Decoding Consciousness and Bioethics [1 ed.] 1527591107, 9781527591103

Table of contents :
Table of Contents
Preface
Consciousness and the Sense of Agency in Psychology and Neuroscience
Neurobioethics of Consciousness
Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy
Communication with People in Altered States of Consciousness
Clinical Ethics in Situations of Serious and Chronic Deterioration
of the State of Consciousness
Law and Consciousness
Reflexive Self-Consciousness
Definition of Cartesian and Lockean Perspectives on Consciousness
The Origins of Consciousness
Consciousness and the Acting Person
Consciousness in the Aesthetic Vision

Citation preview

Decoding Consciousness and Bioethics

Decoding Consciousness and Bioethics: Perspectives on Consciousness and Its Altered States Edited by

Alberto García Gómez and Alberto Carrara

Decoding Consciousness and Bioethics: Perspectives on Consciousness and Its Altered States Edited by Alberto García Gómez and Alberto Carrara This book first published 2023 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2023 by Alberto García Gómez, Alberto Carrara and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-5275-9110-7 ISBN (13): 978-1-5275-9110-3

This publication is the result of a collaborative and interdisciplinary effort of Professors from the Faculty of Bioethics at the Pontifical Athenaeum Regina Apostolorum in Rome and Research Scholars from the UNESCO Chair in Bioethics and Human Rights, who participated in the four-day seminar entitled “Bioethics and Consciousness: an interdisciplinary and interreligious reflection on an essential dimension of the human person” held online on July 2-3 and July 9-10, 2021. The UNESCO Chair in Bioethics and Human Rights (www.unescobio chair.org) was established in 2009 at two universities in Rome, the Ateneo Pontificio Regina Apostolorum and the Università Europea di Roma. The Chair, inspired by the UNESCO Universal Declaration of Human Rights and Bioethics, provides a university forum for reflection and study to promote the application of bioethical principles in the fields of science, medicine, and new technologies.

TABLE OF CONTENTS

Preface ........................................................................................................ x Consciousness and the Sense of Agency in Psychology and Neuroscience........................................................................................ 1 Michela Balconi 1. 2. 3. 4. 5.

TO BE AN AGENT: WHAT IS THE “SENSE OF AGENCY” VS CONSCIOUSNESS?..... 1 A PRELIMINARY DISTINCTION: ACTION AND AWARENESS OF ACTION .............. 2 THE KEY DETERMINANT MECHANISMS FOR THE SENSE OF AGENCY ................ 5 SELF-CONSCIOUSNESS AND THE ILLUSION OF AGENCY? ................................. 7 THE SENSE OF AGENCY FOR SELF AND FOR OTHERS: THE “PERCEPTUAL” BASIS OF EMPATHY ....................................................................................... 9

Neurobioethics of Consciousness: A Multidimensional Stratification of Human Conscious Experience.............................................................. 15 Alberto Carrara 1. 2. 3. 4.

INTRODUCTION........................................................................................... 15 MULTIDIMENSIONAL BOTTOM/UP STRUCTURE OF HUMAN CONSCIOUSNESS .... 18 MULTIDIMENSIONAL TOP/DOWN STRUCTURE OF HUMAN CONSCIOUSNESS.... 22 DRAFT OF A MODEL OF MULTIDIMENSIONAL INTEGRATION AS A SIGN OF THE DUAL-UNITY OF THE HUMAN PERSON ............................................... 23

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy: Clinical Hypnosis ........................................ 25 Maria Paola Brugnoli 1. INTRODUCTION........................................................................................... 25 2. NEUROSCIENTIFIC AND PSYCHOLOGICAL FOUNDATIONS OF CONSCIOUSNESS AND THE MODIFIED STATES OF CONSCIOUSNESS......................................... 27 3. THE MODIFIED STATES OF CONSCIOUSNESS AND CLINICAL HYPNOSIS IN THERAPY ............................................................................................... 32 4. CLINICAL HYPNOSIS IN MEDICAL AND PSYCHOLOGICAL THERAPY ............. 34 5. BIOETHICAL PRINCIPLES IN MEDICINE AND IN CLINICAL HYPNOSIS ............ 35 6. NEUROETHICS AND NEUROBIOETHICS IN PSYCHOLOGICAL THERAPY AND IN CLINICAL HYPNOSIS ....................................................................... 39 7. CONCLUSIONS ............................................................................................ 42

Table of Contents

viii

Communication with People in Altered States of Consciousness: Techniques of Rapport Management ........................................................ 53 Katalin Varga 1. 2. 3. 4. 5. 6. 7.

INTRODUCTION........................................................................................... 53 BUILDING, MAINTAINING AND TRANSFERRING RAPPORT .............................. 54 MAINTAINING RAPPORT.............................................................................. 60 TAKE-OVER OF RAPPORT ............................................................................ 63 TRANSFERRING RAPPORT: INTRODUCING THE NEXT SPECIALIST ................... 67 DESTROYING RAPPORT ............................................................................... 68 CLOSING REMARKS .................................................................................... 69

Clinical Ethics in Situations of Serious and Chronic Deterioration of the State of Consciousness ................................................................... 72 Francisco Ballesta 1. INTRODUCTION........................................................................................... 72 2. GENERAL CRITERIA OF CLINICAL ETHICS ..................................................... 73 3. APPLICATION TO PATIENTS WITH SERIOUS AND CHRONIC DETERIORATION OF CONSCIOUSNESS .................................................................................... 73 4. SOME POSITIVE EXEMPLARY CASES ............................................................. 74 5. SOME NEGATIVE EXEMPLARY CASES ........................................................... 74 6. CULTURAL FACTORS THAT HANDLE THE DUE CARE OF PATIENTS WITH SERIOUS AND CHRONIC DETERIORATION OF CONSCIOUSNESS............... 75

Law and Consciousness ............................................................................ 80 Alberto García Gómez & Ana Maria Ganev 1. LAW AND CONSCIOUSNESS PARTNERSHIP ................................................... 80 2. CONSCIOUSNESS AND HUMAN RIGHTS........................................................ 81 3. CONSCIOUSNESS AND THE COMPENDIUM OF THE SOCIAL DOCTRINE OF THE CHURCH ......................................................................................... 84 4. CONCLUSION.............................................................................................. 86

Reflexive Self-Consciousness .................................................................. 88 Giorgia Salatiello Definition of Cartesian and Lockean Perspectives on Consciousness: Distinguishing and Evaluating What Consciousness Is in Cartesian and Lockean Perspectives ......................................................................... 93 Adrián Canal 1. 2. 3. 4. 5.

INTRODUCTION........................................................................................... 93 DESCARTES AND HIS FOLLOWERS ............................................................... 95 LOCKE ..................................................................................................... 101 FUNCTIONS OF LOCKEAN CONSCIOUSNESS ................................................ 106 CONCLUSION............................................................................................ 109

Decoding Consciousness and Bioethics

ix

The Origins of Consciousness: Emergence or Divine Intervention? ...... 113 Alex Yeung 1. 2. 3. 4. 5.

INTRODUCTION......................................................................................... 114 THE NATURE OF CONSCIOUSNESS FROM A METAPHYSICAL PERSPECTIVE .... 115 NEUROSCIENTIFIC DATA FOR THE PHILOSOPHICAL PROBLEM ..................... 119 ORIGIN AND DEVELOPMENT OF CONSCIOUSNESS ....................................... 121 CONCLUSION............................................................................................ 123

Consciousness and the Acting Person .................................................... 125 Michael Baggot Consciousness in the Aesthetic Vision ................................................... 134 Melissa Maioni 1. INTRODUCTION......................................................................................... 134 2. IS THERE A NEURAL BASIS FOR AESTHETIC EXPERIENCE? ........................... 135 3. IS THERE A RELATIONSHIP BETWEEN STATES OF CONSCIOUSNESS AND THE PERCEPTION OF BEAUTY?............................................................ 147 4. WHAT IS SCIENTIFIC, MEASURABLE, UNIVERSAL AND OBJECTIVE ABOUT BEAUTY, WHICH IS CONSIDERED INTANGIBLE, SUBJECTIVE, DEPENDENT ON INDIVIDUAL TASTE OR CODIFIED BY THE CULTURE OF REFERENCE? ....... 151 5. WHAT IS THE RELATIONSHIP BETWEEN CONSCIOUSNESS, ART AND BIOETHICS? HOW CAN THE PHILOSOPHICAL/BIOETHICAL FIELD DIALOGUE WITH CONTEMPORARY NEUROLOGICAL AND PSYCHOBIOLOGICAL THEORIES? ..... 154 6. CAN AESTHETIC EXPERIENCE BE A DRIVING FORCE FOR MORAL EXPERIENCE, ORIENTED TOWARDS THE GOOD AND THE BEAUTIFUL, WITHOUT FALLING INTO REDUCTIONISM OR A TRANSHUMANIST VISION, IN ORDER TO HELP MAN REACH THE TRUTH? .......................................................................... 157

PREFACE ALBERTO GARCÍA GÓMEZ & ALBERTO CARRARA

Human consciousness is one of the most fascinating mysteries sheltered by the brain, evidencing that what happens between our ears is more important than what happens outside our skull. Besides, how do we know whether someone other than ourselves is conscious? Are the Origins of Consciousness an Emergence or Divine Intervention? Is there a relationship between states of consciousness and the perception of beauty? Why should the law be concerned about consciousness or altered states of consciousness? While these questions seem philosophical or purely theoretical, nevertheless they require a scientific evidence-based approach in order to be able to give answers, undertake certain actions, and understand their multiple implications. Defining altered states of consciousness and distinguishing the main neuropathological states from a clinical outlook are key tasks to help tackle other aspects of human consciousness. To contemplate answers to these questions and grasp the fundamental role of consciousness in our being human and self-awareness of our very own existence, our internal thoughts, as well as how we perceive others and the world, the 19th Summer Bioethics Online Course was dedicated to the fascinating theme, “Bioethics and Consciousness: an interdisciplinary and interreligious reflection on an essential dimension of the human person”. The summer course took place on July 2-3 and 9-10, 2021, and was organized by the Faculty of Bioethics in collaboration with the UNESCO Chair in Bioethics and Human Rights established at the Pontifical Athenaeum Regina Apostolorum and the European University of Rome. The course was coordinated by the Subgroup on Consciousness housed within the Neurobioethics Research Group, with the participation of researchers from other groups. The theme of consciousness is at the center of contemporary bioethical debates. At the early stages of human life, the absence of self-consciousness is considered by some ethicists a valuable criterion in order to confer moral status to a human organism, i.e. the status of personhood, whereas others

Decoding Consciousness and Bioethics

xi

argue that personhood is naturally acquired at the moment of conception. Conversely, it is argued that at the final stages of human life, an apparently irreversible and undetectable loss of any outward signs of consciousness is a sufficient condition for considering these patients apt to become organ donors. However, recently developed neural signal detection methods allow us to detect consciousness in patients with brain damage who are otherwise considered unconscious and unreachable. Of the utmost importance is the need to properly distinguish the precise condition of these patients and to make an accurate clinical diagnosis: persistent or permanent vegetative state, coma, minimally conscious state, and locked-in syndrome. Moreover, two tensions are widespread in neuroscientific, philosophical, and social contexts. On the one hand, there are attempts of reductionism, whether in the merely neurobiological sense or in a functionalist sense. On the other hand, many substitutional approaches have emerged, seeking to identify personal self-consciousness with digitizable information or data. Therefore, further research is needed, as well as exploration from different perspectives regarding what is to be human and the role of consciousness in defining human beings. The 19th Summer Bioethics Online Course was an interdisciplinary and interreligious study of human consciousness with the aim of understanding the plurality of meanings corresponding to the multi-layered complexity of personal dimensions of which it is composed. It culminated with the preparation and the publication of this book offering a comprehensive study of human consciousness from philosophical-anthropological, theologicalspiritual, and socio-legal perspectives. This is a collection of thought-provoking contributions of international experts concerning the role of bioethics in fostering dialogue between different, but related, fields of study concerning human consciousness and its altered states. Furthermore, scientists and various field experts, through some exceptional and rare outlooks, address consciousness by placing emphasis on an ethical reflection upon human consciousness and states of consciousness in an attempt to grasp its origin, the way it manifests, and its socio-legal relevance. Through a unique multidisciplinary approach, this book highlights the need to foster dialogue between bioethics and different states of consciousness for an ethical reflection through cognitive neuroscience.

CONSCIOUSNESS AND THE SENSE OF AGENCY IN PSYCHOLOGY AND NEUROSCIENCE MICHELA BALCONI

Abstract This Chapter’s principal aim is to find the causal explanation of action and the mechanism of conscious control of action implicated to represent the sense of agency, with due considerations for specific implications of the sense of agency for consciousness, selfconsciousness, and action. Secondly, we analyze intentions for actions and for agency in the present and explore the role that intentions have for agency representation in relationship with initiation, control and, execution of action. Thirdly, we focus on the concept of the “illusion of agency”, intended as a critical perspective on the concept of free choice and overt representation of self for action. Lastly, the sense of agency as a precursor of empathic and social behavior is considered, in the light of mirror mechanism and simulation approach.

1. To be an agent: What is the “sense of agency” vs consciousness? The sense of agency is an increasingly prominent field of research in psychology and cognitive neurosciences with specific considerations for theoretical and empirical implications of the sense of agency for consciousness, self-consciousness, and action. The preliminary step is to distinguish the awareness of our own action, and the sense of agency, since they represent different elements of self- awareness and self-monitoring in execution of action. Despite their distinctiveness, they contribute together to cause or generate an action or a certain thought in the stream of consciousness. The purpose of this discussion is to understand the causal explanation of action and the mechanism of conscious control of action implicated in normal and pathological states.

2

Consciousness and the Sense of Agency in Psychology and Neuroscience

The concept of agency includes a tentative list of features and functions such as awareness of a goal, of an intention to act, of initiation of action and of movements, sense of activity, of mental effort, of control, and the concept of authorship. It remains unclear how these various aspects of phenomenology of action and agency are related, to what extent they are dissociable, and whether some are more basic than others. The sources of these features and functions should be specified and how they relate to action specification and action control mechanism. As well, the experiences of intentionality, purposiveness, and mental causation should be considered. The primary question is how do I know that I am the person who is acting (i.e. moving, speaking, thinking)? Psychology and neuroscience of action show the existence of specific cognitive processes allowing the organism to refer the cause or origin of an action to its agent (Georgieff & Jeannerod, 1998). This sense of agency has been defined as the sense that I am the one who is causing or generating an action or a certain thought in my stream of consciousness (Gallagher, 2000). As such, one can distinguish selfgenerated actions from those generated by others, giving rise to the experience of a ‘self-other’ distinction in the domain of action and thus contributing to the subjective phenomenon of self-consciousness. From a neuroscientific perspective, the presence of different neural correlates for the sense of agency may reflect different indicators for agency, sub-processes or levels of agency processing. The primary brain areas involved in the sense of agency are the ventral premotor cortex, the supplementary motor area (SMA and pre-SMA) and the cerebellum, which are housed in the motor system. Moreover, the dorsolateral prefrontal cortex, the posterior parietal cortex, the posterior segment of the superior temporal sulcus, and the insula are implicated in the sense of agency. The primary brain areas constitute a network of sensory-motor transformation and motor control, whereas the second rather represents a set of association cortices implicated in various cognitive functions: for example, the prefrontal cortex could be relevant in various cognitive functions, such as behaviour in the temporal domain (Vogeley & Kupke, 2007). More generally, motor system regions may subserve executive functions, whereas heteromodal associative regions subserve supervisory functions.

2. A preliminary distinction: action and awareness of action We assume that the processes through which the component elements of the phenomenology of action are generated and the processes involved in the awareness and control of action are strongly interconnected.

Michela Balconi

3

Nevertheless, what is an action? For Marcel (2003), it is not only a bodily motion or a simple reaction to an external or internal stimulus. An action is thus not a mere bodily movement, but consists of two parts, the movement and the intention-in-action that causes that movement (Searle, 1983). Action has a certain goal, end-point or effect. The notion of intention can be distinguished as something of which an action is a realization from the notions of intentional directedness and of content. Quite apart from being a realization, action is defined by its directness, having definite endpoints and some degree of voluntariness. For this reason, it is necessary to distinguish an action from a habit and from whether it is caused in the mechanical sense. A movement or behaviour will be seen as an action to the extent that it is “agentive”, indicating that it is self-generated and at one’s will. Physical actions and mental actions are distinct; the former, in general, involves the production of causal effects in the external world through movements of the body of the agent, while mental actions, such as pretending or remembering a name, do not. Firstly, we initiate an analysis of the phenomenology of physical actions, in terms of a sense of oneself as a physical agent producing physical effects in the world via its bodily interactions with it. Jeannerod (2006) holds a componential view of action, and argues that bodily movements are merely the overt part of actions that also necessarily involve a covert, representational part. It can be underlined that an action can be distinguished from a merely bodily movement based on the fact that the individuals are in some particular relation to the movements of their body during the time in which they are performing them and that this relation is one of guidance. Secondly, the agent of an action is aware of the virtue of controlling the person’s action, rather than on the basis of observation or introspection (Balconi & Santucci, 2008). Rational control is the relevant notion of control, where this is described as a matter of practical reasoning leading to action. Thirdly, we can distinguish what and how an action is performed, or the goal pursued and awareness of the means employed to achieve this goal. Specifically, the phenomenology of action itself concerns what is being done. About what, actions have a goal and they involve an element of purposiveness. In other words, we are aware, to some degree, that we are engaged in purposeful activity. About how, beyond being aware of the goal of our action, we have awareness of the specific manner of achieving the desired result. We have previously stated that there is a constitutive link between the agent’s awareness of an action and a sense of agency. Nevertheless,

4

Consciousness and the Sense of Agency in Psychology and Neuroscience

empirical evidence suggests that, although awareness of action and sense of agency normally go together, they can sometimes come apart. Here we focalized whether awareness of an action performed by oneself is sufficient to give one the sense that it is one’s own action. As pointed out in several ways by Dennett (1991), we are not authoritative or incorrigible as to our conscious experience. There are many examples where people are unaware of their phenomenology or are unable to be aware of it. For example, attention constraints render it hard to be aware of all of one’s phenomenology at a time. Alternatively, one may be generally aware of something without knowing exactly what the experience consists, as it happens for emotional experience. In other words, I may be aware of performing a certain action without knowing the exact form the content of that awareness takes. Clinical data suggest, for example, that in schizophrenia the sense of alien control derives from the fact that patients are aware of the content of the action they execute but deny the agent of this action (see also chapter 8; Jeannerod, 2009). Similar dissociations between awareness of action and sense of agency can also occur in non-pathological conditions. Normal subjects can experience a sense of agency for actions someone else is doing in the illusion of control, and do not experience a sense of agency for something they themselves are doing in illusions of action projections (Wegner, 2002). Many experimental investigations of the sense of agency in comparison with awareness of action have manipulated the sensory, particularly visual, consequences of a subject’s actions. In a classical paradigm, a subject was asked to draw a line on a paper by seeing either their own or, unbeknownst to the subject, an “alien hand” (for example experimenter’s hand). The alien hand’s movements spatially deviated from the subject’s own movement. Generally, subjects adjust their own actual movement to the false visual feedback unaware of the adjustment (Daprati et al., 1997; Nielsen, 1963; Slachevsky et al., 2001). However, the sense of agency cannot be considered as being solely influenced by visual reafferences. Only a few experiments manipulated internal signals such as proprioceptive or motor signals. If subjects are instructed to explicitly evaluate self-other agency, internal signals, such as intentions, as much as external signals, such as visual re-afferences, may influence the subject’s judgments. Therefore, what are the main differences between the awareness of action and the sense of agency for self? We could not reduce the sense of agency to the sense of ownership of one’s body despite the wide importance of their interactions (Gallagher, 2000). An action is not only perceived but it is also initiated, controlled or

Michela Balconi

5

inhibited. Thus, we have to take into account the dimension of the agent who is the cause of the action. In this perspective, I may not be the agent of all my bodily movements, such as passive movements when, for example, someone else raises my arm for me. It is only in a second sense that passive movements are mine because all I own, in these cases, is the moving body. Therefore, to be able to self ascribe it (“I am moving”) should be added to the neutral state (performed action). Thus, the sense of agency is intimately linked to the sense of causality, and it results from the intentional binding between intentions, actions, and sensory feedback, which are attracted toward each other, reinforcing the perception of their causal relations. Therefore, in order to understand actions, we need to analyze their causal antecedents, that is what initiates the occurrence of the action (“why am I writing”) and what specifies the content of the action (“why I am doing it so”). Moreover, actions are not only preceded by an intention independent of the execution, they are also continuously represented in the intention-in-action till the end of the action. The sense of agency is not only the experience of an act of will distinct from bodily movements, but also the experience of the continuous control of action execution (Balconi, 2010; Crivelli & Balconi, 2010).

3. The key determinant mechanisms for the sense of agency A large body of evidence suggests that the sense of agency, especially the judgement of agency, strongly depends on the degree of congruence versus incongruence between predicted and actual sensory outcomes (Fourneret & Jeannerod, 1998; Vosgerau & Newen, 2007). Congruence of the predicted with the actual outcome would lead to the attribution of the sense of agency to oneself, whereas incongruence would indicate another agent as the cause of an action (Balconi, 2010; Crivelli & Balconi, 2010). Some cues must be considered as contributing to the sense of agency or its disruption: efferent or central motor signals; reafferent feedback signals from proprioception; vision, actions intentions or thoughts relevant to prioraction; primary knowledge, and cues from environmental context. The predominant explanation for the sense of agency of our own actions is the “central monitoring theory” or “comparator model” that postulates monitoring central and peripheral signals arising as a consequence of the execution of an action. This theory holds that the (central) efferent signals at the origin of an action are matched with those resulting from its execution (the re-afferent signals) and that this comparison provides cues about where

6

Consciousness and the Sense of Agency in Psychology and Neuroscience

and when the action originated (Blakemore, Wolpert and Frith, 1998; Blakemore et al., 2001; Frith, 1992). Synofzik et al. (2008) observed in a recent discussion on the general validity of the comparator model that the sense of agency can be determined by factors that are independent from any specific comparator output at the level of action control and action perception. Awareness and attribution of agency critically rely on higher-order causal inferences between thoughts and actions on the bases of belief states and intentional stances (Wegner, 2002). A clear example of this fact is that we often perform movements acknowledging that they were incongruent to our prediction. Yet we do not attribute their cause to an external origin, but still recognize ourselves as being their agents. In this case, agency is inferred on the basis of higherorder cognitive processing exploiting environmental and contextual cues, but is not evoked by an efference copy or any comparator output. As an alternative to the comparator model, a second model, simulation model, was proposed (David et al., 2008), which proposes a functional role for the motor system. While predicting the behaviour of others, we use our own experiences to simulate those of others (Goldman, 1989). Nonetheless, simulation theory, assuming shared representations for self and other, cannot explain why we normally do not confuse our own and others’ actions. The mirror neuron system does not provide an explicit representation of other agents, and an additional mechanism must be assumed, realizing the representation of myself or someone else as the agent. The determination of the sense of agency should be properly linked to other constructs, and underlining this is the main factor that directly contributes to this sense of agency — the intention of action. More generally, we may state that three principal mechanisms intervene in defining the sense of agency for an actor: the sense of intentionality or intentional causation, based on the efferent binding of an action and its effect; the sense of initiation that binds intention and movement onset; the sense of control of actions and thoughts. These three points will be examined thoroughly. Haggard and colleagues showed, through several experiments, evidence that supported the idea that voluntary, but not involuntary, movements and movement consequences are temporally bound together in conscious awareness (Haggard & Clark, 2003; Haggard et al., 2002). Experimental subjects judged the perceived onset of voluntary movements as occurring later and the sensory consequences as occurring earlier than it was actually the case. Once an intention-to-act was formed, actions and action consequences are more likely attributed to oneself even if they were

Michela Balconi

7

externally generated. It is intended as sense of intentional causation, and intentional binding phenomenon that is valid for themselves and observed action in the others. This was considered as the tendency of subjects to naturally perceive themselves as actually causally effective. Moreover, Wegner and colleagues (Wegner & Wheatley, 1999) investigated the influence of action-relevant thoughts that increased the feelings of self-efficacy over movements, where intentional binding is represented as a link between intention and action and it serves many functions. It may be important during motor learning, for example (Haggard, 2003): I can learn to correct an error if I can associate it with the corresponding intention. It may be useful in the construction of the agenticself, since subjects may have the ability to relate the content of their intentions to the actions and environmental consequences that they produce. In sum, this concept is directly linked to the tendency of subjects to naturally perceive themselves as causally effective and proficient (Wegner & Sparrow, 2004). It was observed that the intentional binding may be related to increased activation of the supplementary motor area (SMA) or pre-SMA, and insula. These brain areas have been associated with awareness and execution of self-generated actions, action preparation, and the subject’s own intentionto-act (Cunnington et al., 2006). Evidence for the relevance of the supplementary motor cortex to the experience of intentional actions also comes from neurological conditions: lesions in the SMA have been associated with the so-called anarchic hand syndrome, wherein patients experience unintended actions of their own hand, as if the hand had an “independent will”. Generally, the sense of intentional causation cannot be the unique and primary factor of the sense of agency. That is, it is a necessary, but not sufficient, component to generate the sense of agency insofar as it can be present when one observes actions performed by other agents. For example, we often cannot remember our prior intentions and yet do not disown the actions. It is not clear how this effect can effectively support the sense of “I” for action, since binding effect and sense of intentional causation also occur when we observe other people’s actions.

4. Self-consciousness and the illusion of agency? There are several senses and kinds of self-consciousness — some are primarily awareness of oneself as a mental entity whereas others are physical entities. Some are long-term and persist overtime whereas others are more occurrent and dwell in the present-tense. Some are detached

8

Consciousness and the Sense of Agency in Psychology and Neuroscience

awareness of oneself and others are more immediate or immersed. One form of self-consciousness is the sense of self as a physical agent; that is the sense of being an entity that exists in the physical world and has physical effects via its physicality. However, there is also a second sense of selfconsciousness, a mental self that is the non-physical realization, such as the experience of one’s intentions as one’s own. The concept of consciousness, whether physical or mental, is or is not necessary for the sense of agency? Some but not all of the processes of action production and agency depend on conscious experiences. In fact, generally a basic form of self-consciousness (awareness or the attribution of who caused the action) is not informed by conceptual thoughts or reflective processing (Gallagher, 2000). Thus, do we conclude that agency is an unconsciously determined illusion? In general it should be considered that it is important for people to feel that they are in control of their actions. Subjects are profoundly interested in maintaining the fiction that they have conscious will. This illusion seems to have positive effects concerning health (Kühn & Brass, 2009) and retrospective construction of the feeling of free choice occurs especially in cases when we are uncertain about the degree of deliberateness of an action. Some important distinctions should be made also about the consciousness of self in action and the consciousness of action per se. The latter is related to the terms of goals of the action. Self-awareness of the goal targeted is one way of being conscious of the action undertaken to reach that goal. The former is related to being conscious of oneself as causal self. In addition, a contrast may be observed between overt and covert aspects of the goal. Whereas the detailed target of the movement remains outside consciousness, the overt goal of the actions, concerning the selection of objects, their use and adequacy for the task under execution etc., can be consciously represented. Nevertheless, the covert aspects of the goal can be consciously accessed. To demonstrate this, subjects in an experiment were instructed to indicate the moment when they became aware of a change in the configuration of a target occurring during their movement. For example, when driving a car, we have to make a change in trajectory because of an unexpected obstacle in the path: we consciously see the obstacle after we have avoided it (Castiello et al., 1991; Jeannerod, 2006). In general, the awareness of a discordance between an action and its sensory consequences emerges when the magnitude of the discordance exceeds a certain threshold. The view of consciousness that arises when it is related to action is a lengthy process that can appear only if adequate time constraints are fulfilled. Secondly, the type of consciousness that is linked to the experience

Michela Balconi

9

of embodied self is discontinuous. It operates on a moment-to-moment basis, and it is bounded to particular bodily event. The embodied sense of agency carries an implicit mode of action consciousness, where consciousness becomes manifest only when required by the specific situation. The information derived from such an experience generally has short life and usually does not survive the bodily event for very long. On the contrary, the sense of consciousness experienced when executing an action gives us a sense of continuity, arising from the belief that our thoughts can have a causal influence on our behaviour. Nevertheless, we generally ignore the cause of our actions, while we perceive ourselves as causal. The dissociation between the two levels of the self, the embodied self and the “narrative” self, has been considered as the origin of an illusion: the narrative self tends to build a cause-effect explanation, whereas the embodied self, by avoiding conscious introspection, reaches simpler conclusions about an action, its goal and its agent by monitoring on-line the degree of congruence between central and peripheral signals generated by the action. In general, the role of consciousness, both short- and long-term type, should be to ensure the continuity of subjective experiences across actions.

5. The sense of agency for self and for others: the “perceptual” basis of empathy Some processes are in relation to the sense of agency, such as imitation and perspective-taking, and more basic, domain-general processes such as executive functions and attention. Imitation and perspective-taking also imply the distinction between oneself and others. Both, a first-person perspective and a sense of self agency, have been proposed as key constituents of self-consciousness (Gallagher, 2000; Metzinger, 2000). Moreover, viewpoint-specific spatial cues have been discussed as indicators for the sense of agency — knowing where the body is and what tools are available helps to determine what the person could have authored. Other actions are generally associated with allocentric, as opposed to egocentric, representations. Auditory stimulation was used in an experimental context to illustrate the dissociation between self-generated from other-generated action. Evidence from studies in human subjects suggested that auditory stimuli are processed differently depending on whether they are a consequence of selfgenerated action. Shafer and Marcus (1973), for example, showed that cortical potentials evoked by self-produced tones have significantly smaller amplitudes and faster component latencies than those produced by a

10

Consciousness and the Sense of Agency in Psychology and Neuroscience

separate machine. More recently, Blakemore, Rees and Frith (1998) found that both, predictability and self-generated action, affect event-related potential (ERP) modulation. The researchers demonstrated that different cortical areas are implicated in predictability versus self-generation of action, showing that the effect of hearing an auditory stimulus depends not only on its predictability, but also whether the stimulus is produced by selfgenerated movement. The two effects are not simply additive, since there is a modulatory effect of motor activity on stimulus predictability. In line with previous considerations, according to the transparency property of subjective experience states that is relatively transparent or obvious to the subjects, the states disclosed by bodily experience are or are not at the same type as the states they can observe through external perception (O’Brien, 2003). At a certain level of conscious experience, others’ sensations and actions are presented to subjects similar to their awareness of one’s own sensations and actions. The transparency effect explains how empathy, imitation, and coordination are possible, insofar as these competencies depend on the perceptual ability to compare one’s sensations and actions with others’. A second relevant aspect concerns the type of knowledge underlying both, our own and others’ behaviour; the fact that there is an asymmetry between the first-person and the third-person perspectives: by observing others’ behaviour, I may be aware of their sensations and actions from the outside, but I do not need observation in my own case since I know from the “inside” that, for example, I am in pain. Nevertheless, how the bodily experience of sensation and action may be transparent with respect to external perception is an important question to be answered. Recent models attempted to find a solution without supposing different modes of perception for internal versus external experience, or that they involve different ways of experiencing the world. Rather, the basis for the sense of ownership is a constitutive relation between bodily experience and its intentional object, which makes such experience implicitly reflective (Dokic, 2003). Moreover, shifting the object of analysis from that of self-perception to the other-perception, recent models proposed a substantial analogy between the two levels, stating that social cognition (or cognition of others from both perceptual or action point of view) may be considered a sort of extended field of the subjective experience. Specifically, Gallagher (2008) wants to defend the role played by direct perception in social cognition. A theory that employs direct perception is quite different from the standard psychology and cognitive science theories of social cognition — the theory theory (TT) and simulation theory (ST).

