Clinical cases of frontallobe lesions have been significantly associated with acquired aggressive behaviour. Restoring neuronal and cognitive faculties of aggressive individuals through invasive brain intervention raises ethical questions in general. However, more questions have to be addressed in cases where individuals refuse surgical treatment. The ethical desirability and permissibility of using intrusive surgical brain interventions for involuntary or voluntary treatment of acquired aggressiveness is highly questionable. This article engages with the description of acquired aggressiveness in general, and (...) presents a rare clinical case to illustrate the difficulties of treating this population. To expand the debate further, this article explores the ethics related to invasive brain surgery in three parts: a) it examines coercive involuntary invasive brain surgery for the benefit of protecting others on individuals suffering from acquired aggressiveness who lack decision-making capacities to consent; b) it addresses voluntary psychosurgery on individuals suffering from acquired aggressiveness who are competent to consent; and, c) it questions whether acquired aggressive individuals, who are legally competent, have a duty to consent to invasive brain surgery, in order to maintain their autonomy by reducing or even eliminate their aggressive drives. Ensuring the safety and efficacy of surgical brain interventions could increase the ethical permissibility of voluntary treatment, but it would not necessarily entail ethical justification for proceeding with invasive brain surgery for treatment of intractable acquired aggressive behaviour. (shrink)
Executive functioning deficits due to brain disease affecting frontallobe functions cause significant real-life disability, yet solid evidence in support of executive functioning interventions is lacking. Goal Management Training (GMT), an executive functioning intervention that draws upon theories concerning goal processing and sustained attention, has received empirical support in studies of patients with traumatic brain injury, normal aging, and case studies. GMT promotes a mindful approach to complex real-life tasks that pose problems for patients with executive functioning deficits, (...) with a main goal of periodically stopping ongoing behavior to monitor and adjust goals. In this controlled trial, an expanded version of GMT was compared to an alternative intervention, Brain Health Workshop (BHW) that was matched to GMT on non-specific characteristics that can affect intervention outcome. Participants included 19 individuals in the chronic phase of recovery from brain disease (predominantly stroke) affecting frontallobe function. Outcome data indicated specific effects of GMT on the Sustained Attention to Response Task (SART) as well as the Tower Test, a visuospatial problem solving measure that reflected far transfer of training effects. There were no significant effects on self-report questionnaires, likely owing to the complexity of these measures in this heterogeneous patient sample. Overall, these data support the efficacy of GMT in the rehabilitation of executive functioning deficits. (shrink)
Ruchkin et al. ascribe a pivotal role to long-term memory representations and binding within working memory. Here we focus on the interaction of working memory and long-term memory in supporting on-line representations of experience available to guide on-going processing, and we distinguish the role of frontal-lobe systems from what the hippocampus contributes to relational long-term memory binding.
The Wisconsin card-sorting test (WCST) is a commonly used clinical tool for the detection of frontallobe dysfunction, specifically executive dysfunction. Patients with lesions outside the frontal lobes sometimes show deficits on the WCST, however, and some researchers have implicated hippocampal dysfunction as the cause of the deficit. But a critical role for the hippocampus seems to be untenable because amnesic patients with bilateral medial temporal lobe (MTL) lesions perform the WCST normally. In the case of (...) epileptic patients, an alternative explanation of the card-sorting impairment is the propagation of abnormal discharges from MTL to frontallobe structures, causing remote interference with executive circuits. (shrink)
Reichle et al. show that saccades in reading are controlled by linguistic processing. The authors' Figure 13 shows the parietal and frontal eye fields as parts of a neural implementation. This commentary presents data from dyslexics performing nonreading saccade tasks. The dyslexics exhibit deficits in antisaccade control. Improvement of the deficits is achieved in 85% of the cases and results in advantages in learning how to read.
Structure and function of the human brain are affected by training in both linguistic and musical domains. Individuals with intensive vocal musical training provide a useful model for investigating neural adaptations of learning in the vocal-motor domain and can be compared with learning in a more general musical domain. Here we confirm general differences in macrostructure (tract volume) and microstructure (fractional anisotropy (FA)) of the arcuate fasciculus (AF), a prominent white-matter tract connecting temporal and frontal brain regions, between singers, (...) instrumentalists, and non-musicians. Both groups of musicians differed from non-musicians in having larger tract volume and higher FA values of the right and left AF. The AF was then subdivided in a dorsal (superior) branch connecting the superior temporal gyrus and the inferior frontal gyrus (STGIFG), and ventral (inferior) branch connecting the middle temporal gyrus and the inferior frontal gyrus (MTGIFG). Relative to instrumental musicians, singers had a larger tract volume but lower FA values in the left dorsal AF (STGIFG), and a similar trend in the left ventral AF (MTGIFG). This between-group comparison controls for the general effects of musical training, although FA was still higher in singers compared to non-musicians. Both musician groups had higher tract volumes in the right dorsal and ventral tracts compared to non-musicians, but did not show a significant difference between each other. Furthermore, in the singers’ group, FA in the left dorsal branch of the AF was inversely correlated with the number of years of participants’ vocal training. Our findings suggest that long-term vocal-motor training might lead to an increase in volume and microstructural complexity of specific white matter tracts connecting regions that are fundamental to sound perception, production, and its feedforward and feedback control which can be differentiated from a more general musician effect. (shrink)
A growing body of literature provides evidence for the prophylactic influence of cardiorespiratory fitness on cognitive decline in older adults. This study examined the association between cardiorespiratory fitness and recruitment of the neural circuits involved in an attentional control task in a group of healthy older adults. Employing a version of the Stroop task, we examined whether higher levels of cardiorespiratory fitness were associated with an increase in activation in cortical regions responsible for imposing attentional control along with an up-regulation (...) of activity in sensory brain regions that process task-relevant representations. Higher fitness levels were associated with better behavioral performance and an increase in the recruitment of prefrontal and parietal cortices in the most challenging condition, thus providing evidence that cardiorespiratory fitness is associated with an increase in the recruitment of the anterior processing regions. There was a top-down modulation of extrastriate visual areas that process both task-relevant and task-irrelevant attributes relative to the baseline. However, fitness was not associated with differential activation in the posterior processing regions, suggesting that fitness enhances attentional function by primarily influencing the neural circuitry of anterior cortical regions. This study provides novel evidence of a differential association of fitness with anterior and posterior brain regions, shedding further light onto the neural changes accompanying cardiorespiratory fitness. (shrink)
Byrne & Russon suggest that there are two kinds of imitation learning – action level and program level – and that the latter is critical for great apes' learning. I have interpreted this phenomenon from the standpoint of clinical neuropsychology and conjecture that action-level imitation might be related to parietal lobe function and program-level imitation might be related to frontallobe function.
