Nada Gligorov

When a patient lacks capacity, medical decisions on their behalf are made according to an advance directive or by surrogate decision making. Often, however, patients’ previously expressed wishes are ambiguous, vague, inconsistent, or fail to anticipate the patient’s current condition. In this paper, we argue that when patient’s wishes are not clear, surrogates must utilize interpretative principles to reach a decision regarding treatment. We identify three such principles: the value-substitution, value-coherence, and volitional principles. We argue that the volitional principle is the most reliable way of capturing what the patient would have wanted when they no longer possess decisional capacity. This approach tasks the surrogate with identifying a medical choice close to what the patient would have agreed to based on previously expressed wishes without attributing the surrogate’s own values to the patient or attempting to provide an interpretation consistent with the patient’s other values. This approach is best positioned to support patients’ sovereignty for those who were previously able to express wishes for or against life-sustaining treatment.

Enhancement can be defined as the improvement of normal individuals. There are several categories of enhancement, including physical enhancement, cognitive enhancement, and moral enhancement. In this chapter, I focus on the argument that cognitive enhancement using pharmaceutical means could cause disruptive changes in personal identity. I distinguish between numerical and narrative identity. I argue that cognitive enhancement would have no effect on numerical identity, but it could affect narrative identity. Narrative identity approximates the common notions of identity because it is characterized as a first-person effort to construct a concept of self. Despite the potential effect on narrative identity, I argue for the permissibility of the use of cognitive enhancers. I maintain that psychological traits can change without disrupting psychological continuity. This view is supported by evidence that individuals experience a great deal of psychological change over time, and the evidence that even when those changes are caused by the use of medication, they do not always create a disruption in narrative identity. I conclude that cognitive enhancement is permissible even when it produces changes in narrative identity.

Neuroethics is an emerging interdisciplinary field with unsettled boundaries. Many of the ethical issues within the purview of neuroethics could be described as resulting from the clash between the scientific perspective on concepts such as free will, personal identity, consciousness, etc., and the putatively commonsense conceptions of those terms. The assumption that undergirds the framing of the conflict between these two approaches is that advances in neuroscience, psychiatry, and psychology can be used to explain phenomena covered by commonsense concepts and in some cases undermine them entirely. This book is focused on the examination of the particular relationship between developments in neuroscience and commonsense moral concepts. Common sense, I argue, has been misinterpreted as a static, either foundational or degenerative, basis of our morality, when it is an ever-shifting repository of theories from many domains. Within this discussion, I focus on the application of neuroscience to human beings, i.e., the ethics of neuroscience. But I also cover issues within the purview of the neuroscience of ethics, and attempt to address the infiltration of neuroscientific knowledge into everyday parlance and the impact of that on our commonsense morality and psychology.

Improvements in our ability to identify brain function as it is occurring through brain imaging have brought to the forefront the issue of mental privacy. Several authors have cited potential infringement on privacy as one of the primary ethical issues related to the application of brain imaging technology to clinical, research, and legal contexts. I challenge the argument that the use of functional magnetic resonance imaging (fMRI) poses a threat to mental privacy and that this type of privacy requires extra protections. I review all the positions about the nature of mental states that establish a category of mental privacy and conclude that none of those views can support both the claim that there is a category of mental privacy and that this type of privacy can be violated through the use of brain imaging. I further argue that the only position about the nature of mental states that erases the epistemological gap between introspection and third-person access to our inner states is eliminative materialism. Eliminativism, however, does this by denying the categories of folk psychology, including the category of mental privacy. Finally, I argue that because no view about the nature of mental states can support the argument that ‘brain reading’ will result in ‘mindreading,’ fMRI does not pose a threat to mental privacy. I conclude that special protections for mental privacy are not required because informational privacy already protects, at least in principle, the privacy of information about patients and about research participants in whatever way it is obtained.

Debates about the ethical implications of advancements in neuroscience often include estimates of how such developments will affect commonsense morality. These predictions rely on a putative clash between commonsense morality and neuroscientific discoveries. In this chapter, I argue that commonsense morality is an empirically evaluable theory, which can be circumscribed in the same way as commonsense psychology—using Lewis’s method of collecting quotidian platitudes. I maintain, however, that if one were to utilize this method of collecting platitudes about morality, such a collection will represent only current commonsense morality. Commonsense morality specific to a particular time and cultural context cannot support unqualified claims that commonsense moral concepts as such are incompatible with scientific discoveries that pertain to the moral domain. Similarly, because general arguments about the character of commonsense concepts cannot be buttressed using these limited samples, commonsense moral concepts should not be used to set immutable boundaries for the development of new theories and conceptual frameworks.

