) highly publicized legal cases related to DNC in the United Kingdom, including the nuanced 2022 case of Archie Battersbee, who was transiently considered dead by neurologic criteria, but ultimately determined to be in a vegetative state/unresponsive-wakeful state; and (3) provides an overview of ethical issues raised by medicolegal challenges to DNC in the United Kingdom and a comparison to the management of these challenges in the USA. (shrink)

Husserl characterizes sleep with the idea of “the relaxation of the will.” One finds a similar approach in the work of Maine de Biran, who explains sleep as “the suspension of the will.” More recently, Brian O’Shaughnessy and Matthew Soteriou have argued that mental actions constitute wakeful consciousness. In clinical practice, patients with disorders of consciousness who show “purposeful” behavior are classified as “minimally conscious,” while those in an “unresponsive wakeful state” merely behave reflexively. To what extent and how (...) are these proposals justified? This question pushes both the first- and the third-personal approaches to their limits: in an unconscious state, like a coma, one cannot reflect upon oneself; likewise, one cannot infer from physiological data whether someone is phenomenally conscious. This work offers a critical review of these proposals regarding the constitutive role for agency in phenomenal consciousness. It then presents revised versions of O’Shaughnessy’s and Soteriou’s Arguments from Synthesis and from Self-Consciousness. The argument is that everything of which one is phenomenally conscious is either a potential reason for a possible agentive power exertion, or just that power exertion itself. The “self” referred to in “self”-consciousness is either the agent or a “non-agent,” carrying out functions for the agent. Agency is therefore constitutive of phenomenal consciousness. The resulting view helps to solve the Combination Problem for panpsychism, by suggesting that agency is what raises sub-personal micro-consciousness to the personal level. The view may also justify the notion of a “Minimally Conscious State” in clinical practice. (shrink)

New Natural Law Theory and the Catholic medico-moral tradition often lead to similar conclusions in hard cases regarding end-of-life care. Considering the provision of artificial nutrition and hydration to patients suffering from post-coma unresponsive wakefulness, however, brings to light subtle ways in which NNL differs from the centuries-old natural law tradition. In this essay, I formalize the methodology embedded within the casuistry of the medico-moral tradition and show how it differs from NNL with respect to the role played (...) by double-effect reasoning and the perspective for analyzing cases regarding care for those who cannot speak for themselves. Importantly, the ordinary/extraordinary means distinction has never historically been understood as an application of double effect and logically cannot be so understood. Given the outsized role that double effect plays in NNL, the theory leads to conclusions that deviate from the Catholic medico-moral tradition and creates additional burdens and duties for the sick. (shrink)

Based on genetic and biochemical advances on the molecular mechanism of circadian rhythms, a computational model for the mammalian circadian clock is used to examine the dynamical bases of circadian‐clock‐related physiological disorders in humans. Entrainment by the light–dark cycle with a phase advance or a phase delay is associated with the Familial advanced sleep phase syndrome (FASPS) or the Delayed sleep phase syndrome (DSPS), respectively. Lack of entrainment corresponding to the occurrence of quasiperiodic oscillations with or without phase (...) jump can be associated with the non‐24 h sleep–wake syndrome. In the close vicinity of the entrainment domain, the model uncovers the possibility of infradian oscillations of very long period. Perturbation in the form of chronic jet lag, as used in mice, prevents entrainment of the circadian clock and results in chaotic or quasiperiodic oscillations. It is important to clarify the conditions for entrainment and for its failure because dysfunctions of the circadian clock may lead to physiological disorders, which pertain not only to the sleep–wake cycle but also to mood and cancer. BioEssays 30:590–600, 2008. © 2008 Wiley Periodicals, Inc. (shrink)