Michela Balconi

11

These two dominant theories both posit something more than a perceptual element as necessary for our ability to understand others that is “mindread” or “mentalize”. In contrast, certain phenomenological approaches, as direct perception model, depend heavily on the concept of perception and the idea that we have a direct perceptual grasp of the other person’s intentions, feelings, thoughts, etc. Both TT and ST start with perception understood as a third-person process, as an observation of the other person, but the addition of certain cognitive elements to each perception allows us to understand the other that we observe. Specifically, TT contends that the way in which we understand another person depends on a practice of mentalizing, wherein we theorize how mental states inform the behaviour of others. ST claims that such a theory is not needed because our own mind serves as a model that can simulate the other person’s mental states. In this model, we observe another person’s behaviour in specific environments, and by simulation we model their beliefs and desires as if we were in their situation. On the contrary, the concept of inter-subjective perception involves a relatively smart process. It is stated that young infants are visually attracted to movement, particularly biological movements. More generally, infants vocalize and gesture in tune with the vocalizations and gestures of another person (Gopnik & Meltzoff, 1997). Without the intervention of theory or simulation, and in a non-mentalizing way, they are able to see bodily movement as expressive of emotion, as goal-directed intentional movement, and to perceive other persons as agents. This should not require advanced cognitive abilities, inference or simulation skills: rather it is a fast, automatic, and highly stimulus-driven perceptual capacity (Scholl & Tremoulet, 2000). This general model also supposes that the mirror resonance mechanism (see Rizzolatti et al., 1996) may be thought of as a structural component of the personal process when it is a perception of another person’s actions. In other words, it is hypothesized that mirror activation is not the initiation of simulation, rather it subtends a direct intersubjective perception of what the other is doing (Gallagher, 2008).

12

Consciousness and the Sense of Agency in Psychology and Neuroscience

References Balconi, M. (2010). Neuropsychology of the Sense of Agency. New York, NY: Nova Science Publishers. 10.1007/978-88-470-1587-6 Balconi, M., & Santucci, E. (2008). Neuropsychological processes of motor imagery compared with motor scripts and action verbs. ERPs applied to motor representation. In Proceedings of the First Meeting of the Federation of the European Societies of Neuropsychology (ESN), United Kingdom Edinburgh (p. 139). Blakemore, S. J., Frith, C. D., & Wolpert, D. M. (2001). The cerebellum is involved in predicting the sensory consequences of action. Neuroreport, 12(9), 1879-1884. 10.1097/00001756-200107030-00023 Blakemore, S. J., Rees, G., & Frith, C. D. (1998). How do we predict the consequences of our actions? A functional imaging study. Neuropsychologia, 36(6), 521-529. 10.1016/S0028-3932(97)00145-0 Blakemore, S. J., Wolpert, D. M., & Frith, C. D. (1998). Central cancellation of self-produced tickle sensation. Nature Neuroscience, 1(7), 635-640. 10.1038/2870 Castiello, U., Paulignan, Y., & Jeannerod, M. (1991). Temporal dissociation of motor responses and subjective awareness: A study in normal subjects. Brain, 114(6), 2639-2655. 10.1093/brain/114.6.2639 Crivelli, D., & Balconi, M. (2010). Agency and inter-agency, action and joint action: theoretical and neuropsychological evidence. In Neuropsychology of the Sense of Agency (pp. 107-122). Springer, Milano. 10.1007/978-88-470-1587-6_6 Cunnington, R., Windischberger, C., Robinson, S., & Moser, E. (2006). The selection of intended actions and the observation of others’ actions: a time-resolved fMRI study. Neuroimage, 29(4), 1294-1302. 10.1016/j.neuroimage.2005.09.028 Daprati, E., Franck, N., Georgieff, N., Proust, J., Pacherie, E., Dalery, J., & Jeannerod, M. (1997). Looking for the agent: an investigation into consciousness of action and self-consciousness in schizophrenic patients. Cognition, 65(1), 71-86. 10.1016/S0010-0277(97)00039-5 David, N., Newen, A., & Vogeley, K. (2008). The “sense of agency” and its underlying cognitive and neural mechanisms. Consciousness and Cognition, 17(2), 523-534. 10.1016/j.concog.2008.03.004 Dennett, D. C. (1991). Consciousness Explained. Little Brown & Co. Dokic, J. (2003). The sense of ownership: An analogy between sensation and action. In J. Roessler & N. Elian (Eds.), Agency and self-awareness: Issues in philosophy and psychology (pp. 321-344). Oxford University Press.

Michela Balconi

13

Fourneret, P., & Jeannerod, M. (1998). Limited conscious monitoring of motor performance in normal subjects. Neuropsychologia, 36(11), 1133-1140. 10.1016/S0028-3932(98)00006-2 Frith, C.D. (1992). The cognitive neuropsychology of schizophrenia. Lawrence Erlbaum Associates. https://doi.org/10.4324/9781315785011 Gallagher, S. (2000). Philosophical conceptions of the self: implications for cognitive science. Trends in Cognitive Sciences, 4(1), 14-21. 10.1016/S1364-6613(99)01417-5 Gallagher, S. (2008). Direct perception in the intersubjective context. Consciousness and Cognition, 17(2), 535-543. 10.1016/j.concog.2008.03.003 Georgieff, N., & Jeannerod, M. (1998). Beyond consciousness of external reality: a “who” system for consciousness of action and selfconsciousness. Consciousness and Cognition, 7(3), 465-477. 10.1006/ccog.1998.0367 Goldman, A. I. (1989). Interpretation psychologized. Mind & Language, 4(3), 161-185. 10.1111/j.1468-0017.1989.tb00249.x Gopnik, A., & Meltzoff, A. N. (1997). Words, thoughts, and theories. MIT Press. Haggard, P. (2003). Conscious awareness of intention and of action. In J. Roessler & N. Elian (Eds.), Agency and self-awareness: Issues in philosophy and psychology (pp. 111-127). Oxford University Press. Haggard, P., & Clark, S. (2003). Intentional action: Conscious experience and neural prediction. Consciousness and Cognition, 12(4), 695-707. 10.1016/S1053-8100(03)00052-7 Haggard, P., Clark, S., & Kalogeras, J. (2002). Voluntary action and conscious awareness. Nature Neuroscience, 5(4), 382-385. 10.1038/nn827 Jeannerod, M. (2006). Motor cognition: What actions tell the self (No. 42). Oxford University Press. 10.1093/acprof:oso/9780198569657.001.0001 Jeannerod, M. (2009). The sense of agency and its disturbances in schizophrenia: a reappraisal. Experimental Brain Research, 192(3), 527532. 10.1007/s00221-008-1533-3 Kühn, S., & Brass, M. (2009). Retrospective construction of the judgement of free choice. Consciousness and Cognition, 18(1), 12-21. 10.1016/j.concog.2008.09.007 Marcel, A.J. (2003). The sense of agency: Awareness and ownership of action. In J. Roessler & N. Elian (Eds.), Agency and self-awareness: Issues in philosophy and psychology (pp. 48-93). Oxford University Press.

14

Consciousness and the Sense of Agency in Psychology and Neuroscience

Metzinger, T. (2000). The subjectivity of subjective experience: a representationalist analysis of the first-person perspective. In T. Metzinger (Ed.), Neural correlates of consciousness: Empirical and conceptual questions (pp. 285-306). MIT Press. Nielsen, T. I. (1963). Volition: A new experimental approach. Scandinavian Journal of Psychology, 4(1), 225-230. 10.1111/j.1467-9450.1963.tb01326.x O’Brien, L. (2003). On knowing one’s own actions. In J. Roessler & N. Elian (Eds.), Agency and self-awareness: Issues in philosophy and psychology (pp. 358-382). Oxford University Press. Rizzolatti, G., Fadiga, L., Gallese, V., & Fogassi, L. (1996). Premotor cortex and the recognition of motor actions. Cognitive Brain Research, 3(2), 131-141. 10.1016/0926-6410(95)00038-0 Schafer, E. W., & Marcus, M. M. (1973). Self-stimulation alters human sensory brain responses. Science, 181(4095), 175-177. 10.1126/science.181.4095.175 Scholl, B. J., & Tremoulet, P. D. (2000). Perceptual causality and animacy. Trends in Cognitive Sciences, 4(8), 299-309. 10.1016/S13646613(00)01506-0 Searle, J. R. (1983). Intentionality: An essay in the philosophy of mind. Cambridge University Press. Slachevsky, A., Pillon, B., Fourneret, P., Pradat-Diehl, P., Jeannerod, M., & Dubois, B. (2001). Preserved adjustment but impaired awareness in a sensory-motor conflict following prefrontal lesions. Journal of Cognitive Neuroscience, 13(3), 332-340. 10.1162/08989290151137386 Synofzik, M., Vosgerau, G., & Newen, A. (2008). Beyond the comparator model: a multifactorial two-step account of agency. Consciousness and Cognition, 17(1), 219-239. 10.1016/j.concog.2007.03.010 Vogeley, K., & Kupke, C. (2007). Disturbances of time consciousness from a phenomenological and a neuroscientific perspective. Schizophrenia Bulletin, 33(1), 157-165. 10.1093/schbul/sbl056 Vosgerau, G., & Newen, A. (2007). Thoughts, motor actions, and the self. Mind & Language, 22(1), 22-43. 10.1111/j.1468-0017.2006.00298.x Wegner, D. M. (2002). The Illusion of Conscious Will. MIT Press. Wegner, D. M., & Sparrow, B. (2004). Authorship processing. In M. S. Gazzaniga (Ed.), The Cognitive Neurosciences (3rd edition; pp. 12011209). MIT Press. Wegner, D. M., & Wheatley, T. (1999). Apparent mental causation: Sources of the experience of will. American Psychologist, 54(7), 480. 10.1037/0003-066X.54.7.480

NEUROBIOETHICS OF CONSCIOUSNESS: A MULTIDIMENSIONAL STRATIFICATION OF HUMAN CONSCIOUS EXPERIENCE ALBERTO CARRARA

Abstract Consciousness has been discussed – and still will be – more than any other dimension both in neuroscience and in philosophy. Together with free will, conscious experience represents one of the two anthropological concepts par excellence that shape and form the human person. Neurobioethics is the systematic and informed reflection dealing with both neuroscience and its interpretations. Therefore, it is a philosophical endeavor focusing on neuroscientific data. Neurobioethics of Consciousness embodies an interdisciplinary consideration of the Neural Correlates of Consciousness to deepen both the nature and the structure of our complex identity experience. In this chapter, a multidimensional stratification of human conscious experience is proposed based on a circular top/down and bottom/up approach that highlights the intrinsic and irreducible embodiment and embeddedness of our mind, body, and environment. The Neurobioethics of Consciousness’ approach adopted here combines the first-person experience of a unified living organism with the third-person perspective of the embodied and embedded human activities of conscious experience. The stratification depicted in this chapter can be helpful in order to better understand our fragile human sense of identity and ownership, which are the premises and the ‘matter’ of our free voluntary experience and the basis of personal responsibility.

1. Introduction Undoubtedly, clinical practice and human self-understanding have both benefited from contemporary neuroscientific developments. Progress, in order to truly serve people’s welfare, needs to be guided, directed, encouraged, corrected, and improved. This task presupposes a certain view

16

Neurobioethics of Consciousness

of the nature of the human person, that is, an underlying anthropology1. Not all the conceptions of human beings and their constitution will convert themselves into clinical, economic, political, social, and cultural conceptions that promote their integral development2. Currently, interdisciplinary research on the nature of the human person includes not only the traditional disciplines of philosophy, psychology, sociology, and medicine, but also empirical results of various neurosciences and neurotechnologies and their respective interpretations. This fruitful dialogue has coalesced into a single concept, that of neurobioethics 3 . Neurobioethics is the systematic and informed reflection dealing with both neuroscience and its interpretations. Therefore, it is a philosophical endeavor focusing on neuroscientific data. There are two anthropological concepts that function as “catalysts” in neuroscientific research and in the corresponding philosophical-cultural (and mass media) thought of our postmodern day: the concepts of consciousness and freedom (or free will). Not surprisingly, a clear understanding of the underlying meanings of these terms shapes and constitutes our vision of the human person. We are faced with two paradoxes. If, on the one hand, the reality of consciousness (understood as subjective experience, i.e., the first-person experience of oneself as a biopsycho-socially integrated being), seems to be a fact, or rather, the “central reality of human existence”4 (the peculiarity that allows us to “build” our own and unique personal identity), conversely, we often tend to reduce it to an epiphenomenon of neuronal states, activated in the correct mode. The same paradox is also found in the reality of free will: on the one hand, it is considered essential and necessary (the foundation of social and responsible

1

Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 600. In English, the concept of ‘personal integral development’ is condensed by several authors in the term ‘flourishing’. The American neurobioethicist James Giordano, for example, has linked this concept to the Aristotelian-Thomistic matrix of contemporary neuroethical thought to identify a set of principles for ‘proper human flourishing’. See JR, Giordano J (2014). A Principled and Cosmopolitan Neuroethics: considerations for international relevance. Philos Ethics Humanit Med. 9 (1): 1-13. 3 The term ‘neuroethics’ dates back to 1973, although its characterization and diffusion has begun to take shape and texture since 2002. Pontius A A (1973). Neuro-ethics of “walking” in the newborn. Percept Mot Skills 37 (1): 235-45. Marcus S J. ed. (2002). Neuroethics: Mapping The Field. Conference Proceedings. May 13-14, 2002 San Francisco, California. New York, The Dana Foundation. 4 Tononi G, Koch C (2015). Consciousness: here, there and everywhere? Phil Trans R Soc B 370: 1-18. 2

Alberto Carrara

17

actions), yet on the other hand, it is identified (or eliminated 5 ) with the functionality of certain areas or networks and hubs of the brain. The extremes of these two paradoxes arise from the same popular contemporary “trend”: localizationism, which states that each brain region codifies for a specific type of human activity. According to German psychiatrist and philosopher Thomas Fuchs, there is a real tendency to believe that we are our brains6. Consciousness and free will are related to each other. On the one hand, human beings can only accomplish a responsible action, that is, they can only act responsibly if their will is equipped with the characteristic or quality that we term “freedom”, or in other words, if they are free. In turn, a necessary condition for performing a voluntary and free action is that the same human agents perceive themselves as an integrated whole, i.e., individuals perceive their identity, and as the center and the driving force behind one’s action. A prerequisite of all this is that the human person, in order to act freely, be in a state of awareness, that is, they must be, on various levels7, conscious. Furthermore, the greater their awareness of oneself, of the world around them, and of their past, present, and future relationship with it, the greater the responsibility of their free choice. From the considerations above emerges a sketch of a certain reciprocal relation between consciousness and identity on the one hand, and free will and personal responsibility on the other. Considering the contemporary neuroscientific and philosophical perspectives concerning the so-called Neuronal Correlates of Consciousness (NCC) as our starting point, the aim of this Chapter is to multidimensionally structure these human conscious experiences in a sort of ever-morecomplex layering, using a circular bottom-up/top-down dynamic that highlights the intrinsic and irreducible embodiment and embeddedness of our mind, body, and environment. Neurobioethics of Consciousness embodies an interdisciplinary consideration of the NCCs to deepen both the nature and the structure of our complex identity experience. This perspective is not reductionist, but “ecological” and bio-psycho-social, 5

The term ‘eliminativism’, in the philosophy of mind, is the trend inaugurated by the Churchlands, Paul and Patricia Smith. According to them, mental states would not be more than neural or neuronal states. For a summary on the current philosophy of mind, I recommend the excellent volume: Jaworski W (2011). Philosophy of Mind. A Comprehensive Introduction. Oxford: Wiley-Blackwell. 6 Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 600607. 7 Bayne T, Hohwy J, Owen A M (2016). Are There Levels of Consciousness? Trends Cogn Sci 20 (6): 405-413.

18

Neurobioethics of Consciousness

wherein the mind and brain are both conceived as embodied and embedded in the living human body’s relationship with its internal and socio-cultural environment8.

2. Multidimensional bottom/up structure of human consciousness As the term ‘consciousness’ is polysemic, we need to consider various connotations of this term to better understand some sort of priority, inclusion, and coextension. Some scientists consider ‘personal consciousness’ as a functional and dynamic modality of humans who are formed at a given moment in life and evolves and matures practically every day. This first comprehensive meaning of the term ‘consciousness’ refers to a phenomenon that belongs to a higher integrative level of psychic activity. From a methodological point of view, i.e. based on the methods and empirical instruments that can be used in clinical and experimental neuroscience, the guiding criterion is that of accessibility, i.e. the ability to grasp, in some way, individual conscious manifestations. According to this criterion, three different meanings of ‘consciousness’ can be distinguished: (a) awareness, (b) shared explicit self-consciousness, and (c) a more exclusive and personal form of consciousness, referred to by some as the ‘phenomenal consciousness’.9 From a phenomenological point of view, there exists a qualitative dimension of ‘consciousness’ termed “aboutness” (intentionality): as conscious beings, we are constantly in relation with the world around us, and with our inner world that reaches out to something.10 In this sense, a state of consciousness is always aware of something; something that foresees, at least potentially, the execution of an action. It is not unusual to conceive the state of consciousness as nothing more than a particular form of perception, or conception, imbued with the planning of an action, which can also remain virtual. It is a thinking toward action, caught in its first germ. 8

Fuchs T (2011). The Brain – A Mediating Organ. J Conscious Stud 18 (7-8): 196221. 9 Boncinelli E (2012). Quel che resta dell’anima. Milano: Rizzoli, 35. 10 Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 605. Fuchs expresses himself it the following way: «From a phenomenological point of view, the principal quality of consciousness is intentionality or ‘aboutness’: As conscious beings, we are always related to the world, directed towards, or caring about something».

Alberto Carrara

19

In a first attempt to prioritize those meanings, ‘awareness’ should be at the bottom, i.e. the ability to realize with great evidence and immediacy where we are, what we are doing, and how we can do it. Then there is a conscious state that can be made explicit and is shared by most adult human beings that comes to be called ‘self-consciousness’ or ‘second-degree consciousness.’ 11 Between the two dimensions, there is a relationship of implication, in the sense that there cannot be self-awareness without awareness, but obviously, the opposite is not true. Therefore, in a hypothetical pyramidal representation, awareness belongs to a lower dimension than self-consciousness. A third dimension of conscience, called ‘phenomenal’, is presented and described in this way: “private, intrinsically incommunicable, and accessible only to he who is directly concerned. By observing certain objects or experiencing certain events, I can feel, and indeed do feel, personal sensations that are very difficult to communicate to others. A clock, a pen, or even more so a picture, can have for me, and only for me, a special and completely subjective meaning. It is a particular cognitive-affective coloring of my states of consciousness, which makes me say ‘I’ and ‘me’”,12 and this is the awareness of our first person. 13 Here emerges the link between consciousness and the emotional-affective dimension, which exceeds the scope of this study.14 There are other dimensions of consciousness to consider, id est, the perception of the external world or ‘exteroception’ (any form of sensation that results from stimuli located outside the body and is detected by exteroceptors, including vision, hearing, touch or pressure, heat, cold, pain, smell, and taste) and the subject’s own internal representation of the self (that which the classics called the “common sense”). These two aspects together give rise to what Gerald Edelman considers the ‘primary consciousness’, the ability to represent a scene of reality, a sort of an interior map of external events, on which to support a reasoning or an action. All of this is a prerequisite to awareness. Therefore, in our pyramidal representation, ‘exteroception’ and the capacity to integrate content belong to an inferior dimension with respect to awareness. According to some authors, “the association between perceptive categorization and memory, ever more vast and organized with the progress of the evolutionary process of animals”, would constitute “a ‘remembered present’, that is, a mental scene that connects, in a constructive and useful 11 Boncinelli

E (2012). Quel che resta dell’anima. Milano: Rizzoli, 36. E (2012). Quel che resta dell’anima. Milano: Rizzoli, 37. 13 Levy N (2014). The Value of Consciousness. J Conscious Stud 21(1-2): 127-138. 14 Boncinelli E (2012). Quel che resta dell’anima. Milano: Rizzoli, 54-56. 12 Boncinelli

20

Neurobioethics of Consciousness

manner, external, contingent events with needs and values of the subject himself”15. In this context, I do not wish to enter the consciousness-memory connection nor the consciousness-affectivity connection (emotions and feelings), but I simply point out that these human realities must also be understood in a multidimensional stratified sense, in a dynamic, reciprocal, and circular “dialogue”. Another dimension of consciousness is ‘interoception’, or a sense of the internal state of the body, such as the primary stimuli of hunger and thirst, a sort of continuous contact with this corporal interiority of ours. A last dimension of consciousness must be added: ‘proprioception’, also referred to as kinaesthesia or kinesthesia, which functions as a sort of prerequisite to human action. Proprioception can be described as the perception everyone has of their own body, of the state of tension of the muscles, also allowing us to understand if we are in an upright position or seating, comfortable or uncomfortable, with our legs stretched out or bent, lying or riding a bicycle, about to do an action or another. Proprioception is a kind of faculty that mostly concerns action and its programming, and it could thus mediate the inextricable hub of perception, possibly conscious, and action. At this level, we find all the neurological conditions in which specific alterations of the neuronal tissue at different levels disrupt processing of the perceptual data and provide an altered image of our corporeal or physical self, which occurs, for example, in apotemnophilia (a neurological disorder characterized by the intense and long-standing desire for amputation of a specific limb) and somatoparaphrenia (a type of monothematic delusion where one denies ownership of a limb or an entire side of one’s body)16. To summarize, human consciousness can be multidimensionally layered bottom-up as follows: interoception – exteroception – integration (common sense) – awareness – understanding of the environment – proprioception – self-awareness – phenomenal consciousness (able to be made explicit through language) and is graphically represented in Image 1. The integration of all these dimensions (not excluding others) gives rise to consciousness; rather, it is consciousness itself. According to Italian neuroscientist and Nobel Prize winner, Rita Levi Montalcini, consciousness is “among the most surprising and fascinating properties of the human brain”, which consists of being aware (the brain) of our own awareness; and by consciousness “she means the state of awareness 15 Boncinelli

E (2012). Quel che resta dell’anima. Milano: Rizzoli, 40. V S (2011). The Tell-Tale Brain: A Neuroscientist’s Quest for What Makes Us Human. New York: W. W. Norton & Company. Chapter 9: An Ape with a Soul: How Introspection Evolved: 245.

16 Ramachandran

Alberto Carrara

21

of our existence as individual entities, which implies the recognition of our actions and of temporal and sequential succession”17. Consciousness, understood in this multidimensional integrative sense, is the privileged locus of the unity of human persons, of their personal identity (i.e. result of diachronic continuity of the conscious experience itself18), the ‘designing center’ 19 of the agent subject. Here the close bond between personal consciousness - identity and free will starts to be woven by acting responsibly20. At this point it would be useful to integrate these notions with the clinical ones concerning the so-called ‘altered states of consciousness’, but this would excessively extend our study.

Image 1 17

Levi Montalcini R (2004). Abbi il coraggio di conoscere. Milano: Bur Rizzoli, 25. Boncinelli E (2012). Quel che resta dell’anima. Milano: Rizzoli, 53. 19 Boncinelli E (2012). Quel che resta dell’anima. Milano: Rizzoli, 43. 20 Annila A (2016). On the Character of Consciousness. Front Syst Neurosci 10: 27, 6. Annila in his study, focused on thermodynamics and consciousness understood as an attribute of an integrated and open system like the human person, which in part expresses what has been shown in these terms: «According to this perspective, consciousness integrates sensory and other inputs with recollections and representations from the past for coherent responses to consume energy gradients more effectively than by unconscious deeds. In concord with common sense a conscious person acts in a more meaningful way than an unconscious one». 18

22

Neurobioethics of Consciousness

3. Multidimensional top/down structure of human consciousness Let us distinguish some traditional paradigms regarding consciousness. As per a psychological approach, consciousness is the self-awareness or the awareness that human beings have of themselves. According to the moral approach, consciousness is the awareness that humans have of the goodness/evilness of their own actions. Finally, according to the personalcreative approach, consciousness is a complex reality identified with the intimate part of the person, a sort of internal “place” of the subject from where intuitions arise and moral judgements are formed 21 . The above mentioned approaches to examine consciousness imply, more or less explicitly, the cognitive aspect, particularly judgment. The Catholic theologian Thomas Aquinas, who synthesized a millenary tradition, confronts this problem in various works, clarifying, in the first place, that consciousness is not a habit, nor a faculty, nor a potency, but an act. In fact, consciousness includes an ordering of knowledge to something known. It is the application of the Aristotelian synderesis to the concreteness of an action22. This could be defined as the “the intelligence ordered towards practical things”23. At this point, it may be said that we have arrived at the ‘embodied selfconsciousness’24, the apex of the multidimensional pyramid which, in order to emerge, requires all of the underlying dimensions described and requires the integration of each of these dimensions and enrichment of the relationship to the dimensions of memory, of affectivity, of language, etc. The temporal dynamism of the conscious experience 25 in which present processes, proceeding from the past, reach out into the future26, should be incorporated as well. Thus, the distinctions between the consequent, concurrent, and prior consciousness (understood as a cognition or judgment 21 Fucek I (1994). La coscienza morale, in: Veritatis Splendor, testo integrale e commentario filosofico-teologico. Milano: San Paolo, 299-305. 22 D’Aquino Tommaso. Summa Theologiae I, q. 79, a. 13, c. 23 Bonaventura. Sentenze, libro 2, dist. 39, a. 2, q. 1. 24 Some authors have called it bodily self-consciousness or also bodily ownership and consciousness embodying: Blanke O (2012). Multisensory brain mechanisms of bodily self-consciousness. Nat Rev Neurosci 13 (8): 556-571. Serino A et al (2013). Bodily ownership and self-location: components of bodily self-consciousness. Conscious Cogn 22 (4): 1239-1252. Annila A (2016). On the Character of Consciousness. Front Syst Neurosci 10: 27, 9. 25 Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 605. 26 Annila A (2016). On the Character of Consciousness. Front Syst Neurosci 10: 27.

Alberto Carrara

23

about action) of a given action brought to fulfillment (that is, enacted) is justified, for the action is either accomplished, is being accomplished, or, having been planned, must still be accomplished, respectively. Such ‘self-awareness’ is able to act, altering neuronal activity (top/down). It suffices to cite cases of the active and conscious use of tools (top) capable of both reshaping the individual bodily framework, as well as expanding the peri-personal space and modulating the representation of relative parts of the body, the whole correlated to functional and anatomical alterations of the cerebral structures that mediate such modifications (down)27. Evidence from recent studies indicate that conscious beliefs about one’s own corporeity (top) are able to alter intrinsic psychological mechanisms of defense of one’s own body that translate into neurophysiological alterations (down)28.

4. Draft of a model of multidimensional integration as a sign of the dual-unity of the human person Mind and brain are human dimensions embodied in the living human body’s relation (the whole, the unity, the compound, id est, the human person) to their inner and socio-cultural environments 29 . This relational perspective is not contained anywhere, not even in functional magnetic resonance imaging; consciousness is therefore not an entity found in isolation, somewhere in the brain, but it is a complex and multidimension of the whole, of the human person30.

27 Garbarini F et al (2015). When your arm becomes mine: pathological embodiment of alien limbs using tools modulates own body representation. Neuropsychologia 70: 402-413. 28 Fossataro C et al (2016). Bodily ownership modulation in defensive responses: physiological evidence in brain-damaged patients with pathological embodiment of other’s body parts. Sci Rep 6: 27737. 29 Fuchs T (2011). The Brain – A Mediating Organ. J Conscious Stud 18 (7-8): 196221. 30 Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 604.605. «From a phenomenological point of view, then, free will is not something attributable to a single mental state but rather to the person as a whole». The author, while speaking of Self (I or Self), highlights both his anchorage to the body materiality, with his topological non localization in some part of the body, and his intrinsic relationality to the other parts that makes the whole of the person: «Thus, the self is not an entity that can be found somewhere in isolation; it is rather the continuous transcending movement towards the world and the others. Mental states depend upon the patient’s relations to numerous other entities and to the world as a

24

Neurobioethics of Consciousness

A dynamic circularity or causal circularity bottom-up/top-down (and vice versa), which has been brought to light through an interdisciplinary approach between neuroscience, psychology, psychiatry, and philosophy, highlights a particular ‘ecological’ vision of the human person, which best accounts for its dual-unity between neurobiology and biography31. Such an anthropological bio(neuro)-psycho-social model acts as a real window of conceptual reference able to integrate, without reducing one to the other, the microscopic dimension of the neurophysiological processes with the macroscopic and temporal dimension of living human beings (i.e., agent) who, through their conscious experiences, shape and make their own identities32.

meaningful whole. These relations are certainly not contained in neuroimaging data. Neither the mind nor the self is to be found inside the skull». 31 Fuchs T (2007). Psychotherapy of the Lived Space: A Phenomenological and Ecological Concept. Am J Psychother 61 (4): 423-439. Annila A (2016). On the Character of Consciousness. Front Syst Neurosci 10: 27, 8. Annila speaks of “biological realism” as the interface between the neural and the mental dimensions of the human person: «Our viewpoint of subjectivity as a natural characteristic complies with monistic consent that consciousness is a real subjective experience embodied by physical processes in the brain. This view is compatible with so-called biological realism at the interface between neural and mental phenomena». Su questo particolare concetto, certamente da approfondire, si può leggere: Fingelkurts A A et al (2010). Emergentist monism, biological realism, operations and brainmind problem. Phys Life Rev 7 (2): 264-268 32 Fuchs T (2006). Ethical issues in neuroscience. Curr Opin Psychiatry 19 (6): 605. The author highlights the temporal and dynamic dimension of Self (I or Self): «Moreover, the temporal dimension of the Self is not captured by the concept of self-representations correlated to certain states of the brain. The Self is a dynamic process of retrospection into the past and projection into the future. This dimension is tightly connected to narrativity: In constructing our identity, our personal life narrative, we continuously arrange and order our experiences in communication and reciprocity with others who may accept, reject or confirm our stories. We register these responses and respond to them in turn. This hermeneutic process of continuous redefinition of the Self in correspondence with others is far beyond the reach of the objectifying and reifying approaches of neuroscience».

