BackgroundThe Supreme Court of Canada removed the prohibition on physicians assisting in patients dying on 6 February 2015. Bill C-14, legalising medical assistance in dying (MAID) in Canada, was subsequently passed by the House of Commons and the Senate on 17 June 2016. As this remains a divisive issue for physicians, the Canadian Neurosurgical Society (CNSS) has recently published a position statement on MAID.MethodsWe conducted a cross-sectional survey to understand the views and perceptions among CNSS members regarding MAID to inform (...) its position statement on the issue. Data was collected from May to June 2016.ResultsOf the 300 active membes of the CNSS who recevied the survey, 89 respondents completed the survey, 71% of whom were attending neurosurgeons and 29% were neurosurgery residents. Most respondents,74.2%, supported the right of physicians to participate in MAID with 7.8% opposing. 37% had current patients in their practice fitting the criteria for MAID. 23.6% had been asked by patients to assist with MAID, but only 11% would consider personally providing it. 84% of neurosurgeons surveyed supported the physicians’ right to conscientious objection to MAID while 21% thought attending surgeons should be removed from the inquiry and decision-making process. 43.8% agreed that the requirment to refer a patient to a MAID service should be mandatory. Glioblastoma multiforme (65%), quadriplegia/quadriparesis secondary to spinal tumour/trauma (54%) and Parkinson’s disease (24%) were the most common suggested potential indications for MAID among the neurosurgical population.ConclusionsOur results demonstrate that most neurosurgeons in Canada are generally supportive of MAID in select patients. However, they also strongly support the physicians’ right to conscientious objection. (shrink)

The objection to R-S accounts that was raised by the possibility of external agents requires the acceptance of two premises, viz., that all R-S accounts allow for puppeteers and that puppeteers necessarily make us unfree. The Metaphilosophical reply shows that to the extent that puppeteers are more problematic than determinism per se, pup-peteers may be explicitly excluded since they violate our paradigm of free will. The Metaphilosophical reply also suggests that we should not expect our mature R-S account to supply (...) logically necessary and sufficient conditions for free will, but rather give us answers that agree with our intuitions regarding paradigms of free and unfree decisions. The Irrelevancy reply completed our reply to incompatibilists who continue to object that determinism per se destroys the R-S program. It may be debated whether my autonomy variable account is a satisfactory way to spell out the Irrelevancy reply, but I think that this type of approach suggests the way to vindicating the R-S view from an important type of objection. (shrink)

Aims to show that the brain is not responsible for consciousness, and uses this assertion to explore profound love and human connection.

When trust is violated, can it ever be recovered? Alison Jacobs needs brain surgery and places ultimate trust in her sister's husband, Grant Kaplan, a world-renowned neurosurgeon and expert in treating her condition. But Grant is hiding a dark secret which threatens the outcome: an addiction to prescription pills. As Alison struggles to rebuild her life, Grant's daughter, Sadie, spends more time with a new friend. Frustrated that her parents exclude her from the conversations about her beloved aunt, Sadie makes (...) increasingly risky choices which could endanger not only her, but her entire family. Alison is also harboring her own secret -- an extramarital affair with a woman. Her close call with mortality spurs her to take a closer look at her marriage, explore her newfound sexuality, and figure out what she wants for her future. How will she rebuild her life and move forward? Can she find a way to repair her broken relationship with her only sister? Secrets swirling around drug use and sexual identity must be dealt with in order for the family to learn to trust each other again. -- Goodreads. (shrink)

Doctor Stephen Strange was a renowned neurosurgeon in his “previous life”, but after his time in Kamar‐Taj he is mostly associated with his mastery of the mystic arts. In Doctor Strange people learn that mastery of physical skills is critical for mastery as a mystic. In addition to the physical skills of martial arts, the portrayal of Doctor Strange is reminiscent of many aspects of Eastern philosophical traditions. Ironically, the reason that Strange originally gave for seeking the elixir is that (...) he swore the Hippocratic Oath, which requires him to prescribe medical treatments for the good of his patients. One problem with applying the Hippocratic Oath to Strange's choice is that it's meant to apply to the doctor‐patient relationship. Perhaps Stan Lee and Steve Ditko, the creators of Doctor Strange, meant to show that, by losing his skill as a surgeon, Strange finally learned what it means to be a good physician. (shrink)

Neurosurgeon Sergio Canavero proposed the HEAVEN procedure – i.e. head anastomosis venture – several years ago, and has recently received approval from the relevant regulatory bodies to perform this body-head transplant in China. The BHT procedure involves attaching the donor body to the head of the recipient, and discarding the body of R and head of D. Canavero’s proposed procedure will be incredibly difficult from a medical standpoint. Aside from medical doubt, the BHT has been met with great resistance from (...) many, if not most bio- and neuroethicists.Given both the known challenges and unknown outcomes of HEAVEN, several important neuroethical and legal questions have emerged should Canavero be successful, including: What are the implications for transplantology in the U.S., inclusive of issues of expense, distributive justice, organizational procedures, and the cost of novel insight? How do bioethical and neuroethical principles, and legal regulations of human subject research apply? What are the legal consequences for Canavero performing a BHT? What are the tentative implications for the metaphysical and legal identity of R should they survive post-BHT? These questions are analyzed, issues are identified, and several solutions are proposed in an attempt to re-configure HEAVEN into a safe, clinically effective, and thus realistically viable procedure.Notably, the permissibility of conducting the BHT in China fosters additional, important questions, focal to whether Western ethics and professional norms be used to guide the BHT – or any neuroscientific research and its use - in non-Western countries, such as China; if the models of responsible conduct of research are identical, similar, or applicable to the intent and conduct of research in China; and what economic and political implications are fostered if/when such avant garde techniques are successful.These questions are discussed as a further impetus to develop a globally applicable neuroethical framework that would enable both local articulation and cosmopolitan inquiry and oversight of those methods and approaches deemed problematic, if and when rendered in more international settings. (shrink)

Neurosurgeons have an especially high rate of exposure to serious ethical challenges in their line of work. The aim of this study was to assess the type and frequency of ethical theories used by neurosurgery residents to make extra- ethical decisions in challenging situations and their relation with the level of residency, and curricular training about medical ethics. A total of 12 neurosurgery residents in Mashhad University of Medical Sciences (MUMS) were interviewed; all the participants were male and aged (...) 29–40 years old. Of all, six were senior and six were junior. Using a systematic review of neurosurgery and medical ethics textbooks, five common cases were selected and a semi-structured, open-ended interview was developed. The interviews were digitally recorded and analyzed in two separate stages. Comparison of the results of the two stages led us to the final judgment about the dominant ethical theory used in each case. In all 60 cases, the decision-making process was compatible with either Deontology (30 cases) or Consequentialism (30 cases). Only in two cases, beside Deontology, the Virtue ethics was used as an alternative in special situations. The ethical theories were not consistent for all the 12 subjects and all the five questions. No statistically significant difference was found between senior and junior residents, neither for each question nor for the aggregate (Odds Ratio = 1.31, 95 % CI = 0.42-4.09, Relative Risk = 1.41, 95 % CI = 0.69-1.9, P-value > 0.20). Only one of the subjects had extracurricular training in medical ethics, consequently precluding further analysis. Although not intended to be evaluated by this study, similar heterogeneity was observed in final decisions. When faced with medical ethics challenges, neurosurgery residents did not follow a consistent ethical theory for making decisions. The type and frequency of theories did not seem to be changed during the residency period. (shrink)

Turing’s much debated test has turned 70 and is still fairly controversial. His 1950 paper is seen as a complex and multilayered text, and key questions about it remain largely unanswered. Why did Turing select learning from experience as the best approach to achieve machine intelligence? Why did he spend several years working with chess playing as a task to illustrate and test for machine intelligence only to trade it out for conversational question-answering in 1950? Why did Turing refer to (...) gender imitation in a test for machine intelligence? In this article, I shall address these questions by unveiling social, historical and epistemological roots of the so-called Turing test. I will draw attention to a historical fact that has been only scarcely observed in the secondary literature thus far, namely that Turing’s 1950 test emerged out of a controversy over the cognitive capabilities of digital computers, most notably out of debates with physicist and computer pioneer Douglas Hartree, chemist and philosopher Michael Polanyi, and neurosurgeon Geoffrey Jefferson. Seen in its historical context, Turing’s 1950 paper can be understood as essentially a reply to a series of challenges posed to him by these thinkers arguing against his view that machines can think. Turing did propose gender learning and imitation as one of his various imitation tests for machine intelligence, and I argue here that this was done in response to Jefferson's suggestion that gendered behavior is causally related to the physiology of sex hormones. (shrink)

