The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in (...) analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

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)

Neuroethics is an interdisciplinary field that arose in response to novel ethical challenges posed by advances in neuroscience. Historically, neuroethics has provided an opportunity to synergize different disciplines, notably proposing a two-way dialogue between an ‘ethics of neuroscience’ and a ‘neuroscience of ethics’. However, questions surface as to whether a ‘neuroscience of ethics’ is a useful and unified branch of research and whether it can actually inform or lead to theoretical insights and transferable practical knowledge to help resolve ethical questions. (...) In this article, we examine why the neuroscience of ethics is a promising area of research and summarize what we have learned so far regarding its most promising goals and contributions. We then review some of the key methodological challenges which may have hindered the use of results generated thus far by the neuroscience of ethics. Strategies are suggested to address these challenges and improve the quality of research and increase neuroscience's usefulness for applied ethics and society at large. Finally, we reflect on potential outcomes of a neuroscience of ethics and discuss the different strategies that could be used to support knowledge transfer to help different stakeholders integrate knowledge from the neuroscience of ethics. (shrink)

Beauchamp and Childress have performed a great service by strengthening the principle of respect for the patient's autonomy against the paternalism that dominated medicine until at least the 1970s. Nevertheless, we think that the concept of autonomy should be elaborated further. We suggest such an elaboration built on recent developments within the neurosciences and the free will debate. The reason for this suggestion is at least twofold: First, Beauchamp and Childress neglect some important elements of autonomy. Second, neuroscience itself needs (...) a conceptual apparatus to deal with the neural basis of autonomy for diagnostic purposes. This desideratum is actually increasing because modern therapy options can considerably influence the neural basis of autonomy itself.Sabine MNeuroScienceAndNorms: Ethical and Legal Aspects of Norms in Neuroimaging at Bonn University Hospital, Germany. Her main research interests are in neuroethics. She is coauthor of three German books about neuroethics and bioethics.Henrik Walter, M.D., Ph.D., is Full Professor of Medical Psychology at the University of Bonn, Germany, and vice-director of the Department of Psychiatry and Psychotherapy at the University Clinic of Bonn. He is author of Neurophilosophy of Free Will and editor of the book From Neuroethics to Neurolaw?. His research fields are biological psychiatry, cognitive neuroscience, neuroimaging, neurophilosophy, and neuroethics. (shrink)

ZusammenfassungFünfzehn Jahre nach ihrer Entstehung ist die Neuroethik ein internationales wissenschaftliches Feld mit enormer Dynamik. Innerhalb weniger Jahre wurden eigene Kongresse, Zeitschriften, Forschungsförderprogramme, Fachgesellschaften und Institute gegründet. Gleichwohl besteht erheblicher Dissens über die Definition und den Gegenstandsbereich dieses neuen Gebiets. Wir argumentieren hier für eine differenzierte Konzeption, wonach neben der Reflexion ethischer Probleme der Neurowissenschaft und ihrer überwiegend neurotechnologischen Anwendungen auch die ethische Reflexion neurowissenschaftlicher Forschung zur Moralität zur Neuroethik gehört. Dies umfasst zwar nicht neurowissenschaftliche oder neuropsychologische Studien zur Moralität, (...) wohl aber die Reflexion der Bedeutung dieser Forschung für die Ethik und das Recht. Wir geben einen Überblick über die wichtigsten Themen der Neuroethik, woraus deutlich wird, wie sehr in verschiedenen gesellschaftlichen Bereichen, auch jenseits von Medizin und Gesundheitswesen, neuroethische Fragen relevant sind. Das Potenzial der Neuroethik als eines neuen Wissenschaftsfeldes liegt darin, durch eine Verknüpfung neurophilosophischer und medizinethischer Themen sowie eine breite interdisziplinäre Vernetzung neue Antworten auf gesellschaftlich drängende Fragen zu finden. (shrink)

