Background: We aimed to determine the smallest changes in health-related quality of life (HRQoL) scores in the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire core 30 and the Brain Cancer Module (QLQ-BN20), which could be considered as clinically meaningful in brain cancer patients. Materials and methods: World Health Organisation performance status (PS) and mini-mental state examination (MMSE) were used as clinical anchors appropriate to related subscales to determine the minimal clinically important differences (...) (MCIDs) in HRQoL change scores (range 0-100) in the QLQ-C30 and QLQ-BN20. A threshold of 0.2 standard deviation (SD) (small effect) was used to exclude anchor-based MCID estimates considered too small to inform interpretation. Results: Based on PS, our findings support the following integer estimates of the MCID for improvement and deterioration, respectively: physical (6, 9), role (14, 12), and cognitive functioning (8, 8); global health status (7, 4(star)), fatigue (12, 9), and motor dysfunction (4(star), 5). Anchoring with MMSE, cognitive functioning MCID estimates for improvement and deterioration were (11, 2(star)) and for communication deficit were (9, 7). Estimates with asterisks were <0.2 SD and were excluded from our MCID range of 5-14. Conclusion: These estimates can help clinicians evaluate changes in HRQoL over time, assess the value of a health care intervention and can be useful in determining sample sizes in designing future clinical trials. (shrink)

The concept of futility is sometimes regarded as a cloak for medical paternalism in that it rolls together medical and value judgments. Often, despite attempts to disambiguate the concept, that is true and it can be applied in such a way as to marginalize the real interests of a patient. I suggest we replace it with a conceptual toolkit that includes physiological futility, substantial benefit (SB), and the risk of unacceptable badness (RUB) in that these concepts allow us to articulate (...) what is at stake in ethical judgments where outcomes are crucial in determining what should be done. (shrink)

Cognitive neuroscientists are currently busy searching for the neural signatures of conscious experience. I shall argue that the notion of neural correlates of consciousness employed in much of this work is subject to two very different interpretations depending on how one understands the relation between the concepts of “state consciousness” and “creature consciousness”. Localist theories treat the neural correlates of creature consciousness as a kind of background condition that must be in place in order for the brain to realise (...) particular conscious experiences. Holists on the other hand take the neural correlates of creature consciousness to be a part of the core realiser of a particular conscious experience. My aim in this paper will be threefold. First I argue we should understand creature consciousness as a property of those creatures that have a minimal sense of self. Given this conception of creature consciousness I argue that the localist position is untenable: creature consciousness cannot simply be a background condition. Finally I argue that the minimal sense of self is a consequence of the temporal structure of consciousness. It follows that any theory of NCCs must explain how experiences with a complex temporal structure can be implemented in neural processing. (shrink)

The proposal that probabilistic inference and unconscious hypothesis testing are central to information processing in the brain has been steadily gaining ground in cognitive neuroscience and associated fields. One popular version of this proposal is the new theoretical framework of predictive processing or prediction error minimization, which couples unconscious hypothesis testing with the idea of ‘active inference’ and claims to offer a unified account of perception and action. Here we will consider one outstanding issue that still looms large at (...) the core of the PEM framework: the lack of a clear criterion for distinguishing conscious states from unconscious ones. In order to fulfill the promise of becoming a unifying framework for describing and modeling cognition, PEM needs to be able to differentiate between conscious and unconscious mental states or processes. We will argue that one currently popular view, that the contents of conscious experience are determined by the ‘winning hypothesis’, falls short of fully accounting for conscious experience. It ignores the possibility that some states of a system can control that system’s behavior even though they are apparently not conscious. What follows from this is that the ‘winning hypothesis’ view does not provide a complete account of the difference between conscious and unconscious states in the probabilistic brain. We show how this problem for the received view can be resolved by augmenting PEM with Daniel Dennett’s multiple drafts model of consciousness. This move is warranted by the similar roles that attention and internal competition play in both the PEM framework and the multiple drafts model. (shrink)

Neurostimulation to restore cognitive and physical functions is an innovative and promising technique for treating patients with severe brain injury that has resulted in a minimally conscious state (MCS). The technique may involve electrical stimulation of the central thalamus, which has extensive projections to the cerebral cortex. Yet it is unclear whether an improvement in neurological functions would result in a net benefit for these patients. Quality-of-life measurements would be necessary to determine whether any benefit of neurostimulation outweighed any (...) harm in their response to different degrees of cognitive and physical disability. These measures could also indicate whether the technique could be ethically justified and whether surrogates could give proxy consent to its use on brain-injured patients. (shrink)

Deep brain stimulation is an experimental procedure for treatment-resistant depression. Some results show promise, but blinded trials had limited success. Ethical questions center on vulnerability: especially on whether depressed patients can weigh the risks and benefits effectively, whether depression causes “desperation,” and whether media portrayals create unrealistic hopes. We interviewed 24 psychiatric inpatients with treatment-resistant depression, qualitatively analyzing their comments. Most had minimal interest in deep brain stimulators. Some might consider them if their depression worsened, if alternatives (...) were exhausted, or if the evidence were stronger. Fears focused on the surgery, adverse effects, and the novelty of the device. Patients felt the depression interfered with their ability to weigh the risks and benefits. Patients seemed highly attuned to the risks, and were skeptical that the treatment would be effective. We conclude that ethical concerns about vulnerability remain, yet patients with treatment-resistant depression were thoughtful and cautious about trying a novel therapy. (shrink)