The idea that the brain is a representational organ has roots in the nineteenth century, when neurologists began drawing conclusions about what the brain represents from clinical and experimental studies. One of the earliest controversies surrounding representation in the brain was the “muscles versus movements” debate, which concerned whether the motor cortex represents complex movements or rather fractional components of movement. Prominent thinkers weighed in on each side: neurologists John Hughlings Jackson and F.M.R. Walshe in favor of complex movements, neurophysiologist (...) Charles Sherrington and neurosurgeon Wilder Penfield in favor of movement components. This essay examines these and other brain scientists’ evolving notions of representation during the first eighty years of the muscles versus movements debate (c. 1873–1954). Although participants agreed about many of the superficial features of representation, their inferences reveal deep-seated disagreements about its inferential role. Divergent epistemological commitments stoked conflicting conceptions of what representational attributions imply and what evidence supports them. (shrink)

Suppose that a team of neurosurgeons and bioengineers were able to remove your brain from your body, suspend it in a life-sustaining vat of liquid nutrients, and connect its neurons and nerve terminals by wires to a supercomputer that would stimulate it with electrical impulses exactly like those it normally receives when embodied. According to this brain-in-a-vat thought experiment, your envatted brain and your embodied brain would have subjectively indistinguishable mental lives. For all you know—so one argument goes—you could (...) be such a brain in a vat right now.1 Daniel Dennett calls this sort of philosophical thought experiment an “intuition pump” (Dennett 1995). An intuition pump is designed to elicit certain intuitive convictions, but is not itself a proper argument: “intuition pumps are fine if they’re used correctly, but they can also be misused. They’re not arguments, they’re stories. Instead of having a conclusion, they pump an intuition. They get you to say ‘Aha! Oh, I get it!’ (Dennett 1995, p. 182). Philosophers have used the brain-in-a-vat story mainly to raise the problem of radical skepticism and to elicit various intuitions about meaning and knowledge (Putnam 1981). The basic intuition the story tries to pump is that the envatted brain, though fully conscious, has systematically false beliefs about the world, including itself. Some philosophers reject this intuition. They propose that the envatted brain’s beliefs are really about its artificial environment or that it.. (shrink)

Recent developments in the field of neurosurgery, specifically those dealing with the modification of mood and affect as part of psychiatric disease, have led some researchers to discuss the ethical implications of surgery to alter personality and personal identity. As knowledge and technology advance, discussions of surgery to alter undesirable traits, or possibly the enhancement of normal traits, will play an increasingly larger role in the ethical literature. So far, identity and enhancement have yet to be explored in a neurosurgical (...) context, despite the fact that 1) neurological disease and treatment both potentially alter identity, and 2) that neurosurgeons will likely be the purveyors of future enhancement implantable technology. Here, we use interviews with neurosurgical patients to shed light on the ethical issues and challenges that surround identity and enhancement in neurosurgery. The results provide insight into how patients approach their identity prior to potentially identity-altering procedures and what future ethical challenges lay ahead for clinicians and researchers in the field of neurotherapeutics. (shrink)

Over the past decades, mood enhancement effects of various drugs and neuromodulation technologies have been proclaimed. If one day highly effective methods for significantly altering and elevating one’s mood are available, it is conceivable that the demand for them will be considerable. One urgent concern will then be what role physicians should play in providing such services. The concern can be extended from literature on controversial demands for aesthetic surgery. According to Margaret Little, physicians should be aware that certain aesthetic (...) enhancement requests reflect immoral social norms and ideals. By granting such requests, she argues, doctors render themselves complicit to a collective ‘evil’. In this paper, we wish to question the extent to which physicians, psychiatrists and/or neurosurgeons should play a role as ‘moral gatekeepers’ in dealing with suspect demands and norms underlying potential desires to alter one’s mood or character. We investigate and discuss the nature and limits of physician responsibilities in reference to various hypothetical and intuitively problematic mood enhancement requests. (shrink)

The sudden onset of severe traumatic brain injury (sTBI) is an event suffered by millions of individuals each year. Regardless of this frequency in occurrence, accurate prognostication remains difficult to achieve among physicians. There are many variables that affect this prognosis. Physicians are expected to assess the clinical indications of the brain injury while considering other factors such as patient quality of life, patient preferences, and environmental context. However, this lack of certainty in prognosis can ultimately affect treatment recommendations and (...) prompt clinical ethical issues at the bedside, as it leaves room for physician bias and interpretation. In this article, we introduce data on neurosurgeon values that may shed light on the process physicians and patients involved in sTBI undergo. In doing so, we highlight the many nuances in decision-making for patients suffering from sTBI and discuss potential solutions to better patient-physician or surrogate-physician interactions. (shrink)

This unique volume is a comprehensive,well-illustrated study of the organization of the white matter pathways of the brain. Schmahmann and Pandya have analyzed and synthesized the corticocortical and corticosubcortical connections of the major areas of the cerebral cortex of the rhesus monkey. The result is a detailed understanding of the constituents of the cerebral white matter and the organization of the fiber tracts. The findings from the 36 cases studied are presented on a single template brain, facilitating comparison of the (...) locations of the different fiber pathways. The summary diagrams provide a comprehensive atlas of the cerebral white matter. The text is enriched by close attention to functional aspects of the anatomical observations. The clinical relevance of the pathways is addressed throughout the text and a chapter is devoted to human white matter diseases. The introductory account gives a detailed historical background. Translations of seminal original observations by early investigators are presented, and when these are considered in the light of the authors' new observations, many longstanding conflicts and debates are resolved. This scholarly book is an important addition to systems and cognitive neuroscience that will be of lasting value to neurobiologists, anatomists, neurologists, neurosurgeons, neuroradiologists, psychiatrists, psychologists, and to their students and trainees. (shrink)

Selected by Choice Magazine as an Outstanding Academic Title What is so special about human life? What is the relationship between flesh and blood and the human soul? Is there a kind of life that is worse than death? Can a person die and yet the human organism remain in some real sense alive? Can souls become sick? What justifies cutting into a living human body? These and other questions, writes neurosurgeon and philosopher Grant Gillett, pervade hospital wards, clinical offices, (...) and operating rooms. In Bioethics in the Clinic: Hippocratic Reflections, Gillett brings the tools of philosophy to bear on some of the most pressing issues confronting bioethicists today. Gillett draws on many schools of thought, including analytic, moral, and postmodern philosophy; utilitarianism; classical ethical theory; phenomenology; and metaphysics. He engages the reasoning of such philosophers as Aristotle, Nietzsche, Wittgenstein, Foucault, Habermas, Levinas, and Martha Nussbaum, and offers both practical and clinical insights into such topics as the principle of "Do no harm," informed consent, confidentiality, cloning, and euthanasia. Opening with an explanation of the axioms to be traced throughout succeeding discussions, with special emphasis on Hippocratic principles, Gillett focuses on general and specific problems of clinical practice, particularly as they affect the physician-patient relationship. The author then goes on to address ethical problems related to both the end of life, including euthanasia, and the beginning of life, such as embryo and stem cell research. Rigorous and elegant, this book will be of interest to those in medical fields, to students and scholars of philosophy, and to lay readers interested in the profound ethical dramas played out in hospitals and doctors' offices every day. (shrink)

