Alexander Green

Disorders of Consciousness (DoC) result in profound functional impairment, adversely affecting the lives of a predominantly younger patient population. Currently, effective treatment options for those who have reached chronicity (prolonged symptom duration over 4 weeks) are extremely limited, with the majority of such cases facing life-long dependence on carers and a poor quality of life. Here we briefly review the current evidence on caseload, diagnostic and management options in the United Kingdom (UK), United States of America (USA) and the European Union (EU). We identify key differences as well as similarities in these approaches across respective healthcare systems, highlighting unmet needs in this population. We subsequently present past efforts and the most recent advances in the field of surgical modulation of consciousness through implantable neurostimulation systems. We examine the ethical dilemmas that such a treatment approach may pose, proposing mediating solutions and methodological adjustments to address these concerns. Overall, we argue that there is a strong case for the utilisation of deep brain stimulation (DBS) in the DoC patient cohort. This is based on both promising results of recent clinical trials as well as technological developments. We propose a revitalization of surgical neuromodulation for DoC with a multicenter, multidisciplinary approach and strict monitoring guidelines, in order to not only advance treatment options but also ensure the safeguarding of patients’ welfare and dignity.

Background Innovative neurosurgical treatments present a number of known risks, the natures and probabilities of which can be adequately communicated to patients via the standard procedures governing obtaining informed consent. However, due to their novelty, these treatments also come with unknown risks, which require an augmented approach to obtaining informed consent. Objective This paper aims to discuss and provide concrete procedural guidance on the ethical issues raised by serious unexpected complications of novel deep brain stimulation treatments. Approach We illustrate our analysis using a case study of the unexpected development of recurrent stereotyped events in patients following the use of deep brain stimulation (DBS) to treat severe chronic pain. Examining these unexpected complications in light of medical ethical principles, we argue that serious complications of novel DBS treatments do not necessarily make it unethical to offer the intervention to eligible patients. However, the difficulty the clinician faces in determining whether the intervention is in the patient's best interests generates reasons to take extra steps to promote the autonomous decision making of these patients. Conclusion and recommendations We conclude with clinical recommendations, including details of an augmented consent process for novel DBS treatment.

A considerable body of research has documented the emergence of what appears to be instrumental helping behavior in early childhood. The current study tested the hypothesis that one basic psychological mechanism motivating this behavior is a preference for completing unfinished actions. To test this, a paradigm was implemented in which 2-year-olds (n = 34, 16 female/18 male, mostly White middle-class children) could continue an adult’s action when the adult no longer wanted to complete the action. The results showed that children continued the adult’s actions more often when the goal had been abandoned than when it had been reached (OR = 2.37). This supports the hypothesis that apparent helping behavior in 2-year-olds is motivated by a preference for completing unfinished actions.

Previous research has established that goal tracking emerges early in the first year of life and rapidly becomes increasingly sophisticated. However, it has not yet been shown whether young children continue to update their representations of others’ goals over time. The current study investigates this by probing young children’s (24-30 months old) ability to differentiate between goal directed actions that have been halted because the goal was interrupted, and because the goal was abandoned. To test whether children are sensitive to this distinction, we manipulated the experimenter’s reason for not completing a goal-directed action - his initial goal is either interrupted by an obstacle, or it is abandoned in favour of an alternative. We measure whether children’s helping behaviour is sensitive to the experimenter’s reason for not completing his goal-directed action by recording whether they complete the experimenter’s initial goal or the alternative goal. The results showed that children (n = 24) helped complete the experimenter’s initial goal significantly more often after this goal had been interrupted than after it had been abandoned. These results support the hypothesis that children continue to update their representations of others’ goals over time by the age of two, and specifically that they differentiate between abandoned and interrupted goals.

Previous research has established that goal tracking emerges early in the first year of life and rapidly becomes increasingly sophisticated. However, it has not yet been shown whether young children continue to update their representations of others’ goals over time. The current study investigates this by probing young children’s ability to differentiate between goal directed actions that have been halted because the goal was interrupted, and because the goal was abandoned. To test whether children are sensitive to this distinction, we manipulated the experimenter’s reason for not completing a goal-directed action - his initial goal is either interrupted by an obstacle, or it is abandoned in favour of an alternative. We measure whether children’s helping behaviour is sensitive to the experimenter’s reason for not completing his goal-directed action by recording whether they complete the experimenter’s initial goal or the alternative goal. The results showed that children helped complete the experimenter’s initial goal significantly more often after this goal had been interrupted than after it had been abandoned. These results support the hypothesis that children continue to update their representations of others’ goals over time by the age of two, and specifically that they differentiate between abandoned and interrupted goals.

This book argues that Levi Gersonides articulates a unique model of virtue ethics among medieval Jewish thinkers. Gersonides is recognized by scholars as one of the most innovative Jewish philosophers of the medieval period. His first model of virtue is a response to the seemingly capricious forces of luck through training in endeavor, diligence, and cunning aimed at physical self-preservation. His second model of virtue is altruistic in nature. It is based on the human imitation of God as creator of the laws of the universe for no self-interested benefit, leading humans to imitate God through the virtues of loving-kindness, grace, and beneficence. Both these models are amplified through the institutions of the kingship and the priesthood, which serve to actualize physical preservation and beneficence on a larger scale, amounting to recognition of the political necessity for a division of powers.