The minimally conscious sta te (MCS) is usually ascribed when a patientwith brain damage exhibits obser vable volitional behaviors that predict recovery ofcognitive funct ions. Nevertheless, a patient with brain damage who lacks motorcapacit y might nonetheless be in MCS. For this reason, some clinicians use neuralsignals as a communicative means for MCS ascription. For instance, a vegetativestate patient is diagnosed with MCS if activity in the motor area is observed whenthe instruction to imagine wiggling toes is given. (...) The validi ty of using neuralsignals in ascribing MCS requires a special sort of inference. That is, no-reportparadigmatic assessments must have inductively strong ways of inferring a pur-ported informationa l content from the observed neural signal that grounds the factthat the patient has top-down cognitive control (or residual volition). Shannon’smathemat ical theory of communication and Bayes’ theorem reveals the formalstructure of neural communication. On the basis of relevant data from the neuro-science literature, I conclude that the formal structure combined with the data showsthat neural signals can be used as a communicative means for operational diagnosticcriteria for MCS ascription. (shrink)

This chapter seeks to recover an approach to consciousness from a general theory of brain function, namely the prediction error minimization theory. The way this theory applies to mental and developmental disorder demonstrates its relevance to consciousness. The resulting view is discussed in relation to a contemporary theory of consciousness, namely the idea that conscious perception depends on Bayesian metacognition; this theory is also supported by considerations of psychopathology. This Bayesian theory is first disconnected from the higher-order thought theory, (...) and then, via a prediction error conception of action, connected instead to the global neuronal workspace theory. Considerations of mental and developmental disorder therefore show that a very general theory of brain function is relevant to explaining the structure of conscious perception; furthermore, this theory can subsume and unify two contemporary approaches to consciousness, in a move that seeks to elucidate the fundamental mechanism for selection of representational content into consciousness. (shrink)

In a recent paper, Kaplan (Synthese 183:339–373, 2011) takes up the task of extending Craver’s (Explaining the brain, 2007) mechanistic account of explanation in neuroscience to the new territory of computational neuroscience. He presents the model to mechanism mapping (3M) criterion as a condition for a model’s explanatory adequacy. This mechanistic approach is intended to replace earlier accounts which posited a level of computational analysis conceived as distinct and autonomous from underlying mechanistic details. In this paper I discuss work (...) in computational neuroscience that creates difficulties for the mechanist project. Carandini and Heeger (Nat Rev Neurosci 13:51–62, 2012) propose that many neural response properties can be understood in terms of canonical neural computations. These are “standard computational modules that apply the same fundamental operations in a variety of contexts.” Importantly, these computations can have numerous biophysical realisations, and so straightforward examination of the mechanisms underlying these computations carries little explanatory weight. Through a comparison between this modelling approach and minimal models in other branches of science, I argue that computational neuroscience frequently employs a distinct explanatory style, namely, efficient coding explanation. Such explanations cannot be assimilated into the mechanistic framework but do bear interesting similarities with evolutionary and optimality explanations elsewhere in biology. (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)

Hemiparetic stroke in adulthood often results in the grouped movement pattern of the upper extremity flexion synergy thought to arise from an increased reliance on cortico-reticulospinal pathways due to a loss of lateral corticospinal projections. It is well-established that the flexion synergy induces reaching constraints in individuals with adult-onset hemiplegia. The expression of the flexion synergy in individuals with brain injuries onset earlier in the lifespan is currently unknown. An early unilateral brain injury occurring prior to six months (...) post full-term may preserve corticospinal projections which can be used for independent joint control and thus minimizing the expression of the flexion synergy. This study uses kinematics of a ballistic reaching task to evaluate the expression of the flexion synergy in individuals with pediatric-onset hemiplegia (PH) ages six to seventeen years. Fifteen individuals with brain injuries before birth (n = 8) and around full-term (n = 7) and nine age-matched controls with no known neurological impairment completed a set of reaches in an admittance controlled robotic device. Descending drive, and the possible expression of the upper extremity flexion snergy, was modulated by increasing shoulder abduction loading. Individuals with early PH achieved lower peak velocities when reaching with the paretic arm compared to controls however no differences in reaching distance were found between groups. Relative maintenance in reaching seen in individuals with early brain injuries highlights minimal expression of the flexion synergy. We interpret this conservation of independent control of the paretic shoulder and elbow as the use of more direct corticospinal projections instead of indirect cortico-reticulospinal pathways used in individuals with adult-onset hemiplegia. (shrink)

Computational psychiatry is a quickly evolving discipline that aims to understand psychopathology in terms of computational, hence algorithmic processes. While cognitive phenomena, especially beliefs or ways of “reasoning”, can more easily be formalized, meaning re-described in mathematical terms and then entered computational models, there is speculation as to whether phenomenology might be formalizable too. In other words, there are speculations in terms of what aspects of the human experience, rather than specific cognitive processes alone, can enter computational models. Here, we (...) explore the possibility of formalizing and modeling a phenomenological account of schizophrenia, using the concepts of “minimal self” and “intentionality”. To test the applicability of these concepts for formalization and modeling, we first aim to clarify some misunderstandings around the very nature of minimal self and intentionality, namely: whether these concepts entail a “minimal” sense of self, or might be better described in “transparent” sensory-integration and information processing terms. We then try to apply the concepts to a computational logic based on Marr’s levels of description, a fundamental account for understanding the rationale of computational psychiatry. Overall, we are asking via what conditions phenomenology can enter a computational logic. (shrink)