Introduction In 2013, Dr. J. Muizelaar and Dr. R. Schrot, two neurosurgeons at the University of California Davis Medical Center (UCDMC), were found guilty of research misconduct due to failure to comply with institutional policies as well as Food and Drug Administration (FDA) regulations governing human subjects research. At issue here, however, is the difference between research and innovative therapy in the clinical setting of patient care where clinical judgment is reasonably to be privileged. Methods The UCDMC investigative document (...) is reviewed along with standard literature on clinical ethics and clinical data about glioblastoma multiforme (GBM) cancer. Results In this paper I argue that, by tendentiously focusing on policies, regulations, and procedures governing human subjects research, the UCDMC investigation failed to account for the centrality of clinical judgment and clinical ethics pertinent to judicious review of this matter, especially given the unique clinical context of terminally ill patients having exhausted standard care treatment options for glioblastoma multiforme (GBM) cancer. Conclusions The UCDMC investigation raises serious problems for clinicians who are engaged in innovative therapy in the clinical setting, requiring a regulatory framework separate from the normal Institutional Review Board (IRB) process. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:'Difficult Patient':A Reflective EssayDaniel McFarlandThe patient who sat across from me knew too much about all brain tumors. According to her, she would never know enough about the one sitting uncomfortably close to her brain's temporal lobe. In her quest for the 'right' answer to her meningioma problem, she became certain that its surgical removal would upend her life, leaving her in neurological taters.She was a small business owner (...) of a practice dedicated to medical massage. Indubitably, she had helped countless clients heal themselves of medical mishaps and avoid or recover from the tyranny of [End Page E13] a medical community that did not always provide respectable, hospitable care. She was certain a craniotomy would end her business, nullifying everything she had spent her life building. She became fluent in the legalese needed to transfer or sell her business in anticipation of surgery. To stave off losing her life's work from a surgical mishap, she sought opinions from a dozen neurosurgeons. They reassured her that a routine surgery like this would be effective with little chance of neurological collateral damage. She did not believe them. In her business she had treated numerous exhausted professionals. Many surgeons with whom she worked professionally frequently referred patients to her. She had seen the poor self-care that many surgeons and doctors brought on themselves in the form of unrelenting stress, drinking, bad eating habits, and even drugs. This made her nervous and untrusting about the care she could receive at the hands of an overworked or impaired surgeon. She scheduled appointments with every neurosurgeon she could find and interviewed them relentlessly, looking for the slightest sign of incompetence, unprofessionalism, antipathy, or lapse in compassion. Given her insistence and dogged nature, she usually found what she was looking for. She would bring her research to the appointments and interview the neurosurgeons on what other doctors had opined. If they were incredulous of research she brought or a technique on which she inquired, they were summarily dismissed.At first glance, which is likely all that she got from many of her visits, these encounters put a spotlight on a 'difficult' patient refusing care. The deeper look that my patient deserved revealed a personal narrative of the oldest child who survived a broken home riddled with drug use and prostitution. She learned to rely on only herself for protection. She took unapologetic control of her fate. Her own mother had at one time offered my patient work as a prostitute. Her father was no better in providing protection and a decent upbringing. He had left her as an eight-year-old with the neglectful mother and four younger siblings to fend for herself, which she did against the odds. She suffered physical, emotional, and spiritual abuse.As an adult, her strong sense of selfhood and boundaries allowed her to have a guarded relationship with both of her parents at a comfortable emotional distance. Her mission and passionate drive to help others heal saved her life. In healing others, she was healing herself. Importantly, her experience marked for her indelibly that while she could do this for herself, others were not reliable and could not heal her. She had only ever trusted and relied upon herself. She was the only one who had never let her down. She was terrified that this might be the first time. The potential surgery risked her cognition, physical capacities, and ability to care for herself. The risk was too great.We met numerous times, uncovering her past, reliving the stories of her tumultuous background, and examining how she established her place in the world away from the horrors of her insecure childhood. She took in my reaction to her stories and saw the horror on my face when I tried to imagine a world where one's parents were not only neglectful but the source of danger. Through my reaction, she may have begun to have some compassion for her own story and put the pieces together. One several occasions, she became enraged when I didn't meet her expectations, or I didn't entertain the diatribe of neurosurgical scholarly work.On one of those... (shrink)