In this article, we argue that felt discontinuity of self plays a role in recovery from substance use disorders. We rely on a view of the self that identifies continuity of the self with the maintenance of a self-concept, and we use it to propose an explanation of how individuals with substance use disorders form concepts of self around those disorders. We argue further that individuals can experience a discontinuity of self, that is, an identity crisis, in two ways. First, a person with a substance use disorder might experience a discontinuity of self when they attempt to maintain a self established prior to developing a substance use disorder. This type of identity crisis might motivate recovery as the individual will seek to resolve it through attempts to maintain an earlier concept of self that is not centered on substance use. Second, a person might experience a discontinuity of self as they seek to establish a self that is not grounded in substance use, which might make recovery more difficult by the need to establish a new concept of self.

Many bioethicists accept the Consciousness Condition (CC): roughly, that a person can be wronged only if she can be benefited or harmed, which is possible only if she retains the capacity for consciousness. We argue that CC is false. People can be wronged even if they permanently lack consciousness and thus have no ability to experience benefit or harm. In support of this claim, we introduce a clinical case in which a profoundly vegetative patient is subjected to unauthorized pelvic examinations for the benefit of medical trainees, then show that the truth of CC falsely implies the patient is not thereby wronged. We also offer a different explanation of the wrong done to patients by such behavior: they have been treated as objects—specifically, as tools for the purposes of others. We argue that our view—the instrumentalization account—not only yields the correct verdict on that case but that it enjoys advantages not shared by bare appeals to respect for autonomy or human dignity.

Scientific inquiry has revealed that pain is a complex and heterogonous phenomenon that is neither localized to a circumscribed region in the brain nor realized by a unique neurological mechanism. This discovery has inspired the application of a new version of eliminativism–scientific eliminativism–to pain. Based on this view, pain is not a natural kind and should be eliminated from scientific theorizing. Scientific eliminativism applied to pain is purportedly distinct from eliminative materialism because the former does not require elimination of the term ‘pain’ from its quotidian uses in folk psychology. In this paper, I challenge the distinction between scientific eliminativism and eliminative materialism and argue that the two versions of eliminativism make the same claims. I argue further that endorsement of scientific eliminativism for pain leads to elimination of the category of pain from folk psychology. To avoid this outcome, I formulate a proposal that obviates the need for eliminativism in any domain.

This chapter will address the axiological objection to cognitive enhancement, which is that the use of cognitive enhancers reduces the value of cognitive achievement. In a recent defense of cognitive enhancement, Carter and Pritchard (2019) utilize the extended mind hypothesis to argue that cognitive enhancers do not compromise knowledge acquisition. In this chapter, it will be demonstrated that the reliance on the extended mind hypothesis leaves some cognitive enhancers vulnerable to the axiological objection. To expand the scope of the argument, it will be shown that criteria for cognitive integration are applicable even to enhancers that cause changes to cognition internal to the human organism. This chapter will begin with a description of several cognitive enhancers and with the identification of the type of cognitive process they purportedly improve. It will then be demonstrated that even when those improvements are internal, they need not affect cognitive character and do not compromise cognitive agency.

There are currently two legally established criteria for death: the irreversible cessation of circulation and respiration and the irreversible cessation of neurologic function. Recently, there have been technological developments that could undermine the irreversibility requirement. In this paper, I focus both on whether death should be identified as an irreversible state and on the proper scope of irreversibility in the biological definition of death. In this paper, I tackle the distinction between the commonsense definition of death and the biological definition of death to show that even the commonsense concept of death is specified by biological facts. Resting on this argument, I argue that any definition of death is a posteriori. Thus, irreversibility is part of any definition of death because the actual phenomenon of death is irreversible. In addition, I show that the proper domain of irreversibility in a definition of death is circumscribed by physical possibilities and that irreversibility in the definition of death refers to current possibilities for the reversal of relevant biological processes. I conclude that, despite recent technological advancements, death is still irreversible.

