The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.     

Are there unconscious perceptual processes?

Blindsight and vision for action seem to be exemplars of unconscious visual processes. However, researchers have recently argued that blindsight is not really a kind of unconscious vision but is rather severely degraded conscious vision. Morten Overgaard and colleagues have recently developed new methods for measuring the visibility of visual stimuli. Studies using these methods show that reported clarity of visual stimuli correlates with accuracy in both normal individuals and blindsight patients. Vision for action has also come under scrutiny. Recent findings seem to show that information processed by the dorsal stream for online action contributes to visual awareness. Some interpret these results as showing that some dorsal stream processes are conscious visual processes (e.g., Gallese, 2007; Jacob & Jeannerod, 2003). The aim of this paper is to provide new support for the more traditional view that blindsight and vision for action are genuinely unconscious perceptual processes. I argue that individuals with blindsight do not have access to the kind of purely qualitative color and size information which normal individuals do. So, even though people with blindsight have a kind of cognitive consciousness, visual information processing in blindsight patients is not associated with a distinctly visual phenomenology. I argue further that while dorsal stream processing seems to contribute to visual awareness, only information processed by the early dorsal stream (V1, V2, and V3) is broadcast to working memory. Information processed by later parts of the dorsal stream (the parietal lobe) never reaches working memory and hence does not correlate with phenomenal awareness. I conclude that both blindsight and vision for action are genuinely unconscious visual processes.     

Is solo practice really dead?

For years, the demise of solo practice has been predicted as a consequence of the corporatization of health care, the rise of managed care programs, and the creation of preferred provider organizations (PPOs). The predictors of the demise are leaders in the health maintenance organization (HMO) and PPO movement and therefore have much to gain if solo practice dries up. A survey of a random sample of licensed psychologists in New Jersey was conducted to determine the current state of private practice. A 58% return of the anonymous questionnaire revealed that 87% were in solo practice; 90% were not members of any PPO; 92% received either no referrals or less than 5% from HMOs; and 92% indicated that their referral rates and practices have either stayed the same or increased in the past three years. Clearly the predictions as far as New Jersey goes are wrong! The findings are discussed in terms of economics, humanistic concerns, and political concerns.     

Models and scientific representations or: who is afraid of inconsistency?

I argue that if we make explicit the role of the user of scientific representations not only in the application but also in the construction of a model or representation, then inconsistent modeling assumptions do not pose an insurmountable obstacle to our representational practices.     

The dead donor rule: lessons from linguistics?

American society traditionally has assumed a univocal notion of "death," largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, "death" can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"     

Reconsidering the dead donor rule: is it important that organ donors be dead?

The "dead donor rule" is increasingly under attack for several reasons. First, there has long been disagreement about whether there is a correct or coherent definition of "death." Second, it has long been clear that the concept and ascertainment of "brain death" is medically flawed. Third, the requirement stands in the way of improving organ supply by prohibiting organ removal from patients who have little to lose--e.g., infants with anencephaly--and from patients who ardently want to donate while still alive--e.g., patients in a permanent vegetative state. One argument against abandoning the dead donor rule has been that the rule is important to the general public. There is now data suggesting that this assumption also may be flawed. These findings add additional weight to proposals to abandon the dead donor rule so that organ supply can be expanded in a way that is consistent with traditional notions of ethics, law, public policy, and public opinion.     

The unconscious transference effect: Are innocent bystanders ever misidentified?

Unconscious transference refers to an eyewitness's misidentification of an innocent bystander for a criminal perpetrator because of the witness's exposure to the bystander in another context. In a series of five field studies involving 330 retail store clerks and 340 students, five retention intervals from 2 hours to 2 weeks, seven bystander-perpetrator intervals from 2 minutes to 2 weeks, three line-up types, two levels of line-up similarity, four different bystanders and four different targets, with one exception no evidence was obtained that could be interpreted to demonstrate the phenomenon of unconscious transference. That is, the resultsr repeatedly failed to reveal more misidentifications of an innocent bystander by witnesses who had been previously exposed to the bystander than by control evewitnesses who had not. To the contrary, the prior observation of the bystander often served to reduce the frequency of misidentification. In the final experiment the kind of misidentification error referred to as unconscious transference did occur, but only within a particular combination of bystander-perpetrator similarity and line-up construction: a combination that, in conjunction with the kind of event used, seems unlikely in real-world settings. Nevertheless, the inclusion of a familiar face in the line-ups often altered witnesses' choices in such a way that choosing someone was more likely when the lineup included a familiar face than when it did not. Finally, in contrast to the current explanations of unconscious transference, it is argued that it may not be a sense of familiarity with the bystander that is the basis of misidentifications; rather, it may also include incorrect inferences about the likelihood that the bystander might be the perpetrator.     