This article discusses ethical questions in neurosurgery as falling into two categories, namely those surrounding what neurosurgeons are currently doing, i.e. their current practices, and those surrounding what neurosurgeons will, theoretically, be capable of doing in the future, i.e. their future practices. It reveals the current and emerging applications of functional neurosurgery as well as the future controversies that will stem from them. It focuses on psychosurgery, enhancement and the brain–machine interface, in order to illustrate the pertinent ethical (...) challenges and the role of the neurosurgeon in helping to address them. These three applications represent natural extensions of each other, as an exploration of the underlying mechanisms of psychopathology will ultimately provide insight into normal brain function. Concerns about the future of implantable technology, and the neurosurgeon's role in installing it, need to be addressed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Life is GoodAnnette ChacosI live in Hervey Bay. I’m a member of several social groups. I have adult children and grandchildren, and many lovely friends. I love to write. Most importantly I love The Lord Jesus Who has been my strength, bringing me through the good times, the not so good times, and the, ‘I’m throwing in the towel’ times.I was first diagnosed with a brain tumour in 1997. (...) Prior to knowing about the tumour and for some time after its removal I had little or no memory of events. The tumour was a left Frontal Meningioma (benign). For some time afterward I was partially [End Page 189] paralyzed. Now there is only some weakness on the right side of my body. Epilepsy too became part of my life. There are different types of seizures, which are rarely, if ever, amusing.Humour is very important. If you can’t laugh at the things that happen life would be a constant tale of woe. I’m very blessed. There are so many people who are much worse off than myself.My storyIn July 1997 my husband went to see if everything was okay because I wasn’t up out of bed yet. I was lying across the bed in a disheveled state. After being cleaned up I was taken to the local hospital. The duty doctor, who hadn’t even seen me, told my son that he didn’t think there was much wrong and to take me home. My sons refused and insisted that the doctor admit me. He did.I was diagnosed with a urinary tract infection. My memories of this are scattered. I learned some time later that I had had a Tonic Clonic seizure (formerly known as “grand mal” seizures which are commonly associated with epilepsy). After I came out of hospital I saw my general practitioner (GP). She sent me for an x–ray, and then to see a Neurosurgeon. An MRI was taken and there was a large tumour in my brain.My memory of this time is poor. I do recall a friend phoning and I told her I was going into hospital to have a brain tumour removed. After fifteen years she is still saying I was so matter of fact about it. I now know that my emotions, like my memory, was at a very low ebb due to the tumour. There was no caring or worrying. If there was, in the next minute, probably second, it was forgotten.Before going into hospital my late husband said to the kids “better take a photograph of your mother in case she dies.” I was told about that comment some time later. What a comfort! Then one day the photo turned up. It was so ugly I tore it up. You’ll note I said the photo was ugly!The operation took place in Canberra hospital, at the end of August. It was to be earlier but they deferred it because an emergency came in. They were going to defer it again, by which time I was mute and non–responsive. My daughter Maria arrived from Melbourne and my daughter Katrina and her husband Kevin came from America with their 3–month–old baby. My son Libe arrived from Sydney. Marcus, my youngest, lived locally, as did my daughter Tania. On hearing the operation was to be deferred again they took action informing hospital staff they were going to the local MP and the A Current Affair television show. So l had the operation—it was much easier to put me under the scalpel than battle the bureaucracy!I have only one film from that MRI. Where the others are I don’t know. According to Dr C, the tumour was very large. But to me, what does size matter—it was no longer there. Most importantly, I survived. The ten days I was in hospital are mostly forgotten. The few people I remember are like snapshots. No one moved, or so it seemed to me.In 2006, the second tumour was removed. It was discovered by the same lovely GP, who found the first one. I was... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Life in LimboM. ChiuWhen my son was 7 years old, he began complaining of headaches. They were frequent, but never seemed severe. “I have a headache!” was always followed by “Can I watch TV?” I didn’t believe the pain was real until it woke him up in the middle of the night. I knew then that something must be wrong. I approached our pediatrician, who said it sounded like (...) migraines, but we should order an MRI to rule anything out. The appointment was scheduled several months in advance, and I always had the urge to cancel it. I was pretty sure my son just wanted to watch TV. The pediatrician told me I might as well do the MRI. He told me that if we skipped it and something was wrong, I would never be able to live with the regret. We kept the Monday morning appointment, and went to the MRI expecting reassurance that nothing was wrong. Instead, we got a phone call later that day. They needed to see us on immediately, but wouldn’t tell me why. Of course, I knew something was wrong. “Is it a tumor?” I asked. “This isn’t something we can discuss on the phone” was the answer I got. An appointment was scheduled for Wednesday. Two days might be “immediately” to medical professionals, but to a parent who just heard that her child had an abnormal MRI, it was an eternity. I planned my son’s funeral in those two days.Our meeting with the Neurologist began with reviewing the MRI. “See this spot here? It shouldn’t be there”. A tumor. 1 ½ × 1 ½ × 2 ½ cm tumor, in the right thalamus. Small, they said. Looks like a Low Grade Glioma they said. The kind of tumor you want to have, if you have to have a brain tumor. A biopsy was scheduled for two weeks later. The [End Page E2] biopsy confirmed it was a Juvenile Pilocytic Astrocytoma (JPA). The neurosurgeon was confident she could remove all of the tumor. We were at one of the best Children’s Hospitals in the world. We were in good hands.A few days before the surgery, a friend who is a medical doctor suggested we get a second opinion. “It couldn’t hurt, it could help”, my husband said. Fortunately, he just sold a start–up company, and was planning to take a few months off from work before starting his next venture. He had time to research, talk to friends in the medical field and make phone calls.Our second opinion from another leading hospital reviewed the MRI’s with us. The neurosurgeon asked, “Did they say tumor? One?” Yes, they did. “See this here?” he said, pointing to a second spot on the MRI. He said it was possibly a second tumor, or more likely, an extension of the first. It was in inoperable location. Surgery wasn’t an option. Chemo would be our best choice. Why would we cut into our son’s brain to remove part of the tumor when he would need to do chemo anyway? Why not try chemo first?I would like to say that we do not fault our original neuro–oncology team for missing this second abnormality. It is hard to notice an ant in the room when there is an elephant staring at you. People make mistakes, and tumors don’t always look the same. That’s what second opinions are for. That is why doctors should encourage patients to get second opinions.We scheduled the surgery for port implantation, and got busy educating ourselves about chemo regimes. It was going to be a long journey. 18 months of transfusions with a pretty low success rate and a high rate of secondary complications. Unsure if we were doing the right thing, we got a third opinion. I am so grateful that my husband was between jobs and had time to devote to finding the best possible treatment for our son. We were financially stable and had great insurance. What do people do when they don’t have this luxury?By now, several months had passed since our first MRI. Our... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Not the End We Planned ForAnonymous FourIn 1997, my four–year–old daughter was diagnosed with a high–risk medulablastoma. She underwent the current treatment program at that time. She suffered multiple complications from the treatment and developed seizures, which caused her to lose her sight and 80% of her hearing. These all contributed to her manifesting many behavioral issues, making her a danger to herself and others. Also during this time, (...) she developed large amounts of brain atrophy from the maximum radiation dose she had been given. In August of 2010, Emily was still deteriorating, her seizures were uncontrollable, and her quality of life was extremely poor. A meeting to discuss how to care for my child if an acute crisis presented was held. The meeting included her parents, oncologist, endocrinologist, pediatric neurologist, social worker and the head of medical ethics. We discussed what course of action would be best for her nothing could be done to reverse her condition or prevent further deterioration. A POLST is a physician order for life sustaining treatment and is appropriate if the doctor feel that the patient has a good chance of death in the next year. The purpose of this document is to have a plan in place in case the patient has a life threatening crises. We chose to put a POLST in place with specific instructions not to intubate. This was a hard decision to make for a parent, but we all felt it was the best choice for her.A few months after the POLST was entered, in November, 2010, I came home from the store and my daughter’s caregivers told me she had complained of a headache different from her usual headaches. They gave her Tylenol with codeine and she went to bed about 4 p.m. When I checked her later she seemed fi ne, merely sleeping her headache off. We [End Page 30] decided to let her sleep some more. Around 8 p.m the caregivers came and got me because they could not wake her up to go to the bathroom, which was her normal routine. I immediately went to try and wake her up but could not. I ran my thumb up the bottom of her foot and there was no reflex response. I yelled for her father that we needed to immediately go to the hospital.We took her to the ER at the local hospital that treated her close to the house. We told them we did know what was happening with her but that there was a POLST in place in her chart. They started lines, a nasogastric tube, and sent her for a CT, which showed massive amounts of blood in her brain. I repeated again to the ER staff and physician that there was a POLST in place but no one acknowledged my statement. I asked for a different physician, one that would respect the POLST, and was told there was no one else nor was there a neurosurgeon available. The attending physician insisted she be intubated in order to be transferred to a partner hospital (more than 20 minutes away) where there was a neurosurgeon on duty. I asked him to please call her oncologist at which point he yelled at me that, “he was not calling anyone else and that she needed to be intubated and transferred to the other hospital.” By this time, four hours had passed and I knew she had not gotten any medication for pain, so I told the physician to go ahead and transfer her since I knew the hospital we were at would not admit her for palliative care. She was then intubated, in violation of the POLST, and transferred to the other hospital where the neurosurgeon there told us what we already feared: That she had experienced a massive bleed in her brain. We requested she be extubated and be given palliative care to make her comfortable until she passed away.It is tragic that our daughter’s last hours involved aggressive medical treatment. As parents we hoped to avoid any additional suffering for our child, we did everything we knew to do to insure aggressive... (shrink)

The manipulation argument poses a significant challenge for any adequate compatibilist theory of agency. The argument maintains that there is no relevant difference between actions or pro‐attitudes that are induced by nefarious neurosurgeons, God, or (and this is the important point) natural causes. Therefore, if manipulation is thought to undermine moral responsibility, then so also ought causal determinism. In this paper, I will attempt to bolster the plausibility of John Martin Fischer and Mark Ravizza's semicompatibilist theory of moral responsibility (...) by demonstrating how their account provides a distinctive line of response to three important types of manipulation. (shrink)

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation (...) of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts. (shrink)

The patient was a 19-year-old man who was the victim of an accidental head injury. The attending neurosurgeon felt that, due to uncontrollable and repeated elevated intracranial pressures, the patient would die within 48 hours. The patient's mother requested that the neurosurgeon contact a urologist to collect the patient's sperm for implantation into the patient's girlfriend. The neurosurgeon felt that the situation raised a number of ethical issues and requested that the hospital's bioethics committee consider the case.