You live your entire waking life immersed in your inner experiences – private phenomena created by you, just for you, your own way. Despite their intimacy and ubiquity, you probably do not know the characteristics of your own inner phenomena; neither does psychology or consciousness science. Investigating Pristine Inner Experience explores how to apprehend inner experience in high fidelity. This book will transform your view of your own inner experience, awaken you to experiential differences between people and thereby reframe your (...) thinking about psychology and consciousness science, which banned the study of inner experience for most of a century and yet continued to recognize its fundamental importance. The author, a pioneer in using beepers to explore inner experience, draws on his 35 years of studies to provide fascinating and provocative views of everyday inner experience and experience in bulimia, adolescence, the elderly, schizophrenia, Tourette's syndrome, virtuosity and more. (shrink)

Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests for eye (...) movements or blinking on command. This is welcomed given that misdiagnosis of the locked-in syndrome has been shown to occur in more than half of the cases (see Laureys and colleagues3 for review). As for the diagnosis of the vegetative state, the scale explicitly tests for visual pursuit, and hence can disentangle the vegetative state from the minimally conscious state (MCS). The diagnostic criteria for MCS have been proposed4 only recently, but Wijdicks and colleagues1 do not mention the existence of this clinical entity in their article. As for the vegetative state, MCS can be encountered in the acute or subacute setting as a transitional state on the way to further recovery, or it can be a more chronic or even permanent condition. The MCS refers to patients showing inconsistent, albeit clearly discernible, minimal behavioral evidence of consciousness (eg, localization of noxious stimuli, eye fixation or tracking, reproducible movement to command, or nonfunctional verbalization).4 The FOUR scale does not test for all of the behavioral criteria required to diagnose MCS.4 It is known from the literature (see Majerus and colleagues5 for review) that about a third of patients diagnosed with vegetative state are actually in MCS, and this misdiagnosis can lead to major clinical, therapeutic, and ethical consequences. We tested the ability of the newly proposed FOUR scale to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting.. (shrink)

Until comparatively recently, say the middle of the last century, spinal cord injury was fatal as pressure sores and other infections took their toll. Those with severe brain injuries, unable to move or even communicate, fared even worse; without movement or feeding such patients were nursed until nature took its course. Over the last few decades medical and nursing advances have enabled some of these vegetative patients to survive for considerable time, provoking, at times, ethical and legal dilemmas. Though they (...) survived, without overt behaviour or clear communication their carers were frequently unsure how much residual function remained. Now real progress is occurring in this area thanks to the application of neuro-scientific methods by some outstanding groups of workers. Subjects with severe brain injury may begin in complete, unresponsive coma but then ‘lighten’ to one of three categories. In vegetative state (VS), patients are apparently awake but without evidence of voluntary behaviour and have no apparent awareness of self or environment, whilst in minimally conscious state (MCS) patients have some behaviour beyond the reflex but are not able to communicate effectively. These conditions usually result from widespread brain damage at either or both cortical and subcortical levels due to injury or anoxia, though they can also be seen in end stage neurological conditions like Alzheimer’s. In locked in syndrome (LIS), patients ‘awake’ from coma, usually due to stroke, aware of their surroundings and their situation but unable to speak or move, beyond eye lid control and eye movement. For many, LIS will be recognised from Bauby’s extraordinary account in ‘The Diving Bell and the Butterfly,’ though, incidentally, it was presaged in Samuel Beckett’s novella ‘The Unnameable.’ LIS reflects a profound disconnection between brain and body, except for the upper cranial nerves involved in eyelid movement. The overriding question is how much awareness these patients have.. (shrink)

It has been widely assumed that Heschel's writings are poetic inspirations devoid of philosophical analysis and unresponsive to the evil of the Holocaust. Who Is Man? contains a detailed phenomenological analyis of man and being which is directed at the main work of Martin Heidegger found primarily in Being and Time and Letter on Humanism. When the analysis of Who Is Man? is unapacked in the light of these associations it is clear that Heschel rejected poetry and metaphor as (...) a means of theological elucidation, that he offered a profound examination of the Holocaust and that the major thrust of his thinking eschews Heidegerrian deconstruction and the postmodernism that ensued in its phenomenological wake. Who Is Man? contains direct and indirect criticisms of Heidegger's notions of 'Dasein', 'thrownness', 'facticity' and 'submission' to name a few essential Heideggerian concepts. In using his ontological connective method in opposition to Heidegger's 'ontological difference', Heschel makes the argument that the biblical notion of Adam as a being open to transcendence stands in oppostion to the philosophical tradition from Parmenides to Heidegger and is the only basis for a redemptive view of humanity. (shrink)