NEUROBIOETHICS OF THE MODIFIED STATES OF CONSCIOUSNESS IN MEDICAL AND PSYCHOLOGICAL THERAPY: CLINICAL HYPNOSIS MARIA PAOLA BRUGNOLI

Abstract Today, neuroscientific advances in the study of bioethics have produced new developments in clinical and psychological therapies. Neurobioethics is the study of bioethics through neuroscience. Philosophical, psychological, medical, social and spiritual questions have showed such inquiries are essential to understand the complex intersection of neuroscientific progress and ethical fields of research in medical and psychological therapies. Some of these debates include whether particular interventions represent treatment or, moral ambiguities and ethical dilemmas arising within the contexts of neuroscientific policy and clinical practice. This Chapter is a scientific review of neurobioethics that examines the scope and meaning of current and future research directions in medical and psychological hypnotherapy.

1. Introduction Ethics in medicine has been faced with a dilemma that reflects on communication: is the good of the sick person (“salus aegroti supema lex”) or rather his will (“voluntas aegroti suprema lex”) more important? Equally important for the purposes of communication are various types of physicians described by the philosophers, Plato and Aristotle. In the current context, their topicality has not diminished: the physician of Plato’s slaves who “like a tyrant” imposes therapy without giving any explanation, and the physicians of free men who make the sick person participate in their investigations, establish close relations with the patient’s family, learns from the sick and “does not prescribe anything before he has not convinced

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

26

the patient” (Nomoi, 720 c-d, Plato. Charmides). The goal of this Chapter is to stimulate a debate on clinical hypnosis in medical and psychological therapy. Neuroscience and new medical technologies must be viewed through the lens of neurobioethics, a new key to medical bioethics, which make us understand that we must open new debates centered on the human being. The great mystery of the study of human suffering, death and dying, remains intact. Through studies on the states of consciousness and clinical hypnosis, our understanding of the awareness of clinical and psychological therapies can be enhanced. Today, novel and far-reaching avenues of knowledge have been unraveled for humanity. Chief among these are medical and neuroscientific fields that can better be analyzed with new diagnostic techniques. The brain can be investigated in clinical studies through functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single photon emission tomography (SPET) that have become indispensable for the knowledge and mapping of brain functions (De Weer A., Da Ros M., Berré J., Melot C., Goldman S., Peigneux P., 2011; Tononi and Koch, 2008; Tononi G., 2004, 2008; De Luca M, Beckmann CF, De Stefano D, Matthews PM, Smith SM., 2006). Currently, though we have the prerequisites for a wealth of knowledge and awareness of respect for suffering and human dignity, but in many difficult circumstances, the path remains steeped in anguish, is slow and highly complex, especially regarding personal choices of the patient and the concerned family. The vast field of human suffering offers grounds for discussion, both for its psychophysical interpretation and therapy (Melzack R., 2001, 2002). Pain and suffering cannot really be described as a purely physical and sensory phenomenon, but must be seen as the inseparable whole of: -

a perceptual part (physical pain, nociception), which is the sensory mode that allows the reception and transport to the central nervous system of stimuli potentially harmful to the body a psycho-experiential part (therefore completely personal, the real experience of pain), which is the psychic, social, and spiritual state, connected to the perception of an unpleasant sensation (Melzack R., 1998, 1999, 2001. 2002; Brugnoli MP., 2014, 2016, 2018, 2019).

On the other hand, the plasticity of the entire brain, espoused through various theories and the extraordinary mind of Nobel Prize winner Rita Levi Montalcini, underscores the adaptability of the brain, even in unfavorable conditions, such as disease and pain (Montalcini RL.,1970). For this reason, the perception of pain and psychological suffering is always very subjective

Maria Paola Brugnoli

27

(Gazzaniga M.S., Ivry R.B., Mangun G.R., 2019). The nervous and biochemical pathways activated by painful sensations and suffering create a series of extremely complex and articulated responses, involving the neuroendocrine system, the immune system, and emotions (Gazzaniga M.S., Ivry R.B., Mangun G.R., 2019; Tononi G, Koch C. 2015; Brugnoli MP, 2014). This property of our brain is crucial to understand the value of psychological therapies as clinical hypnosis. Therapy for pain and suffering must adopt a multidimensional and multidisciplinary approach in an ethical contest of respect for the dignity of those who suffer (Gazzaniga M.S., Ivry R.B., Mangun G.R., 2019). Since pain and suffering, as well as the memory of suffering and chronic pain, can leave a significant imprint on our brain, patients can be helped through positive emotional input and mechanisms via clinical hypnosis (Brugnoli M.P., 2014, 2016, 2018; Agarwal S, Kumar V, Agarwal S, Brugnoli MP, Agarwal A., 2018; Brugnoli MP, Pesce G, Pasin E, Basile MF, Tamburin S, Polati E., 2018; Raz. A., 2004, 2011; Raz A., Landzberg KS, Schweizer HR, Zephrani ZR, Shapiro T, Fan J, Posner MI., 2003).

2. Neuroscientific and Psychological Foundations of Consciousness and the Modified States of Consciousness What is consciousness? Consciousness is a term concerning the ability to perceive, feel, or be conscious of events, objects or patterns, not necessarily implying understanding (Gazzaniga M.S., Ivry R.B., Mangun G.R., 2019; Tononi G, Koch C. 2015). From the neuropsychic point of view, vigilance and awareness are two components of consciousness; vigilance is characterized by a waking state that is not necessarily associated with awareness of what is happening in our world and awareness consists of an awareness of the world around us and, in the most evolved condition, of one’s own being. The state of awake consciousness is established by the harmonious functioning of vigilance and awareness (Gazzaniga M.S., Ivry R.B., Mangun G.R., 2019; Tononi G, Koch C. 2015; LeDoux J., 2002). Vigilance without awareness results in the subject’s appearance with open eyes and a normal sleep-wake cycle but without signs of contact with the environment; this condition can be found in states of coma (Laureys S, Faymonville ME, Peigneux P, et al., 2002; Laureys S, Owen AM, and Schiff ND, 2004). The neuroscientist Antonio Damasio, in his 1994 essay ‘Descartes’ Error’, overturns the cultural tradition that has always devalued emotions because they would disturb the serenity of reason and shows how, on the contrary, they are the basis of the good functioning of the mind: if humans

28

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

lose their emotional capacity, they are unable to find reason. Denying the Cartesian conception of mind-body dualism, Damasio highlights the mutual action of body and brain, which constitute a unique and inseparable organism. Therefore, reason could not function properly without emotions, i.e. without the close connection with the body that constantly offers the basic material for the brain to build images from which thought originates. Damasio thus restores dignity to emotions, which he considers important cognitive dimensions (Damasio A., 1994, 2000, 2007). A significant aspect of clinical hypnosis is to teach the patient, through complete self-awareness and self-hypnosis, not to be overwhelmed by the violence of negative emotions, and to consider more positive ones (Brugnoli M.P., 2014). Can a science of consciousness assert itself together with developments in cognitive neuroscience, and the psychological study of humans? In this regard, it is worthwhile to remember the psychic, human, and spiritual theories of Viktor Frankl, the Austrian neurologist and psychoanalyst. Frankl analyzed consciousness in various ways, during the course of his life and during his imprisonment in Nazi death camps, where he was interned and lost his family during World War II. According to Frankl, consciousness is the intuitive capacity to discover the unique and singular meaning hidden in every situation: it is ethical, instinctive, intuitive, and therefore irrational, alogical, pre-logical, spiritual anticipation, and susceptible to a secondary rationalization (Frankl V.E., 1946-2006, 2000). Consciousness is therefore founded in the unconscious and intuition. It is the spiritual ego that plunges into the unconscious. It manifests not so much as being in a situation or a person, but a power-being and a duty-being not yet realized but waiting to be realized (Frankl V. E., 1946-2006). The Australian mathematician and philosopher, David Chalmers, has made significant contributions to the study of consciousness through his theories. As per Chalmers’ approach for identification and separation of two different investigation problems inherent to consciousness, there are the easy problem, and the hard problem. The easy problem is related to the anatomical-physiological study of neuroscientific models of consciousness. Given the enormous progress in neuroscientific research, in fact, the easy problem is relatively simple, from the theoretical point of view, to find brain correlates of conscious experience. However, this approach to consciousness, according to Chalmers, does not explain all the subjective, psychological, and irreducible character of consciousness. The hard problem is related to the explanation of qualitative, subjective, and psychological aspects of the conscious experience, which escape a

Maria Paola Brugnoli

29

materialistic, rational, and neurological analysis (Chalmers D. J., 1995, 1996). In addition to the rational consciousness of the mind, there are various stages or levels of consciousness during relaxation, clinical hypnosis or meditative techniques used in psychological therapies (Brugnoli A. 1974a, 1974b, 2004, 2005; Brugnoli MP, Brugnoli A., Recchia L., 2016; Brugnoli M.P. 2014; Brugnoli MP, Brugnoli A., 2016). A) The easy problems of consciousness The easy problems of consciousness include those that explain the following neuroscientific and psychological phenomena: x ability to discriminate, categorize, and react to environmental stimuli; x integration of knowledge by a neurocognitive system; x different neurological mental states; x focus of attention; x control of behavior; x neuroscientific difference between different states of consciousness; and x quantum mind In recent years, the scientific study of human consciousness has transformed from a philosophic and psychologic field, into a neuroscientific research topic. At the level of brain mechanisms, the science of consciousness now synthesizes results from a broad range of techniques, including electrophysiology, fMRI, magneto/ electroencephalography (M/EEG), intracranial recordings, neuropsychology, and computational models (De Weer A., Da Ros M., Berré J., Melot C., Goldman S., Peigneux P., 2011; Tononi and Koch, 2008; De Luca M, Beckmann CF, De Stefano D, Matthews PM, Smith SM., 2006; Dehaene, S., Changeux, J.P., Naccache L., Sackur, J., Sergent, C., 2006; Dehaene, S., Naccache, L., 2001). Since the mid-1990s, the intriguing dynamics of consciousness and the brain have attracted a growing body of research in neuropsychology and neuroscience (Searle, J. 1990, 1992; Smith, E. E., and Jonides, J.,1999). In neuroscientific parlance, the binding problem is a neural binding hypothesis, which is an interdisciplinary term that denotes the difficulty of creating a comprehensive and verifiable model for the unity of consciousness. “Binding” refers to the integration of highly diverse neural information in the forming of one’s cohesive experience. The neural binding hypothesis states that neural signals are paired through synchronized oscillations of neuronal

30

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

activity that combine and recombine to allow for a wide variety of responses to context-dependent stimuli. These dynamic neural networks are thought to account for the flexibility and nuanced response of the brain to various situations (Senkowski D., Schneider TR, Foxe JJ, Engel AK, 2008). The binding problem thus attempts to address the mechanism(s) by which we, as humans, experience our reality (Negrao BL, Viljoen M., 2009). Studies of the binding problem in neuroscience stem from the much older psychological study of the binding phenomenon, which has its roots in the ancient philosophical study of the same problems. The close interplay between neuroscience and psychology, in vogue today, is especially relevant to neural binding (Mashour GA., 2004; Negrao BL, Viljoen M., 2009). In everyday life, as each of us live in our “normal” awake state of consciousness, the focus of our awareness is usually the particular thoughts, emotions or perceptions we experience at the surface level of reality (Miller GA., Galanter E. & Pribram KH., 1960). These experiences and perceptions prod us as we move through in our life, in the outer world, or the thoughts and feelings, that we have in our inner world. As we move through life, we perceive, think, act, and feel with the assistance of our “thinking mind”, which is the active portion of our mind that deals with this surface level of reality, through our thoughts, feelings, interpretations of perceptions, and actions. Consciousness depends on spontaneously-emitted pulses from brain stem neurons that ascend in a complex mesh of activating circuits to awaken neurons in the limbic system, thalamus, and cerebral cortex. Without this ascending activation, humans lapse into a coma. Damasio suggested that while the senses of vision, hearing, touch, taste, and smell function through nerve activation patterns that correspond to the state of the external world, emotions are nerve activation patterns that correspond to the state of the internal world (Damasio A., 1989, 1994, 2000). The frontoparietal network plays a central role in the consciousness process and is associated with higher cognitive functions such as planning, decision-making, problem-solving, distinguishing between appropriate and inappropriate actions, abstract thinking, rule learning, processing of spatial information, response selection, long-term memory retrieval, introspection, the ways we experience emotions, join perceptions into a unifying whole, and confer meaning to our perceptions. The frontoparietal network is often referred to as the executive brain that is essential for the process of focusing attention by detecting conflict between inputs and amplifying prefrontal activity, which is biased towards a certain neural pathway, keeping internally generated stimuli in focus and has even been associated with the enigma referred to as free will (LeDoux J., 2002; Miller EK, Cohen JD.,

Maria Paola Brugnoli

31

2001; Squire LR, Bloom FE, McConnell SK, Roberts JL, Spitzer NC, Zigmond MJ, 2003; Squire LR, 2008). Analysis of the relationship between neuropsychological components and the system of conscience cannot fail to consider two discriminating aspects. First of all, we have already emphasized that consciousness is not representable in terms of unitary nucleus, but rather multiple, locally distributed systems. For this reason, in the first instance, it seems misleading to wonder if there is a ‘center’ of consciousness. However, most neural mechanisms and cognitive functions are not located in a predefined space within the cortical system; for example, memory, vision or movement cannot be relegated to a single module or a specific brain region. Also, in the case of consciousness many neuronal populations may contribute differently to the final product of conscious representation. In this sense we can define consciousness as spatially multiple. Secondly, consciousness is definable as a property of a group of components not attributable to the individual starting units, whose extent depends on the set of units activated around a single epicenter. In particular, neural networks can take different forms, depending on the fact that they are distributed, so that neurons belonging to a single network can be located in different parts of the brain or localized, if the neurons are located in only one area. In addition, the type of information represented in a given area is characterized by the type of neuron that produces the input: essentially each network performs a particular type of information processing compared to other networks. New advances in cognitive neuroscience have provided insight into the functional mechanisms of the human brain. Neuroscientists have identified specific brain patterns, for example neuronal oscillations and neural networks, which co-fluctuate with cognitive task and behavioral performance (Buzsaki G., Horva´th, Z., Urioste, R., Hetke, J., and Wise, K., 1992; Buzsáki, 1989, 2002, 2006; Buzsáki G., Draguhn A., 2004). These fluctuations are not random, but are contingent on the definite task and cognitive settings. Natural neuronal systems display a complex combination of serial and parallel structural motifs that enable the performance of disparate functions. For example, layered and hierarchical brain network architectures, theoretically important for sustained limited activity, have been consistently identified over a range of spatial scales in primate cortical systems. Neurons themselves are organized into layers, or “lamina,” and both intra-laminar and inter-laminar connectivity differentially impact function (Hermundstad AM., Brown KS., Bassett DS., and Carlson, JM., 2011; Honey CJ., 2009; Kenet T, Bibitchkov D, Tsodyks M, Grinvald A, Arieli A., 2003; McIntosh AR, Rajah MN, Lobaugh NJ., 2003; Scholz J, Klein MC, Behrens TEJ, Johansen-Berg H., 2009; Bassett DS, Greenfield DL,

32

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

Meyer-Lindenberg A, Weinberger DR, Moore SW, et al., 2010; Kaiser M, Hilgetag CC., 2010; Reid AT, Krumnack A, Wanke E, Kotter R., 2009; Ress D, Glover GH, Liu J, Wandell B., 2007). Applying an in-depth understanding of neuroscientific knowledge might therefore be the key for developing tools to study the brain for different target groups, and to improve various aspects of human consciousness affected in severe diseases (Buzsáki, 2006). Synaptic plasticity provides the basis for most models of learning, memory, and development in neural circuits. Recent applications of dynamic network analyses to functional neuroimaging data have revealed relationships between a number of cognitive conditions and the dynamic reconfiguration of brain networks (Girn M, Mills C, Christoff K., 2019). Investigations of complex integrative actions in brain centers should consider, beside neural networks, glial, extracellular matrix, and fluid channel networks. The brain connectome is a comprehensive map of neural connections, and may be thought of as the brain’s “wiring diagram”. The study of connectomes, known as connectomics, may range in scale from a detailed map of the full set of neurons and synapses within part or all of the nervous system of an organism to a macroscale description of the functional and structural connectivity between all cortical areas and subcortical structures (Sporns O, Tononi G, Kötter R., 2005). B) The hard problems of consciousness are those that seem to resist neuroscientific methods (Chalmers D., 1995) and include the problems of x experience, knowledge, and awareness; and x the capacity of a system to access its own internal states as the modified states of consciousness in therapy (clinical hypnosis) in meditation and spirituality.

3. The Modified States of Consciousness and Clinical Hypnosis in Therapy Results from numerous scientific studies have helped bridge the gap between neural correlates, the mind, and states of consciousness. Although in general speech, we tend to use the terms awareness and consciousness to represent the same thing, they are used to convey different neuroscientific meanings and explain these concepts through our knowledge of brain networks. There are two different views about the extent of neuronal involvement in consciousness:

Maria Paola Brugnoli

33

1. The holistic approach to consciousness emphasizes the perspective that all brain neurons collectively form the neural correlate(s) of consciousness, which therefore cannot be localized only to a specific set of neural cells (Koch C., 2004). 2. The neuronal specificity approach promotes the idea that consciousness depends on the formation of complex arrangements, which can be pinpointed to specific groups of neural cells. According to Llinás and Parè, consciousness is generated by neurons that fire spontaneously in the closedloop system of the cortex, thalamus, and reticular formation (Llinás R, Parè D., 1991). In medicine and psychology, it is important to consider the integration of both these views. Consciousness is evaluated by observing a subject’s arousal behavior and responsiveness, and can be seen as a continuum of different modified states, fluctuating from full alertness and attention, through awake state and sleep, and also, through clinical hypnosis and meditative states. In recent years, clinical hypnosis and the modified states of consciousness have become significant research topics in medical therapies, psychology, philosophy, and neuroscience (Yapko MD, Barretta NP, Barretta PF., 1998; Yapko M.D., 2014; Wark DM., 2006, 2008, 2011; Raz A, Landzberg KS, Schweizer HR, Zephrani ZR, Shapiro T, Fan J, Posner MI., 2003; Raz. A., 2004, 2011; Brugnoli MP, 2016). There are several different modified states of consciousness that can be divided into three main categories (Brugnoli MP., Brugnoli A., Luca R., 2014): 1. Pathological states of consciousness that are observed in many neuropsychological and biochemical pathologies and dysfunctions, and in coma states. 2. States of consciousness modified by drugs, anesthesia, alcohol, medicines, herbs, and plants. 3. Neurophysiological states of consciousness that are the stages from awake to sleep, and the different stages of consciousness during therapies such as clinical hypnosis, introspection, and the meditative states. This discussion will be limited to clinical hypnosis as a modified neurophysiological state of consciousness used in psychological therapy. Hypnosis is an increasingly popular area of research in cognitive science, including notable ventures in the domains of perception, attention, concentration, consciousness, memory, motor control, and control of pain and suffering in humans (Ewin DM., 1978; Jensen MP, Patterson DR.,

34

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

2005; Patterson DR, Jensen MP., 2014; Willmarth E.K., 2015; Anbar R.D., 2011; Alladin A., 2012; Yapko MD., 2014; Nash and Barnier, 2008; Brugnoli MP., 2001, 2002, 2014a; Brugnoli M.P., Brugnoli A., Norsa A., 2006; Brugnoli M.P., Shivchandra Parolini M., 2009; Handel DL., 2001, 2010; Shenefelt P.D., 2011; Néron S., Stephenson R., 2007; Varga K., 2013; Sugarman L.I., Garrison B.L., Williford K.L. 2013; Faymonville ME, et al., 2000). The ever expanding integration of complementary and alternative medicines (CAM) into holistic medicine and the use of CAM as clinical hypnosis in many clinical practices is the result of CAM treatments used for thousands of years. However, it was not until 1999 that the National Institutes of Health (NIH) created the National Center for Complementary and Alternative Medicine (NCCAM) with a mission to define “the usefulness and safety of CAM interventions and their roles in improving health and health care” (PDQ Integrative, Alternative, and Complementary Therapies Editorial Board., 2016).

4. Clinical Hypnosis in Medical and Psychological Therapy In 2015, the Division 30 Executive Committee prepared the following official definition related to Clinical Hypnosis: “Hypnosis: A state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion”. The history, rationale, and guidelines for developing a new definition of hypnosis by the Society of Psychological Hypnosis, Division 30 of the American Psychological Association will be discussed in this Chapter. The definition was developed with the aim of being concise, heuristic, and allowing for alternative theories of the mechanisms (to be determined in empirical scientific study). As well, definitions for hypnotic induction, hypnotizability, hypnotherapy, and neuroscience of hypnosis are provided (Elkins GR, Barabasz AF, Council JR, Spiegel D., 2015a, 2015b; Lynn SJ, Green JP, Kirsch I, Capafons A, Lilienfeld SO, Laurence JR, Montgomery GH., 2015; Barabasz AF, Barabasz M., 2015; Christensen C, Gwozdziewycz N., 2015; Kluft RP., 2015; Santarcangelo EL, Scattina E., 2016). Hypnosis often includes an induction phase to increase mental absorption followed by a suggestion phase providing directions to elicit particular changes in thoughts and behaviors. Top-down regulatory processes such as attention, cognitive control, and monitoring play central roles in mediating responses to hypnotic suggestions (Crawford HJ., 1994; Gruzelier J., 1998, 2013; Raz A., 2004; Egner and Raz, 2007; Dienes, 2012; Lifshitz et al.,

Maria Paola Brugnoli

35

2012; Dienes and Hutton, 2013). Specifically, hypnosis modulates topdown processes to dramatically change the implementation of cognitive strategies during hypnotic responses (Egner and Raz, 2007). Hypnotic suggestions are a function of type and content (Woody and Sadler, 2008), and within this framework, they can either facilitate, suppress, or modify cognition and behaviors in psychotherapy. Clinical hypnosis is a communication therapy, wherein therapists overshadow their way of perceiving reality, to evoke a patient’s experiences and perceptions of suffering in themselves. The hypnotherapeutic approach is an extremely profound form of understanding another person’s suffering, because it is an identification with the feelings of the other. We shift from an attitude of mere external observation (never judge!) to how we feel inwardly: in those shoes, with that experience of life, suffering, and trying to look beyond those eyes (Fortuna F., Tiberius A., 1999; Brugnoli A., 2004; Brugnoli MP., 2014; Brugnoli MP., et al, 2018). The true empathic hypnotherapeutic relationship between therapist and patient should reflect the concept of universal compassion of many religious philosophies and traditions (Brugnoli M.P., 2014; Satsangi A., Brugnoli M.P., 2018). The cognitive and hypnotic modulation of the pain experience describe how electrocortical processes reflect the modulation and experience of pain: the importance of the anterior cingulate not only modulates these processes in particular, but generally, serves as an interface between the limbic system and the neocortex and the integration of cognitive with emotional stimuli (Ray WJ., Slobounov S., 2002; Melzack R., 1998, 1999, 2001, 2002; Melzack R. Wall P.D., 2003). The response that follows, which can be either relaxing or stimulating, have demonstrated efficacy of brainwave modification in areas such as enriched learning, improved sleep, and relaxation (Ray WJ., Slobounov S., 2002).

5. Bioethical Principles in Medicine and in Clinical Hypnosis Clinical hypnosis has now become a viable venue in cognitive science, neuroscience, and psychological therapy (Oakley DA, Halligan PW., 2009, 2013; Raz A., 2004, 2011, 2012; Brugnoli MP., 2014a). We argue that clinical hypnosis paves the road to multiple methodological and therapeutic advances in the exploration of the unconscious mind. Practitioners of clinical hypnosis, have long observed often dramatic emotional, cognitive, behavioral, and physiological changes, occurring during, and as an apparent consequence of, passive/introspective concentration hypnotic trance. In psychological therapy, hypnosis modulates the phenomenological aspects

36

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

of conscious experience, such as pain perception (Jensen MP, Patterson DR., 2005; Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC., 1997; Patterson DR, Jensen MP., 2014; Brugnoli MP, 2014a). Hypnotic analgesia triggers pain-related inhibitory neural mechanisms (Vanhaudenhuyse A., Demertzi A., Schabus M., Noirhomme Q., Bredart S., Boly M., et al., 2011). These changes in perception demonstrate how hypnosis elicits powerful effects over perceptual experience in psychological therapy. Brain imaging studies of this phenomenon underline a dissociation between the somatosensory cortex, involved in processing of nociceptive signals, and the anterior cingulate cortex (ACC), a region associated with conscious access to pain sensation (Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC., 1997; Faymonville ME. et al., 2000; Hofbauer RK, Rainville P, Duncan GH, Bushnell MC., 2001). In order to fully understand the meaning of the ethical dimension and the dignity of care, it is essential to recall that medicine means foremost, taking care of the totality of the human being. In Carmide, Plato wrote: “You cannot cure the eyes without examining the head, nor the head independently of the body, nor the body independently of the soul”. The principles and values which, since ancient times, have governed the professional practice of medicine through oaths and codes of ethics, have bound the physician to always act with the intention of producing the maximum benefit for the patient. Moreover, ethics forbid the physician from using interventions that may cause harm to the patient and from acting against the moral values prevailing in society. The Hippocratic Oath and the professional codes for physicians represented, until the middle of the 20th century, the only ethical normative references. The moral principle that forms the core of medical bioethics is the respect for an individual’s decisional autonomy, which in the medical field is embodied in the practice of informed consent and in various strategies aimed at protecting individuals who are unable to make autonomous choices. Bioethical reflection also applies to the evaluation of moral dimensions involved in the analysis of relationships between risks and benefits in relation to medical interventions. The Nuremberg Code (1947) states foremost that only “voluntary consent” makes experimentation with human subjects morally acceptable. In 1948, the World Medical Association declared the Geneva Declaration, which updates in a secular fashion, the contents of the Hippocratic Oath, and commits physicians to refrain from using, even “under duress”, their knowledge against the laws of humanity. Again, through the 1964 Helsinki Declaration, the World Medical Association reaffirmed the concept that only explicit, and not presumed

Maria Paola Brugnoli

37

consent, can morally justify research on human subjects and that “in medical research the interests of science and those of society must never prevail over the well-being of the subject”. During the 1950s and 1960s, biomedical sciences witnessed a series of revolutionary cognitive and therapeutic developments: the discoveries of molecular biology, advances in resuscitation techniques, advances in pharmacology, and the advent of transplantation medicine, all of which made the prospect of scientific medicine’s control of life, death and disease a reality. In addition to the promises and expectations of a continuous improvement of human health, conflicts emerged between the values privileged by physicians and researchers that spread widely in society. In 1974, the United States Congress voted the National Research Act establishing the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Commission, composed of 11 experts, proposed ethical guidelines for the regulation of experimental research on human subjects and fetuses. In June 1978, the Belmont Report was published: the principles of respect for individuals and their autonomous moral choices, the benefit to human subjects from biomedical research and justice in the social distribution of benefits and disadvantages were first identified as reference criteria for the ethical evaluation of biomedical research and practice. The ideas at the origin of bioethics matured in the United States during the 1960s among moral philosophers of both secular and religious orientation, who developed a growing interest in the application of ethical doctrines to the various fields of human activity and medicine. The historian of medicine, Giorgio Cosmacini, affirms in his book ‘Medicine is not a science’: “Medicine is not a science comparable to other sciences, because its object is a subject: man. The practice of medicine is therefore based on ethical principles”. The term “bioethics” was coined in 1970 by the American oncologist Potter Van Rensselaer to define a hypothesis of environmental and medical ethics. In 1971, at Georgetown University in Washington D.C., the ‘Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics’ was inaugurated, which in fact sanctioned the formalization of the word “bioethics” to indicate a new domain of studies. The concept of bioethics suffered resistance and criticism. Nevertheless, in 1978, the Encyclopedia of Bioethics was published, which foreshadowed the diffusion of this disciplinary and problematic field, leading it towards the unification into a single subject characterized, however, by the existence of an interdisciplinary matrix where medicine, law, biology, psychology, psychiatry, philosophy, and theology contribute

38

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

to the development of intense debates concerning what has previously been indicated as ‘hypothesis of neo-humanism’. It is important to accept that the new biomedical ethics developed subsequently, especially by analyzing the philosophical-legal assumptions of informed consent, and the possibility that patients have the right to refuse, based on their own value system, and the therapy. The intention to differentiate the new moral perspective, from that of traditional medical ethics, thus led to the emergence of the term bioethics with a meaning different from that of the original definition in the first edition of the Encyclopedia of Bioethics (1978) as “the systematic study of human conduct in the area of life sciences and health care, as such conduct is examined in the light of moral values and principles”. Consequently we can consider bioethics in medicine as: the systematic study of the moral dimensions, including the moral vision, decisions, conduct, guidelines, of life and health sciences, using a variety of ethical methodologies in an interdisciplinary approach. We can also consider it the ‘systematic study of human conduct, in the life (and death) and health sciences, examined in the light of moral values and principles’ (Reich WT., 1978). Edmund D. Pellegrino and D. Thomasma in their book ‘For the Patient’s Good: The Restoration of Beneficence in Health Care’ wrote: “Medicine is neither a science nor an art, but a practice that involves ethical principles; if these principles are violated, so is the good of medicine”. We can now add that medicine is not only a science, but also an ethical model at the service of humanity. Since its origins at the time of Hippocrates, medicine has had its Ethical Models: x Principle of non-maleficence (do no harm to the patient). x Principle of charity (doing the good of the patient). In modern times, with the birth of bioethics, the following have been included: x Principle of autonomy (respecting the right of the person assisted to make responsible and conscious decisions regarding health and care problems). x Principle of justice (avoiding discrimination and ensuring a fair distribution of benefits, risks, and costs).