Deep brain stimulation as investigational intervention for symptomatic relief from Alzheimer disease has generated big expectations. Our aim is to discuss the ethical justification of this research agenda by examining the underlying research rationale as well as potential methodological pitfalls. The shortcomings we address are of high ethical importance because only scientifically valid research has the potential to be ethical. We performed a systematic search on MEDLINE and EMBASE. We included 166 publications about DBS for AD into the analysis of (...) research rationale, risks and ethical aspects. Fifty-eight patients were reported in peer-reviewed journals with very mixed results. A grey literature search revealed hints for 75 yet to be published, potentially enrolled patients. The results of our systematic review indicate methodological shortcomings in the literature that are both scientific and ethical in nature. According to our analysis, research with human subjects was performed before decisive preclinical research was published examining the specific research question at stake. We also raise the concern that conclusions on the potential safety and efficacy have been reported in the literature that seem premature given the design of the feasibility studies from which they were drawn. In addition, some publications report that DBS for AD was performed without written informed consent from some patients, but from surrogates only. Furthermore, registered ongoing trials plan to enroll severely demented patients. We provide reasons that this would violate Art. 28 of the Declaration of Helsinki, because DBS for AD involves more than minimal risks and burdens, and because its efficacy and safety are not yet empirically established to be likely. Based on our empirical analysis, we argue that clinical research on interventions of risk class III should not be exploratory but grounded on sound, preclinically tested, and disease-specific a posteriori hypotheses. This also applies to DBS for dementia as long as therapeutic benefits are uncertain, and especially when research subjects with cognitive deficits are involved, who may foreseeably progress to full incapacity to provide informed consent during the required follow-up period. (shrink)

Moral Enhancement wird von einer Reihe einflussreicher Bioethiker propagiert, zum Teil mit dem Anspruch, dass nur dadurch die Menschheit vor ihrem selbstverschuldeten Untergang zu retten sei. Nachdem begründete Zweifel an der Eignung der zum Moral Enhancement vorgeschlagenen Psychopharmaka aufgekommen sind, wurden neurochirurgische Interventionen, insbesondere die Tiefe Hirnstimulation, vorgeschlagen. Diese Ad-hoc-Vorschläge stützen sich auf eine Handvoll neurochirurgischer Eingriffe an geistig schwer behinderten Menschen sowie die Psychochirurgie des letzten Jahrhunderts. In diesem Aufsatz geht es erstens um die Frage, ob Moral Enhancement durch (...) neurochirurgische Methoden überhaupt möglich ist und, wenn ja, inwiefern, und zweitens um die Frage nach dessen ethischer Vertretbarkeit, sofern es möglich ist. Mit den bisher vorgeschlagenen Methoden des neurochirurgischen Moral Enhancement könnte man zwar Aggressionen oder den Sexualtrieb reduzieren, sodass weniger Selbstkontrolle erforderlich wäre, um moralisch angemessen zu handeln. Theoretisch denkbar, aber bisher nicht durch empirische Evidenz gestützt, ist, dass neurochirurgische Eingriffe die Selbstkontrolle verbessern könnten. Nach dem Modell der moralischen Intelligenz von Carmen Tanner und Markus Christen lässt sich zeigen, dass dadurch allenfalls eine Komponente der moralischen Intelligenz verbessert werden könnte, nämlich die moralische Standhaftigkeit. Keiner der bisherigen Vorschläge zielt dagegen auf die Verbesserung der anderen vier Komponenten, also des moralischen Kompasses, der moralischen Sensibilität, der moralischen Urteilsfähigkeit und der moralischen Motivation. Ein umfassendes Moral Enhancement durch neurochirurgische Eingriffe ist mit den gegenwärtig verfügbaren oder vorgeschlagenen Methoden also nicht möglich. Allenfalls lässt sich in Zukunft durch Closed-Loop-Systeme, die bestimmte Impulse automatisch herunter regeln, ein moralkonformeres Verhalten erreichen. Eine nur technisch induzierte Verhaltensverbesserung wäre allerdings höchstens unter Zugrundelegung eines utilitaristischen Moralverständnisses als moralische Verbesserung anzuerkennen. (shrink)