The most powerful lesson learned from the 2013-2016 outbreak of Ebola in West Africa was that we do not learn our lessons. A common sentiment at the time was that Ebola served as a “wake-up call”—an alarm which signalled that an outbreak of that magnitude should never have occurred and that we are ill-prepared globally to prevent and respond to them when they do. Pledges were made that we must learn from the outbreak before we were faced with another. Nearly (...) five years later the world is in the grips of a pandemic of the severe acute respiratory syndrome coronavirus 2 that causes coronavirus disease 2019. It is therefore of no surprise that we are now yet again hearing that the COVID-19 pandemic serves as the “wake-up call” we need and that there are many lessons to be learned to better prepare us for future outbreaks. Will anything be different this time around? We argue that nothing will fundamentally change unless we truly understand and appreciate the nature of the lessons we should learn from these outbreaks. Our past failures must be understood as moral failures that offer moral lessons. Unless we appreciate that we have a defect in our collective moral attitude toward remediating the conditions that precipitate the emergence of outbreaks, we will never truly learn. (shrink)

Did Roland Barthes, Michel Foucault, Jacques Derrida, or other "poststructuralist" theorists writing in the wake of May '68 come up with any good ideas about authorship and related topics in the philosophy of literature? The three volumes under review have a common point of departure in that broad question, but offer a number of contrasting responses to it. In what follows I describe and assess some of the various perspectives on offer in these 700 or so pages. The short answer (...) to my initial question comes at the end. Carla Benedetti's book was first published in 1999 in Milan as L'ombra lunga dell'autore: Indagine su una figura cancellata. Professor of Italian and Theory of Literature at the University of Pisa, and Recurrent Visiting Professor at NYU, she clearly shares some of Foucault's basic assumptions about authorship: "It is the reader or viewer who transforms the artist's selections, which in themselves may even be random or compelled, into subjective choices endowed with intentionality: that intentionality that is capable of providing meaning and artistic value to what we are viewing or reading" (p. 12). Benedetti contends that such attributions are a necessary part of the literary and artistic discursive formation of modernity, and she persuasively demonstrates that the author has not "disappeared," in spite of what Barthes and others may have thought or wished. According to Benedetti, authorialism, or the thesis that artistic value can only derive from original authorship, is the product of a modern ideology. She contends that a self-reflexive, late modernist train of thought generates a highly problematic relation to authorship and such related notions as genius, novelty, and creativity. More specifically, Benedetti finds a Batesonian double bind or paradoxical injunction in modernity's incessant demand for an extreme form of novelty. As soon as something innovative has been done, yet another innovation is desired. Not only does it become harder and harder to make a radically new move in the game, but the entire pursuit appears to be hopeless. Although Benedetti does not say so, the key thought was neatly captured by Oscar Wilde when he quipped: "Nothing is so dangerous as being too modern; one is apt to grow old-fashioned quite suddenly." To be old-fashioned is abhorrent, yet to try to obey the injunction to be "absolutely modern" is to risk becoming old-fashioned in a hurry, so failure seems inevitable. One of the constitutive myths of late modernity has it, then, that artistic activity must be recognized as authorless because it is impossible to create some sort of fundamentally novel work of lasting value. For those in the grip of this unsound thought, it seems necessary to conclude that the writer-no-longer-author must be recognized as an essentially uncreative epigone. Benedetti comments rather sweepingly, "All that poststructuralist thought speaks of, in its multifarious elaborations, is merely our supposed irreversible impossibility to create" (p. 202). She links Derrida's rejection of the possibility of decisive epistemological "ruptures" to the same late modernist mythology. Benedetti concludes her book by saying that the late modernist mythology conflates one kind of novelty with the new in general. This distinction sounds promising, but is not developed any further, and this reader was left wondering how the putative crippling error of a vast artistic dispensation could be revealed by means of a distinction between two kinds of newness. I also wonder whether her diagnosis probes deeply enough into the sources and nature of the modish sensibility that leads perversely to the Last Year in Marienbad syndrome. Not everyone is equally interested in trying to be dazzlingly innovative and fashionable; some who do have this inclination manage to produce excellent works of art; and many artists active in the period in question have not worked with the assumptions Benedetti criticizes. Whatever one thinks about Benedetti's Foucauldian premises about authorship, her book is highly informative, engaging, and replete with astute comments on a wide range of European literary and artistic movements and critical trends. With a keen eye for significant detail, she writes elegantly and discusses many fascinating examples, including interesting, lesser-known Italian ones. A variety of perspectives on authorship are presented.. (shrink)