What type of artificial systems will claim to be conscious and will claim to experience qualia? The ability to comment upon physical states of a brain-like dynamical system coupled with its environment seems to be sufficient to make claims. The flow of internal states in such system, guided and limited by associative memory, is similar to the stream of consciousness. Minimal requirements for an artificial system that will claim to be conscious were given in form of specific architecture (...) named articon. Nonverbal discrimination of the working memory states of the articon gives it the ability to experience different qualities of internal states. Analysis of the inner state flows of such a system during typical behavioral process shows that qualia are inseparable from perception and action. The role of consciousness in learning of skills, when conscious information processing is replaced by subconscious, is elucidated. Arguments confirming that phenomenal experience is a result of cognitive processes are presented. Possible philosophical objections based on the Chinese room and other arguments are discussed, but they are insufficient to refute claims articon’s claims. Conditions for genuine understanding that go beyond the Turing test are presented. Articons may fulfill such conditions and in principle the structure of their experiences may be arbitrarily close to human. (shrink)

In 1968, the Harvard criteria equated irreversible coma and apnea with human death and later, the Uniform Determination of Death Act was enacted permitting organ procurement from heart-beating donors. Since then, clinical studies have defined a spectrum of states of impaired consciousness in human beings: coma, akinetic mutism, minimally conscious state, vegetative state and brain death. In this article, we argue against the validity of the Harvard criteria for equating brain death with human death. Brain death does (...) not disrupt somatic integrative unity and coordinated biological functioning of a living organism. Neurological criteria of human death fail to determine the precise moment of an organism’s death when death is established by circulatory criterion in other states of impaired consciousness for organ procurement with non-heart-beating donation protocols. The criterion of circulatory arrest 75 s to 5 min is too short for irreversible cessation of whole brain functions and respiration controlled by the brain stem. Brain -based criteria for determining death with a beating heart exclude relevant anthropologic, psychosocial, cultural, and religious aspects of death and dying in society. Clinical guidelines for determining brain death are not consistently validated by the presence of irreversible brain stem ischemic injury or necrosis on autopsy; therefore, they do not completely exclude reversible loss of integrated neurological functions in donors. The questionable reliability and varying compliance with these guidelines among institutions amplify the risk of determining reversible states of impaired consciousness as irreversible brain death. The scientific uncertainty of defining and determining states of impaired consciousness including brain death have been neither disclosed to the general public nor broadly debated by the medical community or by legal and religious scholars. Heart-beating or non-heart-beating organ procurement from patients with impaired consciousness is de facto a concealed practice of physician-assisted death, and therefore, violates both criminal law and the central tenet of medicine not to do harm to patients. Society must decide if physician-assisted death is permissible and desirable to resolve the conflict about procuring organs from patients with impaired consciousness within the context of the perceived need to enhance the supply of transplantable organs. (shrink)

The stratification in depth of chromatically homogeneous overlapping figures depends on a minimization rule which assigns the status of being “in front” to the figure that requires the formation of shorter modal contours. This rule has been proven valid also in birds, whose visual neuroanatomy is radically different from that of other mammals, thus suggesting an example of evolutionary convergence toward a perceptual universal. [Shepard].

Neuroimaging studies of brain-damaged patients diagnosed as in the vegetative state suggest that the patients might be conscious. This might seem to raise no new ethical questions given that in related disputes both sides agree that evidence for consciousness gives strong reason to preserve life. We question this assumption. We clarify the widely held but obscure principle that consciousness is morally significant. It is hard to apply this principle to difficult cases given that philosophers of mind distinguish between a (...) range of notions of consciousness and that is unclear which of these is assumed by the principle. We suggest that the morally relevant notion is that of phenomenal consciousness and then use our analysis to interpret cases of brain damage. We argue that enjoyment of consciousness might actually give stronger moral reasons not to preserve a patient's life and, indeed, that these might be stronger when patients retain significant cognitive function. (shrink)

Deep brain stimulation (DBS) of the globus pallidus interna and subthalamic nucleus has restored some degree of motor control in many patients in advanced stages of Parkinson’s disease. DBS has also been used to treat dystonia, essential tremor (progressive neurological condition causing trembling), chronic pain, obsessive-compulsive disorder, Tourette’s syndrome, major depressive disorder, obesity, cerebral palsy, and the minimally conscious state. Although the underlying mechanisms of the technique are still not clear, DBS can modulate underactive or overactive neural circuits and (...) restore disrupted communication between and among groups of neurons in interacting regions of the brain. This can control and relieve many symptoms associated with a range of neurological and psychiatric disorders.But the procedures of implanting and stimulating the electrodes are brain-invasive and entail significant risks. Some patients receiving DBS have experienced intracerebral hemorrhage, infection, cognitive disturbances such as impulsive behavior, and affective disturbances such as mania. It is not known whether continuous electrical stimulation of the brain would reshape synaptic connectivity and permanently alter neural circuits in ways that may not be salutary. The risk of these effects indicates that DBS should be used only when a patient’s condition is refractory to all other interventions and when there is a high probability that the technique will benefit the patient and improve his or her quality of life. If a patient’s quality of life is poor and all other treatment options have been exhausted, then the likelihood of benefit can justify physicians’ exposing patients to some risk. The clinical and ethical significance of the risk in DBS underscores the obligation of physicians to obtain fully informed consent from patients undergoing the procedure. (shrink)