We focus on collaborative activities that engage computer graphics designers and social scientists in systems design processes. Our conceptual symmetrical account of technology design and theory development is elaborated as a mode of mutual engagement occurring in an interdisciplinary trading zone, where neither discipline is placed at the service of the other and nor do disciplinary boundaries dissolve. To this end, we draw on analyses of mutual engagements between computer and social scientists stemming from the fields of computer-supported cooperative work, (...) human−computer interaction, and science and technology studies. We especially build on theoretical work in STS concerning information technology in health care and extend recent contributions from STS with respect to the modes of engagement and trading zones between computer and social sciences. We conceive participative digital systems design as a form of inquiry for the analysis of cooperative work settings, particularly when social science becomes part of design processes. We illustrate our conceptual approach using data from an interdisciplinary project involving computer graphics designers, sociologists, and neurosurgeons with the aim of developing patient-centered visualizations for clinical cooperation on a hospital ward. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Moral Distress for the Physician AssistantSharyn L. KurtzMy morning rounds as an inpatient medical oncology physician assistant began as usual. I arrived at the hospital early to receive 7 a.m. sign out from the covering resident. The overnight report began favorably. All patients remained stable. Even my patient, whom I will call Mrs. Walker,* had a quiet night. However, given her tenuous admission presentation, including altered mental status, hypercalcemia (...) (high levels of calcium in the blood), atrial fibrillation with rapid ventricular response (irregular, rapid heart function), widespread metastatic lung cancer, and recent neurosurgery to stabilize her spine, I decided to prioritize Mrs. Walker’s morning evaluation.Examining her medical chart proved reassuring. Her tachycardia (rapid heart rate) had been better controlled over the past two days. Her hypercalcemia had been treated, such that she was no longer somnolent. In fact, she was now arousable, conversant, and able to offer some input regarding her healthcare wishes. However, because she was experiencing intermittent delirium, her husband continued to act as her primary medical decision–maker.As her health care proxy, Mr. Walker had experienced conflict with the medical team during his wife’s prior hospital admission. However, even though Mr. Walker lived greater than 45 minutes from the hospital and was not able to visit regularly, he and I spoke daily by phone, which allowed me the opportunity to offer regular medical updates. Mr. Walker felt overwhelmed with his wife’s condition, but he was comfortable with the care the medical team had provided thus far. He was encouraged by the small improvements we had noted since her hospital admission five days prior.Mr. Walker stated on hospital admission that he wished for DNR/I orders to be placed, since this cohered with his wife’s previously stated wishes. However, he still wanted “everything else done” in terms of treating his wife’s medical conditions, including treatment of her atrial fibrillation, pain, and electrolyte anomalies. Most of all, he hoped Mrs. Walker would soon have increased mobility, which he felt would grant his wife the best quality of life possible. He was adamant that “being active” was what Mrs. Walker wished for, and that she had never wanted to be confined to bed.Mr. Walker’s requests seemed reasonable. Although Mrs. Walker’s lung cancer was widespread, and although many on the medical team felt she would not improve to the point where palliative chemotherapy could be considered, [End Page E13] she had stabilized. Her recent spine surgery had been successful, and she was healing adequately. The neurosurgeons had cleared Mrs. Walker for increased activity out of bed as soon as she could be fitted with a lumbar brace. The pain and palliative care specialists felt that Mrs. Walker’s residual back pain and delirium could be well managed with oral medications.Prior to my entering Mrs. Walker’s room to begin her physical evaluation, I was met by her seasoned nurse, whom I will call Amy. “Sharyn,” Amy warned, “Mrs. Walker’s heart rate is 150 and she is complaining of chest pain.” I entered Mrs. Walker’s room, and she was notably uncomfortable, grasping her chest. The monitor showed that Mrs. Walker’s heart rate was in fact in the 150’s. She was pale, short of breath, and wheezing. “Mrs. Walker,” I asked, “how severe is your chest pain on a scale from 1 to 10?” Mrs. Walker replied, “Nine.” I asked Amy to obtain an EKG, to provide oxygen, and to administer an IV medication that would slow Mrs. Walker’s heart rate. I stepped out of the room to place the computer orders, and I paged my attending physician to let him know about Mrs. Walker’s change in status. After hearing the update, my attending physician, whom I will call Dr. Clark, stated that he agreed with all of my treatment decisions thus far. He was on his way into the hospital. I planned out my next steps with him on the phone and returned to the patient’s room.The monitor gave evidence that Mrs. Walker’s heart rate was improving. Mrs. Walker reported that her pain was now “4 out of... (shrink)

This article consists of four parts. In the first part it briefly describes the history of body‐to‐head transplantation (BHT) and the surgical plan proposed by Drs. Sergio Canavero and Ren Xiaoping on a human subject. In the second part it argues that the BHT procedure that they propose is scientifically invalid and technically infeasible so therefore would end in failure. In the third part it argues that the present conceivable procedure of BHT cannot be ethically justified because it would bring (...) great harm to the human subject, it is uncertain who would be the possible beneficiary, and valid informed consent cannot be obtained. In the fourth part it argues that the action of performing the procedure of BHT might violate China’s current criminal and civil laws. The conclusion that follows from the arguments above is that BHT should be prohibited now and also in the near future. However, this conclusion does not preclude scientists, neurosurgeons and bioethicists doing research into scientific, technical, surgical and ethical issues raised by BHT. (shrink)

Background and Purpose The decision to perform decompressive craniectomy for patients with malignant MCA syndrome can be ethically complex. We investigated factors that clinicians consider in this decision-making process. Methods A survey including clinical vignettes and attitudes questions surrounding the use of hemicraniectomy in malignant MCA syndrome was distributed to 203 neurosurgeons, neurologists, staff and residents, and nurses and allied health members specializing in the care of neurological patients. These were practicing health care providers situated in an urban setting (...) in Canada where access to health care is covered by national policy and is a human right. Results Eighty-eight participants responded to survey. All participants unanimously supported the procedure for young and healthy patients. Advanced age, the presence of aphasia, comorbid medical conditions, and poor baseline functional status were dominant factors associated with increasing reluctance to offer surgical decompression. Patients’ previously expressed wishes were also an important consideration. Eighty-six percent of respondents agreed that withholding surgery is ethically justified if the outcome is perceived as futile. Conclusions Health care providers use similar factors to determine if aggressive management is justified given anticipated burden on patient quality of life and extended impact on society. This convergence can be harnessed beneficially for the transparent communication of medical options in the ethically complex setting of decompressive hemicraniectomy post-stroke. (shrink)

The “colored-brain thesis”, or strong qualitative physicalism, is discussed from historical and philosophical perspectives. This thesis was proposed by Thomas Case, in a non-materialistic context, and is close to views explored by H. H. Price and E. Boring. Using Mary’s room thought experiment, one can argue that physicalism implies qualitative physicalism. Qualitative physicalism involves three basic statements: perceptual internalism, and realism of qualia; ontic physicalism, charaterized as a description in space, time, and scale; and mind-brain identity thesis. In addition, structuralism (...) in physics, and distinguishing the present version from that suggested by H. Feigl and S. Pepper, realism of the physical description. The “neurosurgeon argument” is presented, as to why the greenness of a visually perceived avocado, which is present in the brain as a physical-chemical attribute, would not be seen as green by a neurosurgeon who opens the observer’s skull. This conception is compared with two close views, Russellian monisms and panprotopsychism. According to the strong qualitative physicalism presented here, the phenomenal experience of a quale q is identical to a physico-chemical quality q, which arises from a combination of the materiality wassociated with the brain, and the causal organization or structure of the relevant elements of the brain S, including in this organization the structure of the self: q. The “explanatory gap” between mental and physical states is shifted to a gap between the physico-chemical qualities q and the organized materiality of a specific brain region q, and is seen as being bridged only by a set of non-explanatory postulates. Keywords: Colored-brain thesis, qualitative physicalism, mind-brain identity thesis, qualia, panprotopsychism, sensorium. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Whisper Before You GoJohn K PettyDavid came with a bang.1A momentary prelude from a dysphonic chorus of pagers announce “Level 1 Pediatric Trauma—MVC ejected” before the abrupt crescendo of the trauma bay doors opening. He is maybe two. Maybe three–years–old. It is hard to tell when a child is strapped in, strapped down, nonverbal, intubated, and alone.The flight team speaks for him, “Four–year–old boy improperly restrained in a single–vehicle (...) crash into a ditch. He was partially ejected. He was unresponsive and pulseless at the scene. He got CPR and code drugs, and they got a pulse back. Emergency medical service (EMS) took him to the nearest hospital where they needled his chest, called for air transport, and scanned him up. He has been shocky for us since we picked him up. Glasgow Coma Scale (GCS) has been three the whole time. They said his head scan showed subarachnoid hemorrhage.”With the words of the flight team as background narrative, we get about doing our thing—hopefully more method and less madness. Bang, bang, bang! Check the tube. Vital signs. IV fluids. Place a chest tube. Hang the blood. Quick X–ray. Neuro exam—nothing. Get him off the board. Warm him up. Place the orogastric (OG) tube. Bang, bang, bang!The neurosurgery resident opens the CT scans from the other hospital. The brain and cervical spine scans show a disaster: some swelling and bleeding in the higher brain, but the worst damage is in the lower brain, brainstem, and top of the spinal cord. I have heard a neurosurgeon describe this pattern before as “internal decapitation.” Such language never makes it into the patient’s chart. For David the last two words of the neurosurgery consult note will eventually read, “Prognosis grim.”He remains unstable in the trauma bay. Inaction is death. We ultrasound his heart, abdomen, and pelvis. He has fluid that shouldn’t be around his heart. He is dying of the neuro injury we cannot control, but the pericardial fluid might be giving him shock, and we can control that. We can’t ignore the fluid. Shouldn’t ignore it. At least, wouldn’t ignore it. So, we bang up to the operating room. Squeezing blood. Spiking fluid. Oxygen tank and crash cart. Up we go.In the operating room, we do much and we do well. We release the fluid around the heart and find it was CPR, not heart injury that put it there. In the pericardial flash we get a view of the cardiac athlete, pounding like the 26th mile of the marathon. We explore the abdomen and find it swollen but innocent of an injury that would take his life. We place our lines and tubes as the neurosurgeons place theirs. If nothing else, we will be able to measure what lies ahead.“Good work, team,” and we bump the door on the way to the pediatric intensive care unit (PICU).The care in the PICU is more Apache brave than Gaelic knight—more bottles, fewer scissors. The curtains and carpets mute the tones. Our efforts continue, but I get a word that David’s father has arrived. He is sitting in a small, private waiting room off of the main PICU waiting room. The PICU staff colloquially refer to this as “the bad news room.” I take a seat next to a solitary man who is having the worst day of his life. His worst day so far.“I am Dr. Petty, and I am one of the doctors who is taking care of your son. I am very sorry about what has happened. Maybe you can tell me a little bit about what you understand is going on, and I’ll tell you what I know.” [End Page 17]He tells me that his wife was driving David back from her sister’s house, just the two of them. He doesn’t know what happened, but he got a call from the other hospital about the crash. His wife was badly hurt. He heard that David had died, but they got him back. Both were transferred up to the... (shrink)

