Deep brain stimulation is a well-established therapy for the motor symptoms of Parkinson’s disease, but there remains an opportunity to improve symptom relief. The temporal pattern of stimulation is a new parameter to consider in DBS therapy, and we compared the effectiveness of Temporally Optimized Patterned Stimulation to standard DBS at reducing the motor symptoms of PD. Twenty-six subjects with DBS for PD received three different patterns of stimulation while on medication and using stimulation parameters optimized for standard DBS. Side (...) effects and motor symptoms were assessed after 30 min of stimulation with each pattern. Subjects experienced similar types of side effects with TOPS and standard DBS, and TOPS were well-tolerated by a majority of the subjects. On average, the most effective TOPS was as effective as standard DBS at reducing the motor symptoms of PD. In some subjects a TOPS pattern was the most effective pattern. Finally, the TOPS pattern with low average frequency was found to be as effective or more effective in about half the subjects while substantially reducing estimated stimulation energy use. TOPS DBS may provide a new programing option to improve DBS therapy for PD by improving symptom reduction and/or increasing energy efficiency. Optimizing stimulation parameters specifically for TOPS DBS may demonstrate further clinical benefit of TOPS DBS in treating the motor symptoms of Parkinson’s disease. (shrink)

IntroductionDeep brain stimulation has become a standard treatment option for select patients with Parkinson’s disease. The selection process and surgical procedures employed have, to date, not been standardized.MethodsA comprehensive 58-question web-based survey was developed with a focus on DBS referral practices and peri-operative management. The survey was distributed to the Parkinson’s Foundation Centers of Excellence, members of the International Parkinson’s Disease and Movement Disorders Society, and the Parkinson Study Group between December 2015 and May 2016.ResultsThere were 207 individual respondents drawn (...) from 59 countries and 6 continents, of whom 64% received formal training in DBS. Thirteen percent of centers reported that DBS could proceed despite a confidence level of < 50% for PD diagnosis. A case-based approach to DBS candidacy was applied in 51.3% of centers without a cut-off for levodopa-responsiveness. Surprisingly, 33% of centers regularly used imaging for diagnostic confirmation of idiopathic PD. Thirty-one percent of centers reported that neuropsychological evaluation did not affect DBS target selection. Approximately half of the respondents reported determination of DBS candidacy based on a multidisciplinary committee evaluation and 1/3rd reported that a committee was used for target selection. Eight percent of respondents felt that psychosocial factors should not impact DBS candidacy nor site selection. Involvement of allied health professionals in the preoperative process was sparse. There was high variability in preoperative education about DBS outcome expectations. Approximately half of the respondents did not utilize a “default brain target,” though STN was used more commonly than GPi. Specific DBS procedure techniques applied, as well as follow-up timelines, were highly variable.ConclusionResults revealed high variability on the best approaches for DBS candidate selection, brain target selection, procedure type, and postoperative practices. Cognitive and mood assessments were underutilized. There was low reliance on multidisciplinary teams or psychosocial factors to impact the decision-making process. There were small but significant differences in practice across global regions, especially regarding multidisciplinary teams. The wide variability of responses across multiple facets of DBS care highlights the need for prospective studies to inform evidence-based guidelines. (shrink)

We estimate that 208,000 deep brain stimulation (DBS) devices have been implanted to address neurological and neuropsychiatric disorders worldwide. DBS Think Tank presenters pooled data and determined that DBS expanded in its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. The DBS Think Tank was founded in 2012 providing a space where clinicians, engineers, researchers from industry and academia discuss current and emerging DBS technologies and logistical and ethical issues facing the field. (...) The emphasis is on cutting edge research and collaboration aimed to advance the DBS field. The Eighth Annual DBS Think Tank was held virtually on September 1 and 2, 2020 (Zoom Video Communications) due to restrictions related to the COVID-19 pandemic. The meeting focused on advances in: (1) optogenetics as a tool for comprehending neurobiology of diseases and on optogenetically-inspired DBS, (2) cutting edge of emerging DBS technologies, (3) ethical issues affecting DBS research and access to care, (4) neuromodulatory approaches for depression, (5) advancing novel hardware, software and imaging methodologies, (6) use of neurophysiological signals in adaptive neurostimulation, and (7) use of more advanced technologies to improve DBS clinical outcomes. There were 178 attendees who participated in a DBS Think Tank survey, which revealed the expansion of DBS into several indications such as obesity, post-traumatic stress disorder, addiction and Alzheimer’s disease. This proceedings summarizes the advances discussed at the Eighth Annual DBS Think Tank. (shrink)