This paper explores whether brain images may be admitted as evidence in criminal trials under Federal Rule of Evidence 403, which weighs probative value against the danger of being prejudicial, confusing, or misleading to fact finders. The paper summarizes and evaluates recent empirical research relevant to these issues. We argue that currently the probative value of neuroimages for criminal responsibility is minimal, and there is some evidence of their potential to be prejudicial or misleading. We also propose experiments (...) that will directly assess how jurors are influenced by brain images. (shrink)

Creativity has received, and continues to receive, comparatively little analysis in philosophy and the brain and behavioural sciences. This is in spite of the importance of creative thought and action, and the many and varied resources of theories of mind. Here an alternative approach to analyzing creativity is suggested: start from the bottom up with minimally creative thought. Minimally creative thought depends non-accidentally upon agency, is novel relative to the acting agent, and could not have been tokened before the (...) time it is in fact tokened, relative to the agent in question. Thoughts that meet these three conditions—agency, psychological novelty, and modal—are what may be called cognitive breakthroughs. Even if such breakthroughs are not necessary to or definitive of richer creativity, they are indeed central to much of creativity. The minimal analysis provides a more workable explanandum for theories of creativity of varied motivation and method. (shrink)

An exciting theory in neuroscience is that the brain is an organ for prediction error minimization. This theory is rapidly gaining influence and is set to dominate the science of mind and brain in the years to come. PEM has extreme explanatory ambition, and profound philosophical implications. Here, I assume the theory, briefly explain it, and then I argue that PEM implies that the brain is essentially self-evidencing. This means it is imperative to identify an evidentiary boundary (...) between the brain and its environment. This boundary defines the mind-world relation, opens the door to skepticism, and makes the mind transpire as more inferentially secluded and neurocentrically skull-bound than many would nowadays think. Therefore, PEM somewhat deflates contemporary hypotheses that cognition is extended, embodied and enactive; however, it can nevertheless accommodate the kinds of cases that fuel these hypotheses. (shrink)

Persons who experience severe brain injury often suffer significant disorders of consciousness. Anoxic injuries from cardiac arrest or strokes and traumatic injuries from falls, vehicular crashes, or assaults can result in several conditions in which patients lose or have diminished consciousness for an extended period of time. Two such conditions that create considerable public confusion and controversy are the vegetative state and the minimally conscious state. Although these conditions have generated significant medical and academic research, the general public and (...) policymakers are often confused about the nature of VS and MCS. The most recent evidence for this confusion is the acrimonious public debate, the extensive media coverage, the prolonged litigation, and the attempts of various governmental officials to intervene in dealing with the plight of Terri Schiavo. (shrink)

We argue that the minimal biological requirements for consciousness include a living body, not just neuronal processes in the skull. Our argument proceeds by reconsidering the brain-in-a-vat thought experiment. Careful examination of this thought experiment indicates that the null hypothesis is that any adequately functional “vat” would be a surrogate body, that is, that the so-called vat would be no vat at all, but rather an embodied agent in the world. Thus, what the thought experiment actually shows is (...) that the brain and body are so deeply entangled, structurally and dynamically, that they are explanatorily inseparable. Such entanglement implies that we cannot understand consciousness by considering only the activity of neurons apart from the body, and hence we have good explanatory grounds for supposing that the minimal realizing system for consciousness includes the body and not just the brain. In this way, we put the brain-in-a-vat thought experiment to a new use, one that supports the “enactive” view that consciousness is a life-regulation process of the whole organism interacting with its environment. (shrink)

Prediction Error Minimization theory (PEM) is one of the most promising attempts to model perception in current science of mind, and it has recently been advocated by some prominent philosophers as Andy Clark and Jakob Hohwy. Briefly, PEM maintains that “the brain is an organ that on aver-age and over time continually minimizes the error between the sensory input it predicts on the basis of its model of the world and the actual sensory input” (Hohwy 2014, p. 2). An (...) interesting debate has arisen with regard to which is the more adequate epistemological interpretation of PEM. Indeed, Hohwy maintains that given that PEM supports an inferential view of perception and cognition, PEM has to be considered as conveying an internalist epistemological perspective. Contrary to this view, Clark maintains that it would be incorrect to interpret in such a way the indirectness of the link between the world and our inner model of it, and that PEM may well be combined with an externalist epistemological perspective. The aim of this paper is to assess those two opposite interpretations of PEM. Moreover, it will be suggested that Hohwy’s position may be considerably strengthened by adopting Carlo Cellucci’s view on knowledge (2013). (shrink)

