Abstract
Neuroscience has made great progress in recent years in detecting mental processes using electrophysiological and imaging techniques. One of the major breakthroughs in this regard has been the detection of residual consciousness in persons diagnosed with a vegetative state. However, this very success gives rise to a number of theoretically as well as ethically crucial follow-up questions. What neuroimaging can provide are highly artificial, mathematically processed images and not direct information about the patient’s mind. Therefore, it is far from clear whether and to what degree behaviourally unresponsive patients are indeed conscious. This is all the more so since we are confronted with a double mediation: one between the person’s mind and the image of the brain and the second between the image and something that we interpret as a meaningful answer of the patient to a question of the physician. For the patient in question it is of vital importance that his ability for consciousness is neither over- nor underrated since both can lead to significant suffering. Above that, residual consciousness or remainders of the person’s self—even if reduced and fragmented—have to be taken into account for treatment or end of life decisions. Unfortunately, there is no consensus in neuroscience about what “consciousness” and “being conscious” really means. To be sure, there is a long tradition regarding notions like these in philosophy. However, philosophical insight does not find its way into neuroscience easily. Against this background, the paper aims at connecting philosophical and neuroscientific understandings of consciousness in order to better understand what may go on inside an otherwise unresponsive patient. The notion of a “self” that might be preserved even if the person in question is not fully conscious or only has some basic form of consciousness will serve as a working concept for this problem. Neuroethics has to solve the conceptual problem of consciousness in order to be able to solve the clinical problem of consciousness and with it the ethical problem of autonomy and the self.
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Notes
- 1.
It is obvious that this understanding of consciousness is too simplistic. However, that is not the fault of James, whose account is richer, but the fault of those present authors who leave it at that.
- 2.
This is impressively shown by Płonka (2015).
- 3.
If this seems silly to you, it would not be much better the other way around: It is difficult—to say the least—searching for something in the brain that you do not know. Searching for a wolf in the woods presupposes to know what a wolf is.
- 4.
Coma is usually a transient state from which patients either decline to brain death or improve to at least a vegetative state.
- 5.
Think of a multi-storey building: The basement represents coma, the first floor is the vegetative state, and so on up to the penthouse where the philosopher’s second order self-consciousness resides. The level-based account has recently been challenged, see below.
- 6.
LIS does not belong to the DOC-family but it is nevertheless of utmost importance in the DOC-Context since a patient may be misdiagnosed with VS even though she is completely conscious (an impressive example give Vanhaudenhuyse et al. 2018).
- 7.
Again, this must not be confused with LIS, where the patient is perfectly clear but cannot communicate.
- 8.
I can only give some hints to research literature and methods here; see Cavaliere et al. (2016) for a concise overview.
- 9.
It goes without saying, that things actually are much more complicated.
- 10.
One could argue that an unconscious patient cannot be harmed because in this case “there is nobody” who could be harmed. However, harm can be more direct (e.g., pain) or more indirect (e.g., violation of interests). Moreover, one has probably to take into consideration various dimensions of consciousness and the self (for more on the concept of self see part 5 below).
- 11.
Actually, consciousness corresponds to a single-storey building in this picture.
- 12.
Think of a patient who is fully conscious of her pain, but of nothing else.
- 13.
- 14.
A patient may be familiar with his mother’s voice or his father’s name without knowing much about his own and his parent’s biography.
- 15.
This is not to say that consciousness is possible without brain activity.
- 16.
In principle, we can never be completely sure whether someone really is conscious. See the zombie arguments in the philosophy of mind.
- 17.
Sapience refers to Block’s access consciousness but seems to have a more comprehensive meaning. While Block’s concept can be used (locally) for the naked information, sapience alludes to the person’s (global) mental life.
- 18.
That critical interests can persist in dementia, unconsciousness and even death need not be disputed here.
- 19.
Remember that I assumed for the sake of clarity that the patient has no prospect of recovery.
- 20.
Block himself argued for at least the conceptual possibility of phenomenal zombies, i.e. creatures with access—but no phenomenal consciousness (Block 1995).
- 21.
Actually, he is not only a philosophical zombie, he is also a “philosophical twin”. This philosophical twin is your exact duplicate minus phenomenal consciousness.
- 22.
Levy’s respective passage is worth citing at length: “But even if it is true that only a conscious being has a point of view, and that there can only be values if there are conscious acts of valuing, I see no reason at all to believe that the consciousness in question has to be phenomenal consciousness. My zombie twin has a point of view. He sees the world from a particular perspective, in an attitude-infused way. Indeed, his idiosyncratic take on things is identical to mine. He also values things. He believes that his life will go better if certain things happen, and therefore he desires that those things happen. He is motivated to do things that make it more likely that those things happen. There are states of affairs that he does not believe he can influence, but toward which he takes attitudes too (he hopes for peace in the Middle East, for instance). He is inclined to say that he values these things, and I am inclined to agree with him.” (Levy 2014, 133).
- 23.
In the philosophical literature on consciousness is the “dreaming driver” a well-known example from everyday experience: Once you know the route from home to your office by heart, you will be able to make the ride “automatically” while dreaming of your lover. It may be the same with the zombie-systems giving the investigator the wrong impression that the patient is conscious.
- 24.
For an instructive comparison of different accounts of consciousness and the self see Morin (2006).
- 25.
The Theory of Mind (ToM) discussed in cognitive psychology probably builds upon this more basic and general “theory” of a mind.
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Stier, M. (2020). Remainders of the Self: Consciousness as a Problem for Neuroethics. In: Kühler, M., Mitrović, V.L. (eds) Theories of the Self and Autonomy in Medical Ethics. The International Library of Bioethics, vol 83. Springer, Cham. https://doi.org/10.1007/978-3-030-56703-3_7
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