Background: Treating medication-refractory freezing of gait in Parkinson’s disease remains challenging despite several trials reporting improvements in motor symptoms using subthalamic nucleus or globus pallidus internus deep brain stimulation. Pedunculopontine nucleus region DBS has been used for medication-refractory FoG, with mixed findings. FoG, as a paroxysmal phenomenon, provides an ideal framework for the possibility of closed-loop DBS.Methods: In this clinical trial, five subjects with medication-refractory FoG underwent bilateral GPi DBS implantation to address levodopa-responsive PD symptoms with open-loop stimulation. Additionally, PPN (...) DBS leads were implanted for CL-DBS to treat FoG. The primary outcome of the study was a 40% improvement in medication-refractory FoG in 60% of subjects at 6 months when “on” PPN CL-DBS. Secondary outcomes included device feasibility to gauge the recruitment potential of this four-lead DBS approach for a potentially larger clinical trial. Safety was judged based on adverse events and explantation rate.Findings: The feasibility of this approach was demonstrated as we recruited five subjects with both “on” and “off” medication freezing. The safety for this population of patients receiving four DBS leads was suboptimal and associated with a high explantation rate of 40%. The primary clinical outcome in three of the five subjects was achieved at 6 months. However, the group analysis of the primary clinical outcome did not reveal any benefit.Interpretation: This study of a human PPN CL-DBS trial in medication-refractory FoG showed feasibility in recruitment, suboptimal safety, and a heterogeneous clinical effect in FoG outcomes. (shrink)

Background: Freezing of gait is a common symptom in Parkinson’s disease and can be difficult to treat with dopaminergic medications or with deep brain stimulation. Novel stimulation paradigms have been proposed to address suboptimal responses to conventional DBS programming methods. Burst-cycling deep brain stimulation delivers current in various frequencies of bursts, while maintaining an intra-burst frequency identical to conventional DBS.Objective: To evaluate the safety and tolerability of BCDBS in PD patients with FOG.Methods: Ten PD subjects with STN or GPi DBS (...) and complaints of FOG were recruited for this single center, single blinded within-subject crossover study. For each subject, we compared 4, 10, and 15 Hz BCDBS to conventional DBS during the PD medication-OFF state.Results: There were no serious adverse events with BCDBS. It was feasible and straightforward to program BCDBS in the clinic setting. The benefit was comparable to conventional DBS in measures of FOG, functional mobility and in PD motor symptoms. BCDBS had lower battery consumption when compared to conventional DBS.Conclusions: BCDBS was feasible, safe and well tolerated and it has potential to be a viable future DBS programming strategy. (shrink)

IntroductionDeep brain stimulation is increasingly used to treat the symptoms of various neurologic and psychiatric conditions. People can undergo the procedure during reproductive years but the safety of DBS in pregnancy remains relatively unknown given the paucity of published cases. We thus conducted a review of the literature to determine the state of current knowledge about DBS in pregnancy and to determine how eligibility criteria are approached in clinical trials with respect to pregnancy and the potential for pregnancy.MethodsA literature review (...) was conducted in EMBASE to identify articles involving DBS and pregnancy. Two reviewers independently analyzed the articles to confirm inclusion. Data extracted for analysis included conditions treated, complications at all stages of pregnancy, neonatal/pediatric outcomes, and DBS target. A second search was then conducted using www.clinicaltrials.gov. The same two reviewers then assessed whether each trial excluded pregnant individuals, lactating individuals, or persons of childbearing age planning to conceive. Also assessed was whether contraception had to be deemed adequate prior to enrollment.ResultsThe literature search returned 681 articles. Following independent analysis and agreement of two reviewers, 8 pregnancy related DBS articles were included for analysis. These articles described 27 subjects, 29 pregnancies, and 31 infants. There was 1 preterm birth at 35 weeks, and 3 patients who experienced discomfort from the DBS battery placement site. All 27 patients had a DBS device implanted before they became pregnant, which remained in use throughout their pregnancy. There was exclusion of pregnant individuals from 68% of 135 interventional trials involving DBS. Approximately 44% of these trials excluded persons of childbearing age not on “adequate contraception” or wishing to conceive in the coming years. Finally, 22% excluded breastfeeding persons.ConclusionThe data from 29 pregnancies receiving DBS treatment during pregnancy was not associated with unexpected pregnancy or post-partum complication patterns. Many clinical trials have excluded pregnant individuals. Documentation of outcomes in larger numbers of pregnancies will help clarify the safety profile and will help guide study designs that will safely include pregnant patients. (shrink)