The use of brain technology that contributes to psychological changes has spurred a debate about personal identity. Some argue that neurotechnology does not undermine personal continuity (Levy, 2011) while others argue that it does (Kreitmair, 2019; Schechtman, 2010). To make these assessments, commentators fail to identify psychological changes that cause personal discontinuity. In this paper, I present a view that identifies personal continuity with the maintenance of a self-concept. I argue that a concept of self requires the ability to self-ascribe physical and psychological features and that the diachronic self emerges with self-ascriptions of features that require endurance over time. I maintain that an adequate concept of self does not depend on the maintenance of any particular combination of self-ascriptions and that it can be maintained despite even significant changes in psychological or physical traits. Finally, I apply the self-concept view to identify changes that can result in discontinuity of self.

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary.We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision should be identified based on a patient’s particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making.

Racial disparities in pain treatment are well documented. Such disparities are explained with reference to factors related to providers, health care structures, and patient behaviors. Racial differences in pain experiences, although well documented, are less well understood. Explanations for such differences usually involve genetic or psychological factors. Here, we argue that racial differences in pain experiences might also be explained by disparities in pain treatment. Based on what we know about the nature of pain, particularly the cognitive and affective aspects of the phenomenon, it is likely that disparities in the treatment of racialized patients can lead to significant racial differences in pain experience that show up at the population level. We argue that the failure of research programs to consider this causal factor is an example of white ignorance. We also consider several implications of the link between racial disparities in pain treatment and racial differences in pain experience.

It is one of the premises of eliminative materialism that commonsense psychology constitutes a theory. There is agreement that mental states can be construed as posited entities for the explanation and prediction of behavior. Disputes arise when it comes to the range of the commonsense theory of mental states. In chapter one, I review major arguments concerning the span and nature of folk psychology. In chapter two, relying on arguments by Quine and Sellars, I argue that the precise scope of commonsense psychology cannot be determined because there are no resources to distinguish claims that are commonsense from all others. I use this conclusion to evaluate Churchland’s proposal that folk psychology should be eliminated in favor of a scientific theory. I argue that, although such an elimination is possible, it is unnecessary because commonsense psychology is in part informed by scientific theories. The properties that are usually attributed to mental states, on my view, are not common sense and would re-emerge even if we replaced our current theory with a scientific one. In chapter three, I examine how this affects eliminativist arguments, such as Churchland’s proposals for how to solve the emergence of the phenomenal character of sensations. I argue that it might be the case that some phenomenal properties are the result of endorsing a particular theory, but phenomenal character as such is a permanent feature of any theory about internal states. Addressing the problem of the incorrigibility of mental states, in chapter four, I challenge Rorty’s idea that such a property is the mark of the mental and can be attributed to our mental states based on our everyday usage of mental terms. The position asserted in the dissertation is compatible with the view that any theory can be revised, but doubts are expressed concerning the likelihood for a complete replacement of the current folk-psychological theory. Taking inspiration form Sellars, in chapter five, I argue that the establishment of a conceptual framework entails a wholistic jump from no concepts to a rudimentary framework. With this leap some properties are solidified and stand in the way of elimination.

Loss of personal identity in dementia can raise a number of ethical considerations, including the applicability of advance directives and the validity of patient preferences that seem incongruous with a previous history of values. In this chapter, we first endorse the self-concept view as the most appropriate approach to personal continuity in healthcare. We briefly describe two different types of dementia, Alzheimer’s dementia (AD) and behavioral-variant frontotemporal dementia (bv-FTD). We identify elements considered important for the continuation of a self-concept, including continuation of memories, consistency in personality traits and personal preferences, and continued endorsement of certain moral tenets. We show that, depending on which element is considered most important for personal identity, continuity of a self-concept for individuals with distinct types of dementia will be affected and assessed differently. Utilizing a variety of empirical evidence, we argue that persistence of memory, personality traits, and preferences are not the most important for the maintenance of personal identity. Instead, as studies aimed to capture the folk-psychological view of personal continuity demonstrate, judgements about continuity depend primarily on the persistent commitment to widely shared moral beliefs. Because of that, we argue that individuals with bv-FTD are more likely to lose their sense of self than individuals whose dementia primarily affects memory, such as Alzheimer’s disease. We end the chapter by showing how the importance of moral beliefs for continuity of self can be used to provide guidance to health-care professionals when considering changes in preference by individuals with dementia.