Disorders of consciousness (DOC) are a family of related neurological syndromes characterized by deficits of varying degrees of wakefulness (e.g., sleep–wake cycles and arousal) or awareness (e.g., reacting to stimuli, interacting with the environment). Although coma rarely persists for more than a few weeks, some patients remain in a subsequent vegetative state or a minimally conscious state for months or years. Caring for patients with DOC raises ethical questions, but the perspectives of healthcare providers on these questions remain poorly (...) documented. We conducted a qualitative study involving healthcare providers with different backgrounds. Semistructured interviews were used to explore attitudes toward ethical issues. We found that contextual (e.g., time, resource allocation) and relational aspects (e.g., communication process, families) shaped how ethical challenges surfaced and were managed. We call for greater awareness of contextual, institutional and social aspects and focus on these issues in training programs. (shrink)

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. (...) The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)

Dreams of chase or pursuit, falling, sex, flying, nudity, failing an examination, one's own and other's death, fire, teeth falling out and some other themes experienced, even if only rarely, by many people all over the world have been labelled 'typical dreams'. This essay argues that typical dreaming, rather a syndrome of themes than monothematic, reflects an extraordinary state of mind and brain. Odd and particularly memorable perceptions, as well as emerging awareness of sleep and dreaming -- i.e. parallels (...) to lucid dreaming, sleep paralysis, complex partial seizure, epileptic and migraine auras, and aspects of dreaming after trauma -- can be traced with some plausibility in all prominent variants of typical dreaming. When viewed from this perspective, for example, dream pursuers are much more a shadow of the bodily self than a metaphor for the psycho- biographical situation or evolutionarily implemented sparring partners who make dreamers fit for the struggle for survival during waking hours. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Authorship Redux:On Some Recent and Not-So-Recent Work in Literary TheoryPaisley LivingstonThe Empty Cage: Inquiry into the Mysterious Disappearance of the Author, by Carla Benedetti, translated by William J. Hartley, 232 pp. Ithaca: Cornell University Press, 2005, $52.50Literature, Theory, and Common Sense, by Antoine Compagnon, translated by Carol Cosman, 224 pp. Princeton: Princeton University Press, 2004, $41.00The Death and Resurrection of the Author?, edited by William Irwin, 237 pp. Westport, (...) Connecticut: Greenwood Press, 2002, $32.95.Did Roland Barthes, Michel Foucault, Jacques Derrida, or other "poststructuralist" theorists writing in the wake of May '68 come up with any good ideas about authorship and related topics in the philosophy of literature? The three volumes under review have a common point of departure in that broad question, but offer a number of contrasting responses to it. In what follows I describe and assess some of the various perspectives on offer in these 700 or so pages. The short answer to my initial question comes at the end.Carla Benedetti's book was first published in 1999 in Milan as L'ombra lunga dell'autore: Indagine su una figura cancellata. Professor of Italian and Theory of Literature at the University of Pisa, and Recurrent Visiting Professor at NYU, she clearly shares some of Foucault's basic assumptions about authorship: "It is the reader or viewer who transforms the artist's selections, which in themselves may even be random or compelled, into subjective choices endowed with intentionality: that intentionality [End Page 191] that is capable of providing meaning and artistic value to what we are viewing or reading" (p. 12). Benedetti contends that such attributions are a necessary part of the literary and artistic discursive formation of modernity, and she persuasively demonstrates that the author has not "disappeared," in spite of what Barthes and others may have thought or wished.According to Benedetti, authorialism, or the thesis that artistic value can only derive from original authorship, is the product of a modern ideology. She contends that a self-reflexive, late modernist train of