Objective: Deep brain stimulation targeted to the ventral intermediate nucleus of the thalamus is effective for motor symptoms in essential tremor, but there is limited data on cognitive outcomes. We examined cognitive outcomes in a large cohort of ET DBS patients.Methods: In a retrospective analysis, we used repeated-measures ANOVA testing to examine whether the age of tremor onset, age at DBS surgery, hemisphere side implanted with lead, unilateral vs. bilateral implantations, and presence of surgical complications influenced the cognitive outcomes. Neuropsychological (...) outcomes of interest were verbal memory, executive functioning, working memory, language functioning, visuospatial functioning, and general cognitive function.Results: We identified 50 ET DBS patients; 29 males; the mean age of tremor onset was 35.84 years with a median age of 38 years. The mean age at DBS was 68.18 years. There were 37 unilateral 30 left, seven right, and 13 bilateral brain implantations. In the subgroup analysis, there was a significant interaction between assessment and age of tremor onset ; F = 4.47; p = 0.043 for working memory. The post hoc testing found improvements for younger onset ET. Similarly, there was a significant interaction between assessment and complications vs. no complications subgroups; F = 4.34; p = 0.043 for verbal memory with worsening scores seen for ET patients with complications. The remaining tests were not significant.Conclusion: In this large cohort of ET patients with, DBS was not accompanied by a significant decline in many cognitive domains. These outcomes were possibly related to the selection of patients with normal cognitive functioning before surgery, unilateral DBS implantations for the majority, and selection of patients with optimal response to DBS. (shrink)

DBS Think Tank IX was held on August 25–27, 2021 in Orlando FL with US based participants largely in person and overseas participants joining by video conferencing technology. The DBS Think Tank was founded in 2012 and provides an open platform where clinicians, engineers and researchers can freely discuss current and emerging deep brain stimulation technologies as well as the logistical and ethical issues facing the field. The consensus among the DBS Think Tank IX speakers was that DBS expanded in (...) its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. After collectively sharing our experiences, it was estimated that globally more than 230,000 DBS devices have been implanted for neurological and neuropsychiatric disorders. As such, this year’s meeting was focused on advances in the following areas: neuromodulation in Europe, Asia and Australia; cutting-edge technologies, neuroethics, interventional psychiatry, adaptive DBS, neuromodulation for pain, network neuromodulation for epilepsy and neuromodulation for traumatic brain injury. (shrink)

In various areas of Anglo-American law, legal liability turns on causation. In torts and contracts, we are each liable only for those harms we have caused by the actions that breach our legal duties. Such doctrines explicitly make causation an element of liability. In criminal law, sometimes the causal element for liability is equally explicit, as when a statute makes punishable any act that has “ caused … abuse to the child….” More often, the causal element in criminal liability is (...) more implicit, as when criminal statutes prohibit killings, maimings, rapings, burnings, etc. Such causally complex action verbs are correctly applied only to defendants who have caused death, caused disfigurement, caused penetration, caused fire damage, etc. (shrink)

Freud justified his extensive theorizing about dreams by the observation that they were “the royal road” to something much more general: namely, our unconscious mental life. The current preoccupation with the theory of excuse in criminal law scholarship can be given a similar justification, for the excuses are the royal road to theories of responsibility generally. The thought is that if we understand why we excuse in certain situations but not others, we will have also gained a much more general (...) insight into the nature of responsibility itself. Nowhere has this thought been more evident than in the century-old focus of criminal law theoreticians on the excuse of insanity, a focus that could not be justified by the importance of the excuse itself. In this paper I wish to isolate two theories of excuse, each of which instantiates its own distinctive theory of responsibility. One is what I shall call the choice theory of excuse, according to which one is excused for the doing of a wrongful action because and only because at the moment of such action's performance, one did not have sufficient capacity or opportunity to make the choice to do otherwise. Such a choice theory of excuse instantiates a more general theory of responsibility, according to which we are responsible for wrongs we freely choose to do, and not responsible for wrongs we lacked the freedom to avoid doing. The second I shall call the character theory of excuse, according to which one is excused for the doing of a wrongful action because and only because such action is not determined by those enduring attributes of ourselves we call our characters. (shrink)

