A growing number of studies show that a significant proportion of patients, who meet the clinical criteria for the diagnosis of the vegetative state (VS), demonstrate evidence of covert awareness through successful performance of neuroimaging tasks. Despite these important advances, the day-to-day life experiences of any such patient remain unknown. This presents a major challenge for optimizing the patient’s standard of care and quality of life (QoL). We describe a patient who, following emergence from a state of complete behavioral unresponsiveness and a clinical diagnosis of VS, reported rich memories of his experience during this time. This case demonstrates the potential for a sophisticated mental life enabled by preserved memory in a proportion of patients who, similarly, are thought to be unconscious. Therefore, it presents an important opportunity to examine the implications for patient QoL and standard of care, both during the period of presumed unconsciousness and after recovery.

Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values.

Since the advent of neuroimaging technologies, their limits and possibilities have captivated scientists and philosophers. Thus far, the debate has largely concerned technical limits of our capacity to “read minds.” This paper extends the discussion concerning the limitations of neuroimaging to issues that are not dependent on technical issues or on our understanding of the complexity of brain activities. The author argues that there is a serious chance that brain scanning cannot replace usual intentional assertions, and that neuroimaging has principled limits. The information that people usually receive by neuroimaging is different in kind from the information they hear from what others tell them. To assert something is to act in a certain way, and scanners do not usually scan actions, but brain activities and the neural correlates of actions. Although it is possible to scan “mental assertions,” our usual assertions are not accompanied by separate “mental assertions.”

This interview study investigates the short- and long-term implications of incidental findings detected through brain imaging on research participants’ lives and their surroundings. For this study, nine participants of the Rotterdam Scan Study with an incidental finding were approached and interviewed. When examining research participants’ narratives on the impact of the disclosure of incidental findings, the authors identified five sets of tensions with regard to motivations for and expectations of research participation, preferences regarding disclosure, short- and long-term impacts and impacts on self and others. The paper shows: (1) that the impact of incidental findings may be greater than participants at first let on; (2) incidental findings can have significant effects on participants’ social environment; and (3) participants may not feel prepared for disclosure even if incidental findings have been discussed during the informed consent process. The authors call for investigators to be aware of research participants’ experiences and these short- and long-term impacts when designing suitable courses of action for the detection and management of incidental findings in research settings.

Dystonia is a movement disorder that can have a debilitating impact on motor functions and quality of life. There are 250,000 cases in the United States, most with childhood onset. Due to the limited effectiveness and side effects of available treatments, pediatric deep brain stimulation (pDBS) has emerged as an intervention for refractory dystonia. However, there is limited clinical and neuroethics research in this area of clinical practice. This paper examines whether it is ethically justified to offer pDBS to children with refractory dystonia. Given the favorable risk-benefit profile, it is concluded that offering pDBS is ethically justified for certain etiologies of dystonia, but it is less clear for others. In addition, various ethical and policy concerns are discussed, which need to be addressed to optimize the practice of offering pDBS for dystonia. Strategies are proposed to help address these concerns as pDBS continues to expand.

Recent improvements in virtual reality (VR) allow for the representation of authentic environments and multiple users in a shared complex virtual world in real time. These advances have fostered clinical applications including in psychiatry. However, although VR is already used in clinical settings to help people with mental disorders (e.g., exposure therapy), the related ethical issues require greater attention. Based on a thematic literature search the authors identified five themes that raise ethical concerns related to the clinical use of VR: (1) reality and its representation, (2) autonomy, (3) privacy, (4) self-diagnosis and self-treatment, and (5) expectation bias. Reality and its representation is a theme that lies at the heart of VR, but is also of specific significance in a clinical context when perceptions of reality are concerned, for example, during psychosis. Closely associated is the autonomy of VR users. Although autonomy is a much-considered topic in biomedical ethics, it has not been sufficiently discussed when it comes to applications of VR in psychiatry. In this review, the authors address the different themes and recommend the development of an ethical framework for the clinical use of VR.

This paper analyzes in the use of virtual reality when used to induce full-body ownership in violent offenders in order to elicit empathetic feelings by allowing them to embody the virtual body of a victim of domestic abuse. The authors explore potentially harmful effects to individuals participating in this kind of therapy and question whether consent is fully informed. The paper concludes with guidelines for ethical research and rehabilitation using this innovative technology.

Today there are multiple implantable medical devices on the market. The type of implants that interface the body’s tissues has been considered to have particular strong ethical implications. This article describes a development of a novel practice for ethical assessment and reflection within medical device research and development of non-CE marked medical devices, taking the perspective of both the ethicist and the researcher. The research case was an EU funded project where the aim was to develop and compare the efficiency of invasive and non-invasive technological medical devices to create meaningful sensations as a novel therapy for phantom limb pain. An Independent Ethical Advisor (IEA) with a regulatory and advisory role was assigned to the project, allowing us to investigate the projects deliberate incorporation of ethics. In the article we suggest and applied a novel framework based on action research for combining ethical assessment with building ethical reflection. The case analyse five different activities / elements: 1) the use of informed consent; 2) a survey amongst the research partners; 3) a workshop session; 4) observation of consortium meetings; and 5) an interview with a participating patient.

This paper aims to explore the role assistive technologies (ATs) might play in helping people with autism spectrum disorder (ASD) and a concomitant responsibility deficit become more morally responsible. Toward this goal, the authors discuss the philosophical concept of responsibility, with a reliance on Nicole Vincent’s taxonomy of responsibility concepts. They then outline the ways in which ASD complicates ascriptions of responsibility, particularly responsibility understood as a capacity. Further, they explore the ways in which ATs might improve a person’s capacity so that responsibility can be properly ascribed to them. After demonstrating that although assistive technologies are likely to be able to enhance a person’s capacity in such a way so that responsibility can be ascribed to them, the authors assert that these technologies will have a number of additional effects on the other aspects of the concept of responsibility.

Patients with amyotrophic lateral sclerosis (ALS) face many difficult, timing-sensitive decisions over the course of their illness, weighing present versus future harms and benefits. Supplemented by interviews with people with ALS, we argue for a relational approach to understanding these decisions and their effects on identity. We highlight two critical aspects of the patient–caregiver relationship: (1) the extent to which each may rely on the other leaves their wellbeing intimately intertwined and (2) patients often require others to help with the imaginative task of considering possible futures for each therapeutic option. We show why family involvement in decisionmaking practices can be so critical, and shed light on the ways intimate others help preserve and protect people’s identities amidst the destabilizing uncertainty illness and treatment can bring.

What purpose can be served by empirically unsubstantiated speculation in ethics? In answering that question, we need to distinguish between the major branches of ethics. In foundational moral philosophy, the use of speculative examples is warranted to the extent that ethical principles and theories are assumed to be applicable even under the extreme circumstances referred to in these examples. Such an assumption is in need of justification, and it cannot just be taken for granted. In applied ethics, the use of unrealistic scenarios is more difficult to justify. It can be positively harmful if it diverts our attention from more urgent issues. Neuroethics is one of the areas of applied ethics where speculative scenarios have taken up much of the attention that could instead have been devoted to problems that are relevant for the treatment and care of patients. Speculative ethics has often been defended with mere possibility arguments that may at first hand seem difficult to refute. It is shown with examples how such claims can be defeated with a combination of science and argumentation analysis.

In this essay, the author reflects on his development as a physician by recounting two patient narratives of patients he cared for as a third year medical student. In the process of telling these stories of sickness, the author also provides a window on medical practice in the 1980’s in an academic medicine center and how practices have changed. Decades before what has been dubbed “narrative medicine,” the author learned the power of words to shape relationships and promote professional formation.