Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests (...) for eye movements or blinking on command. This is welcomed given that misdiagnosis of the locked-in syndrome has been shown to occur in more than half of the cases (see Laureys and colleagues3 for review). As for the diagnosis of the vegetative state, the scale explicitly tests for visual pursuit, and hence can disentangle the vegetative state from the minimally conscious state (MCS). The diagnostic criteria for MCS have been proposed4 only recently, but Wijdicks and colleagues1 do not mention the existence of this clinical entity in their article. As for the vegetative state, MCS can be encountered in the acute or subacute setting as a transitional state on the way to further recovery, or it can be a more chronic or even permanent condition. The MCS refers to patients showing inconsistent, albeit clearly discernible, minimal behavioral evidence of consciousness (eg, localization of noxious stimuli, eye fixation or tracking, reproducible movement to command, or nonfunctional verbalization).4 The FOUR scale does not test for all of the behavioral criteria required to diagnose MCS.4 It is known from the literature (see Majerus and colleagues5 for review) that about a third of patients diagnosed with vegetative state are actually in MCS, and this misdiagnosis can lead to major clinical, therapeutic, and ethical consequences. We tested the ability of the newly proposed FOUR scale to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting.. (shrink)

ObjectiveTo investigate the short-term effect of music therapy combined with binaural frequency difference therapy on patients with consciousness disorder.Materials and methodsNinety patients with definite diagnosis of disorders of consciousness were selected. These patients were randomly divided into control group, experiment 1 group and experiment 2 group, with 30 patients in each group. The control group was treated with routine clinical treatment and rehabilitation. In experiment 1 group, music therapy was added to the control group. In experimental group 2, music therapy (...) combined with binaural α frequency difference therapy was added to the control group. All patients were assessed before and after 30 treatments. The assessment items included Glasgow Coma Scale, Coma Recovery Scale revised, electroencephalogram, upper somatosensory evoked potential, and brainstem auditory evoked potential.ResultsBefore treatment, there were no significant differences in GCS score, CRS-R score, USEP, BAEP, and EEG scores among the three groups. After 30 times of treatment, GCS score, CRS-R score, USEP, BAEP, and EEG scores in 3 groups were significantly higher than those before treatment. And the consciousness rate of experimental group 2 was better than experimental group 1, experimental group 1 was better than the control group and the difference was statistically significant.ConclusionMusic therapy combined with binaural α frequency difference therapy is more effective in stimulating DOC patients. (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)

IntroductionIn highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for (...) withdrawal LSMT in pediatric TBI.MethodsThe pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis.ResultsOf 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years, p = 0.07) and a higher rate of NAT (33.7 percent versus 13.5 percent, p < 0.001). The most common specified perpetrator was a father/stepfather/ male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23, p < 0.05) and NAT (OR 1.86, CI 1.02-3.41, p < 0.05).ConclusionNAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized. (shrink)

In today’s society, it becomes increasingly important to assess which non-human and non-verbal beings possess consciousness. This review article aims to delineate criteria for consciousness especially in animals, while also taking into account intelligent artifacts. First, we circumscribe what we mean with “consciousness” and describe key features of subjective experience: qualitative richness, situatedness, intentionality and interpretation, integration and the combination of dynamic and stabilizing properties. We argue that consciousness has a biological function, which is to present the subject with a (...) multimodal, situational survey of the surrounding world and body, subserving complex decision-making and goal-directed behavior. This survey reflects the brain’s capacity for internal modeling of external events underlying changes in sensory state. Next, we follow an inside-out approach: how can the features of conscious experience, correlating to mechanisms inside the brain, be logically coupled to externally observable properties? Instead of proposing criteria that would each define a “hard” threshold for consciousness, we outline six indicators: goal-directed behavior and model-based learning; anatomic and physiological substrates for generating integrative multimodal representations; psychometrics and meta-cognition; episodic memory; susceptibility to illusions and multistable perception; and specific visuospatial behaviors. Rather than emphasizing a particular indicator as being decisive, we propose that the consistency amongst these indicators can serve to assess consciousness in particular species. The integration of scores on the various indicators yields an overall, graded criterion for consciousness, somewhat comparable to the Glasgow Coma Scale for unresponsive patients. When considering theoretically derived measures of consciousness, it is argued that their validity should not be assessed on the basis of a single quantifiable measure, but requires cross-examination across multiple pieces of evidence, including the indicators proposed here. Current intelligent machines, including deep learning neural networks and agile robots, are not indicated to be conscious yet. Instead of assessing machine consciousness by a brief Turing-type of test, evidence for it may gradually accumulate when we study machines ethologically and across time, considering multiple behaviors that require flexibility, improvisation, spontaneous problem-solving and the situational conspectus typically associated with conscious experience. (shrink)