In this paper, we set out to develop a theoretical and conceptual framework for the new field of Radical Embodied Cognitive Neuroscience. This framework should be able to integrate insights from several relevant disciplines: theory on embodied cognition, ecological psychology, phenomenology, dynamical systems theory, and neurodynamics. We suggest that the main task of Radical Embodied Cognitive Neuroscience is to investigate the phenomenon of skilled intentionality from the perspective of the self-organization of the brain-body-environment system, while doing justice to the (...) phenomenology of skilled action. In previous work, we have characterized skilled intentionality as the organism's tendency toward an optimal grip on multiple relevant affordances simultaneously. Affordances are possibilities for action provided by the environment. In the first part of this paper, we introduce the notion of skilled intentionality and the phenomenon of responsiveness to a field of relevant affordances. Second, we use Friston's work on neurodynamics, but embed a very minimal version of his Free Energy Principle in the ecological niche of the animal. Thus amended, this principle is helpful for understanding the embeddedness of neurodynamics within the dynamics of the system “brain-body-landscape of affordances.” Next, we show how we can use this adjusted principle to understand the neurodynamics of selective openness to the environment: interacting action-readiness patterns at multiple timescales contribute to the organism's selective openness to relevant affordances. In the final part of the paper, we emphasize the important role of metastable dynamics in both the brain and the brain-body-environment system for adequate affordance-responsiveness. We exemplify our integrative approach by presenting research on the impact of Deep Brain Stimulation on affordance responsiveness of OCD patients. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Minding Brain Injury, Consciousness, and Ethics: Discourse and DeliberationsJoseph J. Fins (bio) and James Giordano (bio)The annual John Collins Harvey Lecture at the Georgetown University’s Pellegrino Center for Clinical Bioethics is a forum for addressing contemporary topics at the intersection of medicine and bioethics. This year, in marking the decadal anniversary of the launch of the Brain Research through Advancing Innovative Neurotechnology (BRAIN) Initiative, the Harvey (...) Lecture provided an interactive discussion with renowned clinician, researcher, scholar, and author, Joseph J. Fins, MD—who is the E. William Davis, Jr., MD Professor of Medical Ethics, Chief of the Division of Medical Ethics, and a Professor of Medicine at Weill Cornell Medical College—conducted by James Giordano, PhD, MPhil—who is a Professor of Neurology and Biochemistry, and Chief of the Pellegrino Center’s Neuroethics Studies Program at the Georgetown University Medical Center. The discourse focused upon the topic of covert consciousness, and the ways in which current and developing brain science technologies, together with revised practices of medicine, in general, may afford new opportunities in patient care, but may also give rise to issues, questions, challenges, and opportunities for neuroethics.Prof. James GIORDANO:Prof. Fins, your most recent book, Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness (Fins 2015), addresses your ongoing work to employ current and emerging neurological approaches to reveal conscious functions in patients with profound brain injury and disease. To be sure, the destination—if you will—is to talk about covert consciousness. But in commencing this discussion, I’d like to propose a route, which traces your professional journey to this point in your career, and how it led you on your search to reveal consciousness in those patients who lack expressive capability. You went into palliative care first, and that brought you to where you are today. [End Page 227]Prof. Joseph J. FINS:First, let me thank you and the Pellegrino Center for the honor of giving the John Harvey Collins Lecture in such an interactive manner. The forefront of neurological care—and the neuroethical issues and methods focal to such practice—wasn’t what I initially intended to do professionally, but I think that therein is a good lesson for young people’s career aspirations. Simply put, one doesn’t always know where they’ll end up at the beginning of the journey, and as Kierkegaard said, life is lived forward, but is understood backwards (Kierkegaard 1843).In the nineties and the early 2000s, I was trying to help improve the quality of care of people at the end of life, and I wrote a book, entitled The Palliative Ethic of Care: Clinical Wisdom at Life’s End (Fins 2006), in which I addressed notions of phronesis—practical wisdom—in integrating theory and practice toward improving how people die. I became interested in the Quinlan case (Quinlan 1976), and the right to die, and around the same time, I ran into a colleague of mine at Cornell: Dr. Nicholas D. Schiff. Dr. Schiff is a neurologist, who was a protégé of Fred Plum, who was the originator of the concept of the vegetative state with Bryan Jennett, back in 1972. Fred was both of our teachers here at Cornell. Niko (Dr. Schiff) was interested in patients with disorders of consciousness, and was beginning to envision doing work—that ultimately, we did—using deep brain stimulation (DBS) to try to treat patients in the minimally conscious state, a category that was subsequently codified in 2002.I realized that a whole population of people—with these disorders of consciousness—had been somewhat marginalized, and their neglect essentially devolves back to the considerations of the right to die. The right to die was established in the Quinlan case because Judge Hughes—the presiding chief judge of the New Jersey Supreme Court—talked about Ms. Quinlan’s loss of a cognitive, sapient state as being the moral warrant for her right to die, given the fact that it was viewed as a futile situation. I recognized, over the ensuing years—from my background in palliative and end-of-life care—[1] that we had over-generalized notions of futility... (shrink)