Cognitive processes in unconscious patients? A brain mapping study of the P300 potential

P300 is the most investigated component of the event-related potentials. Being the correlate of an active target discrimination and decision making process it is seen as related to cognition. Such elementary cognitive processes--as expressed in P300--can happen even in states of coma. In four of 35 comatose patients with diffuse head injury we were able to measure the P3-wave showing frontal and parietal components. Accordingly some unawakable patients can still recognize differences in pitch. The structure of components and their psychophysiological meaning are discussed.     

The origins of deference: when do people prefer lower status?

Although the desire for high status is considered universal, prior research suggests individuals often opt for lower status positions. Why would anyone favor a position of apparent disadvantage? In 5 studies, we found that the broad construct of status striving can be broken up into two conceptions: one based on rank, the other on respect. While individuals might universally desire high levels of respect, we find that they vary widely in the extent to which they strive for high-status rank, with many individuals opting for middle- or low-status rank. The status rank that individuals preferred depended on their self-perceived value to the group: when they believed they provided less value, they preferred lower status rank. Mediation and moderation analyses suggest that beliefs about others' expectations were the primary driver of these effects. Individuals who believed they provided little value to their group inferred that others expected them to occupy a lower status position. Individuals in turn conformed to these perceived expectations, accepting lower status rank in such settings.     

Effects of clock monitoring on electroencephalographic activity: is unconscious movement initiation an artifact of the clock?

Electroencephalographic (EEG) activity was recorded while participants waited to make spontaneous key-press movements (Experiment 1) or waited for tones in a pitch judgment task (Experiment 2). In one condition of each experiment, participants also had to report the position of a spot traveling on a clock at the crucial time point (i.e., when they decided to move or when the tone was presented), mimicking a procedure used to assess the time of conscious awareness of an event of interest. In a second condition, there was no clock or temporal judgment. Average EEG activity preceding key presses was substantially different when participants had to monitor the clock than when they did not. Smaller clock-related differences in average EEG activity were also present preceding tone onsets. The effects of clock monitoring on EEG activity could be responsible for previous reports that movement-related brain activity begins before participants have consciously decided to move (e.g., Libet, Gleason, Wright, & Pearl, 1983).     

The death of discipline: is the requiem premature?

There is a current trend among one sector of the professional mental-health community against the use of confrontive discipline with children and toward a positive-only approach to child behavior management. The current paper addresses this position by providing an overview of family process research as well as parent training outcome research related to parent disciplinary (punishment) practices. Consistent with research from developmental psychology showing that “authoritative” parenting is associated with the best developmental outcomes, this overview concludes that child management which combines positive approaches with age appropriate structures, limits, and non-hostile, nonviolent punishment is associated with the best treatment outcomes. The paper challenges positions calling for an end to the use of punishment with children.     

Perception of objects in natural scenes: is it really attention free?

Studies have suggested attention-free semantic processing of natural scenes in which concurrent tasks leave category detection unimpaired (e.g., F. Li, R. VanRullen, C. Koch, & P. Perona, 2002). Could this ability reflect detection of disjunctive feature sets rather than high-level binding? Participants detected an animal target in a rapid serial visual presentation (RSVP) sequence and then reported its identity and location. They frequently failed to identify or to localize targets that they had correctly detected, suggesting that detection was based only on partial processing. Detection of targets was considerably worse in sequences that also contained humans, presumably because of shared features. When 2 targets were presented in RSVP, a prolonged attentional blink appeared that was almost eliminated when both targets were detected without being identified. The results suggest rapid feature analysis mediating detection, followed by attention-demanding binding for identification and localization.     

Does power corrupt? The moderating effect of status

Findings on the effect of power on corruption are mixed. To make sense of these mixed results, three studies were conducted to examine the moderating role of status on this effect. In Study 1, corrupt intent was measured using a corruption scenario that contained manipulations of power and status. In Study 2, corrupt behaviour was measured in a corruption game that contained manipulations of power and status. Study 3 was conducted in real organisational settings, and aimed to expand the external validity of Studies 1 and 2. The results of all three studies consistently indicated that the effect of power was moderated by status. Specifically, power increased corruption when status was low, whereas this effect disappeared when status was high. The implications of reducing the facilitating effect of power on corruption by considering status from the perspective of social hierarchy are discussed.