This article explores the relationships between legal proof and fundamental epistemic concepts such as knowledge and justification. A survey of the legal literature reveals a confusing array of seemingly inconsistent proposals and presuppositions regarding these relationships. This article makes two contributions. First, it reconciles a number of apparent inconsistencies and tensions in accounts of the epistemology of legal proof. Second, it argues that there is a deeper connection between knowledge and legal proof than is typically argued for or presupposed in (...) the legal literature. This connection is illustrated through a discussion of the Gettier problem in epistemology. It is argued that the gap or disconnect between truth and justification that undermines knowledge in Gettier cases also potentially undermines the success of legal verdicts. (shrink)

John Martin Fischer's The Metaphysics of Free Will is devoted to two major projects. First, Fischer defends the thesis that determinism is incompatible with a person's control over alternatives to the actual future. Second, Fischer defends the striking thesis that such control is not necessary for moral responsibility. This review essay examines Fischer's arguments for each thesis. Fischer's defense of the incompatibilist thesis is the most innovative to date, and I argue that his formulation restructures the free will debate. To (...) defend his second thesis Fischer relies upon examples designed to show that an agent is responsible for an unavoidable action. I criticize Fischer's account of these examples, but I also maintain that my criticisms do not compromise his theory of responsibility. I raise several other difficulties for Fischer's theory of responsibility, and I close by offering some suggestions about how he might further defend it. (shrink)

This article aims to highlight why R. S. Peters' conceptual analysis of ‘education’ was such an important contribution to the normative field of philosophy of education. In the article, I do the following: 1) explicate Peters' conception of philosophy of education as a field of philosophy and explain his approach to the philosophical analysis of concepts; 2) emphasize several (normative) features of Peters' conception of education, while pointing to a couple of oversights; and 3) suggest how Peters' analysis might be (...) used to reinvigorate a conversation on one central educational aim—that of how we might educate citizens for the 21st century. (shrink)

This volume collects six of Michael Moore's influential studies on moral and legal objectivity. Presented in an accessible format, the essays are brought together by a thought-provoking introduction. Contents: Introduction ETHICS Moral reality Moral reality revisited Good without God LAW Law as justice The plain truth about legal truth Legal reality: a naturalist approach to legal ontology NAME INDEX.

Like other aspiring geologists in the 1830s, Darwin focused heavily on the rising and falling of the earth's crust. I use his time in the Andes to underscore the importance he placed on larger questions of vertical movement, which mountains helped to solidify in his mind. His most impressive ramblings occurred in 1835 on two high passes in the Andes. Prior to his upland journey, he was well prepared to see the gradual movement of the earth's crust, but his time (...) in the mountains honed his vertical vision. His actual travels up and over enabled him to think more clearly about rise and fall, and how corresponding geographies could link the past to the present. Mountains were instructive backdrops to his theorizing, partly because he traveled through them, but also because his time there, linked with other geographies, became a means to foster his thinking both spatially and temporally. He did not think about mountains, but with them and through them. He is a good example of the broader vertical consciousness that directed many sciences at this time. (shrink)

A reconsideration of mill's theory of "higher pleasures," construed as a way of evaluating changes in preferences or character that result from changes in social environment. mill's account is criticized and partly reconstructed in light of modern preference theory, but viewed favorably as an illuminating attempt to address a fundamental problem in moral evaluation of social institutions. mill's advocacy of the higher pleasures is defended in particular against the charge that it is incompatible with his commitment to liberty.