Maria Paola Brugnoli

39

Physicians must first prepare themselves to help the patient exercise autonomy. In this sense, the bioethical doctrine appears essentially static and cognitive and needs a more flexible formulation tailored to real-life situations. The image that bioethics assumes of the patient, as an abstract decision-maker, who by chance is also a sick person, shows all its limits: in the sense that each patient must be considered a unique and complex individual, with their biographies, life experiences, personal beliefs, values, and intentions: elements that, moreover, can be modified by the disease. Therefore, in addition to medical needs, all patient needs, including psychological, social, and spiritual needs, should be considered, as an inseparable whole, paying attention also to the experiences, sensitivities, and opinions not only of the person assisted, but also that of the family. The above-mentioned ethical principles have a guiding function in the clinical hypnosis medical field, as there are also other ethical models based on which it is possible to define moral qualities and behavioral models that should inspire the practice of care such as: x Ethics of virtue: it shifts the focus from the criteria for defining what the right action is, to the moral qualities of those who perform the action. x Ethics of care: leads to consider not only the dimension of caring, but also the dimension of ‘taking care’. x Ethics of responsibility: which means responding to the call of others, taking on their needs, and being able to evaluate the general consequences of one’s own actions, considering responsibility in a multiple dimension; the interpersonal dimension and the collective and social dimensions. x Ethics of communication: medical ethics made up of dialogue and reciprocity.

6. Neuroethics and Neurobioethics in Psychological Therapy and in Clinical Hypnosis The term ‘Neuroethics’ was first used at the conference ‘Neuroethics: Mapping the Field’ in 2002 (Roskies A., 2002) and can refer to two different fields of study; it can be understood as ‘neuroscience ethics’ or ‘neuroscience of ethics’ (Roskies A., 2002). Neuroscience ethics is a discipline that deals essentially with discussing, from an ethical point of view, the design and execution of a neuroscientific study, and with assessing the ethical and social impact of the results of neuroscientific studies. Neuroscience of Ethics instead deal with investigating, from the brain

40

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

perspective (through scientific and neuroscientific studies), notions and traditional problems of bioethics (Roskies A., 2002). Further, ‘neurobioethics’ is the study of bioethics through neuroscience. As we now understand the neuroscience of clinical hypnosis, we can discuss the neurobioethics of clinical hypnosis. As Prof. Alberto Carrara, director of the GdN, Neurobioethics Study Group at the Pontifical Athenaeum Regina Apostolorum in Rome, explains: “The neologism, neurobioethics, which wants to emphasize: “the centrality of the human person in the field of neuroscientific research and philosophical-theological reflection on it”, was coined and used for the first time in 2005 by the neuroscientist, James Giordano (Director of Neurology and Bioethics at Georgetown University in Washington) (Giordano J. https://clinicalbioethics.georgetown.edu/neuroethicsprogram). Giordano defines three areas of neurobioethics: 1. study of the neurological bases of reasoning, meaning, and moral action. 2. study of the moral implications that emerge from neuroscientific research and its application to the human being, both in clinical and social fields; referring to purely classical bioethics 3. considering the mutual interactions between neuroscientific research and clinical practice and other relevant areas of biomedical sciences, such as the effects of genetic research on neurological health or the use of neuro-technologies in chronic and neurodegenerative diseases that are extremely disabling (Giordano J., 2010, 2011, 2013, 2018; Carrara A, 2012, 2013, 2014,2016). Neurobioethics includes not only the neuroscientific and philosophical study of medical ethics, but also areas such as medical therapy, neuroscience, the study of consciousness, anthropology, medical sociology, health policy, health economics, and even some areas of medicine itself (Derbyshire S.,1999; Benatar D., 2006). In our current understanding, neurobioethics is the study of bioethics through neuroscience: neuroscience of consciousness. The study of consciousness is therefore also the study of a concept not only neuroscientific, but also of neurobioethical interest and an opportunity for research and psycho-social intervention. Giordano, from his studies on pain neuroscience and neuroethics of pain therapy, explains that neuroscience, together with an expanded concept of “mind”, has raised pragmatic and ethical concerns about the experience and treatment of pain. For pain medicine to be authentic, it requires knowledge of the mind-brain, pain, and potential interventions that can and/or should

Maria Paola Brugnoli

41

be provided to the patient. It describes the need for ethics that reflect and is relevant to contemporary neurosciences of pain and suffering, recognition, and appreciation of the sentient human being in pain, the effects of the environment, the values, and nature of healing. Giordano describes how integrative neuroethics of pain care allows, if not obliges, the alignment of facts, values, and moral attitudes as an ongoing process of re-examining, analyzing, and reviewing what we know (and don’t know) about our brain, mind, and the deep self, and how we consider and treat the patient (Kushner T, Giordano J., 2018; Shook JR, Giordano J., 2019). Nevertheless, when we talk about bioethics and neurobioethics in clinical hypnosis therapy, we have to consider much more than just psychological or neurophysiological theories. To better illustrate the various neurobioethical issues in clinical hypnosis, it is appropriate to summarize the path of psychological therapy in i) Taking Care and ii) The Welfare Project. (1) Taking Care: The real ethical tool that guarantees a correct comprehension in care, is the multidimensional evaluation of the person. An appropriate multidimensional evaluation and assessment must have some basic requirements: x it must be a multidimensional and multidisciplinary assessment of the functional status of individuals and their social and housing situation; x must provide for the use of standardized and homogeneous evaluation systems; x it must be aimed at drawing up personalized assistance plans; x it must be traced back to the identification of an appropriate health or social operational manager within the care team. (2) The Welfare Project: The Welfare Project is the humanization of care, whereby attention is given to the person as a whole, made up of organic, psychological, and relational needs. The growing acquisitions in the technological and scientific fields, which today make it possible to treat even once incurable pathologies, cannot be separated from the necessary awareness of the importance of the relational and psychological aspects of care. It is very important in this field:

42

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

x to know how to listen to those who suffer, their needs, their world, their cultures, their religious beliefs, and one must also be able to listen to what the other does not say; x understanding (making the sick understand that they are one of us); x compassion (making the sick and their family understand the present suffering); and x sincerity and communicative clarity

7. Conclusions Ethical issues in medicine and life sciences are the subject of not one, but several relatively new academic fields: “bioethics” and “health and human rights”. Although moral questions have been asked about the ethics of medicine and related areas, it is only in recent decades that new fields dedicated specifically to these issues have emerged. The growth of these fields has stimulated further attention to important moral questions in medicine and biology. Human rights are the fundamental rights and freedoms that belong to every person in the world, from birth to death. These fundamental rights are based on shared values such as dignity, fairness, equality, respect, and independence. As we clinicians know, neuroscientific studies of neurobioethics for clinical hypnosis are in progress. This important emerging field of study on consciousness, self-inner-consciousness, and clinical hypnosis for clinical and psychological therapy has the potential to offer a great deal to our understanding of the human mind, new scientific discoveries about our brain, and psychology of the mind. Consciousness is the personalized energy that knows itself, and its abilities go far beyond human understandings. Our mind is conscious energy in all its forms. The brain is the vital organ, which facilitates the link between “our” mind, matter, and inner-self. Current neurophysiological evidence suggests that aspects of the modified states of consciousness as clinical hypnosis for medical and psychological therapies, may indeed be linked to important knowledge on the human being. Neuroscience today extends over many different fields including cognitive neuroscience, neurology, psychiatry and psychology, neurobiology of spirituality, and the study of consciousness. There is abundant literature on medical, psychological, and bioethics theories, specifically related to psychology and in chronic diseases. In this context, neurobioethics in medicine and in psychology is important to propose new ways of evaluating and treating the sick person in order to integrate clinical, psychological, social, and spiritual care, to relieve total suffering. New studies on

Maria Paola Brugnoli

43

neurobioethics of clinical hypnosis have the potential to provide important insights into possible relationships between aspects of psychology and physiological processes that affect health and well-being in human life. This is a way to understand the respect and dignity of the person (Brugnoli MP. 2014, 2016; Brugnoli MP, Brugnoli A., 2016; Brugnoli MP., Salatiello G., 2020, 2021).

References Agarwal S, Kumar V, Agarwal S, Brugnoli MP, Agarwal A. Meditational spiritual intercession and recovery from disease in palliative care: a literature review. Ann Palliat Med. 2018 Jan;7(1):41-62. doi: 10.21037/apm.2017.08.08. Epub 2017 Sep 20. Review. Alladin, A. (2012). Cognitive hypnotherapy for major depressive disorder. Am J Clin Hypn. 2012 Apr;54(4):275-93. Review. Anbar, R.D. (2011) Clinical pearls gleaned from pediatric hypnosis. Am J Clin Hypn. Jul;54(1):3-4. Barabasz AF, Barabasz M. The New APA Definition of Hypnosis: Spontaneous Hypnosis MIA. Am J Clin Hypn. 2015 Apr;57(4):459-63. doi: 10.1080/00029157.2015.1011507.PMID: 25928787 Benatar D. Bioethics and health and human rights: a critical view. J Med Ethics. 2006;32:17–20. doi: 10.1136/jme.2005.011775. Brugnoli A. (2004) Stati di coscienza modificati neurofisiologici. La Grafica Editrice, Verona, (Italian). Brugnoli A., Brugnoli MP. (2016) I sentieri spirituali nelle cure palliative: manuale pratico di auto-ipnosi e meditazione. Gabrielli Editori, Verona, Italy. Brugnoli MP (2019) Vademecum di neurobioetica degli stati di coscienza: fondamenti neuroscientifici - stati di coscienza modificati - stati di coma - stati di premorte-nde - morte cerebrale - psicotanatologia - dimensione spirituale. Gabrielli Editori, Verona, Italy. Brugnoli MP, Brugnoli A. (2016) I sentieri spirituali nelle cure palliative. Manuale pratico di rilassamento, auto-ipnosi e meditazione. (Italian) Gabrielli Editori, Italy, 2016 ISBN-13: 978-8860993144 Brugnoli MP, Brugnoli A., Recchia L. A New Classification of the Modified States of Consciousness. A peer-reviewed, referenced resource. LAP LAMBERT Academic Publishing. Germany, 2016. ISBN-13 978-3-659-85683-9. Brugnoli MP, Pesce G, Pasin E, Basile MF, Tamburin S, Polati E. The role of clinical hypnosis and self-hypnosis to relief pain and anxiety in severe chronic diseases in palliative care: a 2-year long-term follow-up of

44

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

treatment in a nonrandomized clinical trial. Ann Palliat Med. 2018 Jan;7(1):17-31. doi: 10.21037/apm.2017.10.03. Epub 2017 Dec 12. Brugnoli MP. (2014). Clinical hypnosis in pain therapy and palliative care: a handbook of techniques for improving the patient’s physical and psychological well-being. Charles C. Thomas Publisher, IL, USA. http://www.ncbi.nlm.nih.gov/nlmcatalog/101610051 Brugnoli MP. (2016) Clinical hypnosis for palliative care in severe chronic diseases: a review and the procedures for relieving physical, psychological and spiritual symptoms. Ann Palliat Med. 2016 Oct; 5(4):280-297. doi: 10.21037/apm.2016.09.04. Review. Brugnoli MP. (2018) Clinical hypnosis in Palliative Care: neural correlates, clinical, psychological and spiritual therapies. Ann Palliat Med 2018;7(1):3-6. doi: 10.21037/apm.2017.09.11 Brugnoli MP., Salatiello G. (2020) Autocoscienza: fondamenti neuroscientifici, psicologici, filosofici, teologici e spirituali. Gabrielli Editori, Verona, Italy. Brugnoli MP., Salatiello G. (2021) Stati di coscienza introspettivi e meditativi: aspetti neuroscientifici, psicologici, filosofici, teologici e spirituali. Gabrielli Editori, Verona, Italy. Brugnoli, A. (1974a). [Hypnotherapy of pain]. Minerva Med. 1974 Sep 12;65(63):3288-95. Italian. No abstract available. PMID:4422563 Brugnoli, A. (1974b). [Hypnotic therapeutic methods for pain]. Minerva Med. 1974 Jun 20;65(47):2637-41. Italian. No abstract available. PMID:4844365 Brugnoli, A. (2004). Stato di coscienza totalizzante, alla ricerca del profondo Se. La Grafica Editrice, Verona, (Italian). Brugnoli, M.P. (2001). Neurofisiologia di realtà percepita e realtà rappresentata: quale relazione tra working memory e visualizzazione mentale in ipnosi. Acta Ipnologica, 3,21-22. (Italian). Brugnoli, M.P. (2002). Rilassamento ed ipnosi in età evolutiva. Acta Hypnologica, 1,8-14. (Italian). Brugnoli, M.P., Brugnoli A., Norsa A. (2006). Nonpharmacological and noninvasive management in pain: physical and psychological modalities. La Grafica Editrice. Verona. Brugnoli, M.P., Brugnoli, A., Recchia, L. (2016) A new classification of the modified states of consciousness. LAP Lambert Academic Publishing, Germany. ISBN 978-3-659-85683-9 Brugnoli, M.P., Shivchandra Parolini, M. (2009). La via della pace interiore: tecniche di rilassamento e di meditazione per il benessere dell’anima. Del Miglio Editore. Verona. (Italian).

Maria Paola Brugnoli

45

Buzsaki, G. (1989). Two-stage model of memory trace formation: a role for ‘‘noisy’’ brain states. Neuroscience 31, 551–570. Buzsaki, G. (2002). Theta oscillations in the hippocampus. Neuron 33, 325– 340. Buzsáki, G. (2006). Rhythms of the Brain. New York, NY: Oxford University Press. Buzsáki, G., Draguhn, A. (2004). Neuronal oscillations in cortical networks. Science 304, 1926–1929 10.1126/science.1099745 Buzsaki, G., Horva´th, Z., Urioste, R., Hetke, J., and Wise, K. (1992). High frequency network oscillation in the hippocampus. Science 256, 1025– 1027. Carrara A. (2012) La Coscienza tra mente e cervello, aspetti filosofici, bioetici, psicodinamici, clinici. Studia Bioethica, 2012; 5 (3) (Italian). Carrara A. (2013) Recensione di W. Glannon: Brain, Body, and Mind. Neuroethics with a Human Face. Rivista internazionale di Filosofia e Psicologia, 2013; 4 (3), 398-400 (Italian). Carrara A. (2014) Coscienza e libertà tra neuroscienze, filosofia e riflessione bioetica. Studia Bioethica, 2014; 7 (1) (Italian). Carrara A. (2016) Cervello, economia e memoria: la persona umana nella riflessione neurobioetica. Studia Bioethica, 2016; 9 (2) (Italian). Chalmers, D. (1995) Facing Up to the Problem of Consciousness. Journal of Consciousness Studies 2(3):200-19. Chalmers, D. (1996). The Conscious Mind. Oxford: Oxford University Press. Christensen C, Gwozdziewycz N. (2015) Revision of the APA Division 30 Definition of Hypnosis. Am J Clin Hypn. 2015 Apr;57(4):448-51. doi: 10.1080/00029157.2015.1011498.PMID: 25928784 Cosmacini G. (2008) La medicina non è una scienza: Breve storia delle sue scienze di base. (Italian) Raffaello Cortina Editore, Italy. Crawford, H.J. (1994). Brain dynamics and hypnosis: attentional and disattentional processes. Int. J. Clin. Exp. Hypn. 42 204–232 10.1080/00207149408409352 Damasio A. (1994) Descartes’ Error: Emotion, Reason, and the Human Brain. New York: Putnam’s Sons, 1994. Damasio A. (2007) Neuroscience and ethics: intersections. Am J Bioeth. 2007 Jan;7(1):3-7. Damasio, A. (1989). Time-locked multiregional retroactivation: A systemslevel proposal for the neural substrates of recall and recognition. Cognition. 33:25–62.

46

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

Damasio, A. (2000). A second chance for emotions. In: Lane R, Nadel L, editors. Cognitive Neuroscience for Emotion. New York: Oxford Books. pp. 12–23. De Luca, M., Beckmann, C.F., De Stefano, D., Matthews, P.M., Smith, S.M., (2006). fMRI resting state networks define distinct modes of longdistance interactions in the human brain. Neuroimage, 29 (4) pp. 1359– 1367. De Weer A-S, M Da Ros, J Berré, C Mélot, S Goldman, P Peigneux (2011) Environmental influences on activity patterns in altered states of consciousness. Eur J Neurol. 2011 Dec;18(12):1432-4. doi: 10.1111/j.1468-1331.2011.03477.x. Epub 2011 Jul 19. De Weer, A., Da Ros, M., Berré, J., Melot, C., Goldman, S., Peigneux, P. (2011). Environmental influences on activity patterns in altered states of consciousness. Eur. J. Neurol. 18, 1432–1434. 10.1111/j.1468-1331.2011.03477.x Dehaene, S., Changeux, J.P., Naccache L., Sackur, J., Sergent, C. (2006). Conscious, preconscious and subliminal processing: a testable taxonomy. Trends Cogn. Sci. 10, 204–211. 10.1016/j.tics.2006.03.007 Dehaene, S., Naccache, L. (2001). Towards a cognitive neuroscience of consciousness: basic evidence and a workspace framework. Cognition 79, 1–37. 10.1016/s0010-0277(00)00123-2 Dienes, Z. (2012). Is hypnotic responding the strategic relinquishment of metacognition?. In Foundations of Metacognition eds Beran M., Brandl J. L., Perner J., Proust J., editors. (Oxford: Oxford University Press. 267–277. Dienes, Z., Hutton, S. (2013). Understanding hypnosis metacognitively: rTMS applied to left DLPFC increases hypnotic suggestibility. Cortex. 2013 Feb; 49(2):386-92. Egner, T., Raz, A. (2007). Cognitive control processes and hypnosis.In Hypnosis and Conscious States ed. Jamieson G., editor. New York: Oxford University Press. Elkins GR, Barabasz AF, Council JR, Spiegel D. (2015a) Advancing Research and Practice: The Revised APA Division 30 Definition of Hypnosis. Am J Clin Hypn. 2015 Apr;57(4):378-85. doi: 10.1080/00029157.2015.1011465.PMID: 25928776 Elkins GR, Barabasz AF, Council JR, Spiegel D. (2015b) Advancing research and practice: the revised APA Division 30 definition of hypnosis. Int J Clin Exp Hypn. 2015;63(1):1-9. doi: 10.1080/00207144.2014.961870.PMID: 25365125 Ewin, D.M. (1978). Relieving suffering--and pain--with hypnosis. Geriatrics. 1978 Jun;33(6):87-9.

Maria Paola Brugnoli

47

Faymonville, M.E., Laureys, S., Degueldre, C., DelFiore, G., Luxen, A., Franck, G., Lamy, M., Maquet, P. (2000). Neural mechanisms of antinociceptive effects of hypnosis. Anesthesiology. May; 92(5):125767. Frankl V. (2000) Recollections: An Autobiography. Basic Books, Cambridge, MA 2000. ISBN 978-0738203553. Frankl V. (2006) Man’s Search for Meaning. An Introduction to Logotherapy, Beacon Press, Boston, 2006. ISBN 978-0807014271 (Originally published in 1946) Gazzaniga M.S., Ivry R.B., Mangun G.R., (2019) Cognitive Neuroscience: The Biology of the Mind.W.W. Norton & Company; Fifth International Student edition (2019) Giordano J. (2011) Neuroethics: traditions, tasks and values. Human Prospect. 2011; 1:2–8. Giordano J. (2013) Ethical considerations in the globalization of medicine-an interview with James Giordano. BMC Med. 2013 Mar 14; 11():69. Giordano J. (2018) Looking Ahead: The Importance of Views, Values, and Voices in Neuroethics-Now. Camb Q Healthc Ethics. 2018 Oct; 27(4): 728-731. doi: 10.1017/S096318011800021X. Giordano J., Gordijn B. (2010) Scientific and Philosophical Perspectives in Neuroethics: Contents. Cambridge University Press. Girn M, Mills C, Christoff K. (2019) Linking brain network reconfiguration and intelligence: Are we there yet? Trends Neurosci Educ. 2019 Jun; 15: 62-70. doi: 10.1016/j.tine.2019.04.001. Epub 2019 Apr 6. Gruzelier, J. (1998). A working model of the neurophysiology of hypnosis: a review of evidence. Contemp. Hypn. 15 3–21 10.1002/ch.112 Gruzelier, J. (2013). EEG-neurofeedback for optimising performance. I: a review of cognitive and affective outcome in healthy participants. Neurosci. Biobehav. Rev.10.1016/j.neubiorev.2013.09.015 Handel, D.L. (2001). Complementary therapies for cancer patients: what works, what doesn’t, and how to know the difference. Tex Med. Feb; 97(2):68-73. Handel, D.L. (2010). Follow-up review of the success rates of hypnosis. Commentary. Am J Clin Hypn. 2010 Jan;52(3):173-5. Hofbauer, R.K., Rainville, P., Duncan, G.H., Bushnell, M.C. (2001). Cortical representation of the sensory dimension of pain. J Neurophysiol. 2001 Jul; 86(1):402-11. Hursthouse R, Pettigrove G. “Virtue Ethics”, The Stanford Encyclopedia of Philosophy (Winter 2018 Edition), Edward N. Zalta (ed.). https://plato.stanford.edu/archives/win2018/entries/ethics-virtue/, Accessed 14 Sept 2018.

48

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

Jensen, M.P., Patterson, D.R. (2005). Control conditions in hypnoticanalgesia clinical trials: challenges and recommendations. Int J Clin Exp Hypn.Apr;53(2):170-97. Kaiser, J., Lutzenberger, W. (2003). Induced gamma-band activity and human brain function. Neuroscientist 9: 475–84. doi:10.1177/1073858403259137. PMID 14678580. Kluft RP. (2015) The Revised APA Division 30 Definition of Hypnosis: An Appreciation, a Commentary, and a Wish List. Am J Clin Hypn. 2015 Apr;57(4):431-8. doi: 10.1080/00029157.2015.1011495.PMID: 25928781 Koch, C. (2004). The quest for consciousness: a neurobiological approach. Englewood, US-CO: Roberts & Company Publishers. p. 429. ISBN 09747077-0-8. Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage. 2002;17(2):732–41. Laureys S, Owen AM, and Schiff ND. Brain function in coma, vegetative state, and related disorders. Lancet Neurol 2004; 3: 537-46. LeDoux J. (2002) Synaptic self: how our brains become who we are. New York: Viking,2002:175-99. Lifshitz, M., Campbell, N.K., Raz, A. (2012). Varieties of attention in hypnosis and meditation. Conscious Cogn. 2012 Sep; 21(3):1582-5. Llinás, R., Paré, D. (1991). Of dreaming and wakefulness. Neuroscience 1991; 44: 119-39. Lynn SJ, Green JP, Kirsch I, Capafons A, Lilienfeld SO, Laurence JR, Montgomery GH. (2015) Grounding Hypnosis in Science: The “New” APA Division 30 Definition of Hypnosis as a Step Backward. Am J Clin Hypn. 2015 Apr;57(4):390-401. doi: 10.1080/00029157.2015.1011472.PMID: 25928778 Mashour, G.A. (2004). Consciousness Unbound. Toward a paradigm of general anesthesia. Anesthesiology 2004; 100: 428-33. Melzack, R. (1998) Pain and stress: clues toward understanding chronic pain. In: Sabourin, M., Craik, F., Robert, M. (eds) Advances in psychological science, vol.2, Biological and cognitive aspects, Psychology Press, Hove, pp 63-85. Melzack, R. (1999) Pain and stress a new perspective. In: Gatchel RJ, Turk DC (eds) Psychosocial factors in pain. Guilford Press, New York, pp89106. Melzack, R. (2001) Pain and the neuromatrix in the brain. J Dent Educ.; 65:1378-1382.

Maria Paola Brugnoli

49

Melzack, R. (2002) Evolution of pain theories. Program and abstracts of the 21st Annual Scientific Meeting of the American Pain Society; March 14-17; Baltimore, Maryland. Abstract 102. Melzack, R., Wall, P.D. (2003). Pain management. Churchill Livingstone. Miller, E.K., Cohen, J.D. (2001). An integrative theory of prefrontal cortex function. Annu Rev Neurosci. 2001; 24():167-202. Miller, G.A., Galanter, E. & Pribram, K.H. (1960). Plans and the Structure of Behavior. Holt, Rinehart & Winston, New York. Montalcini RL. (1970) [Laboratory of Cellular Biology. Department of Neurobiology, Rome] Ric Sci. Jul-Aug 1970;40(4):296-8. PMID: 5500897 [Article in Italian]. Nash, M. R., Barnier, A. J. (2008). The Oxford Handbook of Hypnosis: Theory, Research and Practice. Oxford: Oxford University Press. Negrao, B.L., Viljoen, M. (2009). Neural correlates of consciousness. Afr J Psychiatry 2009; 12: 265-269 BL Néron, S., Stephenson, R. (2007). Effectiveness of hypnotherapy with cancer patients’ trajectory: emesis, acute pain, and analgesia and anxiolysis in procedures. Int J Clin Exp Hypn.Jul;55(3):336-54. Oakley, D.A., Halligan, P.W. (2009). Hypnotic suggestion and cognitive neuroscience. Trends Cogn Sci. 2009 Jun; 13(6):264-70. Oakley, D.A., Halligan, P.W. (2013). Hypnotic suggestion: opportunities for cognitive neuroscience. Nat Rev Neurosci. 2013 Aug; 14(8):565-76. Patterson, D.R., Jensen, M.P. (2014). Hypnosis and clinical pain. Psychol Bull. 2003 Jul; 129(4):495-521. PDQ Integrative, Alternative, and Complementary Therapies Editorial Board. (2016). Levels of Evidence for Human Studies of Integrative, Alternative, and Complementary Therapies (PDQ®): Health Professional Version. PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-.2016 Apr 1. Pellegrino ED., Thomasma DC. (1988) For the Patient’s Good: The Restoration of Beneficence in Health Care by Edmund D. Pellegrino. Oxford University Press Inc. Plato. Charmides. Translated by Jowett, Benjamin – via Wikisource. See original text in Perseus program. https://worddisk.com/wiki/Early_life_of_Plato/ Rainville, P., Duncan, G.H., Price, D.D., Carrier, B., Bushnell, M.C. (1997). Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science. 1997 Aug 15; 277(5328):968-71. Ray, W.J., Slobounov, S. (2002). Modulation and experience of external stimuli: toward a science of experience and interoception. Acta Biol Hung. 2002;53(4):551-8.

50

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

Raz A. (2011) Hypnosis: a twilight zone of the top-down variety Few have never heard of hypnosis but most know little about the potential of this mind-body regulation technique for advancing science. Trends Cogn Sci. 2011 Dec; 15(12):555-7. Raz A. (2004) Atypical attention: Hypnosis and conflict reduction. In Cognitive Neuroscience of Attention ed. Posner M. I., editor. New York: Guilford Press. Raz A., Landzberg KS, Schweizer HR, Zephrani ZR, Shapiro T, Fan J, Posner MI. (2003) Posthypnotic suggestion and the modulation of Stroop interference under cycloplegia. Conscious Cogn. 2003, Sep; 12 (3): 332-46. Raz, A. (2012). Translational attention: from experiments in the lab to helping the symptoms of individuals with Tourette’s syndrome. Conscious Cogn. Sep;21(3):1591-4. Raz, A., Landzberg, K.S., Schweizer, H.R., Zephrani, Z.R., Shapiro, T., Fan, J., Posner, M.I. (2003). Posthypnotic suggestion and the modulation of Stroop interference under cycloplegia. Conscious Cogn. Sep; 12 (3): 332-46. Reich WT. (1978) (Editor). Encyclopedia of Bioethics, Vol. 1. THE FREE PRESS div MACMILLAN PUBL CO; First edition January 1. Roskies A. (2002) Neuroethics for the new millennium. Neuron, 2002; 35 (1): 21–23. doi: 10.1016/S0896-6273(02)00763-8. doi:10.1016/S0896-6273(02)00763-8. Santarcangelo EL, Scattina E. (2016) Complementing the Latest APA Definition of Hypnosis: Sensory-Motor and Vascular Peculiarities Involved in Hypnotizability. Int J Clin Exp Hypn. 2016 Jul-Sep; 64 (3): 318-30. doi: 10.1080/00207144.2016.1171093.PMID: 27267676 Satsangi AK, Brugnoli MP. (2018) Anxiety and psychosomatic symptoms in palliative care: from neuro-psychobiological response to stress, to symptoms’ management with clinical hypnosis and meditative states. Ann Palliat Med. 2018 Jan;7(1):75-111. doi: 10.21037/apm.2017.07.01. Epub 2017 Aug 9. Review. Searle, J. (1990). Consciousness, explanatory inversion and cognitive science. Behavioral and Brain Sciences, 13: 585-642. Searle, J. (1992). The Rediscovery of the Mind. Cambridge, MA: MIT Press. Senkowski, D., Schneider, T.R., Foxe, J.J., Engel, A.K. (2008). Crossmodal binding through neural coherence: implications for multisensory processing. Trends in Neurosciences 31 (8). doi:10.1016/j.tins.2008.05.002.