BackgroundThe prognosis of hypertensive intracerebral hemorrhage is poor at high altitudes. The objective of this study was to explore whether hyperbaric oxygen can improve the results of computed tomography perfusion imaging and the neurological function of patients with HICH, and influence the hemoglobin concentration.MethodThe patients with HICH were treated with puncture and drainage. Twenty-one patients were treated with HBO after the operation, and the other patients received conventional treatment. CTP was performed twice, and all indices were measured. Scatter plots were (...) used to determine the effect of hemoglobin concentration on CTP imaging. Receiver operating characteristic curves were plotted to analyze the effects of hemoglobin concentration and hematoma volume on recovery results. The patients were followed up for 6 months.ResultsForty-one patients with HICH were treated with puncture and drainage. In total, 21 were treated with HBO after the operation, and 20 received conventional treatment as the control group. No significant differences in the CBV and CBF values of the two groups were noted before treatment. After 10 days, the values of CBV and CBF in the HBO group were significantly higher than those in the control group. A scatter diagram showed there was no significant in the HBO group, but significant correlation for the CBV and CBF values in the control group’s hematoma center and margin. The ROC curves showed that hematoma volume had an influence on prognosis of the control group. The Glasgow Coma Scale scores of the HBO group were significantly higher than those of the control group.ConclusionsHBO therapy can improve the postoperative CBV and CBF values of patients with HICH and ameliorate their prognoses. There was no significant correlation between HBO group and hemoglobin concentration on admission. (shrink)

As a member of the New York State Task Force on Life and the Law and the author of Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness, the author draws upon his work as a clinical ethicist during the COVID-19 Spring surge in New York to analyze the impact of ventilator allocation guidelines proposed by the Task Force on people with disorders of consciousness. While a non-discriminatory methodology was intended by the Task Force, the author concludes (...) that the guidelines would have discriminated against people with disorders of consciousness had they been promulgated. This was due to errors in exclusion criteria, the utilization of the Sequential Organ Failure Assessment (SOFA) score, and the Glasgow Coma Scale which assesses motor output and not consciousness. While allocation and triage decisions may be neccessary during a pandemic, the ethical integrity of these determinations depend upon proper metrics. (shrink)

OBJECTIVE: Following two randomized controlled trials that demonstrated reduced mortality and better neurological outcome in cardiac arrest patients, mild therapeutic hypothermia was implemented in many intensive care units. Up to now, no large observational studies have confirmed the beneficial effects of mild therapeutic hypothermia. DESIGN: Internet-based survey combined with a retrospective, observational study. PATIENTS: All patients admitted to an intensive care unit in The Netherlands after cardiac arrest from January 1, 1999 until January 1, 2009. DATA SOURCE: Dutch National Intensive (...) Care Evaluation database. METHODS: The moment of implementation of mild therapeutic hypothermia for each hospital participating in the Dutch National Intensive Care Evaluation database was determined with an Internet survey. To compare mortality before and after implementation of mild therapeutic hypothermia, the odds ratio adjusted for Simplified Acute Physiology Score II score, age, gender, propensity score, and in- or out-of-hospital cardiac arrest was calculated. Patients were excluded if 1) they were admitted to an intensive care unit that did not respond to the survey, 2) they were admitted within 3 months after implementation of mild therapeutic hypothermia, 3) they had a Glasgow Coma Scale score of >8, or 4) they did not satisfy the Simplified Acute Physiology Score II inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 13,962 patients were admitted to an intensive care unit following cardiac arrest. In total 8,645 patients were excluded, 5,544 because of a Glasgow Coma Scale score of >8. Of the resultant 5,317 patients, 1,547 patients were treated before and 3,770 patients after implementation of mild therapeutic hypothermia. Patients admitted after implementation of mild therapeutic hypothermia had lower minimal and maximal temperatures (p < .0001) during the first 24 hrs on the intensive care unit compared to patients admitted before implementation of mild therapeutic hypothermia. The adjusted odds ratio of the hospital mortality of patients treated after implementation of mild therapeutic hypothermia was 0.80 (95% confidence interval of 0.65-0.98, p = .029). CONCLUSION: The results of this retrospective, observational survey suggest that implementation of mild therapeutic hypothermia in Dutch intensive care units is associated with a 20% relative reduction of hospital mortality in cardiac arrest patients. (shrink)