In this response to the review of Moore, Causation and Responsibility, by Larry Alexander and Kimberly Ferzan, previously published in this journal, two issues are discussed. The first is whether causation, counterfactual dependence, moral blame, and culpability, are all scalar properties or relations, that is, matters of more-or-less rather than either-or. The second issue discussed is whether deontological moral obligation is best described as a prohibition against using another as a means, or rather, as a prohibition on an agent strongly (...) causing a prohibited result that was not about to happen anyway while intending to do so. (shrink)

This article examines the variety of men's responses to feminism in late nineteenthand early twentieth-century United States through texts that addressed the claims raised by the turn-of-the-century women's movements. Antifeminist texts relied on traditional arguments, as well as Social Darwinist and natural law notions, to reassert the patriarchal family and to oppose women's suffrage and participation in the public sphere. Masculinist texts sought to combat the purported feminization of American manhood by proposing islands of masculinity, untainted by feminizing forces; proscribed (...) homosociality was also cast as an effective antidote to homosexuality. Profeminist texts openly embraced women's claims for changes in public participation and private and family life, both out of a sense of justice and the conviction that such changes would benefit men and challenge the emerging industrial capitalist order. Parallels to contemporary men's responses to the women's movement are suggested. (shrink)

This essay concerns Scott Shapiro's criticism that H.L.A. Hart's theory of law suffers from a Although other philosophers of law have summarily dismissed Shapiro's criticism, I argue that it identifies an important requirement for an adequate theory of law. Such a theory must explain why legal officials justify their actions by reference to abstract propositional entities, instead of pointing to the existence of social practices. A virtue of Shapiro's planning theory of law is that it can explain this phenomenon. Despite (...) these sympathies, however, I end with the suggestion that Shapiro's criticism of Hart, as it stands, is incomplete. Careful attention to Hart's notion of the internal point of view indicates that he was aware that legal justification ends with abstract objects, not practices, and that he offered his own explanation of this phenomenon. (shrink)

The article explores the agreements and disagreements between the author and the authors of Responsible Brains on how neuroscience relates to moral responsibility. The agreements are fundamental: neuroscience is not the harbinger of revolutionary revision of our views of when persons are morally responsible for the harms that they cause. The disagreements are in the details of what is needed for neuroscience to be the helper of the moral sciences.

The present study investigates whether people can infer the preferences of others from spontaneous facial expressions alone. We utilize a paradigm that unobtrusively records people's natural facial reactions to relatively mundane stimuli while they simultaneously report which ones they find more appealing. Videos were then presented to perceivers who attempted to infer the choices of the target individuals—thereby linking perceiver inferences to objective outcomes. Perceivers demonstrated above-chance ability to infer target preferences across four different stimulus categories: people (attractiveness), cartoons (humor), (...) paintings (decorative appeal), and animals (cuteness). While perceivers' subjective ratings of expressivity varied somewhat between targets, these ratings did not predict the relative “readability” of the targets. The findings suggest that noncommunicative, natural facial behavior by itself suffices for certain types interpersonal prediction, even in low-emotional contexts. (shrink)

In The Birth of the Clinic, The Order of Things, and Discipline and Punish, Foucault writes a "history of the present" by showing the connections between the archaeology of knowledge and criticism. In the first, he is fundamentally concerned with the changes in human perception evident at the end of the eighteenth century and the relation of these changes to the fundamental structures of experience. Underlying the history of medicine is the moral and political attempt to link the development of (...) science with the development of bourgeois freedom. In The Order of Things, he cites archaeology as a method of uncovering the fundamental paradigms of cultures and their systems of thought. Finally, in Discipline and Punish, he considers discourse a domain of power relations and thus establishes a link between knowledge and power. A "history of the present" is a self-conscious field of power relations and political struggle. (shrink)

In contrast to The Methods of Ethics, Sidgwick’s Practical Ethics counsels not trying to “get to the bottom of things” in our efforts to reach “some results of value for practical guidance and life.” For Sidgwick, both practical and theoretical ethics should start from the Morality of Common Sense. Although he retained his utilitarian outlook in Practical Ethics, this paper suggests that the Morality of Common Sense has the resources to hold its own against utilitarian revision.