Maria Paola Brugnoli

51

Shenefelt, P.D. (2011). Ideomotor signaling: from divining spiritual messages to discerning subconscious answers during hypnosis and hypnoanalysis, a historical perspective. Am J Clin Hypn. 2011 Jan; 53 (3): 157-67. Shook JR, Giordano J. A principled and cosmopolitan neuroethics: considerations for international relevance. Philos Ethics Humanit Med. 2014; 9: 1. Smith, E. E., & Jonides, J. (1999). Storage and executive processes in the frontal lobes. Science, 283, 1657-1661. Sporns O, Tononi G, Kötter R. (2005) The human connectome: A structural description of the human brain. PLoS Computational Biology. (September 2005) 1 (4): e42. Bibcode:2005PLSCB.1.42S. Squire, L.R. (2008). Fundamental neuroscience (3rd ed.). Academic Press. p. 1256. ISBN 0123740193. Squire, L.R., Bloom, F.E., McConnell, S.K., Roberts, J.L., Spitzer, N.C., Zigmond, M.J., editors. (2003). Fundamental Neuroscience. 2nd edition. Academic Press,1353-94. Sugarman, L.I., Garrison, B.L., Williford, K.L. (2013) Symptoms as solutions: hypnosis and biofeedback for autonomic regulation in autism spectrum disorders. Am J Clin Hypn.Oct;56(2):152-73. Tononi G, Koch C. Consciousness: here, there and everywhere? Philos Trans R Soc Lond B Biol Sci. 2015 May 19;370(1668). pii: 20140167. doi: 10.1098/rstb.2014.0167. Review. Tononi, G. (2004). An information integration theory of consciousness. BMC Neurosci. 5:42. 10.1186/1471-2202-5-42 Tononi, G. (2008). Consciousness as integrated information: a provisional manifesto. Biol. Bull.215, 216–242. 10.2307/25470707 Vanhaudenhuyse, A., Demertzi, A., Schabus, M., Noirhomme, Q., Bredart, S., Boly, M., et al. (2011). Two distinct neuronal networks mediate the awareness of environment and of self. J. Cogn. Neurosci. 23, 570–578. 10.1162/jocn.2010.21488 Varga, K. (2013). Suggestive techniques connected to medical interventions. Interv Med Appl Sci. 2013 Sep;5(3):95-100. doi: 10.1556/IMAS.5.2013.3.1. Epub 2013 Sep 16. Wark DM. (2008) What we can do with hypnosis: a brief note. Am J Clin Hypn, 2008, Jul;51(1):29-36. Review. Wark DM. (2011) Traditional and alert hypnosis for education: a literature review. Am J Clin Hypn. 2011, Oct;54(2):96-106. Review. Wark, D.M. (2006). Alert hypnosis: a review and case report. Am J Clin Hypn.Apr;48(4):291-300.

52

Neurobioethics of the Modified States of Consciousness in Medical and Psychological Therapy

Willmarth, E.K. (2015) Foreword to the Special Issue: Rediscovering Jay Haley’s Contributions to Hypnosis. Int J Clin Exp Hypn. 63(4):373-5. doi: 10.1080/00207144.2015.1062687. Woody, E., Sadler, P. (2008). Dissociation theories of hypnosis. InThe Oxford Handbook of Hypnosis eds Nash M. R., Barnier A. J., editors. Oxford: Oxford University Press. 81–110. Yapko MD, Barretta NP, Barretta PF. (1998) Clinical training in Ericksonian hypnosis. Am J Clin Hypn. 1998, Jul;41(1):18-28. Yapko MD. (2011) Mindfulness and Hypnosis: The Power of Suggestion to Transform Experience. WW Norton & Co Inc., 2011.

COMMUNICATION WITH PEOPLE IN ALTERED STATES OF CONSCIOUSNESS: TECHNIQUES OF RAPPORT MANAGEMENT KATALIN VARGA

Abstract1 Since individuals in an altered state of consciousness are highly sensitive to suggestion, therapeutic suggestion can be immediately applied to them. However, to be effective, a positive rapport is necessary between the practitioner and the patient. This chapter presents different techniques for establishing, maintaining, and closing the rapport, illustrated with case vignettes.

1. Introduction For millions of years, mankind used the other human being — social support and caring for one another — as main tools of healing and principal remedies. All modern pharmacological and technological possibilities have been made available only for the last “millisecond” of the day of human evolution. There has been a progressive and clear recognition that we can very fruitfully combine ancient remedies and the modern medical arsenal. It is recognized now that the special relationship - called the “therapeutic alliance” – has its own therapeutic value (Mead & Bower 2000). Several experts on this topic stress the importance of the physician-patient relationship. Balint (1957/2000), for example in his book “The doctor, his patient and the illness” stresses “by far the most frequently used drug in general practice was the doctor himself, i.e. that it was not only the bottle of 1

The preparation of this Chapter has been supported by the MTA-ELTE Lendület Adaptation Research Group, supported by the Hungarian Academy of Sciences (project number: LP-2018-21/2018)

54

Communication with People in Altered States of Consciousness

medicine or the box of pills that mattered, but the way the doctor gave them to his patient – in fact, the whole atmosphere in which the drug was given and taken.” (Balint, 1957/2000, p. 1.). Ewin (2009) referring to Emile Coué, a French pharmacist, says “he recognized that the medicines he dispensed were much more effective when he suggested how curative they would be. He finally arrived at a clear definition of the word suggestion, and said that “Suggestion has occurred when there is subconscious acceptance of an idea.” (Coué, 1905 p. 50)”. But how can we make individuals accept our ideas when they are fully occupied by their pain, fear, and anxiety? Coming to our rescue here is the art of “rapport”, “the first and most important objective of any client– practitioner interaction.” (Leach, 2005, p. 262) The modern concept of rapport stresses three key characteristics: (1) mutual attentiveness, i.e., both members of the dyad pay attention to each other, (2) the interaction is characterized by positivity (friendliness, care for each other), and (3) coordination, balance, and harmony can be seen in the course of the interaction between the members of the dyad. (Tickel-Degnen & Rosenthal, 1990, Bernieri, Gillis, Davis & Grahe, 1996). In the medical context, two (or more) people are in “rapport” when they pay attention to each other, cooperate in a progressive fashion, and synchronize their interactions for a common goal.

2. Building, maintaining and transferring rapport Professionals establish and build a rapport, which is part of their task, apart from manual duties or technical interventions. We are in a “winner” position when the rapport builder ensures that the other is paying attention, there is a common goal, an agreement, and preferably a coordinated synchrony between parties. The rapport should be maintained throughout the diagnostic or therapeutic maneuvers and procedures by continuously fostering the client for working together towards the goal. Professionals should continuously convey to patients that they appreciate the cooperation, and their active contribution to the process. When our professional role ends, we need to transfer rapport to the person (another health care professional or relatives) who continues taking care of the patient. If this is a treatment in various consecutive settings, we might even transfer the rapport to ourselves. In this Chapter, I present some examples from my practice, or from the practice of my colleagues, highlighting the general importance of rapport, along with few real-life case vignettes on some techniques of rapport-

Katalin Varga

55

management while communicating with people in trance. Case vignettes are described in detail elsewhere (Varga, 2011, Varga, 2015) but portions directly related to rapport are described here, while protecting the identities of the patients. For an excellent summary of the theoretical models of rapport, I recommend Józsa (2011).

2.1. Rapport building: introducing ourselves Introduction is the first step and a crucial point. Professionals should introduce themselves, regardless of the criticality of the situation. Neglecting basic elements of initial rapport-building rituals may carry unfavorable messages, such as “the situation is too serious, there is no time for that” or (worse) “I am not interested in your personality, therefore I will not show mine”. Vignette #1 is a perfect example of how to introduce oneself. Vignette #1 A young woman rolled into a ditch with her car. In the accident, she bruised her chest, and supposedly some of her ribs also got broken causing her intense pain when breathing. Fortunately, though, she did not suffer any more serious injuries other than these. However, because she could not get out of the severely damaged car by herself, a technical rescue team was also called in for her rescue operation. I arrived on the spot in an ambulance. By this time, more than a hundred onlookers, the police and the fire-service had already gathered at the scene of the accident as well. When we arrived, two firemen were seen kneeling beside the wreck that imprisoned the patient. The young woman kept screaming for help. Her face was distorted with terror and she kept saying that she could not breathe and would suffocate in no time. The injured shows evident signs of stress and disorientation. The attending specialists – it seems – hadn’t been able to calm her down. The situation needed to be resolved in front of a huge audience. When we reached the car, I first made a personal contact with the patient. “My name is Csaba Diószeghy. I am an ambulance doctor, and I will help you to get out of here. I will get you to the hospital as comfortably and as fast as possible. They are already waiting for you there, and soon you will feel much better.” Creating contact was exemplary: the introduction with the full name is the basic element of building rapport. The wording conveys professionalism: from now on an ambulance doctor (as well) tends to the patient. All this can

56

Communication with People in Altered States of Consciousness

also be interpreted as a yes-set preparing the following suggestions: the doctor informs the patient about the immediate goal (getting to the hospital); all this is done with the words “comfortably” and “fast” (positivity). This information concerning the future is followed by a clear, direct suggestion (you’ll feel much better) Dr. Csaba Diószeghy, Anesthesiologist-Intensive Care, Oxyologist-Emergency Medicine Specialist

2.2. Building rapport: getting the attention As people in negative trance usually pay attention to their pain, anxiety, and the panic of people around or some other unfavorable condition, rapport building almost always has to deal with their attention. We need to get their attention somehow and direct it to what we are doing. Then we immediately use suggestions depending to our therapeutic goals (analgesia, blood clotting, relaxation etc.). Often, it is as simple as asking for the patient’s attention, with direct instruction or suggestion. This happened in the case described in Vignette #2. Vignette #2 A man, trapped under a truck in a traffic accident, suffered multiple injuries, and was lying on the road. I applied a very simple method. “Do you hear my voice?” I asked. When he responded, I said, “I’m a local doctor, and I’m asking you to pay attention to my voice. Listen to what I’m saying… Concentrate… concentrate more… even more and more…” The establishment of the rapport begins with a basic question, which on the one hand clarifies a really important detail (whether the voice of the professional reaches the injured); on the other hand, it can also function as a yes-set element, whose following element is communicating the fact that the speaker is a physician. In the given situation, the fact that the injured is immediately dealt with by a professional is a circumstance that deepens trust. The patient’s attention from the presumed pain is now directed towards the physician. The key to the solution is establishing a rapport that someone, amid the enormous panic, is also aware of the person of the injured and professionally applies alternatives that can function even in such a difficult situation.

Katalin Varga

57

Subsequently, additional sophisticated suggestion is applied. The suggestion utilizes the background noises connected to the accident and the rescue (utilization): far from distracting the patient’s attention, they help enhance the patient’s concentration. Additional reinforcement on simultaneously focusing the attention deepens the positive version of the trance-state. Mhairi McKenna MD, Hypnotherapist Vignette #3 shows how special surprising techniques are needed to make the patient pay attention to us and start working together. Vignette #3 While preparing for surgery or when facing any type of injury, or when talking to the critically ill, I frequently raise the following question: “Have you ever considered how wonderful it is that we are not like a plastic bag?” Listeners normally stare at me, waiting for an answer. This not only facilitates rapport but also open patients to therapeutic suggestion on the self-reparatory capacity of our organism: “Plastic bags have no capacity to mend themselves… if there is a rupture.… But the human body has this wonderful capacity to heal itself. Just imagine the complexity of this process. Our body locates the site where repair is needed, cleans it, removes any “garbage” from this area away, and then transports the material needed to heal and rejoin the tissues in the area… and obviously this process makes noise… it is the noise of reconstruction.” Example from my practice

2.3. Rapport building: using special names As described earlier, the key aspects of rapport are positivity, trust, and confidence. Professionals, however, should build rapport quickly with a stranger. Fortunately, Ewin (2009) brought to our attention the importance of names, and as “the patient’s name carries emotion” we can utilize it for rapport building. Ewin says: “I ask a new patient “What do you like your friends to call you? May I call you that? (…) This is an indirect suggestion that I want to be thought of as a friend” (p.44). I used almost verbatim this question with a young patient (Vignette #4).

58

Communication with People in Altered States of Consciousness

Vignette #4 An 18-year-old patient had lost consciousness reportedly as a result of drug overdose. He had been lying on his side for a prolonged period of time as a result of which his left arm had gangrened and had to be amputated from the shoulder down. He remained for 2 weeks in a coma in the hospital intensive care unit (ICU). Psychological support was needed as he was depressed and suicidal. I entered his room, approached him and sat down next to him. He barely looked up at me, which was not a good sign of cooperation. It was obvious that rapport should be built carefully, especially as it was not he who asked for my help, but his physician. We had no connection, and our goals probably were just opposite: he wants to die, we wanted him to survive and recover. I introduced myself: “I am Katalin Varga, a psychologist. Your doctor asked me to contact you.” I started building a rapport by introducing myself and sharing my profession and reason for seeing that patient: simply sharing the facts. I then asked: “How do you think we could cooperate more efficiently: if we are on a first-name basis or otherwise, on a more formal basis?”. This is a therapeutic double-bind. It does not matter what he prefers, in both cases I offer an efficient cooperation. My question also projects a longer perspective: implication of survival, orientation to the future. At this point he just briefly mentions: “First name”. So we do have a promising connection, but the rapport has to be taken care of. So I ask: “What do your friends call you?” He told me: Luis. “Can I call you that, too?” His affirmative nod indicated the acceptance of implied suggestion: our cooperation would be friendly. Following this, an honest and constructive conversation started, and we agreed to work together to help him cope with this new life situation. This included formal hypnosis sessions for the pain in his leg and the phantom pain of his amputated arm. Our cooperation lasted for six sessions, during the intensive care and through the rehabilitation. Example from my practice

Katalin Varga

59

2.4. Building rapport: “we language” The “we language” is another tool to build rapport; not you alone, not me alone: but we together. For instance, instead of “please check what position do you prefer”, it is better to say “let’s check what position do you prefer”. A tiny difference, but “we language” conveys that we are working together, and have common goals. Your concern is my concern. This togetherness can also be reflected by referring to some common characteristics that the professional and patient share: We both prefer cats to dogs. We both visited Paris. We both like to walk in fresh, white snow, etc. Medical communication is a usual practice at my workshops or classes, wherein I give 3-5 minutes to randomly paired persons to find something that characterizes both of them. It is surprising how easy it is. Watkins and Watkins outline a special arithmetic of therapeutic support: if the patient’s problem is 10 units, and his ego-strength is only 5 units, then the therapist should lend 10 units of her ego-strength so that together (5+10=15) they are more than the problem (Watkins and Watkins, 1986). In Vignette #5, a patient needed the support of the midwife. This was provided – among other techniques – by “we-language”. Vignette #5 I met Katalin 6 years ago when she was expecting her first baby. Years later, we met again in the hospital, at her caesarean section. At the morning of her surgery, she was very nervous, and I tried not to leave her alone. She was afraid that her heart would ‘jump out’, or that she would have a panic attack. And she was worried about what would happen in the surgical room. As the first step I told her: “How wonderful is it, that we are here again and soon you can hold your much-awaited baby in your hands! Listen to her calm, rhythmical heart beat; just how peacefully he is waiting to be given birth.” (emphasis is mine, KV) The previous connection provides an excellent opportunity to reestablish good rapport. The mention of ‘again’ reminds her of the previous good rapport as well as anticipating the undeniable success of the first birth (yes-set). But the previous rapport does not guarantee good cooperation this time. A new rapport should be established. That is why the specialist adds the future-oriented key-suggestion (goal): ‘you can soon hold your baby in your

60

Communication with People in Altered States of Consciousness

hands’, mixed with a new fact (his heart beat can be heard). This is further accentuated by carefully selected adjectives, which turn the situation into a pleasant, rhythmical, and peaceful one (reframing). Ágnes Rákócziné Krämer, Midwife, Perinatal Advisor, Lactation Specialist (IBCLC)

3. Maintaining rapport Following rapport building, the professional’s task is to maintain it for which there are several simple techniques: x light physical contact (holding hand, touching shoulder). x we can also reassure the patient by saying: Uhm…. All right… You are doing well….. x another possibility – especially during psychotherapy – is to repeat the main points of the patient’s communication (verbatim or just the main ideas).

3.1. Maintaining rapport: we language In Vignette #6, the “we language” can be observed not only for building but also for maintaining rapport. This is also a good example for how to take over the rapport from someone else (in this case from the mother). Vignette #6 Along with his mother, a six-year old arrives at my dental office suffering from a toothache, which has lasted for days. His cheek is inflamed and he is tired and crabby. I sit next to them in the waiting room, and introduce myself to him and to his mother. As a non-verbal form of pacing, I go to the waiting room instead of expecting the next patient to come to my domain. It may seem as a waste of time at first, but this will indeed be a good investment in the future if cooperation goes well. This gesture expresses adaptation, attention, and patience (‘I have time’) towards the patient. Congruent with this, I introduce myself first to the child. This supports the child’s autonomy, giving a sense of control. Children in general, but especially when in trouble, are in close rapport with their parents, in this case with the mother. Rapport building should be formulated so that the rapport has to be taken over from the mother.

Katalin Varga

61

“You probably know that doctors work in order to help you and the other children,” I say. Referring to this fact strengthens the sense of control (the boy surely knows this). The position of the dentist is defined as “help”, that anticipates collaboration. The undeniable facts are preparing a yes-set. There is a fish tank with a couple of colorful fish in it in the waiting room. I point to it and say: “It often happens that children with similar symptoms tell the fish how brave they were in the dentist’s chair just before they go home.” New elements of the yes-set precede the main, future-oriented suggestion: the child will be brave and go home. The attention is directed to the future: following the treatment. This goal — going home — is attractive to the child, especially as it will be following a successful ‘helping” treatment. Furthermore, ‘other children’ also survived the situation, as they were brave. The modelling sets an example to the still-frightened boy. “Maybe you will want to talk to them too, won’t you?” The question actually is an indirect suggestion: lead to a strong answer: ‘of course’. Following this, the young patient smiles and bravely enters my office. The boy tells his problem without me asking, and points to where it hurts. I show him the dental mirror. He takes it into his hand and examines it. Together we have a look at his teeth. The child’s sense of control is further supported by introduction of the tools, explanation of the steps of the treatment, and examination in cooperation. “Have you noticed how this little tooth wiggles? Maybe the tooth fairy is waiting for it under your pillow already. Look, this pretty little corner is the first sign of your new tooth that would like to come out. Let’s help this new tooth to pop up, should we?” The two friendly questions refer to the unavoidable fact that it needs to be pulled out, which is further justified by the new tooth trying to come out. Based on the already established rapport and sense of control, the cooperation is very probable. Especially since as a dentist, I invited the boy with ‘we language” ‘Let’s help him!’, even to the decision making ‘Should we?’. He is checking his teeth in the mirror with bright eyes and a wide-open mouth. “You just keep your mouth open, we push your milk-tooth out of the way, like a snowdrop sticks its head out from underneath the snow at the end of winter and pushes its hat away. Look, it’s out already! We are going to wrap

62

Communication with People in Altered States of Consciousness

it up so that you can put it under your pillow for the fairy. You have done very well!” I clearly and positively formulate the expected behavior (not denying the non-preferred one). The intervention is reframed as ‘push away’ and something to do together. This is accompanied by a sweet metaphor, and the magic image of the fairy mentioned previously. Explicitly complementing the child further strengthens his sense of control. The boy examines his tooth in the mirror and notes the result with contentment. I accompany the young patient back to the waiting room and observe as the boy tells the fish happily that his nice and new tooth has come out like a snow-drop. This is an important experience for myself as a dentist, as I can tell the next patient with conviction that the fish are happy to listen stories of interventions. Krisztina Varga, Dentist

3.2. Building and maintaining rapport: synchrony Theoretical approaches of rapport building stress interactional synchrony as a key element (Tickel-Degnen & Rosenthal, 1990, Bernieri, Gillis, Davis & Grahe, 1996). The authors define synchrony as “The smooth meshing of interaction” (Bernieri and Rosenthal, 1991, p. 403). Feldman (2015) stresses the crucial role of synchrony in early development, normally with the mother. In a fortunate situation, a child enjoys regular synchrony with the child’s mother. “A synchronous interaction is the one that involves shared affection, joint attention, and responsivity on the part of both parent and child” (Skuban, Shaw, et al., 2006, p. 424). In medical context, a synchronous interaction may serve as the resemblance of exercising maternal care and attention (for details, see Varga, 2013). An extremely special instance of rapport building and maintaining is described by an intensive care clinical psychologist (Vignette #7). In a chaotic situation, there was no possibility for verbal communication between the psychologist and the critically-ill patient. Vignette #7 is a good example for the possibility to build non-verbal rapport: connection can be established even under difficult circumstances.

Katalin Varga

63

Vignette #7 A man in his 60s is admitted to the ICU following complications of hip operation. He is still half-asleep, but as 5-6 people rush to treat him and to set the appropriate machines and drains, he resists firmly. A nurse asks me to hold his hand while she takes his blood. I start to squeeze his wrist. I try to do it firmly, then I suddenly let it go, as a result of which he relaxes his hand too. I start to stroke his hand. He first relaxes, but gradually starts to fight back again. This of course is not surprising; a vulnerable, half-unconscious man is being assaulted by multiple painful pokes, strange pulling, and touching from every direction. Amidst this chaos, I try to speak to him, but it surely is difficult for him to listen. I cannot get near his head either. I squeeze his hand again, and he relaxes again when I do. During such a break, I start to tap a simple rhythm on his palm. I interrupt the sequence sometimes. In response he scratches my palm and I stroke his hand. When we lose the synchrony, he becomes tense again, and I start all over: I squeeze his hand firmly, let it go, he relaxes, then I tap the rhythm on his hand. The same simple rhythm every time. He scratches back. My mind wonders off. He keeps fighting, and all I can do is tiredly hang onto his hand. Suddenly he relaxes again, and I realize he does not just scratch, but taps the rhythm on my palm. Adrienn K. Szilágyi, Clinical Psychologist It is interesting to imagine this situation from the perspective of the patient, who is in a critical state. Many professionals are working ‘with his body’, touching him, performing various interventions, some invasive. Amidst this, he is able to find and be in contact – bi-directionally communicate - with the one who is in synchrony with him. To recall, joint rhythm, and harmonious interaction are key elements of rapport.

4. Take-over of rapport Often, patients are referred to us by colleagues. In this case, building a rapport is usually easier, as we can rely on the already-established rapport with other specialists. Vignette #8 not only exemplifies the take-over of rapport, but also shows how to build rapport with the patient’s relatives. The key to good cooperation is positive attitude of the whole family.

64

Communication with People in Altered States of Consciousness

Vignette #8 A physician asked for advice concerning a patient, who I learned suffers from high cholesterol and was recently also diagnosed with diabetes (about 2 weeks ago), for which he needs to take insulin. However, he has already been informed about this at another hospital. He arrived with his wife and daughter. They were quite anxious, and the little girl was bored. “My name is Kriszta Kertész, I am a dietician. You did well coming here to discuss the details of the diet. The reason why the doctor didn’t give you any medication for the cholesterol is because you can achieve a lot with the appropriate diet.” Informing during rapport-building is based on facts: they came to see the dietician. This is welcomed by the specialist (positivity), and expresses the other – might not be expected – advantage (positivity again): the diet helps with cholesterol (informing). I subsequently started the consultation. I briefly mentioned the blood sugar level as well, which was followed by the wife’s surprise: Really? He can eat this? I asked what she was told at the other hospital. It turned out that for 2 weeks, since he was diagnosed with diabetes, his wife was anxious and did nothing but cry out of desperation. She wanted to provide the best possible diet for her husband, but they had forbidden everything. The couple is desperate because of the double whammy- diagnoses of cholesterol and diabetes. They feel that they cannot cope and follow these events. It turned out that at the other hospital, they had received consultation, but only obtained conventional information, which reveals an overweight person on pills as well as a normal-weight young man on insulin. I started to encourage them and reframe the information and food prohibitions they previously received. “In fact, this is not a diet, but a healthy way of eating. Everyone should eat and live like this. This is a healthy lifestyle that we are talking about here. We will develop an individually tailored diet together, taking into consideration sport habits, feasts, and special occasions. He can live a full life; he doesn’t need to give up anything.” This easy approach helps develop a solution together that suits the family’s lifestyle. The specialist reframes the situation: she approaches it not from the perspective of banned things but emphasizing that this healthy diet should be followed by everyone. As this communication influences the

Katalin Varga

65

lifestyle of the whole family, managing the rapport for the moment is not enough. The solution should be extended to the future. Krisztina Kertész, Dietitian

4.1. Take-over of rapport: without preparation Often, we can build a rapport by following a colleague, but without any preparation. Here, the patient is not specifically referred to us, and the ground is not prepared. Nevertheless, we can build a rapport with the patient, because we have a good rapport with the colleague, as shown in Vignette #9. Vignette #9 A woman with a complex bone fracture is admitted to the ICU following surgery. At post-surgery, in the morning, her wound started to bleed severely. The orthopaedic surgeon recommended pressure bandage, which had just been started when I reached the ICU. The woman screamed in pain. I had already learned at the handover that the anaesthesiologist used spinal anaesthetic and nerve blockade. The surgery itself lasted for 3.5 hours and the patient received 3 units of blood. Immediately after surgery, things appeared normal without any bleeding, the anaesthetics appeared to work, and the patient complained of no pain before feeling the pressure of the wound. When I stepped to her bed, she was short of breath, her eyes were shut and she screamed occasionally of pain. “Good morning, I am Doctor Székely. I can see that your wound hurts a lot.” “Yes it does”, replied the patient. The physician starts with presenting himself and welcoming the patient according to the time of day: as we saw earlier, this is the “default” way of establishing rapport. Wishing ‘good morning’ implies that the problem is not as severe as not to follow the usual protocol, and also a possibility to apply a positive word (good), even if it seems just an element of a routine utterance. “I am an anaesthesiologist working in this hospital. Like the one who made your surgery, pain-free yesterday. I came to help.” The patient looked up at the physician: first sign of attention, the contact is starting to be established. The physician ‘takes over the rapport’ from the anaesthesiologist of the previous day. The physician defines his function as ‘helper’: another bite of

66

Communication with People in Altered States of Consciousness

positivity. As the surgery yesterday was pain-free, the evolving rapport is associated with success. A more sophisticated technique — a yes-set — is forming below the surface; (1) I am Dr Székely, (2) I can see your wound hurts a lot, (3) I am an anaesthesiologist working in this hospital, (4) like the one who made your surgery pain-free yesterday. This set of undeniable facts – that most probably evoke an internal “yes” in the patient – is to prepare the targetsuggestion: I came to help. “Everything was all right yesterday, wasn’t it? You didn’t feel any discomfort during the surgery, did you?” The physician is not simply applying a new positive idea by telling ‘it was all right yesterday’, but as he is asking it, there is an expectation for answer. And he receives a confirmatory response (all right) from a patient who half a minute ago was complaining ‘hurts a lot’. “No, it was all right yesterday.” “We can help you today as well to make you as comfortable as possible. And you can help with this too.” By simply linking yesterday with today, the physician repeatedly offers help. The goal, which the physician summons is obviously attractive to the patient in pain, especially that this is also formulated positively: as comfortable as possible. The patient opens up to the idea of collaboration. She asks: “How?” “Look at me and hold my hand. I will help you slow down the breathing. You will feel lighter! Take a deep breath (I lift up her hand a little), then exhale slowly” (I put down her hand). The rapport is strengthened by eye contact, and touch, with a repetition of the intention to help. The important suggestion (you will feel lighter) is linked to the easy-tocontrol exercises (look at me, hold my hand). The physician conducts the patient with the movement of his hand as well. Clear suggestions concerning the breathing are connected to the joint movements. There is a synchrony between the movement of the physician and the patient, and a developing synchrony of the breathing rhythm that was 40-50 breaths per minute at the beginning. “Now together!” (I breathe with her, holding her hand: I lift it up then down, slowly decreasing the rhythm). “Can you see how easy it is? You might not have thought of just how simply this can be!” The two individuals’ synchronicity is expressed at both, physiological and explicitly behavioural levels. The physician raises the patient’s attention to the success, calling it ‘simple’.

Katalin Varga

67

Following these suggestions and joint activity with the physician, the patient managed to bear the pain. She was concentrating on her breathing. Even if the pain was visible on her, the bleeding practically stopped, and she did not need any further transfusion. Dr. Gábor Székely, Anesthesiologist, Intensive-therapy specialist, Psychologist

5. Transferring rapport: Introducing the next specialist Upon successfully managing and establishing a good and cooperative rapport with a patient, it is important to utilize it, and/or transfer it to our colleagues. We can facilitate to reach a trustful, still cooperative relationship with another person. This happened in the case described in Vignette #10. Vignette #10 An elderly patient in the ICU barely managed to communicate during assisted breathing. After three unsuccessful attempts at extubation, his exhaustion wore him out and he had to revert to the ventilator. The physician contacted the patient, who was complaining. “I would like to go home.” “Good. When would you like to go home?” “Now” It is very important that the physician justifies the wish of the patient: go home. Objective logic would say that is impossible in his actual condition. But the physician utilizes it as a good source of motivation: he surely would not go home; only the exact time needs to be clarified. The patients feels understood, the “pacing” is ready, the physician can go on with “leading”: “Would you like to know what you need to do to go home as soon as possible?” “Yes, I would.” The yes response is the first sign of cooperation. This is the point where the physician can, and does, prepare the ground for the next specialist, transferring the rapport to the physiotherapist. “I’ll tell you. We have a physiotherapist here, whom I will shortly introduce you to. She will help you today. She will tell you how best you can use your lungs now that you have regained your strength in the last couple of days. She will show you how to do breathing exercises so that you can do them on your own. You will nicely cough out the discharge and everything else that needs to come out. All right?”

68

Communication with People in Altered States of Consciousness

“Yes.” Dr. Gábor Székely, Anesthesiologist, Intensive-therapy specialist, Psychologist Transferring rapport can performed generally, and not only to a specific colleague, as shown in Vignette #11. Vignette #11 A young ICU patient wanted to leave the hospital. Following rational explanation and several suggestive techniques, I ended this session by telling him: “Please feel free to ask any questions or queries of who you feel you can trust the most, should it be the nurse, physician, or me, and we will find answers for you.” I use the “question or query”, rather than problem or complaint, with the intention of maintaining a cordial atmosphere following the initial desperately mistrustful situation. I transferred the patient’s good rapport with me to a wide range of colleagues, or to even myself: we all could provide reassuring answers to future questions. The therapeutic double-blind guarantees the appropriate solution, no matter whom he might choose. At the same time this is a future-oriented perspective, indirectly suggesting survival, which strengthens the acceptance of staying in the hospital. Example from my practice

6. Destroying rapport The rapport should be “destroyed” in some special cases, such as when it is unhelpful to be bound to someone who promised to be a good partner for achieving a desired goal, as noted in Vignette #12. Vignette #12 A good friend, Adel, contacted me crying when she learned that her obstetrician will not be there at the time of her elected cesarean surgery. She was desperate and helpless “without her doctor”. As I was aware that it will be a cesarean, and another obstetrician will attend to the surgery, I weakened the rapport between the “loved” obstetrician and Adel.

Katalin Varga

69

“There are not too many ways to open a can. Everyone uses the canopener practically the same way. There are not too many ways of performing a cesarean. It’s all the same, no matter which obstetrician is doing it.” Following this suggestion, Adel calmed down, and even smiled. The surgery with the alternate obstetrician-in-charge went well. Even years later, Adel mentions my “can opener” metaphor with a good feeling. Example from my practice.