En contra de les aparences, la meva intenció és ridiculitzar i desactivar l’estratègic ús de referències a personatges de ficció per part dels mass media, els quals pretenen identificar el fundador de WikiLeaks amb tot aquest projecte —quelcom que facilita tant la deslegitimació com la mercantilització. Així, aquest article qüestiona la dominant personalització de la web de filtracions en Julian Assange, tot mostrant algunes de les més rellevants diferències i/o contradiccions entre el rerefons normatiu de WikiLeaks i la pseudo-filosofia política (...) de l’australià. La meva tesi és que la justificació de la il·legal revelació d’informació secreta i confidencial com a pràctica de desobediència civil es posa en perill per la contaminació de postulats utilitaristes i neoliberals. (shrink)

Social commentators have long asked whether racial categories should be conserved or eliminated from our practices, discourse, institutions, and perhaps even private thoughts. In _A Theory of Race_, Joshua Glasgow argues that this set of choices unnecessarily presents us with too few options. Using both traditional philosophical tools and recent psychological research to investigate folk understandings of race, Glasgow argues that, as ordinarily conceived, race is an illusion. However, our pressing need to speak to and make sense of (...) social life requires that we employ something like racial discourse. These competing pressures, Glasgow maintains, ultimately require us to stop conceptualizing race as something biological, and instead understand it as an entirely social phenomenon. (shrink)

La clase de filosofía, desde la perspectiva del docente, no debe considerarse como una mera actividad transeúnte o predicamental. El presente estudio quiere examinarla, siguiendo la metafísica de la vida de Tomás de Aquino, como una obra vital, que requiere, por un lado, que el profesor se haga una sola cosa —una sola vida, podemos decir— con la doctrina que va a explicar y, por el otro, que esta intelección actual, sin movimiento alguno, dé lugar a la «concepción» y al (...) «parto» de lo entendido en una palabra del corazón, la cual, por su dinamismo intrínseco, tiende, a su vez, a manifestarse exteriormente en una palabra sonora, en un «verbum vocis». Esta exteriorización, por la cual aquella íntima operación que constituye la vida del que filosofa se corporeiza en forma de «diálogo», es, precisamente, la clase de filosofía. La técnica pedagógica debe tener en cuenta el orden intrínseco por el cual la vida humana, mediante la formación de una palabra del corazón, procede a su propia perfección, y no debe olvidar que el perfeccionamiento vital del profesor es causa (instrumental) del perfeccionamiento vital del alumno; es decir, quien no «produce», quien no «engendra», quien no «crea» interiormente lo que está explicando —independientemente de si se trata o no de una novedad— difícilmente ofrecerá unos medios adecuados para que el alumno conciba y dé a luz, en la intimidad de su mente, a un «verbum cordis». (shrink)

En este libro, que se titula «Sobre los nombres divinos [De divinis nominibus]», siguiendo la costumbre de aquellos que han transmitido la ciencia magistralmente [artificiose], Dionisio empieza, en primer lugar, presentando algunas consideraciones necesarias para todo el estudio sucesivo, y, en segundo lugar, prosigue exponiendo el objeto principal [de su tratado] en el capítulo tercero.

En este artículo se investigan los presupuestos ontológicos de aquellos nombres divinos que pueden predicarse de Dios y de las criaturas. En un primer momento, se destaca la anterioridad metafísica del ente como atributo de Dios. Después, al descubrir que el ente es un concepto análogo, se examinan las distintas modalidades de analogía confrontando dos textos: Summa contra Gentiles, I, cap. 34 y De Veritate, q.2, a.11. Finalmente, se muestra que la analogía de proporcionalidad es la que debe preferirse para (...) predicar algo acerca de Dios, y se pone de manifiesto en qué medida se funda sobre la cuarta vía «ex gradibus qui in rebus inveniuntur». (shrink)