In the 2016 film Doctor Strange, the title character undergoes a radical transition from successful neurosurgeon to highly skilled sorcerer. Unsurprisingly, he finds this transition difficult, in no small part because he thinks that sorcery seems somehow “unscientific.” Nevertheless, he eventually comes to adopt sorcery as wholeheartedly as he had embraced medicine. Some of his reasons for making this transition are personal, such as his desire to fix his injured hands and, later, to help others. Strange also displays the same (...) sorts of motivations that might drive any scientist: his intellectual curiosity drives him to understand how the Ancient One cured a paraplegic, and his desire to make a positive difference leads him to push the boundaries of sorcery. -/- This chapter will examine what Strange’s transition can teach us about the nature of scientific inquiry. More specifically, we’ll think about when it might make sense for scientists like Dr. Strange to change their approach. This will also allow us to explore what it means to practice science more generally. Some of what we learn might be surprising. For example, while it might seem obvious to us (and maybe even to Strange) that sorcery can’t count as a science, there are reasons for doubting this quick conclusion, at least in the sort of world that Dr. Strange lives in. Finally, we’ll consider what all of this means for science in our world, where things differ quite significantly. (shrink)

To preserve postoperative brain function, it is important for neurosurgeons to fully understand the brain's structure, vasculature, and function. Intraoperative high-frequency electrical stimulation during awake craniotomy is the gold standard for mapping the function of the cortices and white matter; however, this method can only map the “focal” functions and cannot monitor large-scale cortical networks in real-time. Recently, an in vivo electrophysiological method using cortico-cortical evoked potentials induced by single-pulse electrical cortical stimulation has been developed in an extraoperative setting. (...) By using the CCEP connectivity pattern intraoperatively, mapping and real-time monitoring of the dorsal language pathway is available. This intraoperative CCEP method also allows for mapping of the frontal aslant tract, another language pathway, and detection of connectivity between the primary and supplementary motor areas in the frontal lobe network. Intraoperative CCEP mapping has also demonstrated connectivity between the frontal and temporal lobes, likely via the ventral language pathway. Establishing intraoperative electrophysiological monitoring is clinically useful for preserving brain function, even under general anesthesia. This CCEP technique demonstrates potential clinical applications for mapping and monitoring large-scale cortical networks. (shrink)

The vulnerability of patients receiving significantly innovative neurosurgical procedures, either as research or as non-standard therapy, presents particularly potent challenges for those attempting to substantially advance clinical Neurosurgical practice in the most ethically and efficacious manner. This beginning formulation has built into it several important notions about research participation, balancing values, and clinical advancement in the context of neurological illness. For the time being, allow vulnerability to act as a placeholder for circumstances or states of being wherein the established checks (...) and balances of power and interest are no longer sufficient in promoting the just treatment of persons. Further, the phrase to substantially advance Neurosurgical practice encompasses radical innovation as well as significant research into new procedures. Finally, few of these explorations involve true randomized placebo controlled trials, but rather they enroll patients rightfully hoping for some benefit by means of undergoing the procedure.When a neurosurgeon asks me, as an ethicist, to meet with a patient who has medically refractory disease and no good standard therapy options remaining, he is asking for help concerning whether to offer, as a last chance, an unproven therapy as either innovation or research. (shrink)

_‘Informative, accessible, and fun to read— this is an excellent reference guide for undergraduates and anyone wanting an introduction to the fundamental issues of metaphysics. I know of no other resource like it.’– __Meghan Griffith, Davidson College, USA_ _'Marvellous! This book provides the very best place to start for students wanting to take the first step into understanding metaphysics.Undergraduates would do well to buy it and consult it regularly. The quality and clarity of the material are consistently high.' – __Chris (...) Daly, University of Manchester, UK_ Ever wondered about Gunk, Brains in a Vat or Frankfurt’s Nefarious Neurosurgeon? With complete explanations of these terms and more, _Metaphysics: The Key Concepts_ is an accessible and engaging introduction to the most widely studied and challenging concepts in metaphysics. The authors clearly and lucidly define and discuss key terms and concepts, under the themes of: time particulars & universals realism & antirealism free will personal identity causation and laws. Arranged in an easy to use A-Z format, each concept is explored and illustrated with engaging and memorable examples, and accompanied by an up-to-date guide to further reading. Fully cross-referenced throughout, this remarkable reference guide is essential reading for students of philosophy and all those interested in the nature of reality. (shrink)

Ten years ago, Megan Shinal sought the care of neurosurgeon Steven Toms for the surgical treatment of a recurrent nonmalignant tumor in the pituitary region of her brain. In their twenty-minute meeting, Shinal did not make a final decision about which surgical approach she wished to pursue. Subsequently, she spoke with Tom's physician assistant once by phone and once in person, when she signed the consent form, which did not appear to designate which surgical approach she had chosen. During the (...) operation—a total resection—Toms perforated Shinal's carotid artery, resulting in hemorrhage, stroke, brain injury, and partial blindness. The jury found that Toms had fulfilled his informed-consent obligations prior to performing the resection; however, in June 2017, the Supreme Court of Pennsylvania overturned the decision, relying on the Pennsylvania Medical Care Availability and Reduction of Error Act. The court found that the language of the act is unambiguous in its requirement that “a physician's duty to provide information to a patient sufficient to obtain her informed consent is non-delegable.” Presumably, this rule of nondelegation applies beyond the surgical theater to other major treatment decisions. And it is unclear whether it applies to other professionals in a subordinate position to the treating physician, such as residents and fellows. (shrink)

The Consensus Statement of the Third International Congress on Concussion in Sport in November 2008 defined concussion as a “complex pathophysiologic process affecting the brain, induced by traumatic biochemical forces.” Definitions of concussion vary slightly between various professional organizations of neurosurgeons, neurologists, and orthopedic surgeons, but all share the common characteristics of trauma affecting the head or body resulting in transient neurologic deficits or symptoms. Underlying the symptoms of concussion is a complex pathophysiologic process at the cellular level. While (...) concussion is typically thought of as resulting from a direct impact to the head, a concussion can also be sustained as a result of an impact to the body causing the force of the impact to be transmitted to and absorbed by the brain. (shrink)