7. Closing remarks Because we, professionals, risk our mental health by being in close rapport with patients who are suffering, dying or in distress, special techniques should be used to maintain our physical and mental health. There are various highly personalized techniques and one tried and tested strategy is to withdraw our mental and emotional energy from the patient and close the rapport. We can close the “professional (internal) file” while washing our hands between patients. A deep breath or closing the actual – paper or electronic – file could serve to close our actual rapport with the given patient, especially when a professional sees several dozens of patients in a shift. A highly challenging situation is when our patient dies. In this case, we should also manage our “rapport” with that patient. Based on the reflections of a neuropsychologist’s personal diary concerning emotional involvement with her patients, when a patient dies, she writes her feelings, and when there is nothing else to say she writes: “God rest him soul in peace”, and internally surveys her feelings. If she senses that the rapport really can be “withdrawn” she dots the end of the sentence. This is her ritual for closing the rapport. The main avenue to burn out is to leave our emotional involvement unacknowledged, without reflections, and let the rapport with various patients open, overlapped, and jammed. Excellent examples and exercises of this reflective work have been reported by Carolusson (2011).

70

Communication with People in Altered States of Consciousness

References Balint, M. (1957/2000) The doctor, his patient and the illness. 2nd edition, Churchill Livingstone: London. Bernieri, F. J., Gillis, J. S., Davis, J. M., & Grahe, J. E. (1996) Dyad rapport and the accuracy of its judgment across situations: A lens model analysis. Journal of Personality and Social Psychology, 71(1), 110-129. Bernieri, F. J., Rosenthal, R. (1991) Interpersonal coordination: Behavior matching and interactional synchrony. In: Feldman, R. S., Rimé, B. (ed.) Fundamentals of nonverbal behavior. Cambridge University Press, Cambridge, 401-431. Carolusson, S. (2011) There is someone in there Recito Förlag Coué, E. (1905). L’Autosuggestion et son Application Pratique. Les Editions des Champs-Elysées, Paris. Ewin, D. (2009) 101 things I wish I’d known when I started using hypnosis. Crown House Publishing Ltd, Carmarthen Feldman, R. (2015). Sensitive periods in human social development: New insights from research on oxytocin, synchrony, and high-risk parenting. Development and Psychopathology, 27(02), 369–395. Józsa E (2011) The concept and role of rapport in medical communication in: Varga K. (ed.) (2011) Beyond the words. Communication and suggestion in medical practice. Nova Science Publisher, New York. 5774. Leach, M.J. (2005) Rapport: A key to treatment success. Complementary Therapies in Clinical Practice, 11(4), 262–265. Mead, N. & Bower, P. (2000) Patient-centeredness: a conceptual framework and review of the empirical literature. Social Science & Medicine, 51(7), 1087-1110. Skuban, E. M., Shaw, D. S., Gardner, F., Supplee, L. H., Nichols, S. R. (2006) The correlates of dyadic synchrony in high-risk, low-income toddler boys. Infant Behaviour and Development, 29, 423-434. Tickle-Degnen, L. & Rosenthal, R. (1990) The Nature of Rapport and Its Nonverbal Correlates. Psychological Inquiry, 1(4), 285-293. Varga K. (2013) The phenomenology of hypnotic interaction Nova Science Publisher, New York. Varga K. (2015) Communication strategies in Medical Settings. Peter Lang, Frankfurt am Main. Varga, K. (2017) Suggestive techniques without inductions for medical interventions. In: Jensen M. P. (ed.) The Art and Practice of Hypnotic Induction: Favorite Methods of Master Clinicians, edited by, Denny Creek Press, pp.114-135.

Katalin Varga

71

Varga, K. (Ed.). (2011). Beyond the words: Communication and suggestion in medical practice. New York, NY: Nova Science Publishers. Watkins, J. G., & Watkins, H. H. (1986). Ego states as altered states of consciousness. In B. B. Wolman, & M. Ullman (Eds.), Handbook of states of consciousness (133-158). New York: Van Nostrand Reinhold.

CLINICAL ETHICS IN SITUATIONS OF SERIOUS AND CHRONIC DETERIORATION OF THE STATE OF CONSCIOUSNESS FRANCISCO BALLESTA

Abstract Care of patients with serious and chronic deterioration of consciousness presents a considerable challenge for health systems. Throughout recent history, we have witnessed the resolution of many of these cases with the suppression of life. Why is this happening in contradiction with the most elementary criteria of clinical ethics? What are the measures that should be put into practice with these patients?

1. Introduction Patients with severe and chronic deterioration of consciousness present an enormous challenge for health systems and a constant source of controversy in bioethical circles. Here, we present an analysis of the ethical criteria that must be considered regarding clinical decisions taken in relation to this type of patient. At the end, the reader must be able to 1) identify the criteria that should regulate the care of this type of patient in connection with the Therapeutic Alliance paradigm, 2) make a list of the most important measures that must be implemented in the healthcare of these patients, 3) explain factors that, in the current cultural context, hinder the appropriate care of these patients. To achieve these objectives, we will briefly discuss the following topics: 1) general criteria of clinical ethics, 2) application of these criteria to the care of patients in a situation of serious and chronic impairment of the state of consciousness, 3) presentation of some positive exemplary cases, 4) presentation of some negative exemplary cases, and 5) analysis of the circumstances that promote the dissemination of negative exemplary cases.

Francisco Ballesta

73

Our reflections are assisted by discussions resulting from the International Congress on “Life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas”, organized by the World Federation of Catholic Medical Associations (FIAMC) and the Pontifical Academy for Life (PAV), held in Rome (17-20 March 2004).

2. General criteria of clinical ethics The starting point is the therapeutic alliance established between the physician and the patient with a clear and precise objective. The therapeutic alliance exists to preserve the life and care of the patient’s health. Another important element is the basic right to receive care provided to one’s own situation of need in health matters. In this general context, some other principles must be specified. In the first place, a fundamental element of the therapeutic alliance is the consent, on the part of patients, to the actions of the health personnel on them. Thus, in an ordinary way, consent, is something tacit, is presupposed, and is granted in various ways, usually with the simple “no opposition”. In special situations, procedures are required to document patient consent. Second, given the purpose of the therapeutic alliance, the patient cannot demand, nor can the physician implement, measures not aimed at preserving life and restoring health, or involving therapeutic obstinacy. Third, the priority of clinical judgment must be considered when establishing therapeutic measures. Regarding this point, it should be noted that clinical judgment is formulated exclusively based on the risk versus benefit balance for life and health of the patient, without being influenced by other criteria such as residual quality of life, sociological and economic criteria etc.

3. Application to patients with serious and chronic deterioration of consciousness Firstly, the relationship of healthcare personnel to patients with severe and chronic impairment of consciousness is also a therapeutic alliance and the general criteria described above applies to these patients. Second, these patients, like any other, have the right to receive the necessary care for the preservation of their lives and the improvement of their clinical situation. In this context, the reference points outlined in the Congress (FIAMC and PAV 2004, 580) on “Life-sustaining treatments and vegetative state: scientific advances and ethical dilemmas” underline some of these cares:

74

Clinical Ethics in Situations of Serious and Chronic Deterioration of the State of Consciousness

a) “Correct and thorough diagnostic evaluation to avoid possible mistakes and to orient rehabilitation in the best way.” b) “Basic care, including hydration, nutrition, warmth, and personal hygiene.” c) “Prevention of possible complications and monitoring for any possible signs of recovery.” d) “Be treated as any other patient with reference to general assistance and affective relationships.” Another element, not mentioned in this document, is the treatment, not just the prevention, of the possible complications that may arise. This is done with any “normal” patient but it is debated whether, in the case of patients with severe and chronic deterioration of consciousness, it would not be a matter of therapeutic obstinacy. Obviously, this hypothesis departs from the principles that we have mentioned previously and supposes an unfair discrimination in the consideration of these patients.

4. Some positive exemplary cases We consider positive exemplary cases where the general criteria that we established earlier have been applied to prolong the life of patients with preservation of their quality. Some of these cases are those of Elaine Esposito (1978, USA) (Lewiston Evening Journal 1978), Edwarda O’Bara (2012, USA) (Cavaliere 2012), Aruna Ramchandra (2015, India) (BBC News 2015) and Cristina Magrini (2019, Italy) (Boffi 2019). We invite the reader to study them in detail.

5. Some negative exemplary cases We consider negative exemplary cases where the previously established general criteria have not been applied, resulting in the abbreviation of the lives of these patients through various euthanasia-type measures, mainly the deprivation of food and hydration. Accompanied by abundant controversies in bioethical environments and social communication media, they are better known than positive exemplary cases. Some of these cases are those of Karen Ann Quinlan (1985, USA) (McFadden 1985), Nancy Cruzan (1990, USA) (Annas 1990), Anthony Bland (1993, UK) (Cole and Duddington 1993) (Finnis 1993), Terry Schiavo (2005, USA) (Hook and Mueller 2005), Eluana Englaro (2009, Italy) (Striano, Bifulco, and Servillo 2009) (Luchetti 2010) (Moratti 2010) and Vincent Lambert (2019, France) (Kishore 2016) (Veshi 2017) (Breeden 2019). We invite the reader to study them in detail

Francisco Ballesta

75

to realize the anomalies found, in each one of them, in relation to the reference criteria.

6. Cultural factors that handle the due care of patients with serious and chronic deterioration of consciousness The analysis of negative exemplary cases gives rise to the question of why these cases occur when the ethical criteria that should be applied are so clear? To answer this question, evidence from a series of cultural factors that interfere with its application, with dire results will be analyzed, including seven elements in particular that we consider to be of special importance. 1. The therapeutic alliance has been subtly deformed by the influence of principialism. This bioethical paradigm, currently dominant, does not adequately reflect the anthropological reality, which forms the basis of the physician-patient relationship and produces serious problems. One of the problems is the opposition between the physician and the patient, understood more as a conflict of powers (paternalism / autonomy) than as an alliance. Related to this is also the fact of having lost sight of the purpose of this relationship, the common goal that the alliance causes, which is nothing other than the promotion of the patient’s life and health. The loss of this element completely disfigures the therapeutic alliance that becomes a struggle of wills, subjected to the law of the strongest, the opposite of a collaboration around a common goal. 2. Confusion resulting from the clinical situation of patients with severe and chronic deterioration of consciousness compared to that of a terminal patient (immediate and inevitable death), applying to the former, criteria that are only valid in the case of terminal patients, such as orders of no-resuscitation or of do-not-treat complications that arise in the course. Let us recall that patients in a vegetative state cannot, in any way, be considered terminal patients, since their condition can be stable and enduring.” (FIAMC and PAV 2004, 580) 3. The consideration of artificial feeding and hydration as therapy (which could be legal not to implement or withdraw) instead of considering them as ordinary care such as hygiene and nursing care that is not legal to eliminate. In this regard, we have to recall the words of Pope John Paul II to participants in the aforementioned Congress: “[…] I should like particularly to underline how the administration of water and food, even when provided by artificial

76

Clinical Ethics in Situations of Serious and Chronic Deterioration of the State of Consciousness

means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering.” (Pope John Paul 2005, 274). 4. Regarding the confusion between the value of people (their dignity) and the quality of their lives, the texts of the Congressional documents that we are taking into consideration are very clear: “We acknowledge that every human being has the dignity of a human person […] Such a dignity, based on human nature itself, is a permanent and intangible value that cannot depend on specific circumstances of life and cannot be subordinated to anyone’s judgment […] We recognize the search for the best possible quality of life for every human being as an intrinsic duty of medicine and society, but we believe that it cannot and must not be the ultimate criterion used to judge the value of a human being’s life.” (FIAMC and PAV 2004, 580). “Considerations about the ‘quality of life’, often actually dictated by psychological, social, and economic pressures, cannot take precedence over general principles […] Moreover, to admit that decisions regarding man’s life can be based on the external acknowledgment of its quality, is the same as acknowledging that increasing and decreasing levels of quality of life, and therefore of human dignity, can be attributed from an external perspective to any subject, thus introducing into social relations a discriminatory and eugenic principle.” (Pope John Paul 2005, 274) 5. Make the value of life depend on the will (explicit or supposed, current or manifested in advance) of the people. Taking the power of personal autonomy to this extreme leads to the absurdity of suppressing the basis of autonomy itself. “We acknowledge that the dignity of every person can also be expressed in the practice of autonomous choices; however, personal autonomy can never justify decisions or actions against one’s own life or that of others: in fact, the exercise of freedom is impossible outside of life.” (FIAMC and PAV 2004, 580). 6. The reduction of life to a legal category, a legal asset to protect that could conflict with other legal rights such as autonomy. Law, with its own vocabulary and methodology, could be opening a gap in something as fundamental as the identification of the person, in the first place, with one’s physical existence, one’s life. Separating these

Francisco Ballesta

77

aspects leads us to the absurdity of seeing the suppression of the person as ethically correct for the sake of another legal good. (Ballesta Ballester 2019, 95-96) 7. The more or less implicit consideration of these people as a family, social burden... It is unquestionable that patients, in the situations we are considering, require a great deal of care and resources. This fact, if not counteracted with a constant action that reinforces the consideration due to these people, can cause their reduction to the burden and the devaluation of their dignity. In this regard, the following texts, which may also serve as a conclusion, enlighten us. “(Vegetative state) patients cannot be considered as ‘burdens’ for society; rather, they should be viewed as a ‘challenge’ to implement new and more effective models of health care and of social solidarity.” (FIAMC and PAV 2004, 581). “It is necessary, above all, to support those families who have had one of their loved ones struck down by this terrible clinical condition. They cannot be left alone with their heavy human, psychological, and financial burden. Although the care for these patients is not, in general, particularly costly, society must allot sufficient resources for the care of this sort of frailty, achieved through appropriate, concrete initiatives such as, for example, the creation of a network of awakening centers with specialized treatment and rehabilitation programs; financial support and home assistance for families when patients are moved back home at the end of intensive rehabilitation programs; the establishment of facilities that can accommodate patients without families to deal with the problem or to provide “breaks” for those families who are at risk of psychological and moral burn-out.” (Pope John Paul 2005, 275)

References Annas, G. J. 1990. “Nancy Cruzan and the Right to Die.” N Engl J Med 323 (10): 670–73. https://doi.org/10.1056/NEJM199009063231010. Ballesta Ballester, Francisco José. 2019. La Comisión Palacios: Una Bioética Que No Es Ética: Editorial Académica Española. BBC News. 2015. “Aruna Shanbaug: Brain-Damaged India Nurse Dies 42 Years After Rape.” Accessed October 03, 2021. https://www.bbc.com/news/world-asia-india-32776897. Boffi, Emanuele. 2019. “Cristina Magrini, 38 Anni in Stato Vegetativo E Neanche Una Piaga: È Morta a Bologna La Donna Accudita Per Quasi

78

Clinical Ethics in Situations of Serious and Chronic Deterioration of the State of Consciousness

Quarant’anni Dal Padre Romano. Un Uomo Dal Coraggio Leonino E Dalla Fede Mai Esibita.” Accessed October 03, 2021. Breeden, Aurelien. 2019. “Vincent Lambert, Frenchman at Center of Rightto-Die Case, Dies at 42.” The New York Times, July 11, 2019. https://www.nytimes.com/2019/07/11/world/europe/vincent-lambertdead.html. Cavaliere, Victoria. 2012. “Florida Woman Dies After Spending 42 Years in a Coma Florida Woman Dies After Spending 42 Years in a Coma Florida Woman Dies After Spending 42 Years in a Coma.” Daily News, November 28, 2012. http://www.nydailynews.com/news/national/florida-woman-dies-42years-coma-article-1.1207154. Cole, A. P., and J. G. Duddington. 1993. “Dangers of the Bland Decision.” Bulletin of medical ethics No. 85: 2. FIAMC, and PAV. 2004. “Considerations on the Scientific and Ethical Problems Related to the Vegetative State.” The national Catholic bioethics quarterly 4 (3): 579–81. Finnis, J. M. 1993. “Bland: Crossing the Rubicon?” The Law quarterly review 109: 329–37. Hook, C. Christopher, and Paul S. Mueller. 2005. “The Terri Schiavo Saga: The Making of a Tragedy and Lessons Learned.” Mayo Clinic Proceedings 80 (11): 1449–60. https://doi.org/10.4065/80.11.1449. Kishore, R. R. 2016. “Vincent Lambert, Dignity in Dying and the European Court: A Critical Evaluation and the Global Reflections.” Eur J Health Law 23 (2): 141–57. https://doi.org/10.1163/15718093-12341381. Lewiston Evening Journal. 1978. “Elaine Esposito Dies After 37 Years in Coma.” November 27, 1978. https://news.google.com/newspapers?id=guApAAAAIBAJ&sjid=t2UF AAAAIBAJ&hl=es&pg=1280%2C3590088. Luchetti, Marco. 2010. “Eluana Englaro, Chronicle of a Death Foretold: Ethical Considerations on the Recent Right-to-Die Case in Italy.” Journal of Medical Ethics 36 (6): 333–35. https://doi.org/10.1136/jme.2009.034835. McFadden, Robert D. 1985. “Karen Ann Quinlan, 31, Dies. Focus of ‘76 Right to Die Case.” The New York Times, June 12, 1985. https://www.nytimes.com/1985/06/12/nyregion/karen-ann-quinlan-31dies-focus-of-76-right-to-die-case.html. MORATTI, SOFIA. 2010. “The Englaro Case: Withdrawal of Treatment from a Patient in a Permanent Vegetative State in Italy.” Camb Q Healthc Ethics 19 (3): 372–80. https://doi.org/10.1017/S0963180110000150.

Francisco Ballesta

79

Pope John Paul. 2005. “Address of Pope John Paul II to the Participants in the International Congress on “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas”, Saturday, 20 March 2004.” NRE 19 (4): 273–75. https://doi.org/10.3233/NRE-2004-19402. Striano, Pasquale, Francesca Bifulco, and Giuseppe Servillo. 2009. “The Saga of Eluana Englaro: Another Tragedy Feeding the Media.” Intensive Care Med 35 (6): 1129–31. https://doi.org/10.1007/s00134-009-1484-6. Veshi, Denard. 2017. “Comments on the Lambert Case: The Rulings of the French Conseil D’état and the European Court of Human Rights.” Med Health Care and Philos 20 (2): 187–93. https://doi.org/10.1007/s11019-016-9724-3.

LAW AND CONSCIOUSNESS ALBERTO GARCÍA GÓMEZ & ANA MARIA GANEV

Abstract Considering that law is the interface where public policy meets individual behavior, it is for its potentially immediate practical applications with social and political consequences that law and neuroscience ought to collaborate in a cross-disciplinary manner. While cognitive neuroscience studies the brain processes that underlie thought and human behavior, legal systems are concerned with the regulation of human behavior. It is therefore reasonable to claim that both disciplines are destined to be “natural partners”. More specifically, human behavior is the product not only of genetics and physical brain functions, but also of other processes such as rational planning and self-reflection. How one sees oneself is linked to the nature of one's relationships with others and the rules that guide those relationships. This essay will highlight the importance of consciousness, considered as a conscious awareness of self, and how it shapes the concept of psychosocial integrity, which is one of the fundamental values that is recognized, respected and protected by the 2005 UNESCO Universal Declaration on Bioethics and Human Rights and the Compendium of the Social Doctrine of the Church.

1. Law and Consciousness Partnership The intersection of neuroscience and the law on many levels and on various issues, and more so the combined study of these two fields has given rise to a new discipline, Neurolaw. While cognitive neuroscience studies the brain processes that underlie thought and human behavior, legal systems are concerned with the regulation of human behavior. It is therefore reasonable to claim that both disciplines are destined to be “natural partners” (Goodenough & Tucker 2010; Ienca & Andorno 2017).

Alberto García Gómez & Ana Maria Ganev

81

As a matter of fact, it is the organization and functioning of the brain that determines how we enact and obey laws. Why should the law be concerned about novel neuroscientific discoveries and processes? Considering that law is the interface where public policy meets individual behavior, it is for its potentially immediate practical applications with social and political consequences that law and neuroscience ought to collaborate in a cross-disciplinary manner. One risk on the part of the law is to remain silent or still, paralyzed by both scientific unfamiliarity and ethical disorientation. There are real problems that claim our attention, which the legal system will have to face while neurobiological studies continue relentlessly to probe the human mind, i.e. the reasons for our actions, emotional states, decision-making processes, aesthetics, morality issues such as free will and responsibility, and the link between consciousness and the brain; all vital topics that neurobiologists are currently engaged in actively investigating in order to comprehend why we behave the way we do. More specifically, human behavior is the product not only of genetics and physical brain functions, but also of other processes such as rational planning and self-reflection. Being aware of one’s self-reflective thoughts represents the cornerstone upon which the concept of consciousness is built. Furthermore, consciousness is an intrinsic feeling of existence, a private and inaccessible experience, difficult to study, to ascertain or to measure it accurately; it is to feel alive and to be aware of it, and most importantly it is a human faculty different from the ability to exchange information with the external world. Indeed, others cannot directly know what one is thinking, feeling or perceiving, because they don’t have access to another person’s senses, thoughts or experience. How one sees oneself is linked to the nature of one’s relationships with others and the rules, including moral precepts, that guide those relationships. This essay will highlight the importance of consciousness, considered as a conscious awareness of self, and how it shapes the concept of psychosocial integrity, which is one of the fundamental values that is recognized, respected, and protected by the 2005 UNESCO Universal Declaration on Bioethics and Human Rights and the Compendium of the Social Doctrine of the Church.

2. Consciousness and Human Rights Consciousness requires awareness. Tantamount to awareness is comprehension of self, one’s surroundings, and perception of environmental stimuli (Owen, 2013). A self will have a sense of “Self”, which means in

82

Law and Consciousness

effect, self-awareness. The self should be capable of being recognized as a self by others, but this is not always possible due to impaired capacities of patients to show explicit signs of consciousness or due to the lack of sensitive technology able to detect any manifestation of the presence of consciousness. Thus a “Self” is always to be assumed, unless there is strong evidence of the contrary. Let us ponder on particular cases of patients who suffered a severe brain injury, due to a stroke or trauma, and as a consequence may lose consciousness for weeks, sometimes longer. It can be difficult to tell if they have retained any degree of awareness, due to their unresponsive state. However, with the progress of life support technology, clinicians and scientists now acknowledge that patients with these brain injuries can experience different states of consciousness. These patients, who exhibit a certain level of “covert consciousness,” or the presence of a subjective experience and a certain degree of conscious awareness in the absence of a behavioral response, are much more likely to recover from their injuries than those without it. The aforementioned severe brain injuries that lead to chronic disorders of consciousness may be the cause of prolonged comas, vegetative or minimally conscious states, and locked-in syndrome. Such altered states of consciousness, when the sense of self-awareness cannot be signaled to the external world, should be regarded as a state of vulnerability. One should be granted the right to feel protected even when one cannot express any behavioral reflexes. It is noteworthy that fostering fundamental human rights, especially the right to life and physical integrity, allow patients with disorders of consciousness to be kept alive, and thanks to brain studies aimed at helping them, it is possible for neuroscientists and neurologists to detect and ascertain that such patients do have a sense of self-awareness, or mental processes matching consciousness. The Universal Declaration on Bioethics and Human Rights (2005) comprehensively addresses the connection between life sciences and human rights and was mainly conceived as an extension of international human rights law into the field of biomedicine (Andorno 2013). In fact, the Universal Declaration on Bioethics and Human Rights (2005) contains a global understanding of bioethics, including social and environmental dimensions, along with biomedical and technological domains. The Declaration is a global normative document and addresses ethical issues while giving consideration to a person’s sense of identity, which includes biological, psychological, social, cultural, and spiritual dimensions. Fundamental human rights can be effectively protected only by ensuring respect for the life of human beings and their vulnerabilities.

Alberto García Gómez & Ana Maria Ganev

83

Article 8 of the Declaration particularly addresses the need to have respect for human vulnerability and personal integrity stating that: “In applying and advancing scientific knowledge, medical practice and associated technologies, human vulnerability should be taken into account. Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected”. Firstly, vulnerability is regarded as a human condition, inherent to existence, and it requires the care of others, the responsibility and solidarity of others in the recognition and non-exploitation of that condition (Andorno 2009). In order not to be afraid of being vulnerable, one has to feel safe by being protected by the care of others and by appropriate laws that guarantee the safeguard of the individual’s fundamental human rights. In addition, integrity should be considered as a multidimensional trait of the individual, as a oneness that each person comprises, a unity of its physical, psychological, social, intellectual, and spiritual dimensions. Human beings are an inseparable unity that demands respect and requests a right of non-interference from others in the private sphere of the self. By demanding such inviolability, the principle of “respect for human vulnerability and personal integrity” strengthens the concept of the intrinsic worth of human beings, thus pointing to other basic principles such as personal identity and human dignity. Self-awareness, assumed as human beings’ intimate and privileged relationship with themselves, makes them feel complete, shaping one’s mental picture of personal identity besides influencing a person’s perception of others as owing a sense of “self” as well and recognizing in them the same human dignity. Human dignity is the foundation of human rights; rights derive from human dignity. As Andorno (2013) notes: “the notion of human dignity attempts to respond to the question - why do human beings have rights? and the answer is that they are entitled to rights precisely because they possess intrinsic worth”. The promotion of respect for human dignity is one of the main aims of the Universal Declaration on Bioethics and Human Rights (2005): “to promote respect for human dignity and protect human rights, by ensuring respect for the life of human beings, and fundamental freedoms, consistent with international human rights law” (Article 2.c) and is also the first principle governing the whole field of biomedicine: “human dignity, human rights, and fundamental freedoms are to be fully respected” (Article 3.1). In order to support and actively encourage the protection of human dignity, appropriate norms that regulate social life are needed. Indeed, an individual’s sense of personal identity, perception of his own conscious

84

Law and Consciousness

awareness, physical, and mental integrity, all develop in the psycho-social context. Thus, by acknowledging one’s value, inherent in every human being, a person will assign a “self” as well as human dignity equally to others.

3. Consciousness and the Compendium of the Social Doctrine of the Church The Compendium of the Social Doctrine of the Church is another valuable tool for acknowledging the importance of human personal identity, based on human dignity and sense of integrity; all these insights are intrinsically linked to self-perception and self-awareness. The Compendium is a collection of concise but detailed values and principles about the fundamental framework of Catholic social teaching, where the human person and society are placed in relationship with the light of the Gospel. In this perspective, humans are invited to discover themselves as transcendent beings in every dimension of their lives, including those related to social, economic, and political contexts. A relevant chapter in the Compendium highlights the most significant facets of the human person: unity of body and soul (“corpore et anima unus”), openness to transcendence and uniqueness, intrinsic human dignity as well as equal dignity of all people, freedom, responsibility, and social nature of human beings. The Church’s social doctrine attempts to emphasize the necessity of contemplating all the many aspects of the human person: “Humans exist as unique and unrepeatable beings, they exist as an “I” capable of self-understanding, self-possession, and self-determination. Humans are intelligent and conscious beings, capable of reflecting on themselves and therefore of being aware of themselves and their actions. However, it is not intellect, consciousness, and freedom that define the person, but rather the person who is the basis of the acts of intellect, consciousness, and freedom. These acts can even be absent, for even without them the human does not cease to be a person”. How one sees oneself is linked to the nature of one’s relationships with others, therefore it is needful to spotlight the inherent correlation between consciousness and socialization. Indeed, it is vitally important to consider every neighbor, without exception, as another self. Openness to transcendence belongs to human beings, the ability to come out of oneself, from the selfcentered preservation of one’s own life, in order to enter into a relationship of dialogue and communion with others. As Pope Francis observes in one of his encyclical letters “Laudato Si’” (2015): “We are always capable of going out of ourselves towards the other. Unless we do this, other creatures

Alberto García Gómez & Ana Maria Ganev

85

will not be recognized for their true worth”. Therefore, it is our responsibility not to overlook our neighbor, and more so, to support an equally-valuable self-awareness, even if impaired or altered, beyond our own. The path leading every conscience to interact with every other conscience is enlightened by the principles of the social doctrine, namely human dignity, common good, subsidiarity, and solidarity. These principles are key to building a good, authentic, and renewed social life. The Church’s social doctrine, amongst all the principles, calls attention to the relevance of human dignity, which spurs the common and personal growth of everyone. Therefore, there is a need to recognize as another self every neighbor without exception, taking into account first of all their life and the means necessary for living it with dignity. When transposed to every aspect of social life, human dignity, along with unity and equality of all people, gives rise to the principle of common good. In the Compendium, the concept of common good is presented as “the total sum of social conditions, which allow people, either as groups or as individuals, to reach their fulfilment more fully and more easily”. From the principle of common good stems the criteria for making decisions concerning the application of the principle of subsidiarity, meaning that all superior order societies must adopt a perspective of help (“subsidium”), care, support, promotion, and development of lower-order societies. Such common growth can take place only with the practice of solidarity. The principle of solidarity highlights the intrinsic social nature of human beings, as well as the equality of all in dignity and rights. People and social groups share among themselves some special bonds, like fraternity and social friendship; an interconnectedness of such nature can only arise when individuals interact through reciprocal recognition of a conscious sense of “self”. Besides the above mentioned principles that must lead the way and guide a social and political organization worthy of humans, the Church’s social doctrine also indicates several fundamental values. Principles and values are characterized by a relationship of reciprocity. Each fundamental value is inherent in all human beings, in their dignity, and fostering a person’s authentic development. Essentially, these values are truth, freedom, justice, and love (caritas). Their practice ensures the successful accomplishment of an integral personal fulfillment and a more human social existence. Moreover, integral human development can be achieved principally in charity and truth; truth which corresponds to human dignity as persons and charity that matches the notion of love as an act of mercy.

86

Law and Consciousness

As Pope Benedict XVI points out in the encyclical letter “Caritas in veritate” (2009): “Likewise the truth of ourselves, of our personal conscience, is first of all given to us. In every cognitive process, truth is not something that we produce, it is always found, or better, received. Truth, like love, is neither planned nor willed, but somehow imposes itself upon human beings”. Since truth is a gift received by everyone, charity in truth is a force that builds community, it brings people together by setting aside all limits and obstacles.