Si prescindiéramos de la composición acto-potencial entre «essentia» y «esse» en la línea del ente creado, necesariamente nos veríamos arrojados al monismo spinozista, esto es, a admitir que solamente hay una substancia (a) única, (b) infinita, (c) increada, (d) necesariamente existente, (e) acto puro, (f) identificada, en último término, con la misma substancia de Dios. En el capítulo LII del segundo libro de la Summa contra gentiles, Santo Tomás obtiene esos atributos divinos a partir de siete argumentos que tienen como (...) objetivo probar que, en el caso que no se aceptara la diferencia real entre essentia y esse en el ente finito —tanto material como inmaterial—, necesariamente deberíamos reconocer que sólo hay una substancia con los seis atributos anteriormente mencionados (cada argumento da lugar a un atributo distinto, exceptuando los dos primeros que desembocan en el mismo, a saber, el de la unicidad). En el artículo presente, siguiendo la interpretación de Norberto del Prado, nos proponemos exponer cómo puede refutarse el monismo spinozista desde la doctrina de Santo Tomás en dos etapas: la primera viene representada por el ya citado capítulo de la Summa contra gentes; la segunda, por la cuarta vía (Summa Theologiae, I, q.2, a.3). (shrink)

An analysis of 'racism' in terms of disrespect. This article argues against the views that racism should be understood in reductive ways as, variously, an attitude of ill-will (Jorge Garcia), a cognitive object such as ideology (Tommie Shelby), a behavior (Michael Philips), or some disjunctive hybrid (Lawrence Blum). In fact, it argues that racism should be conceptually released from having any one location. The disrespect analysis favored here can accommodate a variety of important desiderata for a theory of racism.

In the debate over the reality of race, a three-way dispute has become entrenched: race is biologically real, socially real, or simply not real. These three theses have each enjoyed increasingly sophisticated defenses over roughly the past thirty years, but we argue here that this debate contains a lacuna: there is a fourth, mostly neglected, position that we call ‘basic racial realism.’ Basic racial realism says that though race is neither biologically real nor socially real, it is real all the (...) same. Our goal is to establish this theory's credentials and provide it with initial support. It appears to be in a strong dialectical position and to nicely capture what many want from a theory of race. (shrink)

We ordinarily think that, keeping all else equal, a life that improves is better than one that declines. However, it has proven challenging to account for such value judgments: some, such as Fred Feldman and Daniel Kahneman, have simply denied that these judgments are rational, while others, such as Douglas Portmore, Michael Slote, and David Velleman, have proposed justifications for the judgments that appear to be incomplete or otherwise problematic. This article identifies problems with existing accounts and suggests a novel (...) alternative theory: what best accounts for our preference for an uphill over a downhill life (and many other episodes) is that losses of momentary value are themselves bad and gains in momentary value are themselves good. (shrink)

Expressivist theories of punishment received largely favorable treatment in the 1980s and 1990s. Perhaps predictably, the 2000s saw a slew of critical rejections of the view. It is now becoming evident that, while several objections to expressivism have found their way into print, three concerns are proving particularly popular. So the time is right for a big picture assessment. What follows is an attempt to show that these three dominant objections are not decisive reasons to give up the most plausible (...) forms of the view. Moreover, in addition to the three common objections, expressivism has an acknowledged question mark concerning whether the value of punitive expression outweighs its drawbacks. Here I also map out some promising avenues that the expressivist can take to answer this question. (shrink)

The word “objective” is of course the trouble–maker here, Miss Smith assumes that if an aesthetic statement is held to be objective then it is the physical existence of the work of art that constitutes the objectivity: i.e. if a work of art is exteroceptively perceivable, then an aesthetic statement involving it is objective. Some writers, however have held that in genuine works of art there is manifested an ultimate spiritual Reality which we apprehend when we appreciate such works. On (...) this theory, an aesthetic statement has an objective reference if the subject of it succeeds in expressing or communicating such a supersensible Reality: if it fails to do so, then the statement is subjective, i.e. it can be analysed completely into a statement about our feelings or emotions. (shrink)

In a recent article In Mind , called A Religious Way of Knowing , Mr. C. B. Martin considers the claim made by some theologians to know the existence of God on the basis of direct experience of God. His paper is, he says, “an attempt to indicate how statements concerning a certain alleged religious way of knowing betray a logic extraordinarily like that of statements concerning introspective and subjective ways of knowing. It is not my wish to go from (...) a correct suggestion that the logic is very, very like to the incorrect suggestion that the logic is just like.”. (shrink)

In this paper we argue that our conception of and intuitions about paradoxes are themselves paradoxical. Specifically, we argue that our commitment to the existence and nature of paradoxes is inconsistent with a norm of rationality—which is a paradox.

In this debate-format book, four philosophers--Joshua Glasgow, Sally Haslanger, Chike Jeffers, and Quayshawn Spencer--articulate contrasting views on race. Each author presents a distinct viewpoint on what race is, and then replies to the others, offering theories that are clear and accessible to undergraduates, lay readers, and non-specialists, as well as other philosophers of race.