thought generates a highly problematic relation to authorship and such related notions as genius, novelty, and creativity. More specifically, Benedetti finds a Batesonian double bind or paradoxical injunction in modernity's incessant demand for an extreme form of novelty. As soon as something innovative has been done, yet another innovation is desired. Not only does it become harder and harder to make a radically new move in the game, but the entire pursuit appears to be hopeless. Although Benedetti does not say so, the key thought was neatly captured by Oscar Wilde when he quipped: "Nothing is so dangerous as being too modern; one is apt to grow old-fashioned quite suddenly." To be old-fashioned is abhorrent, yet to try to obey the injunction to be "absolutely modern" is to risk becoming old-fashioned in a hurry, so failure seems inevitable. One of the constitutive myths of late modernity has it, then, that artistic activity must be recognized as authorless because it is impossible to create some sort of fundamentally novel work of lasting value. For those in the grip of this unsound thought, it seems necessary to conclude that the writer-no-longer-author must be recognized as an essentially uncreative epigone. Benedetti comments rather sweepingly, "All that poststructuralist thought speaks of, in its multifarious elaborations, is merely our supposed irreversible impossibility to create" (p. 202). She links Derrida's rejection of the possibility of decisive epistemological "ruptures" to the same late modernist mythology.Benedetti concludes her book by saying that the late modernist mythology conflates one kind of novelty with the new in general. This distinction sounds promising, but is not developed any further, and this reader was left wondering how the putative crippling error of a vast artistic dispensation could be revealed by means of a distinction between two kinds of newness. I also wonder whether her diagnosis probes deeply enough into the sources and nature of the modish sensibility that leads perversely to the Last Year in Marienbad syndrome. Not everyone is equally interested in trying to be dazzlingly innovative and fashionable; some [End Page 192] who do... (shrink)

Self‐awareness—knowledge of self and of one's mental states—is of central importance in ensuring the properties constitutive of consciousness in rational beings. A modified Cartesian thesis is defended: that a well‐formed state of self‐conscious wakefulness is such that the present contents of that mind must be insightfully given to its owner. This is demonstrated through investigating four different states in which insight is diminished and consciousness absent or impaired: sleep, trance, intoxication, and psychosis. These states are analytically explored, and the (...) thesis proven in each case. It emerges that the very items that constitute consciousness in unthinking animals, do the same in thinking animals, only in a more developed form. The differentia of the state of self‐conscious wakefulness is analysed into the co‐presence of a syndrome of mutually necessitating properties : self‐knowledge, rationality, freedom, thinking, etc. When this syndrome is conjoined with the availability of the perceptual attention, together with experience, the state is fully constituted. This is the answer to the fundamental question: what is consciousness? (shrink)

Ford, Norman In 1972 Brian Jennett and Fred Plum recommended the term 'persistent vegetative state' to describe a state of continuing 'wakefulness without awareness', which can follow a variety of severe insults to the brain. Their description of the syndrome has stood the test of time, but PVS continues to be a source of medical, legal, and ethical debate.

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. (...) The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)

A common finding in the study of emotion and decision making is the tendency for fear and anxiety to decrease risk taking. The current meta-analysis summarises the strength and variability of this...

We discuss the view that a hole is identical to the region of spacetime at which it is located. This view is more parsimonious than the view that holes are sui generis entities located at those regions surrounded by their hosts and it is more plausible than the view that there are no holes. We defend the spacetime view from several objections.