4. Conclusion A wood cutter ventured into a forest to ask the trees to give him a handle for his axe. It seemed so modest a request that the principal trees granted it right away, and it was settled among them that the plain homely ash tree should furnish what was needed. No sooner had the wood cutter fitted the wood for his purpose, than he began chopping down the noblest trees in the wood. By the time the oak grasped the entire matter, it was too late, and he whispered to a neighboring cedar, “With our first concession we lost everything. If we had not sacrificed our humble neighbor, we might still be able to stand for ages.” (“The Trees and the Axe”, an Aesop’s fable). Thus, when the rich surrender the rights of the poor, they provide a handle to be used against their own privileges. Our humble neighbor is relatable to a vulnerable person, ourselves or another human being who should be protected, taken care of and safeguarded by fundamental human rights law that ensures respect for the life of all individuals and regard for human dignity as the intrinsic worth of human beings. Hence it is vitally important to consider every neighbor, without exception, as another self.

References Andorno, R. (2011). The dual role of human dignity in bioethics. Medicine, Health Care and Philosophy, 16(4), 967–973. Andorno, R. (2013). Human Dignity and Human Rights. Handbook of Global Bioethics, 45–57. Caritas in veritate (June 29, 2009) | BENEDICT XVI. (2009, June 29). Vatican.Va. https://www.vatican.va/content/benedict-xvi/en/encyclicals/documents/ hf_ben-xvi_enc_20090629_caritas-in-veritate.html#_edn89 Compendium of the Social Doctrine of the Church. (2004). Vatican.Va. https://www.vatican.va/roman_curia/pontifical_councils/justpeace/doc uments/rc_pc_justpeace_doc_20060526_compendio-dott-soc_en.html

Alberto García Gómez & Ana Maria Ganev

87

Goodenough, O. R., & Tucker, M. (2010). Law and Cognitive Neuroscience. Annual Review of Law and Social Science, 6(1), 61–92. Ienca, M., & Andorno, R. (2017). Towards new human rights in the age of neuroscience and neurotechnology. Life Sciences, Society and Policy, 13(1). Laudato si’ (24 May 2015) | Francis. (2015, June 18). Vatican.Va. https://www.vatican.va/content/francesco/en/encyclicals/documents/pa pa-francesco_20150524_enciclica-laudato-si.html Owen, A. M. (2013). Detecting Consciousness: A Unique Role for Neuroimaging. Annual Review of Psychology, 64(1), 109–133. UNESCO. (2005, October 19). Universal Declaration on Bioethics and Human Rights: UNESCO. Unesco.Org. http://portal.unesco.org/en/ev.phpURL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html

REFLEXIVE SELF-CONSCIOUSNESS GIORGIA SALATIELLO

Abstract Self-awareness, of which the reflective character is affirmed, is a peculiarly and exclusively human capacity, since the infrahuman beings do not possess any form of self-awareness, while in God His being and His consciousness are fully identified and He knows himself with an act of simple intuition. It is therefore necessary to investigate what exactly this reflection or complete return to oneself consists of, first of all from a gnoseological and metaphysical perspective. Immediately afterwards, the anthropological implications are taken into consideration and particular attention is paid to the theme of freedom which is not possible without selfawareness. Finally, but with no less importance, we want to bring attention to the relevant repercussions that the theme of self-awareness has for bioethics, assuming an integral and in no way reductive conception of the person.

Self-consciousness in its reflexive mode, as we will attempt to discuss here, is a peculiarly and exclusively human capacity. In fact, infrahuman beings, capable only of sensible knowledge, do not possess any form of selfconsciousness, but can only have an incipient (or emergent) and embryonic consciousness directed toward the external environment, without any possibility of perceiving even themselves as they turn to other than themselves. In God, on the other hand, existence, intelligence, and consciousness are fully identified and He gets to know Himself by an act of simple and unfailing intuition, by which He also knows all the things placed by Him in existence. The analysis of consciousness, albeit synthetically, is, therefore, preliminary to the investigation of reflective self-consciousness, and it is necessary to bring attention to its essential characterizing elements, which are intentionality and presence to self.

Giorgia Salatiello

89

While intentionality is not a recent concept and has been studied in medieval philosophy, it has been the focus of recent interest of phenomenological studies and neuroscience. Intentionality denotes “the fact that in the cognitive activity of the living, there occurs a kind of participation or identification of the subject with objects, which, while still remaining themselves, become in some way part of the subject”1, achieving a particular kind of unity that is not physical but, precisely, intentional. It immediately becomes clear that the concept of intentionality is difficult to define because it refers to something that each person finds within themselves prior to any possibility of explication. Even more complex is the perspective of the presence to self, considering how deeply it inheres in the subjective interiority, but such an approach is inescapable since it represents the necessary step to initiate the analysis of the reflexive self-consciousness. The premise of subsequent insights can be identified in one of Thomas Aquinas’ works referring to the mind, wherein he states that “it is present to itself and similarly God is present to it before any species are received from sensible things”.2 We will not dwell for now on what refers to God, for we will return later to it, but it should be noted that with this quote, we are placed in the very heart of the Thomist gnoseology. Such gnoseology, in fact, is based on two fundamental assertions, which are, respectively, the rooting of the intellectual dimension of knowledge in the sensible one that can only address material realities and, consequently, the necessity of the abstractive procedure to free the universal from the peculiarities of matter and form the concept that can, thus, be present to the intellect. The mind, which represents the top of the soul, however, because of its spirituality is immaterial and requires no abstraction to be present to itself, with an implicit and non-thematic presence that never fails, even when no conscious attention is directed to it. According to St. Augustine, in such presence of self to self properly consists self-consciousness. However, Thomas Aquinas, who, true to Aristotle’s theory of knowledge, denies that anything is cognizable without abstraction, not even about oneself can there be knowledge without prior abstraction and the crucial distinction between habitual and actual selfconsciousness is introduced, which will be considered next. ***************************************

1

E. AGAZZI, Alcune osservazioni sul problema dell’intelligenza artificiale, in Rivista di Filosofia Neo-Scolastica, 1/1967, pp. 1-34, p. 16. 2 THOMAS AQUINAS, Quaestiones disputatae de veritate, Q. 10, a. 2, ad 5.

90

Reflexive Self-Consciousness

In Aquinas’ approach, which is accepted here, the presence to self represents the origin of every intellectual act that flows from it as from its source, directing itself to the external world of persons and things, which, in this way, become known objects, thanks to the abstraction of the universal from matter. The intellectual act, however, does not stop at the objects, but by a reflexive movement, which we might refer to as circular, returns to the subject itself which, thus, by one and the same act gets to know the object and itself.3 This is the reflection of the intellect on itself, or, following Aquinas, the “reditio completa” or the complete return, and it is straightaway necessary to highlight that the object is not an extrinsic mediation that stands between the subject and itself, but is the necessary condition for there to be knowledge and, therefore, transition of the intellect from potency to the act of knowing. The absence of extrinsic mediations explains, then, why the concept of “perception,” usually used for sensible knowledge, can be used for reflexive self-consciousness, indeed, in order to highlight its immediacy. That is to say, that the actual self-consciousness, humanly accessible only through reflection referenced earlier, can be denoted as an exit and a return. Meanwhile, the presence to self, referred to as habitual self-consciousness, is its unfailing premise that guarantees the continuity of self-consciousness even when no intellectual acts are set (or assumed). If the immateriality (intangibility) of the soul allows it to be present to itself before any abstraction, a fortiori this can be said of God who, implicitly and in an athematic sense, is always present at the bottom of the soul itself, even when, on the level of thematization, His existence is ignored or even denied. There is, namely, an implicit knowledge of God based on an openness that, in this case, is not intentional but ontological, because it coincides with the very constitutive structure of the subject that finds Him present to itself regardless of any explicit recognition. Since knowledge accompanies every proper human act, we are far from an unrealistically intellectualistic conception, and reflection accompanies not only with the activity of the intellect, but also with that of the will and the motions of affectivity, giving us an integrated vision of the human being who, in all its dimensions, can know himself and, therefore, self-possess: “For the intellect intends itself and the will, and the essence of the soul and all the other soul’s powers”.4

3

Cfr with the ground text on reflective self-awareness: THOMAS AQUINAS, Quaestiones disputatae de veritate, Q. 1, a. 9. C.. 4 THOMAS AQUINAS, Quaestiones disputatae de veritate, Q. 22, a. 12, c.

Giorgia Salatiello

91

*************************************** Although in extreme synthesis, we have outlined the metaphysical and gnoseological foundations of reflective self-consciousness thus far, the main anthropological and ethical implications need to be drawn from them. The reference to the capacity of self-possession allows a direct transition to the anthropological implications of reflexive self-consciousness, since selfpossession is the indispensable condition of freedom. Freedom, in fact, is configured, first of all, as autonomy that places the subject in his own hands, without any heteronomous dependence on the will of others or the course of events, and this means not only that he can decide about his own actions, but before that he can decide about himself and the human being he intends to be, acquiring a physiognomy that is, precisely, the result of his free choices. It can be easily understood that selfconsciousness and freedom are two sides of the same coin and that they mutually imply each other since without self-consciousness there can be no freedom, while, on the other hand, only in freedom is the already mentioned autonomy in which self-possession consists. The consideration of freedom as a constitutive ontological capacity entails, however, a direct and further shift from strictly anthropological to ethical implications, placing the concept of responsibility at the center of attention, since only in regard to personally free decisions can one be responsible, to oneself, to others and ultimately, if a believer, to God. By placing the concept of responsibility at the center of attention, the inquiry expands from the mere consideration of the subject and his abilities to that of the dense network of relationships, with the world and with other subjects, in which he is entrenched. Primarily, the category of responsibility, with reference to the world, confronts the issue, particularly felt today, of the defense and protection of the environment, of which we cannot be absolute and despotic masters, but responsible custodians, to whom it is entrusted. Of equal relevance emerges the responsibility to the subjects with whom we are in relationship, in awareness that every decision always has consequences and repercussions that are not limited to the author of that choice, but affect others too, leading to a series of consequences towards which, remaining indifferent is not possible. Only self-conscious and responsibly-free subjects can establish interpersonal relationships wherein both symbiotic fusion that nullifies subjectivity, and the dependence of one on another, which constitutes the denial of the inviolable human dignity, are avoided. ***************************************

92

Reflexive Self-Consciousness

As we approach the conclusion of this brief overview, it is possible to make a statement that requires further study and from which a crucial implication must be drawn. If it can be stated that reflective self-consciousness grounds the person, then is the opposite, that the person grounds the reflective selfconsciousness, not true? To answer this question, it is necessary, as mentioned above, to delve into the concept of reflexive self-consciousness, distinguishing in it capacity from actual exercise.5 The capacity of self-consciousness, indeed, is one of the essential properties of human nature and, consequently, can never be absent when one is in the presence of a human being who cannot lack anything of what constitutes his nature. On the other hand, however, as already mentioned, reflexive self-consciousness is not a faculty as the others, but is the pinnacle where they all converge and, in this sense, the claim that it is indeed the reflexive self-consciousness that constitutes the person, giving him his peculiar physiognomy, can be preserved (or attested). The seemingly opposite statement, namely, that the person grounds selfconsciousness, does not, in fact, conflict with the previous one, since only a personal subject can be reflexively self-conscious and thus arrive at selfpossession. Having set forth this insight, the implication that follows, and that is crucial precisely for bioethics, must be considered, resuming the distinction between capacity and actual exercise and avoiding the risk of not considering, as persons, all those in whom there is no actual selfconsciousness. The essential faculty of self-consciousness, as we have seen, can never be lacking, since being given with human nature, but its exercise can be prevented by a multiplicity of internal or external obstacles within the subject, ending up in situations in which the exercise of this faculty is completely absent. There is no need to highlight the relevance of these statements for bioethics and for the protection of the dignity of every human being, with no fracture between the concept of an individual of human species and that of the person, which are radically co-extensive. Apparently, the reflections held here are far, with their theoretical scope, from the urgency of bioethical issues. We hope, instead, that we have succeeded in showing how, with these reflections that we are right at the heart of bioethics, and cannot give up being deeply reflexive, as is required by the interdisciplinary approach that characterizes it.

5

Cfr.: J. B. LOTZ, Ontologia, Barcelona 1962.

DEFINITION OF CARTESIAN AND LOCKEAN PERSPECTIVES ON CONSCIOUSNESS: DISTINGUISHING AND EVALUATING WHAT CONSCIOUSNESS IS IN CARTESIAN AND LOCKEAN PERSPECTIVES ADRIÁN CANAL

Abstract This article aims to shed some light on the notion of consciousness in Descartes and Locke. The first section seeks to provide concise meanings of consciousness in the Cartesian tradition. In his analysis of the cogito, Descartes uses the Latin term “conscientia” and shifts its moral meaning to endow it with a psychological connotation. The Cartesians characterize consciousness as an interior sentiment that accompanies thinking and is non-evaluative. Consciousness is immediate, reflexive, and is different from reflection. The second section focuses on Locke’s use of consciousness. Locke defines consciousness as a special kind of awareness of everything that passes in man’s mind. This definition implies that man is aware of all his thoughts, actions, and of himself. Consciousness is immediate and implies inherent reflexivity; it is different from perception, reflection, and memory. A third section considers the continuity between Descartes and Locke and explains how the great ideas of the past can shed light on problems of the present.

1. Introduction Elucidating the nature of consciousness is one of the most important and bewildering domains of philosophy. Consciousness plays a crucial role in explaining disparate fields of psychology, neuroscience, philosophy, and other disciplines. Due to its puzzling nature, consciousness has inspired numerous debates and raises many questions. What produces consciousness?

94

Definition of Cartesian and Lockean Perspectives on Consciousness

Is consciousness a synonym for perception? Is consciousness a higher-order or a same-order perception? Does someone remain a person once consciousness is lost? This paper presents the perspectives of Rene Descartes (1596-1650) and John Locke (1632-1704), two renowned philosophers who assigned a fundamental role for consciousness in their philosophical quests. The relevance of Descartes and Locke, as well as other 17th century philosophers springs from the shift they inspired in the philosophy of consciousness through their concepts for the philosophical examination of the content, function, and power of the mind. 1 These philosophers did not forge the notion of consciousness, but assumed the meaning would be understandable and elaborated no precise definitions. Early philosophers used similar notions or referred to the conscious phenomenon; variants of consciousness appear in Plato (Carmides), Aristotle (De Anima), the Stoics (Syneidesis), Plotinus (Synaisthesis), St. Augustine (Introspection), Ralph Cudworth (Consciousness), and others. Several interpretations of Cartesian and Lockean consciousness have been documented. While this Chapter does not intend to debate with the commentators, it aims to present an overview of Descartes’ and Locke’ notions and provide references to more detailed studies. The position taken here holds that Descartes and Locke posit consciousness as an internal reflexive perception that always accompanies thinking. They understand consciousness as a self-referential, non-evaluative awareness that accompanies all mental acts, including sensory perception, thought, memory, and reflection. Consciousness accompanies all mental acts; however, it should not be mingled or conflated with mental acts. Descartes and Locke set the stage for later considerations on the nature of consciousness. However, while they were pioneers who broke ground in their formulations on the nature of consciousness, their proposals are rudimental and lack the sophisticated nuances of the concept of consciousness in contemporary thought, such as state consciousness – creature consciousness, phenomenal consciousness, access consciousness, and others.2 There are no sections or chapters entitled on consciousness in Descartes’ and Locke’ writings. Combing through their corpora is a challenge when outlining their proposals. Nevertheless, the greatness of 1 Cfr. CATHERINE G. DAVIES, Conscience as consciousness, the idea of selfawareness in French philosophical writing from Descartes to Diderot, (Oxford: Voltaire Foundation Oxford, 2008), p. 1. 2 Cfr. Larry M. Jorgensen, “Seventeenth-Century Theories of Consciousness” The Stanford Encyclopaedia of Philosophy, (Spring 2020 Edition), Edward N. Zalta (ed.), URL = https://plato.stanford.edu/archives/spr2020/entries/consciousness-17th/

Adrián Canal

95

their intuitions merits consideration today because their elaborations can supply alternative perspectives to contemporary debates on consciousness. This study comprises two parts. The first part describes three different ways to understand the notion of consciousness in the writings of Descartes, and also that of two Cartesians, Louis De La Forge (1632-1666) and Antoine Arnauld (1612-1694), who complement and enrich the Cartesian view. The second part analyzes Locke’s treatment of consciousness and includes the nature and functions of consciousness; treatment of consciousness is one of the pillars in his account on personal identity.

2. Descartes and his followers There is no unified interpretation of Cartesian consciousness.3 Whereas certain interpretations contrast sharply, others differ only in small nuances. The view presented here claims that consciousness overarches through both the Cartesian and Lockean traditions, which flows with the mainstream current of contemporary scholars. This continuity does not mean they are identical, but rather, one builds upon the other.

3

Robert McRae, “Descartes’ Definition of Thought” In Cartesian Studies, ed. R. J. Butler, (Oxford: Basil Blackwell, 1972), 55-70; Margaret Wilson, Descartes, (London and New York: Routledge, 1978); D. Radner, “Thought and Consciousness in Descartes” Journal of the History of Philosophy, Vol. 26, No. 3. (July 1988): 439452; Richard E. Aquila, “The Cartesian and Certain “Poetic” Notion of Consciousness” Journal of the History of Ideas, Vol. 49, No. 4 (Oct. – Dec., 1998): 543-562; Marleen Rozemond, Descartes’s Dualism, (Cambridge Mass., London: Harvard University Press 1998); Lilli Alanen, Descartes’ Concept of Mind, (Cambridge, MA and London: Harvard University Press, 2003); Villi Lähteenmäki, “Orders of Consciousness and Forms of Reflexivity in Descartes”. in Consciousness: From Perception to Reflection in the History of Philosophy, ed. Sara Heinämaa, Villi Lähteenmäki and Pauliina Remes (Dordrecht: Springer 2007), 180181; B. Henning, “Cartesian Conscientia” British Journal for the History of Philosophy 15 (3), 2007): 455-484; Janet Broughton, “Self-Knowledge” in A Companion to Descartes, ed. J. Broughton and J. Carriero (Oxford: Blackwell Publishing, 2008): 179-195; Udo Thiel, “Cudworth and Seventeenth-Century Theories of Consciousness” in The Uses of Antiquity, ed. Stephen Gaukroger (Dordrecht: Springer Science + Business Media, 1991) 79-99; Udo Thiel, The Early Modern Subject (Oxford: Oxford University Press, 2011); Alison Simmons, “Cartesian Consciousness Reconsidered” Philosophers’ Imprint, Vol. 12, No. 2 January 2012): 1-21; Katherine Morris, “The Hard Problem of Understanding Descartes on Consciousness” in The Bloomsbury Companion to the Philosophy of Descartes, (London: Bloomsbury Academic, 2018): 11-26.

96

Definition of Cartesian and Lockean Perspectives on Consciousness

Light is an eloquent analogy that unveils Cartesian consciousness. Consciousness could be compared to a lamp that, by shedding its light in a dark room, allows the subject to perceive different objects in a room — windows, furniture, and walls. Ordinarily, subjects focus their attention on external objects. However, they can focus on understanding the nature of this light that illuminates the room. The analysis of consciousness focuses the subjects’ attention on the light that allows them to see objects, whether they are external or in their mental operations. Light is always shining, irrespective of whether subjects concentrate on external objects or the light. Descartes was a pioneer in pointing to the existence of this light.4 He saw no need to explain his notion of consciousness; he considered it a clear and distinct notion available to everyone’s good sense. Though for the most part his readers understood him, his exposition, however, has ambiguities. The first ambiguity in Descartes’ exposition of Cartesian consciousness is a lack of distinction in the word expressing moral and psychological aspects, either in Latin or French languages. Descartes purposely replaced the French conscience in Clerselier’s paraphrase of conscientia with different terms avoiding its moral connotation 5 in Clerselier’s translation of Descartes’s works from Latin to French. For the French philosopher, the psychological conscience implies a vast range of mental and physical activities, including external perceptions, imagining, doubting, understanding, affirming, denying, and willing.6 This interpretation focuses only on the psychological dimension of consciousness. The second ambiguity is Descartes’ use of conscience as both, a first and a second-order act of perception. The first-order act of perception implies an immediate awareness of what happens. Because the act is immediate, it does not require an additional mental act. When individuals see an object, they immediately acknowledge it. A second-order act of perception implies a further mental act; reflection is a clear example. One sees an object, considers it, and concludes: these are elements of reflection. In addition, individuals could consider themselves through reflection, which could 4

Cfr. Lähteenmäki, “Orders of Consciousness and Forms of Reflexivity in Descartes”, 180-181. 5 Davies, Conscience as consciousness, 9. 6 References to Rene Descartes’ writings are to Œuvres de Descartes, 12 vols. ed. Charles Adam and Paul Tannery (Paris: Vrin, 1964-1976). Translations from The Philosophical Writings of Descartes, 3. Vols. Vols. 1-2 ed. and trans. John Cottingham, Robert Stoothoff, and Dugald Murdoch (cited as CSM I and CSM II), Vol. 3 with Anthony Kenny (cited as CSMK), (Cambridge: Cambridge University Press, 1984-1991). Cfr. AT VII 28; CSM II 19; AT VII 76-77; CSM II 52-53; AT VII 176; CSM II 124.

Adrián Canal

97

imply memory, ascribing a value to the object, and other mental activities. By claiming that for Descartes, consciousness is not an equivocal concept, I seek to elucidate this ambiguity in the interpretation of Descartes’ use of conscience. This discussion proposes three meanings of Cartesian consciousness. Firstly, Descartes equates consciousness with thought. Secondly, he uses consciousness to define thought. This use implies that consciousness is a property of thought and it accompanies thought. Hence, thought is not a synonym of consciousness but a more basic relation of self-awareness. Thirdly, he defines consciousness as reflection or reflexivity. In the case of reflection, he presents it as a second-order perception. Descartes uses conscientia with a psychological meaning in many of his works. The main texts are the Metaphysical Meditations and the Principles of Philosophy. As a starting point, Descartes supposes that the I, the mind or res cogitans, always thinks.7 Upon this premise, he builds a syllogism. In his second Metaphysica Meditation, he points out that the first thing one is aware of is the “I.” This “I” can doubt, understand, affirm, deny, will, imagine, and have sensory perceptions. All these activities are not different from thinking or the self. According to Descartes, the conscious “I” always sees the light, hears a noise, and feels the heat.8 In thinking, the subject is immediately aware of these activities. In conclusion, thinking and being conscious are the same thing. Furthermore, responding to the second objection to his Meditations, Descartes insists that understanding, willing, imagining, having sensory perceptions, and so on fall under the standard concept of thought or perception or consciousness. All these actions exist permanently and inseparably in the substance called ‘thinking thing’ or ‘mind.’9 Consciousness is present in all these activities. Responding to objections raised against Descartes’ Meditations, he expresses thought and consciousness as synonyms, making it clear that the way to affirm the cogito necessarily goes through awareness. I may not, for example, make the inference ‘I am walking; therefore I exist, except insofar as the awareness of walking is a thought. The inference is certain only if applied to his awareness, and not to the movement of the body.10

7

Cfr. Descartes, AT VII 356-357; CSM II 246-257. Cfr. Descartes, AT VII 27-28; CSM II 18-19. 9 Cfr. Descartes, AT VII 176; CSM II 124. 10 Descartes, AT VII 352; CSM II 244. 8

98

Definition of Cartesian and Lockean Perspectives on Consciousness The fact that there can be nothing in the mind, insofar as it is a thinking thing, of which it is not aware, seems to me to be self-evident.11

These premises lead to the conclusion that consciousness is interchangeable with thought. Some authors base the principle of epistemological transparency on this supposition. “Our awareness of our thought is immediate, certain, and infallible; there is nothing in my mind of which I am not, in some manner, conscious.”12 Secondly, Descartes defines thought by using consciousness. This definition implies that consciousness is more basic than thought; it is a component of thought. The notions are no longer interchangeable, but consciousness is a property of thinking. Thought includes consciousness. In the Principles of Philosophy, Descartes asserts: By the term ‘thought,’ I understand everything that we are aware of as happening within us, so far as we have an awareness of it. Hence, thinking is to be identified here not merely with understanding, willing and imagining, but also with sensory awareness. But if I take ‘seeing’ or ‘walking’ to apply to the actual sense or awareness of seeing or walking, then the conclusion is quite certain, since it relates to the mind, which alone has the sensation or thought that it is seeing or walking.13

In replying to objections, Descartes claims it seems evident that there can be nothing in the mind, of which it is not aware. 14 The mind cannot be unaware of any of its thoughts. As soon as an infant has a mind and can think, he is aware of his thoughts. This way of expressing consciousness leads to conclude that consciousness is an element of thought. Its meaning is restricted to being a part of thought. Thirdly, Descartes defines consciousness as reflection or reflexivity. He gives two meanings to reflection. The first type is a second-order perception; it implies a deep understanding necessary for scientific progress. The second type is reflection as an inherent reflexivity to the actions of the mind. Descartes insists that we are always aware of the objects and operations of our minds. “There can be nothing in the mind, of which it is not aware.” 15 However, we are not always aware of the mind’s faculties or powers. To 11

Descartes, ‘Conversation with Burman, 16 April 1648’ AT V 149; CSMK 335. Wilson, Descartes, Routledge, 45, 132. 13 Descartes, AT VIII A 7; CSM I 195. 14 Cfr. Descartes, AT VII 246; CSM II 171-172. 15 Descartes, AT VII 246; CSM II 171. 12

Adrián Canal

99

notice these capabilities, one must concentrate. Ordinarily, the subject is only potentially aware of those capabilities. 16 The texts here imply two types of awareness. The latter is the ordinary immediate awareness of our thoughts; the former arises as a fruit of concentration. At this moment, it becomes a second-order act of perception. It requires an act of the will to become aware, in this case, of the capabilities of the mind. The subject directs his attention to the consideration of these capabilities. Another example of this dual conception of consciousness appears in a conversation with Burman, dated April 16, 1648. Descartes describes consciousness as reflection: It is correct that to be aware is both to think and to reflect on one’s thoughts. But it is false that this reflection cannot occur while the previous thought is still there; this is because, as we have seen, the soul is capable of thinking of more than one thing at the same time, and of continuing with a particular thought which it has. It has the power to reflect on its thoughts as often as it likes, and to be aware of its thought in this way. 17

This passage binds the two instances of consciousness in thinking and reflection. Descartes sustains that consciousness is present in our immediate thoughts, with certainty and without the possibility of errors. Consciousness is also present in our acts of reflection. The awareness appears here as an adherent reflexivity present in both moments, in our immediate perception and the reflection upon our thoughts. Descartes has more to say on the meaning of conscience or awareness as related to reflexivity: It is true that no one can be certain that he is thinking or that he exists unless he knows what thought is and what existence is. But this does not require reflective knowledge, or the kind of knowledge that is acquired by means of demonstrations; still less does it require knowledge of reflective knowledge, i.e. knowing that we know, and knowing that we know that we know, and so on ad infinitum. This kind of knowledge cannot possibly be obtained about anything. It is quite sufficient that we should know it by that internal awareness, which always precedes reflective knowledge.18 And equally, this kind of pondering or reflecting is not required in order for a thinking substance to be superior to matter. The initial thought by means of which we become aware of something does not differ from the second thought by means of which we become aware that we were aware of

16

Cfr. Descartes, AT VII 246-247; CSM II 172. Descartes, AT V 149; CSMK 335. 18 Descartes, AT VII 422; CSM II 285. 17

100

Definition of Cartesian and Lockean Perspectives on Consciousness it, any more than this second thought differs from the third thought by means of which we become aware that we were aware that we were aware.19

The results of this analysis show that Descartes places several ways of interpreting consciousness. In his writings, one finds different meanings of the notion. Vili Lähteenmäki effectively summarizes it by distinguishing three types of consciousness. First, there is the rudimentary consciousness; this is a basic awareness present in the perceptions of children and animals. A second type is reflexive consciousness; this comes about through intellectual perception or acts of the will; it is immediate and is not a highorder perception. The third type is the result of attentive reflection, whereby subjects choose to reflect about their thoughts, ponders them, or mulls over them. 20 These types of consciousness explain the variety of mental activities, from perceiving to willing, from the deliberation of action to solving a problem. I conclude the section on Descartes with a pair of interpretations of his followers, Louis De La Forge and Antoine Arnauld. De La Forge was the first to apply consciousness in its psychological aspect, which is echoed in the writings of successive Cartesians: Malebranche, Pierre S. Regis, J. Du Hamel, Francois Lamy, and others. In his work Traité de l’esprit de l’homme (1664), De La Forge accounts for conscience explicitly as an inherent reflexivity of thought itself. He calls it a sentiment interieur that is not different from the actions we perform or the passions we experience. Conscience immediately accompanies all acts of thought, including reflection; it is not a second-order act of perception. Reflection is not an element of thought; it is a different type of thought. Reflection is not as basic as the conscience. A necessary condition for reflection is that there are other previous thoughts. Having examined all the various actions and passions of the mind and having considered what is found in each one of them in particular, and what they have in common, I think I can define the nature of thought as that consciousness, awareness, and inner feeling by which the mind is aware of everything it does or suffers and, in general, of everything which takes place immediately in itself at the same time as it acts or is acted on. I say ‘immediately’ to let you know that this testimony and inner feeling [sentiment intérieur] is not distinct from the action or passion and that the actions and passions themselves make the mind aware of what is taking place within itself. Thus, you will not confuse this inner feeling with the reflection 19

Descartes, AT VII 559; CSM II 382. Cfr. Lähteenmäki, ‘Orders of Consciousness and Forms of Reflexivity in Descartes’ p. 194.

20

Adrián Canal

101

we sometimes make on our actions, which is not found in all our thoughts because it is only one type of thought.21

In his book, Des vraies et des fausses idées (1683), Antoine Arnauld follows and develops the notions of de La Forge and explains consciousness in terms of two types of reflection: réflexion virtuelle and réflexion expresse. Réflexion virtuelle sustains that our thought is essentially reflective of itself; it is “sui conscia.” The subject that thinks is conscious of thinking. It involves an immediate relating to oneself as the subject of one’s thoughts and is present in all his perceptions. It is an immanent reflexivity of thought. Through this type of thought, we acknowledge that our soul is ours, that it is I who knows, and I that know that I know; I know myself and thus know all other things. 22 This type of consciousness foreshadows Locke’s own notion of consciousness. In réflexion virtuelle, one can already perceive the person, the subject that Locke identifies with consciousness. Arnauld defines réflexion expresse as a more explicit type of reflection. Through it, we examine our perceptions using another perception; this is a characteristic of scientific inquiry. De La Forge and Arnauld carry on the Cartesian tradition by elaborating on it, as their accounts can be said to summarize Descartes’s formulations of the concept of consciousness. Consciousness, conscientia in Latin, or conscience in French, implies a psychological aspect; it accompanies thinking and denotes an interior sentiment with certain reflexivity. These philosophical discoveries made their way across the English Channel and flowed into Locke’s account on personal identity.