_From the president of Wesleyan University, a compassionate and provocative manifesto on the crises confronting higher education_ In this bracing book, Michael S. Roth stakes out a pragmatist path through the thicket of issues facing colleges today to carry out the mission of higher education. With great empathy, candor, subtlety, and insight, Roth offers a sane approach to the noisy debates surrounding affirmative action, political correctness, and free speech, urging us to envision college as a space in which students (...) are empowered to engage with criticism and with a variety of ideas. Countering the increasing cynical dismissal—from both liberals and conservatives—of the traditional core values of higher education, this book champions the merits of different diversities, including intellectual diversity, with a timely call for universities to embrace boldness, rigor, and practical idealism. (shrink)

Yaffe's handling of two general questions is assessed in this review. The first question is why mere attempts (as opposed to successful wrongdoing) should be made punishable in a well-conceived criminal code. The second question is how attempt liability should be conceived in such a code. As to the first question, Yaffe's nonsubstantive mode of answering it (in terms of his ) is contrasted to answers based on some more substantive desert-bases; Yaffe's own more substantive kind of answer (in terms (...) of a desert-base of ) is examined in light of the implication that the traditional requirements of trying and intending are mere proxies for faulty reason recognition and response as the basis for blaming and punishing attempts. As to the second question, Yaffe's analysis of trying in terms of a is examined in some detail. Canvassed here are the subquestions of: (1) whether appropriate assessibility by certain norms of rationality can give the nature of intending and thus of trying; (2) whether the externally de dicto intent requirements of criminal law statutes can easily be interpreted and applied by standard, extensional methods; (3) whether the distinctions between various kinds of elements within the content of intentions, can be justified ontologically or only practically; (4) whether actors necessarily intend results of their actions that are to other results that clearly are intended, and if not, whether such actors are nonetheless just as blameworthy for those results as if they did intend them; and (5) whether intention with respect to circumstance-elements differ (in either their psychology or in their moral effect) from beliefs with respect to such circumstance-elements. (shrink)

This article details how patent law works to create discrete, immutable biological ‘objects’. This socio-legal maneuver is necessary to distinguish these artifacts from the unwieldy realm of the natural world. The creation of ‘objects’ also serves the interests of capital, where a stable, unchanging, immutable object goes hand in hand with commodification. Yet this stabilization is incomplete. Pointing to a variety of different examples, this article illustrates how biotech patents do not speak to specific, immutable things. Biotech patents, rather, are (...) better understood as ontologically fluid, which is to say their identity cannot be ‘fixed’ — or, at least, not without undermining the very existence of today’s biotechnology regime. The article concludes by speaking briefly about how this mutability is perpetuating certain inequalities, particularly between holders of various property forms. (shrink)

Excerpt from Guest Editor's Note, from Special Issue: Nietzsche and Religion. The papers in this themed edition of the Journal are a selection drawn from those given at the Eighth Annual Conference of the Friedrich Nietzsche Society held at the University of Greenwich in 11-13 September 1998.

In contrast to The Methods of Ethics, Sidgwick’s Practical Ethics counsels not trying to “get to the bottom of things” in our efforts to reach “some results of value for practical guidance and life.” For Sidgwick, both practical and theoretical ethics should start from the Morality of Common Sense. Although he retained his utilitarian outlook in Practical Ethics, this paper suggests that the Morality of Common Sense has the resources to hold its own against utilitarian revision.

Ayn Rand's first novel, We the Living, offers an early form of the author's nascent philosophy—the philosophy Rand later called Objectivism. Robert Mayhew's collection of entirely new essays brings together pre-eminent scholars of Rand's writing. In part a history of We the Living, from its earliest drafts to the Italian film later based upon it, Mayhew's collection goes on to explore the enduring significance of Rand's first novel as a work both of philosophy and of literature.

Critical readings of the novels and essays by the Pakistani writer Mohsin Hamid tend to emphasize the social and political aspects of his work. In his discussion of Hamid's best known novel, Peter Morey, for example, affirms that "in both its form … and its content, The Reluctant Fundamentalist addresses contemporary questions about national vs globalized structures of power."1 He then goes on to cite Matthew Hart and Jim Hansen, for whom the novel "is concerned with subjects like cross-cultural romance, (...) transnational capitalism, and the limits of cosmopolitan space."2 As they see it, the story of Changez, the novel's protagonist, "is about the resurgence of inter-national politics from within the carapace of... (shrink)

The third edition of a work that defines the field of cognitive neuroscience, with extensive new material including new chapters and new contributors.