The relationship between brain and mind has been extensively explored through the developments within neuroscience over the last decade. However, the ontological status of mind has remained fairly problematic due to the inability to explain all features of the mind through the brain. This inability has been considered largely due to partial knowledge of the brain. It is claimed that once we gain complete knowledge of the brain, all features of the mind would be explained adequately. (...) However, a challenge to such a position is downward causation: How do we explain the causal power that mental states exert over brain activities? If we agree that downward causation occurs, then to what extent could a sole explanation of brain activities account for our behaviour? (For they would in themselves be conditioned by the mental states which are left unexplained). This dissertation is an attempt to understand relation between brain and mind through the concept of emergence, placed in the context of complex systems approach. This will create a space to account for the causal power of mental states. The complex systems approach says that as the complexity of a system increases, we witness the emergence of novel qualities and after a certain threshold (of complexity), the emergence of a novel structure. When the body (and correspondingly, brain) reaches a certain level of complexity, the mind emerges. The brain is a complex system from which the mind emerges. The brain, consisting of billions of neurons interacting with each other, regulates the body placed in the environment. The interaction of neurons (local interactions involving self-organization) result in dynamical brain signatures (global synergy). Such signatures are correlative to mental states. Mind is the process of a living organism embodying an intentional stance. This object could be the subject itself or another distinct from the subject. With the emergence of mind, the causal powers of brain are conditioned by the mind. Such a conditioning is evident through the causal efficacy of mental states. While the brain is minimal condition for the mind to emerge, the mind in itself is embedded (showcased/explicated/manifested) throughout the body. The mind is a process that belongs to body-as-a-whole with the novel quality of intentionality. A preliminary to understanding this relation is its metaphysical inclination. A large portion of the history of philosophy of mind has advocated a metaphysics of entities where the mind and body have been seen as two entities with distinct essences. However, such attribution of entity-ship does not take into account the processual nature of these existents (that they are essentially dependent on their environment for their existence and sustenance). Thus, the category of processual unity has been introduced which sought to account for existent as emergent wholes that move towards a stable equilibrium through self-organization. By considering existents to be processual unities, we can account for their identity as a whole-in-itself (what has been called organizational closure) and also for their processual nature. The brain is a component of the body which is a complex system and is representative of the body’s stance in the world. The brain, consisting of billions of neurons interacting with each other, regulates the body placed in the environment. The interaction of neurons (local interactions involving self-organization) result in dynamical brain signatures (global synergy). Such signatures are correlative to mental states. These mental states in turn condition the brain patterns, that allows the embodying of mental states. Thus, the three-way process of the representation of body in the world by the brain, the emergence of mental state through dynamic brain patterns and the reciprocal causal power on the brain patterns by the mental states marks embodiment. The relation between brain, body and mind can be outlined as follows: A. There are complex interactions in the brain. These interactions are representative of the body’s stance in the world and are present in form of dynamical brain signatures. B. The dynamical brain signatures lead to emergence of mind as a process. The mental state has causal power which conditions the brain. C. The brain conditioned by causal power of the mind carries out embodiment of the mind throughout the body. In the dissertation, an exposition on relation between brain and mind through complex system approach is followed by a brief on relation between body and mind. The radical embodiment approach adopts the nonlinear dynamic systems theory to understand relation of brain, body and mind. It states a shift from mapping of cognitive states onto Neural Correlates of Consciousness to their mapping through dynamic brain signatures. Every mental state is embedded throughout the body. The dissertation explores the three features of consciousness, intentionality and qualia. These have previously formed a challenge within a dualistic framework and the dissertation intends to show a direction in which they can be accounted for, within the complex systems approach and radical embodiment viewpoint. After a certain threshold of the rate of production of cell assemblies is bypassed, we become conscious of the representation itself. This leads to emergence of phenomenal states. Qualia is the qualitative character of such states, which belong to the body-as-a-whole and for this reason, cannot be reduced to properties of any of the components from which it emerges (the dynamic brain signatures) or in which it is embodied (the body and its individual parts) alone. Intentionality is the novel property of mind of moving towards a certain set of attractors where attractors refer to the states that the system prefers (which would positively contribute to its fitness). The scope of this dissertation is to delineate the relation of brain to the mind and unravel some persistent troubles of philosophy of mind within such delineation. The types of components and their relation within the mind preceded by a thorough study of how the mind is embodied is an area yet to be extensively explored in the coming works. (shrink)

Brain-computer interfaces (BCIs) are being investigated as an access pathway to communication for individuals with physical disabilities, as the technology obviates the need for voluntary motor control. However, to date, minimal research has investigated the use of BCIs for children. Traditional BCI communication paradigms may be suboptimal given that children with physical disabilities may face delays in cognitive development and acquisition of literacy skills. Instead, in this study we explored emotional state as an alternative access pathway to communication. (...) We developed a pediatric BCI to identify positive and negative emotional states from changes in hemodynamic activity of the prefrontal cortex (PFC). To train and test the BCI, 10 neurotypical children aged 8–14 underwent a series of emotion-induction trials over four experimental sessions (one offline, three online) while their brain activity was measured with functional near-infrared spectroscopy (fNIRS). Visual neurofeedback was used to assist participants in regulating their emotional states and modulating their hemodynamic activity in response to the affective stimuli. Child-specific linear discriminant classifiers were trained on cumulatively available data from previous sessions and adaptively updated throughout each session. Average online valence classification exceeded chance across participants by the last two online sessions (with 7 and 8 of the 10 participants performing better than chance, respectively, in Sessions 3 and 4). There was a small significant positive correlation with online BCI performance and age, suggesting older participants were more successful at regulating their emotional state and/or brain activity. Variability was seen across participants in regards to BCI performance, hemodynamic response, and discriminatory features and channels. Retrospective offline analyses yielded accuracies comparable to those reported in adult affective BCI studies using fNIRS. Affective fNIRS-BCIs appear to be feasible for school-aged children, but to further gauge the practical potential of this type of BCI, replication with more training sessions, larger sample sizes, and end-users with disabilities is necessary. (shrink)

BackgroundWhether patients in the vegetative state (VS), minimally conscious state (MCS) or the clinically related locked-in syndrome (LIS) should be kept alive is a matter of intense controversy. This study aimed to examine the moral attitudes of lay people to these questions, and the values and other factors that underlie these attitudes.MethodOne hundred ninety-nine US residents completed a survey using the online platform Mechanical Turk, comprising demographic questions, agreement with treatment withdrawal from each of the conditions, agreement with a series (...) of ethical principles and three personality tests.ResultsMore supported treatment withdrawal from VS (40.2 % agreed, 17.6 % disagreed) than MCS (20.6 %, 41.2 %) or LIS (25.3 %, 35.8 %). Agreement with treatment withdrawal was negatively correlated with religiosity (r = −0.272, P < 0.001), though showed no significant relationship with need for cognition or empathy, and only a partial association with utilitarian judgment in a standard moral dilemma. Support for treatment withdrawal was most strongly associated with endorsement of the importance of patient autonomy, dignity, suffering, best interests. Distributive justice was not given significant weight by most. Importantly, agreement with treatment withdrawal was noticeably higher when considered from a first as opposed to third person perspective for VS (Z = −6.056, P < 0.001), MCS (Z = −6.746, P < 0.001) and LIS (Z = −6.681, P < 0.001).ConclusionLay attitudes to withdrawal of treatment in brain damaged patients are largely shaped by values similar to those central to the secular ethical debate. Neither traditional values such as the sanctity of life nor utilitarian values relating to resource allocation seem to play a central role. Far greater weight is given to autonomy, which may explain why participants were far more willing to endorse withdrawal of treatment when the issue was presented in the first person, or in relation to a concrete case involving a patient’s explicit wishes. Surveys focusing on abstract cases presented in the third person may not provide an accurate picture of lay attitudes to these critical ethical questions. (shrink)