Objective: To analyse the process of end of life decisions in a neurosurgical environment.Methods: All 113 neurosurgical patients, who were subject to so called end of life decisions within a one year period were prospectively enrolled in a computerised data bank. Decision pathways according to patient and physician related parameters were assessed.Results: Leading primary diagnoses of the patients were traumatic brain injury and intracranial haemorrhage. Forty-five patients had undergone an emergency neurosurgical operation prior to end of life decision, N = (...) 69 were conservatively treated, which included intracranial pressure recording, or they were not offered neurosurgical care because of futile prognosis. N = 111 died after a median of two days. Two, in whom the end of life decisions were revised, survived. Clear decisions to terminate further treatment were made by a senior staff member on call being informed by the senior resident on call , difficult decisions on the basis of extensive round discussions , and very difficult decision by an interdisciplinary ethical consult . Decisions were further substantiated by electrophysiological examinations in N = 59.Conclusion: End of life decisions are to be considered standard situations for neurosurgeons. These decisions may reach a high rate of “positive” prediction, if substantiated by electrophysiological examinations as well as on the grounds of clinical experience and respect for the assumed will of the patient. The fact that patients may survive following revision of an end of life decision underlines the necessity for repeated reassessment of these decisions. Ethical training for neurosurgeons is to be encouraged. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:An Encounter with the Art and Science of MedicineAnonymous Five“Let Nothing Upset YouLet Nothing Frighten YouEverything is ChangingOnly God is Changeless”—St. Theresa of AvilaSt. Teresa’s prayer is on the front cover of each of four binders dedicated to storing insurance authorizations, studies, references, and reports about our daughter’s brain tumor treatment. They represent our experience, what we learned, the information we were given, and the information we sought out. (...) I kept them in case our daughter ever wanted to understand how my husband and I arrived at a decision for her treatment that was in direct opposition to the strong recommendation of her primary treatment team of physicians.On December 10, 2003, I received an urgent call from our daughter’s neurologist requesting that we meet with the doctor late that afternoon. For six months prior to that appointment, our daughter had been telling us about odd sensations with breathing, nausea, and balance. Sometimes she would seem extremely distressed for a short period of time or report that her friends told her about doing or saying things that didn’t make sense and that she didn’t remember. We consulted a series of physicians as her symptoms became steadily more intense and more prevalent. Our family practice physician referred us to an allergy specialist and a pulmonologist. There were a number of tests for allergies and lung problems. As the tests and treatments did not help, our daughter became increasingly unwilling to go to doctor’s appointments. My husband and I were confused and deeply concerned about the lack of progress. The next series of referrals included a gastroenterologist and a neurologist. The gastroenterologist suggested our daughter had partial–complex epilepsy, concurred with our plan to see a neurologist, and mentioned she should have an MRI.I remember the neurologist putting the MRI scans up, pointing to the large dark spot which he called a “large mass” (5 cm), that could be either a cluster of blood vessels or a neoplasm. He said his office had arranged for us to meet a neurosurgeon the following day. We all remember the same thing about that visit—the image of the large dark mass on the scan—and the neurologists flat, brisk tone. We met with the neuro-surgeon the next day. Her team was kind and sympathetic—she was positive, up beat and direct. She did not think this mass was blood vessels. She thought it was a large tumor that needed to be removed right away. Our daughters surgery was scheduled for the following Friday—December 19, 2003. She had turned 15 on November 5.Four and a half hours after our daughter was wheeled into the operating room, her surgeon told us they had removed 98% of the tumor. She said there was no cure, but there was a good prognosis based on the surgical outcome. Several days later, she called us and said she had more data, and it looked like the resection was closer to 90%. The first pathology report, a “first impression” directly after surgery, described our daughter’s tumor as an astrocytoma, probably high grade. Three weeks after surgery, we met with a panel of doctors—two oncologists and radiologist—who explained that based on the final pathology report, our daughter’s tumor was classified as an ependymoma, grade 2. We were dismayed. First, there had been the change in the estimated success of the resection and now a complete shift in both grade and tumor type.The team recommended radiation to follow her surgery, which they said was standard treatment. We began to try to inform ourselves about her tumor. Her father, an agronomist, did an extensive search in PubMed to evaluate and sort through the literature on low–grade gliomas and radiation. What he could find was inconclusive and grim. Most reports in the literature suggested at best delayed mortality at five years after radiation. [End Page E7] Meanwhile, our daughter went through a spinal MRI and the preparatory “fitting” of the mask to immobilize her head during radiation.E7I consulted with a friend who had worked as an EKG tech. She urged... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Death Perception:How Temporary Ventilator Disconnection Helped my Family Accept Brain Death and Donate OrgansThomas B. FreemanThe night of my nephew’s closed head injury in Boston, I was on call as a neurosurgeon at Tampa General Hospital. I was therefore not shocked at first when my telephone rang at four o’clock in the morning, but I soon understood the severity of the tragic news. The next half hour was a (...) blur of frantic phone calls and devastating decisions leading to surgery to remove a subdural hematoma from my nephew’s head, even though he was only two brain stem reflexes away from brain death.I thought that my experience as a neurosurgeon would somehow help me. However, when my sister–in–law asked me if this was just like the other tragic closed head injuries that I had seen in 26 years of practice, my answer was very simple: this was the only severe closed head injury I had ever seen—in my family. At this point, I was no longer a neurosurgeon. I was an uncle. My nephew’s closed head injury overwhelmed both his brain’s capacity to survive and my entire family’s ability to think rationally or objectively while grieving so intensely.It is in this context that we were asked to consider organ donation. The appeal for organ donation is one of altruism. My nephew’s parents agreed that organ donation would be an important way to honor their son’s life, allow him to make one final contribution to save the lives of several patients, and help to bring peace to the family.I will never forget, however, my niece’s distraught response. She is altruistic by nature, but was tremendously conflicted by the choice to donate her own brother’s organs. At this point, all discussions about organ donation stopped until we could understand the source of her conflict. Since she did not have legal authority regarding the final decision, some family members wondered if organ donation should be allowed if she could not come to terms with the choice. She felt isolated, because she was the only person in the room who was experiencing conflict. As a neurosurgeon, I have always advised other families in this situation that they may have more peace if they can make such decisions unanimously, regardless of who has the ultimate legal authority for decision–making. This helps bring healing to the family, eliminates disruption of family values and unity, and reduces possible feelings of guilt.I asked my niece what she was feeling. She stated something that I had never heard before as a neurosurgeon. She had listened to the words that her brother was brain dead, but she felt that he was somehow still alive, since he was breathing on a ventilator and his heart was beating. She felt powerless due to her inability to do anything more for [End Page 9] him. She also wanted to be there when her brother “died,” which she would recognize by the cessation of his heartbeat. She would not abandon her brother.I searched for a way to respect my niece’s wishes and her legitimate request, while preserving the ability to proceed with organ donation. Solving this conundrum proved to be a pivotal part of the beginning of both her mourning process and acceptance of his death.As an uncle, I experienced the clear dissociation that modern medicine creates between medical care and the natural human process of recognizing and accepting death. My family observed the subtle difference between a deep coma and brain death. They noticed that my nephew’s color had changed when his temperature dropped to 94o F before the heating blanket was placed. They perceived the decrease in muscle tone when he stopped breathing faster than the ventilator rate. Outside of that, there was no significant difference in his appearance when he was “alive” or “dead.”In spite of heroic measures and superlative surgical and medical care, his closed head injury progressed unremittingly until he became brain dead 36 hours later. The diagnosis of “brain death” was pronounced to the family. Accepting the death of someone who is... (shrink)