Bioethics needs an elaborated concept of autonomy based on empirical knowledge about the prerequisites of the capacity of autonomy. Whereas Beauchamp and Childress, and many other bioethicists have discussed social influences on the capacity of autonomy in depth, neurobiological influences have received less attention. A comprehensive concept of autonomy should consider both social and biological factors that can diminish the capacity of autonomy. This article focuses on neurobiological influences that can reduce the capacity of autonomy. The thesis of this article (...) is that the integration of neuropsychiatric knowledge into the concept of autonomy is essential for evaluating demands for harmful medical treatments which might be caused by a brain disease, and deciding on involuntary treatments of patients who suffer from substantial lack of autonomy due to neuropsychiatric disorders. Diametrically opposed to such a comprehensive concept of the capacity of autonomy is the concept of ‘liberty of illness’. In Germany, this concept is supported not only by anti-psychiatric groups but also by the Federal Constitutional Court. Several real cases demonstrate how the brain can be ‘hijacked’ by parasites, antibodies or technical devices. Applying the concept of ‘liberty of illness’ to persons whose decision-making capacity is severely affected by neuropsychiatric disorders is cynical. These patients neither chose their disease nor would refuse effective treatment if their will was not disturbed by the disease. Respect for autonomy should be understood as the positive obligation to save, support or restore the biological prerequisites of the capacity for autonomous decision-making. (shrink)

This essay employs insights from embodied approaches to cognition to develop a tighter grasp on the phenomenon of camera mobility. Close readings of two early masterpieces of German cinema investigate how the viewer relates to camera movement on the basis of kinaesthetic empathy and is thereby transported, emotionally gripped or expelled from the storyworld. I argue that the construction of the fictional world is based on this specific viewing attitude, which invites us either to merely observe or, in contrast, to (...) engage with the events on screen. As a consequence, the investigation of camera movement on the basis of embodied cognition helps us both to gain a deeper understanding of how we are drawn into the space defined by camera movement and to open up the possibility of a ‘natural’ history of camera conventions as they were established at this early stage of cinema. (shrink)

BackgroundPsychiatric neurosurgery is experiencing a revival. Beside deep brain stimulation, several ablative neurosurgical procedures are currently in use. Each approach has a different profile of advantages and disadvantages. However, many psychiatrists, ethicists, and laypeople are sceptical about psychiatric neurosurgery.MethodsWe identify the main concerns against psychiatric neurosurgery, and discuss the extent to which they are justified and how they might be overcome. We review the evidence for the effectiveness, efficacy and safety of each approach, and discuss how this could be improved. (...) We analyse whether and, if so, how randomised controlled trials can be used in the different approaches, and what alternatives are available if conducting RCTs is impossible for practical or ethical reasons. Specifically, we analyse the problem of failed RCTs after promising open-label studies.ResultsThe main concerns are: reservations based on historical psychosurgery, concerns about personality changes, concerns regarding localised interventions, and scepticism due to the lack of scientific evidence. Given the need for effective therapies for treatment-refractory psychiatric disorders and preliminary evidence for the effectiveness of psychiatric neurosurgery, further research is warranted and necessary. Since psychiatric neurosurgery has the potential to modify personality traits, it should be held to the highest ethical and scientific standards.ConclusionsPsychiatric neurosurgery procedures with preliminary evidence for efficacy and an acceptable risk–benefit profile include DBS and micro- or radiosurgical anterior capsulotomy for intractable obsessive–compulsive disorder. These methods may be considered for individual treatment attempts, but multi-centre RCTs are necessary to provide reliable evidence. (shrink)

In his critical comment on our paper in this journal, Shaw argues that ‘false assumptions’ which we have criticised are in fact correct . He suggests that the risk of addiction to neuroenhancers may not be relevant, and that safety and research in regard to neuroenhancement do not pose unique ethical problems. Here, we demonstrate that Shaw ignores key empirical research results, trivialises addiction, commits logical errors, confuses addictions and passions, argues on a speculative basis, and fails to distinguish the (...) specific ethical conditions of clinical research from those relevant for research in healthy volunteers. Therefore, Shaw's criticism cannot convince. (shrink)