I argue in favor of the Minimal Approval account, an original account of an agent’s moral responsibility for her actions, understood as the conditions that must be met so that an agent’s actions speak for her such that she can appropriately be blamed on their basis. My account shares a general theoretical orientation with Deep Self views, but diverges in several respects. I argue that Deep Self views tend to seriously over-generate exemptions, such that agents are exempt from responsibility (...) even from ordinary weak-willed actions. Accordingly, much of my focus is on giving a more nuanced, and in certain senses narrower, explanation of genuine exemption cases. While I address the advantages the Minimal Approval account has over competing accounts throughout these chapters, the account also aims to provide an empirically informed response to a certain sort of skeptical worry about how it could be the case that anyone is ever responsible for what they do at all. One commonplace thought is that when agents’ behaviors are due to compulsion their “brains make them do it.” But, in a literal sense, it might seem that our brains make all of us do everything that we do. In this dissertation I head off this worry by directly addressing both what the difference is, and what it should mean for our practices. (shrink)

For more than thirty years, in most of the world, the irreversible cessation of all brain function, more commonly known as brain death, has been accepted as a criterion of death. Yet the philosophical basis on which this understanding of death was originally grounded has been undermined by the long-term maintenance of bodily functions in brain dead patients. More recently, the American case of Jahi McMath has cast doubt on whether the standard tests for diagnosing brain (...) death exclude a condition in which the patient is not dead, but in a minimally conscious state. I argue that the evidence now clearly shows that brain death is not equivalent to the death of the human organism. We therefore face a choice: either we stop removing vital organs from brain dead patients, or we accept that it is not wrong to kill an innocent human who has irreversibly lost consciousness. (shrink)

ObjectiveWhen regaining consciousness, patients who emerge from a minimally conscious state (EMCS) present with different levels of functional disability, which pose great challenges for treatment. This study investigated the frontoparietal activity in EMCS patients and its effects on functional disability.Materials and methodsIn this preliminary study, 12 EMCS patients and 12 healthy controls were recruited. We recorded a resting-state scalp electroencephalogram (EEG) for at least 5 min for each participant. Each patient was assessed using the disability rating scale (DRS) to determine (...) the level of functional disability. We analyzed the EEG power spectral density and sensor-level functional connectivity in relation to the patient’s functional disability.ResultsIn the frontoparietal region, EMCS patients demonstrated lower relative beta power (P < 0.01) and higher weighted phase lag index (wPLI) values in the theta (P < 0.01) and gamma (P < 0.01) bands than healthy controls. The frontoparietal theta wPLI values of EMCS patients were positively correlated with the DRS scores (rs = 0.629, P = 0.029). At the whole-brain level, EMCS patients only had higher wPLI values in the theta band (P < 0.01) than healthy controls. The whole-brain theta wPLI values of EMCS patients were also positively correlated with the DRS scores (rs = 0.650, P = 0.022). No significant difference in the power and connectivity between the frontoparietal region and the whole brain in EMCS patients was observed.ConclusionEMCS patients still experience neural dysfunction, especially in the frontoparietal region. However, the theta connectivity in the frontoparietal region did not increase specifically. At the level of the whole brain, the same shift could also be seen. Theta functional connectivity in the whole brain may underlie different levels of functional disability. (shrink)

The value of resting electroencephalogram (EEG) in revealing neural constitutes of consciousness (NCC) was examined. We quantified the dynamic repertoire, duration and oscillatory type of EEG microstates in eyes-closed rest in relation to the degree of expression of clinical self-consciousness. For NCC a model was suggested that contrasted normal, severely disturbed state of consciousness and state without consciousness. Patients with disorders of consciousness were used. Results suggested that the repertoire, duration and oscillatory type of EEG microstates in resting condition quantitatively (...) related to the level of consciousness expression in brain-damaged patients and healthy-conscious subjects. Specifically, results demonstrated that (a) decreased number of EEG microstate types was associated with altered states of consciousness, (b) unawareness was associated with the lack of diversity in EEG alpha-rhythmic microstates, and (c) the probability for the occurrence and duration of delta-, theta- and slow-alpha-rhythmic microstates were associated with unawareness, whereas the probability for the occurrence and duration of fast-alpha-rhythmic microstates were associated with consciousness. In conclusion, resting EEG has a potential value in revealing NCC. This work may have implications for clinical care and medical–legal decisions in patients with disorders of consciousness. (shrink)

