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 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 due to restrictions related to the COVID-19 pandemic. The meeting focused on advances in: optogenetics as a tool for comprehending neurobiology of diseases and on optogenetically-inspired DBS, cutting edge of emerging DBS technologies, ethical issues affecting DBS research and access to care, neuromodulatory approaches for depression, advancing novel hardware, software and imaging methodologies, use of neurophysiological signals in adaptive neurostimulation, and 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)
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)
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)
Michael S. Brady offers a new account of the role of emotions in our lives. He argues that emotional experiences do not give us information in the same way that perceptual experiences do. Instead, they serve our epistemic needs by capturing our attention and facilitating a reappraisal of the evaluative information that emotions themselves provide.
September 11, 2001 brought to legal awareness an issue that has long puzzled metaphysicians. The general issue is that of event-identity, drawing the boundaries of events so that we can tell when there is one event and when there are two. The September 11th version of that issue is: how many occurrences of insured events were there on September 11, 2001 in New York? Was the collapse of the two World Trade Center Towers one event, despite the two separate airliners (...) crashing into each tower? Or were these two separate insured events? (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)
The traditional desire view of painfulness maintains that pain sensations are painful because the subject desires that they not be occurring. A significant criticism of this view is that it apparently succumbs to a version of the Euthyphro Dilemma: the desire view, it is argued, is committed to an implausible answer to the question of why pain sensations are painful. In this paper, I explain and defend a new desire view, and one which can avoid the Euthyphro Dilemma. This new (...) view maintains that painfulness is a property, not of pain sensations, but of a pain experience, understood as a relational state constituted by a pain sensation and a desire that the sensation not be occurring. (shrink)
Suffering, in one form or another, is present in all of our lives. But why do we suffer? On one reading, this is a question about the causes of physical and emotional suffering. But on another, it is a question about whether suffering has a point or purpose or value. In this ground-breaking book, Michael Brady argues that suffering is vital for the development of virtue, and hence for us to live happy or flourishing lives. After presenting a distinctive (...) account of suffering, and a novel account of its core element, unpleasantness, Brady proceeds to focus on three claims that are central to his picture. The first is that forms of suffering, like pain and remorse, can themselves constitute virtuous responses. The second is that suffering is essential for four important classes of virtue - virtues of strength, such as fortitude and courage; virtues of vulnerability, such as adaptability and humility; moral virtues, such as compassion; and the practical and epistemic excellences that make up wisdom. His final claim third is that suffering is vital for the social virtues of justice, love, and trust, and hence for the flourishing of social groups. (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)
The concept of causation is fundamental to ascribing moral and legal responsibility for events. Yet the precise relationship between causation and responsibility remains unclear. This book clarifies that relationship through an analysis of the best accounts of causation in metaphysics, and a critique of the confusion in legal doctrine.
This article details the degree to which the ideal of punishment proportional to desert forces changes in how we think of deontological morality. More specifically, the proportionality ideal forces us to abandon the simple, text-like view of deontological moral norms, and it forces us to acknowledge that those norms are not uniformly categorical in their force.
The concept of causation is fundamental to ascribing moral and legal responsibility for events. Yet the precise relationship between causation and responsibility remains unclear. This book clarifies that relationship through an analysis of the best accounts of causation in metaphysics, and a critique of the confusion in legal doctrine. The result is a powerful argument in favour of reforming the moral and legal understanding of how and why we attribute responsibility to agents.
The perceptual model of emotions maintains that emotions involve, or are at least analogous to, perceptions of value. On this account, emotions purport to tell us about the evaluative realm, in much the same way that sensory perceptions inform us about the sensible world. An important development of this position, prominent in recent work by Peter Goldie amongst others, concerns the essential role that virtuous habits of attention play in enabling us to gain perceptual and evaluative knowledge. I think that (...) there are good reasons to be sceptical about this picture of virtue. In this essay I set out these reasons, and explain the consequences this scepticism has for our understanding of the relation between virtue, emotion, and attention. In particular, I argue that our primary capacity for recognizing value is in fact a non-emotional capacity. (shrink)
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)
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.
A recalcitrant emotion is one which conflicts with evaluative judgement. (A standard example is where someone is afraid of flying despite believing that it poses little or no danger.) The phenomenon of emotional recalcitrance raises an important problem for theories of emotion, namely to explain the sense in which recalcitrant emotions involve rational conflict. In this paper I argue that existing ‘neojudgementalist’ accounts of emotions fail to provide plausible explanations of the irrationality of recalcitrant emotions, and develop and defend my (...) own neojudgementalist account. On my view, recalcitrant emotions are irrational insofar as they incline the subject to accept an evaluative construal that the subject has already rejected. (shrink)
Groups engage in epistemic activity all the time--whether it be the active collective inquiry of scientific research groups or crime detection units, or the evidential deliberations of tribunals and juries, or the informational efforts of the voting population in general--and yet in philosophy there is still relatively little epistemology of groups to help explore these epistemic practices and their various dimensions of social and philosophical significance. The aim of this book is to address this lack, by presenting original essays in (...) the field of collective epistemology, exploring these regions of epistemic practice and their significance for Epistemology, Political Philosophy, Ethics, and the Philosophy of Science. (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.