Walter Freeman, the self styled neurosurgeon, became famous (or infamous) for psychosurgery. The operation of frontal leucotomy swept through the world (with Freeman himself performing something like 18,000 cases) but it has tainted the whole idea of psychosurgery down to the present era. Modes of psychosurgery such as Deep Brain Stimulation and other highly selective neurosurgical procedures for neurological and psychiatric conditions are in ever-increasing use in current practice. The new, more exciting techniques are based in a widely held philosophical (...) position on the relationship between the mind, brain and soul, which is the key to ethical debates in this area. Psychosurgery has always posed questions of responsibility, personality, character, identity, spirit, relationship, integrity, and human flourishing and they do not go away when we enter the brave new world of neuroethics and Deep Brain Stimulation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.1 (2005) 23-24 [Access article in PDF] Schechtman's Narrative Account of Identity Grant Gillett Keywords personal identity, narrative self, memory I have long been an admirer of Schechtman's sensitive and psychologically realistic account of personal identity. In the present piece, she addresses the issues surrounding personal identity through Locke's view and problems attending that view and the psychological continuity theories descended from it.She examines the (...) claim that the person is more extensive than the conscious mind and includes aspects of nonconscious mental activity. Schechtman argues that one must have a self-conception that includes a trajectory where present experience unfolds meaningfully out of one's past replete with implications for what one does and how one does it. She locates, in current writing on the self, the idea of a perceiver or narrator self who tries to make sense out of herself as a human being with certain thoughts and feelings and is sometimes at a loss to do so. To this potentially very rich starting point we need only add the fact that a person draws on discursive and narrative skills that have been inscribed in her being to do this narrative, editorial, and judicial task and that many of these skills have been imbibed with mother's milk (and father's voice). From this discursively inscribed set of resources and orientations arise guilt, shame, pride, aspiration, vulnerability, and that crucial sense of who one is as a person among others.It follows that here we might also find the source of the discontents that induce a person to apply to a psychiatrist or counselor for help with the narrative work required to fashion a liveable self. If Schechtman is right, the cognitive capacities contributing to memory and "keeping track of oneself"(in a deep and satisfying way) are to be found in part in the nonconscious domain rather than the thin layer of consciousness and propositional attitude psychology that enters the mind of an analytic philosopher or a psychiatrist uninterested in depth.I think she is right and that this paper and her more extensive work on the constitution of self represent a fertile point at which psychiatrists and psychotherapists can begin the task of understanding the nature of identity and the challenges involved in finding one that will serve the unfolding project of understanding and forming the self. I believe that the resources that individuals need for this task are derived from one's rootedness in culture and human relationships where the levels of self that support consciousness can be nurtured according to what Michel Foucault calls the techniques proper to the care of the self. Schechtman has done us a favor in taking the debates surrounding neo-Lockean [End Page 23] views of personal identity and outlining a perspective on identity and memory that can lead us to develop our understanding of the complexity of the human psyche as it roams through the jungle/jumble of discursive life and tries to nourish itself on what it finds there.Grant Gillett is a Professor of Medical Ethics at the University of Otago in Dunedin, New Zealand. He is also a practicing neurosurgeon. His philosophical work is in philosophy of mind and psychiatry, continental philosophy, and bioethics. His most recent books are The Mind and Its Discontents (Oxford University Press) and Bioethics in the Clinic (Johns Hopkins University Press). He works on postmodern and traditional analytic approaches to mind, language, and psychiatry. He can be reached at Dunedin Hospital and Otago Bioethics Centre, University of Otago Medical School, PO Box 913, Dunedin, New Zealand, or via e-mail at [email protected].... (shrink)

Ethical questions in medicine have become common topics of discussion during the past twenty years. Bitter disputes have arisen regarding abortion, suicide, human experimentation, as well as the management of the dying patient and the severely disabled newborn. These issues are loaded with such emotion that it is sometimes difficult to look at them in a rational manner. Noted neurosurgeon and author Milton D. Heifetz has made the tough decisions in tragic, often anguishing situations. As a member of hospital ethics (...) committees for many years, Dr. Heifetz found that discussions of complex issuesmany involving urgent matters of life and deathwere all too often clouded by tradition, dogma, and gut reactions. A comprehensive moral foundation with the flexibility to respond to often rapidly changing circumstances is desperately needed if health-care professionals are to confront head-on the daily questions of medical ethics. Dr. Heifetz offers this moral grounding to help all who must make difficult medical choices: physicians, nurses, patients, families, and policy makers struggling to develop substantive rules for medical conduct. (shrink)

Explore the mind and world of the brilliant neurosurgeon-turned-Sorcerer Supreme Doctor Stephen Strange Marvel Comics legends Stan Lee and Steve Ditko first introduced Doctor Stephen Strange to the world in 1963—and his spellbinding adventures have wowed comic book fans ever since. Over fifty years later, the brilliant neurosurgeon-turned-Sorcerer Supreme has finally travelled from the pages of comics to the big screen, introducing a new generation of fans to his mind-bending mysticism and self-sacrificing heroics. In Doctor Strange and Philosophy, Mark D. (...) White takes readers on a tour through some of the most interesting and unusual philosophical questions which surround Stephen Strange and his place in the Marvel Universe. Essays from two-dozen Philosophers Supreme illuminate how essential philosophical concepts, including existentialism, epistemology, metaphysics, and ethics, relate to the world of Doctor Strange. Fans will find answers to all their Strange questions: How does Doctor Strange reconcile his beliefs in science and magic? What does his astral self say about the relationship between mind and body? Why is he always so alone? And what does he mean when he says we’re just “tiny momentary specks within an indifferent universe”—and why was he wrong? You won’t need the Eye of Agamotto to comprehend all that is wise within. Doctor Strange and Philosophy offers comic book fans and philosophers alike the chance to dive deeper into the world of one of Marvel’s most mystical superheroes. (shrink)

Saturday sets out to depict the contemporary world with its ambiguities and paradox. In the novel, like in a mirror painting, every event, character and conflict is highlighted from diverse, often contradictory, angles by the narrator's extensive commentary, flashback and reference to other books. The prevailing happiness of mass protests against the war on Iraq is countered by the recollection of mass graves, an element of Saddam's callous regime, the real terrorist threat is contrasted with national paranoia, and the Prime (...) Minister's performance of truthfulness is scrutinized by means of Paul Ekman's study of micro-expressions. The technique of dualistic depiction is further used in order to describe the characters. Reworking the idea of two sides of the same coin, McEwan offers the novel as a metaphorical study of the intricacies of human personality. Therefore, Baxter becomes simultaneously an offender and a victim, John Grammaticus turns from a successful poet into an alcoholic womanizer, and Lilian Perowne's physical and mental disintegration is contrasted with her past as a champion swimmer. McEwan's dichotomous description of the world echoes Barthes's binaries, not only in the duality itself, but also in the fact that the juxtaposition of contradictory images constitutes a more complete depiction of an event or a person. The contrast between the opposing ideas is further accentuated by the use of different jargons: the language of medicine, media, upper-class, working-class, and the like. The use of language throughout the novel seems to repeat the notion that by means of jargons people control and exclude others, highlighting their authority and constructing their position of supremacy. Saturday, which captures acutely the events of a single day in the life of a renowned neurosurgeon, Henry Perowne, presents issues, such as the terrorist threat or the creation of media reality, that appear international in consciousness. The essay illustrates how, with admirable artistry, McEwan incorporates meaningful images, visually complex descriptions and different kinds of language into a diary account, for readers to enjoy a more objective comment on the contemporary world. (shrink)

Treatment of diseases of the brain by drugs or surgery necessitates an understanding of its structure and functions. The philosophical neurosurgeon soon encounters difficulties when localising the abstract concepts of mind and soul within the tangible 1300-gram organ containing 100 billion neurones. Hippocrates had focused attention on the brain as the seat of the mind. The tabula rasa postulated by Aristotle cannot be localised to a particular part of the brain with the confidence that we can localise spoken speech to (...) Broca's area or the movement of limbs to the contralateral motor cortex. Galen's localisation of imagination, reasoning, judgement and memory in the cerebral ventricles collapsed once it was evident that the functional units-neurones-lay in the parenchyma of the brain. Experiences gained from accidental injuries (Phineas Gage) or temporal lobe resection (William Beecher Scoville); studies on how we see and hear and more recent data from functional magnetic resonance studies have made us aware of the extensive network of neurones in the cerebral hemispheres that subserve the functions of the mind. The soul or atman, credited with the ability to enliven the body, was located by ancient anatomists and philosophers in the lungs or heart, in the pineal gland (Descartes), and generally in the brain. When the deeper parts of the brain came within the reach of neurosurgeons, the brainstem proved exceptionally delicate and vulnerable. The concept of brain death after irreversible damage to it has made all of us aware of 'the cocktail of brain soup and spark' in the brainstem so necessary for life. If there be a soul in each of us, surely, it is enshrined here. (shrink)