Unter Body Integrity Identity Disorder (BIID) versteht man das sehr seltene Phänomen, dass jemand die Amputation einer oder mehrerer gesunder Gliedmaßen oder die Beibringung einer Querschnittslähmung verlangt. Manche dieser Menschen verstümmeln sich selbst; andere fordern von Chirurgen eine Amputation oder die Durchtrennung des Rückenmarks. Von Psychologen und Psychiatern gibt es unterschiedliche Erklärungsansätze für dieses Phänomen; bisher ist aber keine erfolgreiche psychotherapeutische oder pharmazeutische Therapie bekannt. Betroffenenvertreter erklären den Amputationswunsch in Analogie zu dem Verlangen von Transsexuellen nach chirurgischer Angleichung an ihr (...) Wunschgeschlecht. Unter Medizinethikern ist die Amputation gesunder Gliedmaßen höchst umstritten; einerseits wird aus dem Autonomie-Prinzip das Recht auf Körpermodifikation abgeleitet, andererseits wird angenommen, dass der Amputationswunsch aus innerem Zwang oder Wahn resultiert. Neurologische Befunde legen nahe, dass BIID wahrscheinlich eine hirnorganisch bedingte Störung des Körperbildes ist, vergleichbar mit bestimmten Schlaganfallfolgen. Wenn BIID eine neuropsychologische Störung ist, zu deren Symptomen fehlende Krankheitseinsicht und eine durch inneren Zwang eingeschränkte Fähigkeit zu vernünftigen Entscheidungen gehören, sind die von BIID-Aktivisten und einigen Medizinethikern geforderten Amputationen kontraindiziert und stellen Körperverletzungen an Menschen mit einer neuropsychologischen Störung dar. Statt des Kurierens an einem Symptom sollte eine kausale Therapie entwickelt werden, mit dem Ziel der Integration des als fremd empfundenen Körperteils in das Körperbild. (shrink)

The Hellenistic monarchies arose from the collapse of Alexander’s empire, and represented new forms of rule. This study demonstrates how the Hellenistic ruler presented himself and his family in picture, text and on official occasions. In particular the representation of the Hellenistic royal couple and the role of the queen at court are examined on the basis of the Ptolemaic dynasty. Central aspects of the study are the political background to the marriage between Ptolemy II, during his reign that marriage (...) between royal siblings and the deification of the ruling royal couple were introduces, and his sister Arsinoë II, and how the royal couple presented themselves to Greeks, Macedonians, and Egyptians. (shrink)

The article uses the Sissi trilogy as a case study to offer a new perspective on popular film in the 1950s in general and on Heimatfilm in particular. Rather than reading those films as the expression of a wilful collective amnesia, the article aims to show that, despite representing a sugar-coated world of royal romance, these films form a crucial part of people’s coping with the past. In adopting a phenomenological approach to cinematic representation, the article emphasises the fact that (...) realism is not to be sought in the fantastic setting of the costume spectacle but in narrative structure. The conventionality of narrative patterns and iconographies is brought out as an integral part of a social practice of narrativising, and thereby integrating, historical events within the private sphere of everyday experience. Within this familiar sphere, urgent issues of the 1950s such as gender relations and national identity were addressed and renegotiated. The argument culminates in the claim that it is only by suspending rash moral judgement and acknowledging this ‘privatisation’ as a necessary element in people’s narrative coping with the past that a new perspective on films like Sissi can emerge to provide us with a more complete picture of the 1950s. (shrink)

Name der Zeitschrift: Klio Jahrgang: 97 Heft: 1 Seiten: 329-332.

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in (...) analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

Zum Hirntod werden zwei Fragen erneut kontrovers diskutiert: erstens, ob der Hirntod mit dem Tod gleichzusetzen ist, zweitens, wie man den Hirntod sicher diagnostiziert. Neue empirische Erkenntnisse erfordern eine neue Auseinandersetzung mit diesen Fragen: Erstens haben zahlreiche Studien ein längeres Überleben und die Integration von Körperfunktionen von hirntoten Patienten nachgewiesen. Der President's Council on Bioethics hat im Dezember 2008 eingestanden, dass die bisher vertretene Begründung für das Hirntodkriterium, nämlich die Annahme des engen zeitlichen und kausalen Zusammenhangs des Hirntodes und der (...) Desintegration der körperlichen Funktionen, empirisch widerlegt sei. Trotzdem hält der Council am Hirntodkriterium fest, stützt es aber nun auf eine neue naturphilosophische statt empirische Begründung, die den lebenden Organismus über die aktive Auseinandersetzung mit der Welt als notwendiges Kriterium für Leben bestimmt. Diese naturphilosophische Begründung ist nicht falsifizierbar und scheint den Interessen der Transplantationsmedizin geschuldet. Zweitens geben Studien mit fMRT und PET an hirntoten Patienten Anlass, an der Reliabilität der üblichen Hirntoddiagnostik zu zweifeln. Aus ethischen Gründen sollte eine Hirntoddiagnostik auf dem Stand der besten verfügbaren Technologie gesetzlich vorgeschrieben werden, also zumindest die Angiographie, in Zweifelsfällen auch fMRT oder PET. (shrink)