Background: Patients in a vegetative state pose problems in diagnosis, prognosis and treatment. Currently, no prognostic markers predict the chance of recovery, which has serious consequences, especially in end-of-life decision-making. Objective: We aimed to assess an objective measurement of prognosis using advanced electroencephalography (EEG). Methods: EEG data (19 channels) were collected in 14 patients who were diagnosed to be persistently vegetative based on repeated clinical evaluations at 3 months following brain damage. EEG structure parameters (amplitude, duration and variability within (...) quasi-stationary segments, as well as the spatial synchrony between such segments and the strength of this synchrony) were used to predict recovery of consciousness 3 months later. Results: The number and strength of cortical functional connections between EEG segments were higher in patients who recovered consciousness (P < .05 – P < .001) compared with those who did not recover. Linear regression analysis confirms that EEG structure parameters are capable of predicting (P = .0025) recovery of consciousness 6 months post-injury, whereas the same analysis failed to significantly predict patient outcome based on aspects of their clinical history alone (P = .629) or conventional EEG spectrum power (P = .473). Conclusions: The result of this preliminary study demonstrates that structural strategy of EEG analysis is better suited for providing prognosis of consciousness recovery than existing methods of clinical assessment and of conventional EEG. Our results may be a starting point for developing reliable prognosticators in patients who are in vegetative state, with the potential to improve their day-to-day management, quality of life, and access to early interventions. (shrink)

Neuroscience has studied deductive reasoning over the last 20 years under the assumption that deductive inferences are not only de jure but also de facto distinct from other forms of inference. The objective of this research is to verify if logically valid deductions leave any cerebral electrical trait that is distinct from the trait left by non-valid deductions. 23 subjects with an average age of 20.35 years were registered with MEG and placed into a two conditions paradigm (100 trials for (...) each condition) which each presented the exact same relational complexity (same variables and content) but had distinct logical complexity. Both conditions show the same electromagnetic components (P3, N4) in the early temporal window (250–525 ms) and P6 in the late temporal window (500–775 ms). The significant activity in both valid and invalid conditions is found in sensors from medial prefrontal regions, probably corresponding to the ACC or to the medial prefrontal cortex. The amplitude and intensity of valid deductions is significantly lower in both temporal windows (p = 0.0003). The reaction time was 54.37% slower in the valid condition. Validity leaves a minimal but measurable hypoactive electrical trait in brain processing. The minor electrical demand is attributable to the recursive and automatable character of valid deductions, suggesting a physical indicator of computational deductive properties. It is hypothesized that all valid deductions are recursive and hypoactive. (shrink)

Objective: The value of spontaneous EEG oscillations in distinguishing patients in vegetative and minimally conscious states was studied. Methods: We quantified dynamic repertoire of EEG oscillations in resting condition with closed eyes in patients in vegetative and minimally conscious states (VS and MCS). The exact composition of EEG oscillations was assessed by the probability-classification analysis of short-term EEG spectral patterns. Results: The probability of delta, theta and slow-alpha oscillations occurrence was smaller for patients in MCS than for VS. Additionally, only (...) patients in MCS demonstrated fast-alpha oscillation occurrence. Depending on the type and composition of EEG oscillations, the probability of their occurrence was either aetiology dependent or independent. The probability of EEG oscillations occurrence differentiated brain injuries with different aetiologies. Conclusions: Spontaneous EEG oscillations have a potential value in distinguishing patients in VS and MCS. Significance: This work may have implications for clinical care, rehabilitative programs and medical–legal decisions in patients with impaired consciousness states following coma due to acute brain injuries. (shrink)

Increases of absolute brain size during evolution reinforced stronger structuring of brain connectivity. One consequence is the hierarchical cluster structure of neural systems that combines predominantly short, but not strictly minimal, wiring with short processing pathways. Principles of “large equals well-connected” and “minimal wiring” do not completely account for observed patterns of brain connectivity. A structural model promises better predictions.

In his paper, Jakob Hohwy outlines a theory of the brain as an organ for prediction-error minimization, which he claims has the potential to profoundly alter our understanding of mind and cognition. One manner in which our understanding of the mind is altered, according to PEM, stems from the neurocentric conception of the mind that falls out of the framework, which portrays the mind as “inferentially-secluded” from its environment. This in turn leads Hohwy to reject certain theses of embodied (...) cognition. Focusing on this aspect of Hohwy’s argument, we first outline the key components of the PEM framework such as the “evidentiary boundary,” before looking at why this leads Hohwy to reject certain theses of embodied cognition. We will argue that although Hohwy may be correct to reject specific theses of embodied cognition, others are in fact implied by the PEM framework and may contribute to its development. We present the metaphor of the “body as a laboratory” in order to highlight wha... (shrink)

Philosophical debates about free will have focused on determinism—a potential ‘threat from behind’ because determinism entails that there are conditions in the distant past that, in accord with the laws of nature, are sufficient for all of our decisions. Neuroscience is consistent with indeterminism, so it is better understood as posing a ‘threat from below’: If our decision-making processes are carried out by neural processes, then it might seem that our decisions are not based on our prior conscious deliberations or (...) reasoning. The response to this threat will require a neurophilosophical theory of mind that makes sense of the causal role of our conscious reasons and reasoning. Without such a theory, our conscious self seems bypassed by the neural processes in our brains, and this view seems to explain why many scientists assume that neuroscience challenges free will. However, I argue that most people are amenable to the possibility of a future theory of mind that is physicalist (if not reductionist), yet preserves much of our ordinary experience and understanding of conscious decision-making and self-control. I outline such a theory using the resources of causal interventionism. I argue that this view is best understood as a minimal revision to our understanding of free will, rather than an elimination of it. And I argue that this view has more reasonable and effective implications for our moral and legal practices than an eliminativist or skeptical theory of free will. (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.

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)