Adaptive decision making and veridical decision making are based on different mechanisms. Veridical decision making is based on the identification of the correct response, which is intrinsic to the external situation and is actor-independent. Adaptive decision making is actor-centered and is guided by the actor's priorities. The prefrontal cortex is particularly critical for adaptive decision making and less so for veridical decision making. However, most experimental procedures used in cognitive psychology and neuropsychology focus on veridical decision making and ignore adaptive (...) decision making. Innovative experimental procedures are required to characterize the contribution of the prefrontal cortex to adaptive decision making. We have designed a prototype for such procedures, the Cognitive Bias Task, and present the novel findings generated by this task. (shrink)
This study examined the performance of 41 patients with focal prefrontal cortical lesions and 38 healthy controls on a task-switching procedure. Three different conditions were evaluated: single tasks without switches and two switching tasks with the currently relevant task signalled either 1500 ms (Long Cue) or 200 ms (Short Cue) before the stimulus. Patients with Superior Medial lesions showed both a general slowing of reaction time (RT) and a signifi cantly increased switch cost as measured by RT. No other prefrontal (...) group showed this increased reaction time switch cost. Increased error rates in the switching conditions, on the other hand, were observed in patients with Inferior Medial lesions and, to a lesser extent, ones with Superior Medial lesions. Patients with left dorsolateral lesions (9/46v) showed slower learning of the task as indicated by a high error rate early on. Several different processes are involved in task-switching and these are selectively disrupted by lesions to specifi c areas of the frontal lobes. (shrink)
This article focuses on maternal-fetal surgery (MFS) and on the concept of clinical equipoise that is a widely accepted requirement for conducting randomized controlled trials (RCT). There are at least three reasons why equipoise is unsuitable for MFS. First, the concept is based on a misconception about the nature of clinical research and the status of research subjects. Second, given that it is not clear who the research subject/s in MFS is/are, if clinical equipoise is to be used as (...) a criterion to test the ethical appropriateness of RCT, its meaning should be unambiguous. Third, because of the multidisciplinary character of MFS, it is not clear who should be in equipoise. As a result, we lack an adequate criterion for the ethical review of MFS protocols. In our account, which is based on Chervenak and McCullough's seminal work in the field of obstetric ethics, equipoise is abandoned. and RCT involving MFS can be ethically initiated when a multidisciplinary ethics review board (ERB), having an evidence-based assessment of the risks involved, is convinced that the value of answering the research hypothesis, for the sake of the health interests of future pregnant women carrying fetuses with certain congenital birth defects, justifies the actual risks research participants might suffer within a set limit of low/manageable. (shrink)
How should a practice, subservient to a public good, be regulated in order to guarantee fair access without encouraging improper claims? In the first place, a clear understanding of the goal of the practice is indispensable for knowing what criteria the regulation must contain. As to the purely formal aspect, the regulation of any practice must include both general rules and particular instances. Finally, to resolve conflicts, committees in which different kinds of expertise are represented should be installed. These three (...) theses are illustrated by the Dutch regulation for cosmetic surgery. (shrink)
Despite intense academic debate in the recent past over the use of ‘sham surgery’ control groups in research, there has been a recent resurgence in their use in the field of neurodegenerative disease. Yet the primacy of ethical arguments in favour of sham surgery controls is not yet established. Preliminary empirical research shows an asymmetry between the views of neurosurgical researchers and patients on the subject, while different ethical guidelines and regulations support conflicting interpretations. Research ethics committees faced (...) with a proposal involving sham surgery should be aware of its ethical complexities. An overview of recent and current placebo-controlled surgical trials in the field of Parkinson's Disease is provided here, followed by an analysis of the key ethical issues which such trials raise. (shrink)
BackgroundBariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open (...) and transparent decision making process.DiscussionA wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.SummaryPerforming bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents. (shrink)
Surgery is an increasingly common and expensive mode of medical intervention. The ethical dimensions of the surgeon-patient relationship, including respect for personal autonomy and informed consent, are much discussed; but broader equity issues have not received the same attention. This paper extends the understanding of surgical ethics by considering the nature of evidence in surgery and its relationship to a just provision of healthcare for individuals and their populations.
Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily a medical (...) condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity. (shrink)