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that standard applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust.

In 1959 two French neurologists, Pierre Mollaret and Maurice Goullon, coined the term coma dépassé to designate a state beyond coma. In this state, patients are not only permanently unconscious; they lack the endogenous drive to breathe, as well as brainstem reflexes, indicating that most of their brain has ceased to function. Although legally recognized in many countries as a criterion for death, brain death has not been universally accepted by bioethicists, by the medical community, or by the public. I this paper, I defend brain death as a biological concept. I challenge two assumptions in the brain death literature that have shaped the debate and have stood in the way of an argument for brain death as biological. First, I challenge the dualism established in the debate between the body and the brain. Second, I contest the emphasis on consciousness, which prevents the inclusion of psychological phenomena into a biological criterion of death. I propose that the term organism should apply both to the functioning of the body and the brain. I argue that the cessation of the organism as a whole should take into account three elements of integrated function. Those three elements are: 1) the loss of integrated bodily function; 2) the loss of psychophysical integration required for processing of external stimuli and those required for behavior; and, 3) the loss of integrated psychological function, such as memory, learning, attention, and so forth. The loss of those three elements of integrated function is death.

A number of studies within the domain of neuroscience have shown that conscious awareness of the decision to perform an action is preceded by unconscious activity in the brain. This in turn is taken to indicate that unconscious brain activity is the cause of action and not conscious willing. In this chapter, I assess arguments that unconscious brain activity is a threat to the common notion of free will. I dispute the idea that the common view of free will requires conscious willing. Additionally, I argue for the claim that unconscious processes play a role in the formation of conscious volitions. Based on that, I argue against the view that volition must be conscious. In this chapter, I also tackle the purported incompatibility between free will and scientific determinism. After assessing calls for the elimination of the commonsense concept of free will, I conclude that the incompatibility between the two notions rests on an unfavorable characterization of commonsense free will. I further argue that any concept of free will requires endorsement of a particular background theory and because of that I question whether any such concept can be properly characterized as common sense.

In 1959 two French neurologists, Pierre Mollaret and Maurice Goullon, coined the term coma dépassé to designate a state beyond coma. In this state, patients are not only permanently unconscious, but lack brain stem reflexes and the endogenous drive to breathe, indicating that most of their brain has ceased to function. Although legally recognized in many countries as a criterion for death, brain death has not been universally accepted by bioethicists, by the medical community, or by the public. In this paper, I defend brain death as a biological concept. I reassess three assumptions in the brain death literature that have shaped the debate and have stood in the way of an argument for brain death as biological. First, I target the assumption that the biological notion of death has to satisfy a traditional concept of death. I argue instead that the purportedly traditional notion of death is already a scientifically laden concept. Second, I challenge the dualism established in the debate between the body and the brain. Third, I contest the emphasis on consciousness, which prevents the inclusion of psychological phenomena into a biological criterion of death. I propose that the term organism should apply both to the functioning of the body and the brain. I argue that the cessation of the organism as a whole should take into account three elements of integrated function. Those three elements are: (1) the loss of integrated bodily function; (2) the loss of psychophysical integration required for processing of external stimuli and those required for behavior; and, (3) the loss of integrated psychological function, such as memory, learning, attention, and so forth. The loss of those three elements of integrated function is death.

The moral condemnation of memory modifying technologies (MMTs) often relies on the view that memory provides a veridical representation of the past and that it can be used to ground personal identity. In this chapter, I present a range of studies that substantiate the claim that autobiographical memory is unreliable and cannot be used to ground narrative identity. I use this evidence to argue that MMTs that have the potential to alter autobiographical memory do not jeopardize personal identity. Given its flexibility, I argue, narrative identity can be maintained despite changes in memory. I further argue that maintenance of particular memories is not required for authenticity. Because of the spontaneous fluctuations of each person’s character traits, values, and preferences over time, I claim that first-person endorsement of core traits or the identification of core memories as formative of narrative identity is required to establish one’s true self. In addition, I dispute the argument that memory modification poses a challenge to authenticity and provide examples of instances where such modification can promote authenticity.