This chapter focuses on the question of whether true belief can have final value because it answers our ‘intellectual interest’ or ‘natural curiosity’. The idea is that sometimes we are interested in the truth on some issue not for any ulterior purpose, but simply because we are curious about that issue. It is argued that this approach fails to provide an adequate explanation of the final value of true belief, since there is an unbridgeable gap between our valuing the truth (...) on some issue for its own sake, and that truth's being valuable for its own sake. (shrink)
Starting from Marr's ideas about levels of explanation, a theory of the data structures and access processes in human memory is demonstrated on 10 tasks. Functional characteristics of human memory are captured implementation-independently. Our theory generates a multidimensional task classification subsuming existing classifications such as the distinction between tasks that are implicit versus explicit, data driven versus conceptually driven, and simple associative versus higher order, providing a broad basis for new experiments. The formal language clarifies the binding problem in episodic (...) memory, the role of input pathways in both episodic and semantic memory, the importance of the input set in episodic memory, and the ubiquitous calculation of an intersection in theories of episodic and lexical access. (shrink)
The perceptual model of emotions maintains that emotions involve, or are at least analogous to, perceptions of value. On this account, emotions purport to tell us about the evaluative realm, in much the same way that sensory perceptions inform us about the sensible world. An important development of this position, prominent in recent work by Peter Goldie amongst others, concerns the essential role that virtuous habits of attention play in enabling us to gain perceptual and evaluative knowledge. I think that (...) there are good reasons to be sceptical about this picture of virtue. In this essay I set out these reasons, and explain the consequences this scepticism has for our understanding of the relation between virtue, emotion, and attention. In particular, I argue that our primary capacity for recognizing value is in fact a non-emotional capacity. (shrink)
Although Hume’s theory of the passions has been vigorously criticized by contemporary philosophers, Hume’s immediate successors are seldom credited with serious criticisms of that theory. In fact, insofar as their views are considered at all, they typically are summarily dismissed. Alasdair MacIntyre’s treatment is a good illustration.
To understand the history of Advaita Vedānta and its rise to prominence, we need to devote more attention to what might be termed “Greater Advaita Vedānta,” or Advaita Vedānta as expressed outside the standard canon of Sanskrit philosophical works. Elsewhere I have examined the works of Niścaldās, whose Hindi-language Vicār-sāgar was once referred to by Swami Vivekananda as the most influential book of its day. In this paper, I look back to one of Niścaldās’s major influences: Sundardās, a well-known Hindi (...) poet and a direct disciple of Dādū Dayāl. Sundardās is typically classified as a bhakti poet rather than an Advaita Vedāntin; certainly he is not included in existing surveys or histories of Vedānta. In his youth, however, he studied Sanskrit and Vedānta in Banaras, and his poems present us with a mind that found no contradiction in claiming Dādū as his master and at the same time embracing the teachings of Advaita Vedānta. I argue that not only should Sundardās be included in histories of Advaita Vedānta, he should be credited for his originality: not only did he “Vedānticize” the Dādū Panth, he “Dādūized” Vedānta. I conclude by comparing Sundardās to two Sanskrit intellectuals from roughly the same period: Mahādeva Sarasvatī Vedāntin and Annambhaṭṭa, both of whom, like Sundardās, had commitments to Advaita Vedānta as well as to other intellectual traditions. (shrink)
ABSTRACTThis article defends the importance of epistemic safety for legal evidence. Drawing on discussions of sensitivity and safety in epistemology, the article explores how similar considerations apply to legal proof. In the legal context, sensitivity concerns whether a factual finding would be made if it were false, and safety concerns how easily a factual finding could be false. The article critiques recent claims about the importance of sensitivity for the law of evidence. In particular, this critique argues that sensitivity does (...) not have much of an effect on the value of legal evidence and that it fails to explain legal doctrine. By contrast, safety affects the quality of legal evidence, and safety better explains central features of the law of evidence, including probative value, admissibility rules, and standards of proof. (shrink)
There is a loud and persistent drum beat of support for schools, for citizenship, for diversity and inclusion, and increasingly for labor market readiness with very little critical attention to the assumptions underlying these agendas, let alone to their many internal contradictions. Accordingly, in this book I examine the philosophical, motivational, and practical challenges of education theory, policy, and practice in the twenty-first century. As I proceed, I do not neglect the historical, comparative international context so essential to better understanding (...) where we are, as well as what is attainable in terms of educational justice. I argue that we must constructively critique some of our most cherished beliefs about education if we are to save the hope of real justice from the rhetoric of imagined justice. (shrink)