3. Locke Locke was no stranger to the developments in the notion of consciousness in continental Europe. The influence of Louis de la Forge and Antoine Arnauld appears in Locke’s major work, An Essay concerning Human Understanding.23 Locke’s notion is best understood in terms of an 21

L. De La Forge, Traité de l’esprit de l’homme, Trans. Desmond E. Clarke. (Dordrecht: Springer Science + Business Media, 1997), 57. 22 Cfr. Antoine Arnauld, “Des vraies et des fausses idées” in Œuvres Philosophiques D’Arnauld, (Paris : L’Hachette Livre) 352. 23 Locke was familiar to both authors. In his library there was a pair of books belonging to De La Forge: Tractatus de mente humana…secundum Principia R. Descartes… and De mente humana; and by Arnauld: Des vraies et des fausses idées. John R. Harrison and Peter Laslett, The Library of John Locke, (Oxford: Clarendon Press, 1971) de La Forge, 1156, p. 137 and Arnauld, 124, p. 75.

102

Definition of Cartesian and Lockean Perspectives on Consciousness

Arnauldian réflexion virtuelle. On his part, Locke enriched the Cartesian conception with the views of the Cambridge Neo-Platonist, Ralph Cudworth.24 Locke’s notion of consciousness is not simple to grasp. He seldom uses it in the Essay. In his chapter on retention, memory, and in the chapter, Identity and Diversity, where the concept appears, Locke criticizes Descartes’s views that the soul always thinks. Some of Locke’s contemporaries understood consciousness as synonymous with perception, memory, or reflection, and is agreed to by some authors. 25 Further, recent Lockean scholarship has argued convincingly in Locke’s favor.26 Without entering interpretative debates, I shall provide a sympathetic reading of Locke’s views and present basic elements of Lockean consciousness. In the Essay, Locke provides the following definitions of consciousness: Consciousness is the perception of what passes in man’s own mind.27 Consciousness is inseparable from thinking, and as it seems to me it is essential to it: It being impossible for anyone to perceive, without perceiving, that he does perceive. When we see, hear, smell, taste, feel, meditate, or will anything, we know that we do so. Thus, it is always as to our present sensations and perceptions. And by this everyone is to himself, that which he calls self: It not being considered in this case, whether the same self be continued in the same, or diverse substances. For since consciousness

24

For a more detailed account of Locke’s sources see Thiel, The Early Modern Subject, 97-102; Shelley Weinberg, Consciousness in Locke, (Oxford: Oxford University press, 2016) 1-24. 25 Locke’s contemporaries include: Thomas Reid, Essays on the Intellectual Powers of Man, ed. Derek R. Brookes, (University Park, PA.: The Pennsylvania State University Press, 2002); J. Butler, The Analogy of Religion, Natural and Revealed, (London 1736). Authors closer to us are: John L. Mackie, Problems from Locke, (Oxford: Clarendon Press, 1976); M. Stuart, Locke’s Metaphysics, (Oxford: Oxford University Press, 2013). 26 Galen Strawson, Locke on Personal Identity, (Princeton NJ – Oxford: Princeton University Press, 2011); Thiel, The Early Modern Subject, Lähteenmäki, “Locke on Consciousness and What it is About” in Studia Leibnitiana, 43 (2) (2011): 160-178; Jessica Gordon-Roth, “Locke on Personal Identity” Stanford Encyclopedia of Philosophy, accessed June 28, 2021, https://plato.stanford.edu/entries/lockepersonal-identity/; Weinberg, Consciousness in Locke; R. Boeker, Locke on Persons and Personal Identity, (Oxford: Oxford University Press, 2021). 27 John Locke, An Essay Concerning Human Understanding, ed P. H. Nidditch, (Oxford: Clarendon Press, 1975). From now on, I quote Essay, Book numbers, Chapter, and Sections, II, i, 19.

Adrián Canal

103

always accompanies thinking, and ‘tis that, that makes everyone to be, what he calls self.28

Several elements jut out from these texts. First, consciousness is an everpresent awareness of all perceptions; it comprehends all mental activities, including the will; through it, one considers himself the same self through time. This awareness is internal, reflexive, and it inheres to the subject in all his activities. Consciousness understood in this sense is non-evaluative, and it accompanies all mental acts immediately. Finally, consciousness is intuitive; thus, it provides an immediate and absolute certainty. To provide an adequate explanation of consciousness, it behooves to clarify some of the objections that identify it with perception, reflection, or memory. Sometimes, these notions appear as synonymous to consciousness. However, a thorough reading of Locke’s writings identifies consciousness as being richer than perception, reflection, and memory. In II. i. 19 of the Essay, Locke defines consciousness as the perception of what passes in man’s mind. Now, the terms have different meanings. By using the senses, internal or external, perception apprehends external and internal objects; it implies cognition. Perception is limited to that moment. Once the object is no longer present, perception ends. On the other hand, consciousness accompanies perception and is aware of one’s own being. In IV. ix. 3, Locke claims that we are conscious of our own being in every act of sensation, reasoning, or thinking, with the highest degree of certainty. Furthermore, through consciousness, not perception, Locke acknowledges that the subject recognizes his personal identity.29 Locke never asserts that personal identity relies on perception. Concerning reflection, some of Locke’s commentators uphold that he equates consciousness with reflection.30 Some passages give the impression that both notions are interchangeable, as when Locke asserts that, “Reflection is said to be ‘the perception of the Operations of our own Minds within us.”31 At another place, he claims that consciousness is characterized as ‘the perception of what passes in man’s own mind.’32 These texts hint at 28

Essay, II, xxvii, 9. Cfr. Essay II. xxvii. 16; II. xxvii. 24. 30 For instance, Reid, Essays on the Intellectual Powers of Man, 268-269; Gottfried W. Leibniz, Nouveaux essais sur l’entendement humain, trans. and ed. Peter Remnand and Jonathan Bennett (Cambridge: Cambridge University Press, 1996): 118; Mark Kulstad, “Locke on Consciousness and Reflection”, in Studia Leibnitiana 16. 2 (1984): 143-167. 31 Essay, II, i, 4. 32 Essay, II, i, 19. 29

104

Definition of Cartesian and Lockean Perspectives on Consciousness

Locke giving the same definition for both reflection and consciousness. However, an attentive reading will identify differences between them and favors a broader understanding of consciousness. The main characteristics of consciousness clarify its distinction from reflection. Consciousness is intuitive; hence, it is immediate, and it provides absolute certainty. 33 The relation between consciousness and thought is direct; no mediation of ideas is necessary. Consciousness denotes an immediate awareness that accompanies all the acts of thinking and is essential and inseparable from them. With regard to mental operations, consciousness is an inherent reflexivity that is part of their nature. Consciousness is a fundamental awareness of the self to himself. Thinking consists of being conscious that one thinks.34 These features are not present in reflection. Furthermore, without consciousness, reflection would lack the material to reflect. Reflection is not an immediate relation of oneself to oneself; instead, it comes after the subject perceives an object and sees himself judging it and its relation to himself. By reflection […], I would be understood to mean, that notice which the Mind takes of its own Operations, and the manner of them, by reason whereof, there come to be Ideas of these Operations in the Understanding35.

In reflection, the subject turns his own mental operations into objects of inner observation. Reflection is not intuitive nor immediate as consciousness but requires special attention. Through reflection, the mind observes its own operations; it relates to itself and elaborates new ideas from this relation. Reflection implies a process inside the mind and it is a source of ideas (II. i. 4, 5). Often Locke mentions that reflection is linked to contemplation.36 The essential difference is that reflection is a higher-order perception, whereas consciousness is not. A higher-order perception implies that the understanding turns inward upon itself, reflects on its own operations, and makes them the object of its own contemplation.37 The mind considers its 33

In a letter from Wynne to Locke, he tries to identify in detail what type of knowledge consciousness is. Locke’s answer is lost, but from Wynne’s letter, it is possible to infer the answer. There are three possible objects of intuition: Internal perception or sensation of our own existence; consciousness of our thoughts and the perception of self-evident truths. The Correspondence of John Locke, Vol. V, letter no. 1884. 34 Essay, II, i, 19. 35 Essay, II, i, 4. 36 Essay, II, i. 4; II, i, 6-8. 37 Essay, II, i, 8.

Adrián Canal

105

own thoughts with attention.38 These activities are not necessary in the case of consciousness. Without consciousness, there would be no reflection because there would not be any object on which to reflect. For Locke, both sensation and reflection are conscious acts; however, they are not necessarily accompanied by an act of reflection. Consciousness belongs to thought itself; it is an aspect of thinking. Locke makes an analogy comparing being hungry with feeling hunger. It is the same thing with consciousness.39 Memory also plays a role in personal identity. It does not only provide evidence for personal identity but also helps to constitute it. However, many identify Lockean consciousness with memory. Some of the most significant objections come from Thomas Reid (1710-1796), Anthony Flew (19232010), and Matthew Stuart (1966 born).40 A contrast between consciousness and memory elucidates the difference between them. For Locke, memory remembers past consciousness41; this implies that the person requires awareness of the actions or events to remember ideas or facts. Consciousness is a condition for remembering. Memory unites interrupted moments of consciousness and provides preceding evidence for personal identity.42 Memory only stores past events. Locke identifies it with a storehouse or repository of past perceptions.43 Consciousness relates to the present, to preceding moments with the aid of memory, and to the future through self-concern. Through memory, the subject remembers past experiences and can reconstruct his past. Ordinarily, memory requires an act of the will to recall past events. The ability and promptness to find those ideas depend on each person. There could be defects of memory such as forgetfulness or stupidity.44 Consciousness does not require acts of the will for its ordinary activities; it always accompanies thinking. By relating experiences, consciousness and memory constitute the person over time. However, memory is not a source of unity of the self. In

38

Essay, II, i, 7. Essay, II, i, 19. 40 Reid, Essays on the Intellectual Powers of Man; Anthony Flew, “Locke and the Problem of Personal Identity” in Locke and Berkeley, ed. Charles B. Martin and David M. Armstrong (Garden City, N.Y.: Anchor / Doubleday, 1968): 155-178; Matthew Stuart, Locke’s Metaphysics (Oxford: Clarendon Press, 2013). 41 Essay, II, xxvii. 23. 42 Essay, II, xxvii. 10. 43 Essay, II, x. 2. 44 Essay, II, x. 7-8. 39

106

Definition of Cartesian and Lockean Perspectives on Consciousness

contrast, consciousness unites the body and the mind, the subject and its operations.45

4. Functions of Lockean consciousness Locke attributes two crucial functions to consciousness. First, consciousness constitutes a unifying factor in different areas of the subject. This section shall focus on unity at two levels: self and the body, and the self with its operations. The second function consists of appropriation. Based on Locke’s forensic definition of person, the subject appropriates actions through consciousness. Thus, the subject becomes responsible for his actions. According to Locke, on the Great Day, when God shall judge the living and the dead, persons shall receive reward or punishment as retribution for the actions they performed.46 Consciousness unites body and mind. For Locke, the body plays a fundamental role in perception. The body is the site of all physical experiences, particularly of pleasure and pain. It is through the senses that we receive impressions. Consciousness is present in all parts of the body. Locke describes the union of the body with the self as vital (II. xxvii. 11, 25). 47 If someone loses part of his body, that part will no longer have consciousness. Locke demonstrates the unity of the body to consciousness with the example of the little finger.48 If somebody loses a body part, the severed member no longer experiences heat, cold, pleasure, or pain. Nonetheless, if the body loses a member, personal identity remains the same. The body is vitally united to our thinking conscious self. It is our very self that enjoys pleasures or suffers pain in the body. We consider all our limbs as part of ourselves. If body and consciousness are united, the “personal self” remains united. The body is the means of all experience; through its perceptions, one forms ideas. The body exercises consciousness. It seems that defining the person through consciousness excludes the body. Some of Locke’s experiments or puzzling cases suggest that the soul jumps from body to body. Yet, the same person remains with the same body.49 Persons have a particular concern for the physical body, which might not be essential for

45

For more on this topic see Sydney Shoemaker, “Personal Identity and Memory” “The Journal of Philosophy”, Vol 56, No. 22 (Oct. 22, 1959) pp. 868-882. 46 Essay, II, xxvii. 22, 26. 47 R. Boeker, Locke on Persons and Personal Identity, p. 107. 48 Essay, II, xxvii. 11. 49 Essay, II, xxvii. 14, 15.

Adrián Canal

107

the definition of person, but it is vital for the human being. There can be no consciousness without a body. Consciousness plays an essential role in uniting the operations of the subject; these include sensations, perceptions, thoughts, and actions through time. Thus, through consciousness, the subject gathers all his operations. Locke describes how only consciousness unites different existences and actions into the same person, even if these are distant in time.50 He claims that if one is aware of having seen Noah’s Ark during the Flood and the overflowing of the Thames recently, that subject is the same person. Furthermore, it is consciousness that unites different substances into one person (II. xxvii. 10).51 Nothing but consciousness can unite remote Existences into the same Person, the Identity of Substance will not do it. For whatever Substance there is, however framed, without consciousness, there is no Person: and a Carcase may be a Person, as well as any sort of Substance be so without consciousness.52 Lastly, consciousness is the source of the subject’s diachronic identity. Through consciousness, aided by memory, the subject unites his past experiences; he is aware of all his mental activities in the present, and he is concerned about his future happiness or misery as a consequence of his actions. Locke attributes this unifying capability to consciousness alone. Consciousness allows the self, which has existed for continued duration, to find itself to be the same self that performed actions in the past.53 In conclusion, through consciousness, the subject unites the changing body with the self. Theoretically, in Locke’s experiments on thought, consciousness would unite the existence of different substances through time. 54 The conscious self gathers all present experiences and perceptions, memories of the past, and concern for future happiness. Locke underpins the importance of consciousness in keeping the subject united with all his

50

Essay, II, xxvii. 16, 17, 24. It would lead us too far to provide an insight into the debate surrounding Locke’s conception of substance. However, Locke was skeptical about the mind’s ability to know substances. Locke’s skepticism about substance originated from his corpuscular view of reality and spurred him to find an alternative foundation for personhood. 52 Essay, II. xxvii. 23. 53 Essay, II, xxvii. 25. 54 For more on Locke’s mental experiments see Kathryne. Tabb, “Madness as Method: Locke’s Thought Experiments about Personal Identity” British Journal for the History of Philosophy, 26, 5 (2018): 871-889. 51

108

Definition of Cartesian and Lockean Perspectives on Consciousness

activities. Many things change in the subject; however, the changeless principle is consciousness. A final element to consider is the function of appropriation. In their analysis of appropriating function of consciousness in some cases, recent scholars have used appropriation to defend Locke from objections concerning the memory theory.55 The notion of appropriation, based on,56 holds that a person appropriates actions and their merit if he can remember performing it. Furthermore, a person is morally accountable for any action, even if it was done a thousand years ago, because it was appropriated by self-consciousness. As far as the subject was aware of acting, he is responsible. Person is a Forensic Term appropriating Actions and their Merit; and so belongs only to intelligent Agents capable of a Law and Happiness and Misery. This personality extends its self beyond present Existence to what is past, only by consciousness, whereby it becomes concerned and accountable, owns and imputes to its self past Actions, just upon the same ground, and for the same reason, that it does the present. These notions are founded in a concern for Happiness, the unavoidable concomitant of consciousness, that which is conscious of Pleasure and Pain, desiring, such that, that self, which is conscious, should be happy. And therefore, whatever past Actions it cannot reconcile or appropriate to that present self by consciousness, it can no more be concerned in, than if they had never been done.57 Through appropriation, all the events and actions that fall under the subject’s perception are his. These events have a configuring element on the subject’s history; he cannot set apart the actions and events to be appropriated, but accepts all of them. Naturally, there is a distinction between the actions that the subject appropriates. Many situations do not depend on the person, such as if it rains or the sun shines. Moreover, a person observes other people’s actions, but he has no control over them. The subject recalls those facts without being responsible for them. He is only responsible for the actions he freely chose to perform; these entail merit or punishment. Hence, when acting, the subject has concern for his future happiness or misery. “I being as concern’d, and as justly accountable for 55 Mackie, Problems from Locke; Michael Ayers, Locke: Epistemology and Ontology, 2 vols. (London and New York: Routledge, 1991; Kenneth Winkler, “Locke on Personal Identity”, Journal of the History of Philosophy, 29 N. 2 (April 1991): 201-226; Antonia Lolordo, Locke’s Moral man (Oxford: Oxford University Press, 2012); Boeker, Locke on Persons and Personal Identity. 56 Essay, II, xxvii. 16 and 26. 57 Essay, II, xxvii. 26.

Adrián Canal

109

any Action that was done a thousand Years since, appropriated to me now by this self-consciousness, as I am, for what I did the last moment”.58 Appropriation has two dimensions, one subjective and the other objective. It is subjective because the subject alone knows the actions and events registered by his awareness; he witnessed the events, he felt, thought, understood. This could raise suspicions about moral responsibility. Locke takes up the case of the drunkard that has no consciousness of the actions performed during his drunkenness (II. xxvii. 22).59 Divine rectification is the way out of subjectivity. At the Great Day or the Last Judgement, God shall open the secrets of every heart and will give everyone according to his actions.60 By divine rectification, appropriation has its objective dimension. Ruth Boeker analyses the term ‘appropriation’ in Locke’s Second Treatise on Government. This analysis regards property appropriation in the light of the Natural Law tradition. Her aim is to further elucidate the appropriation theory and defend it from criticism. In chapter V. § 26, Locke describes how one appropriates land, animals, and the fruits of the earth by the mixing of his labor.61 Similarly, Boeker proposes that in consciousness, there is a mixing of oneself with the actions that he performs. Boeker’s analogy between appropriation of material goods and the appropriation of actions and the moral accountability attached to them suits Locke’s purposes well. Hence, in perceiving events, physical or mental, and in acting, the subject experiences physical or mental labor.62

5. Conclusion In the light of contemporary research on Descartes and Locke who offer a rudimentary notion of consciousness, this paper contributes to understanding Cartesian and Lockean consciousness. Their usages or formulations were not wholly free from ambiguities that led to hermeneutic difficulties. Nonetheless, their analysis of the mind shifted the concept of consciousness from a moral to a psychological perspective, sparking a debate that continues even in our time.

58

Essay, II, xxvii. 16. See, Lolordo, Locke’s Moral Man, 72-73. 60 Essay, II, xxvii. 26. 61 Cfr. John Locke, Two Treatises of Government, ed. Peter Laslett (Cambridge: Cambridge University Press, 1988) 62 Cfr. Ruth Boeker, “The Role of Appropriation in Locke's Account of Persons and Personal Identity”, Locke Studies, Vol. 16 (2016) 24-25. https://doi.org/10.5206/ls.2016.648. 59

110

Definition of Cartesian and Lockean Perspectives on Consciousness

Bibliography Alanen, Lilli. Descartes’s Concept of Mind. Cambridge, MA, London: Harvard University Press, 2003. Aquila, Richard E. “The Cartesian and a Certain “Poetic” Notion of Consciousness.” Journal of the History of Ideas 49, no. 4 (1988): 543. Arnauld, A., and C. Jourdain. Oeuvres Philosophiques D’Arnauld. Hachette, 1843. Ayers, Michael. Locke: Epistemology and Ontology. London and New York: Routledge, 1991. Boeker, Ruth. “The Moral Dimension of Locke’s Account of Persons and Personal Identity.” History of Philosophy Quarterly 31, no. 3 (2014): 229–47. http://www.jstor.org/stable/43488100. Boeker, Ruth. “The Role of Appropriation in Locke’s Account of Persons and Personal Identity.” Locke Studies 16 (2016): 3–39. https://doi.org/10.5206/ls.2016.648. Boeker, Ruth. Locke on Persons and Personal Identity. Oxford: Oxford University Press, 2021. Broughton, Janet, and John Peter Carriero. A Companion to Descartes. Blackwell companions to philosophy. Oxford: Blackwell, 2007. http://onlinelibrary.wiley.com/. Butler, J. The Analogy of Religion, Natural and Revealed. London, 1736. Butler, R. J. Cartesian Studies. Oxford: Blackwell, 1972. Davies, Catherine Glyn. Conscience as Consciousness: The Idea of SelfAwareness in French Philosophical Writing from Descartes to Diderot. Oxford: Voltaire Foundation, 1990. Descartes, René. Œuvres de Descartes, 12 vols. ed. Chales Adam and Paul Tannery, Paris: Vrin, 1964-1976. Descartes, René. The Philosophical Writings of Descartes: 3 Vols. ed John Cottingham, Robert Stoothoff, Dugald Murdoch, Anthony Kenny, Cambridge: Cambridge University Press, 1984-1991. Forge, Louis. Treatise on the Human Mind (1664). Translated by Desmond Clarke, International Archives of the History of Ideas / Archives Internationales d’Histoire des Idées. Dordrecht: Springer Netherlands, 1997. https://doi.org/10.1007/978-94-017-3590-2. Gaukroger, Stephen. The Uses of Antiquity: The Scientific Revolution and the Classical Tradition. Australasian Studies in History and Philosophy of Science 10. Dordrecht: Springer Netherlands, 1991. Gordon-Roth, Jessica. Locke on Personal Identity, 2019. Accessed April 5, 2020. https://plato.stanford.edu/entries/locke-personal-identity/.

Adrián Canal

111

Harrison, John, and Peter Laslett. The Library of John Locke. By John Harrison and Peter Laslett. Second Edition. Oxford: Clarendon Press, 1971. Heinämaa, Sara, Vili Lähteenmäki, and Pauliina Remes. Consciousness: From Perception to Reflection in the History of Philosophy / Edited by Sara Heinämaa, Vili Lähteenmäki and Pauliina Remes. Dordrecht: Springer, 2007. http://www.springer.com/gb/. Hennig, Boris. “Cartesian Conscientia.” British Journal for the History of Philosophy 15, no. 3 (2007): 455–84. https://doi.org/10.1080/09608780701444915. Jacquette, Dale. The Bloomsbury Companion to the Philosophy of Consciousness. Bloomsbury companions. London: Bloomsbury Academic, 2018. Jorgensen, Larry M. Seventeenth-Century Theories of Consciousness, 2010. Accessed September 10, 2021. https://plato.stanford.edu/entries/consciousness-17th/. Kulstad, Mark A. “Locke on Consciousness and Reflection.” Studia Leibnitiana 16, no. 2 (1984): 143–67. Lähteenmäki, Vili. “The Sphere of Experience in Locke.” Locke Studies 8 (2008): 59–99. https://doi.org/10.5206/ls.2008.1002. Lähteenmäki, Vili. “Locke on Consciousness and What It Is About.” Studia Leibnitiana 43 (2011): 160–78. Lännström, Anna. “Locke’s Account of Personal Identity: Memory as Fallible Evidence.” History of Philosophy Quarterly 24, no. 1 (2007): 39–56. Locke, John. An Essay Concerning Human Understanding. Ed. by P. Nidditch. Oxford: Clarendon Press, 1979. Locke, John. Two Treatises of Government, ed. Peter Laslett. Cambridge: Cambridge University Press, 1988. LoLordo, Antonia. Locke’s Moral Man. Oxford: Oxford University Press, 2012. Mackie, J. L. Problems from Locke. Oxford: Clarendon, 1976. Newman, Lex. The Cambridge Companion to Locke’s “Essay Concerning Human Understanding”. Cambridge: Cambridge University Press, 2007. Radner, Daisie. “Thought and Consciousness in Descartes.” Journal of the History of Philosophy 26, no. 3 (1988): 439–52. Reid, Thomas, Essays on the Intellectual Powers of Man ed. Derek R. Brookes, and Knud Haakonssen. University Park, PA.: The Pennsylvania State University Press, 2002.

112

Definition of Cartesian and Lockean Perspectives on Consciousness

Rozemond, Marleen. Descartes’s Dualism. Cambridge, Mass., London: Harvard University Press, 1998. Shoemaker, Sydney S. “Personal Identity and Memory.” The Journal of Philosophy 56, no. 22 (1959): 868-82. https://doi.org/10.2307/2022317, https://philpapers.org/rec/SHOPIA. Simmons, Alison. “Cartesian Consciousness Reconsidered.” Philosopher’s Imprint 12, no. 2 (2012). Strawson, Galen. Locke on Personal Identity: Consciousness and Concernment. Princeton, N.J., Oxford: Princeton University Press, 2011. Stuart, Matthew. Locke’s Metaphysics. Oxford: Clarendon Press, 2013. Tabb, Kathryn. “Madness as Method: On Locke’s Thought Experiments About Personal Identity.” British Journal for the History of Philosophy 26, no. 5 (2018): 871–89. Thiel, Udo. “Hume’s Notions of Consciousness and Reflection in Context.” British Journal for the History of Philosophy 2, no. 2 (1994): 75–115. Thiel, Udo. The Early Modern Subject: Self-Consciousness and Personal Identity from Descartes to Hume. Oxford: Oxford University Press, 2014. Weinberg, Shelley. Consciousness in Locke. Oxford: Oxford University Press, 2016. Wilson, Margaret Dauler. Descartes. London and New York: Routledge, 1978. Winkler, Kenneth. “Locke on Personal Identity.” Journal of the History of Philosophy 29, no. 2 (1991): 201–26. Yolton, John W. A Locke Dictionary. The Blackwell philosopher dictionaries. Oxford, UK, Cambridge, Mass., USA: Blackwell, 1993.

THE ORIGINS OF CONSCIOUSNESS: EMERGENCE OR DIVINE INTERVENTION? ALEX YEUNG

Abstract The answer to the question of the origin of consciousness in the human person depends on the nature of consciousness. Taking the lead from an Aristotelian-Thomistic perspective, enriched by progress in the neurosciences, consciousness refers to the concomitant experiential quality of some intentional acts, specifically acts of intellectual knowledge. Neural correlates to conscious features can give insight into the “easy problem” of consciousness, as well as to the origins of consciousness in the human biological development. The “hard problem” of consciousness, on the other hand, is not resolvable by simply identifying neural correlates, but rather needs to be approached philosophically – or even theologically. In this sense, we propose that (intellectual) consciousness cannot be simply identified with some supervenient or emergent property of the brain, nor with a res cogitans of a Cartesian framework. Metaphysical reflection first centers on the principle of unity of the human person: Not being simply an aggregate of parts, but rather a substantial unity, the presence of a soul (Aristotelian form) is required. The biological continuity of this substantial unity, initiated at the moment of union of the sexual gametes, is ordered to intellectual and volitive (and therefore concomitantly conscious) activity, and therefore reveals the soul to be spiritual and thus subsistent. The development of the human being to the stage where first, phenomenal, and then reflexive, consciousness are manifest confirm the presence of the human person; their absence on the other hand – during sleep, in embryonic development, or due to disease – is never in and of itself conclusive of the lack of personal presence or dignity.

114

The Origins of Consciousness

1. Introduction The question of the origin of consciousness is theoretically situated as a subset of the question of the origin of human life, and of the origin of life and all things in general. The question is often expressed as a kind of intellectual antinomy: Is consciousness a product of the brain or a divine act of God? The idea is that if consciousness can be explained as an epiphenomenon or emergent property of brain activity, then no further causal explanation is necessary. And on the other hand, if consciousness requires intervention of a transcendent cause, then almost in a priori fashion, material causes, such as the brain, will never be sufficient to explain it. The insertion of “or/and” in the title of this article seems to allow the possibility of a both-and solution: consciousness could possibly require both a sufficient physical cause, as well as a direct spiritual, and thus divine, cause. The method adopted in what follows will be formally philosophical – specifically metaphysical – drawing upon the Aristotelian-Thomistic tradition, although being the realist philosophy that it is, data drawn from the other sciences, such as biology, neuroscience, and psychology, are necessary aids towards elaborating a specific solution. Metaphysical analysis, as with the natural sciences, begins with experience of the world as it is, although it differs from the latter insofar as it doesn’t terminate in the enunciation of testable physical laws and models, but goes on to unveil purely intelligible principles required to explain why things are as they are. Now, things reveal their essences to us through their action: this is expressed in the metaphysical adage agere sequitur esse. This profound principle resolves one of the basic antinomies of metaphysical reflection on reality, how things can both be perfectly what they are and yet tend regularly towards a state of further perfection specific to them. This realistic principle not only reaffirms that things are what they are, but that it is precisely in the measure of this whatness that accounts for how it acts always or for the most part. In this sense, metaphysical reflection intuits that the principle that makes something what it is, is the very same principle that determines that thing’s intrinsic finality and, consequently, it’s characteristic operation.1 Applied to the theme of consciousness, the question of its causal origins depends upon the question of the whatness or nature of consciousness, which in turn calls upon the notion of its finality. Certainly, empirical 1

Beyond the common sense truth expressed in this dense metaphysical paragraph, a satisfactory metaphysical account in the Aristotelian-Thomistic tradition has been perhaps only developed recently: See Alain Contat, “Esse, essentia, ordo. Verso una metafisica della partecipazione operativa,” Espíritu, No. 61 (2012): 55-65.

Alex Yeung

115

sciences can reveal much about consciousness – psychological data regarding the onset of self-reports of consciousness, experiments to identify neural correlates of conscious activity, brain lesion studies into aberrations of normal conscious activity, and so on – yet these empirical sciences are methodologically impotent to treat the fundamental nature of consciousness (just as they cannot dictate the fundamental nature of matter, or life, or the human person….). This does not disvalue the relevance of the empirical sciences in this question, but rather only speaks to the irrenounceability of metaphysical studies pertaining consciousness. So, after reviewing what metaphysics has to say about the nature of consciousness, we will proceed to analyze its origins.

2. The nature of consciousness from a metaphysical perspective The present article cannot give a detailed metaphysical analysis of reality, but basically assumes that the being/becoming antinomy is resolved by discovering the presence of metaphysical principles of act and potency at different levels of analysis. If this holds true, in general, for all (created) beings, we should not be surprised if these principles are applicable, with suitable specifications, to human beings. Regarding human consciousness, the important levels of analysis are the following: substance-accident, substance-faculty, faculty-operation, and operation-habit. From the time of Descartes, it has been commonplace to think of consciousness as falling into the metaphysical category of substance. Consciousness is taken as a thinking, spiritual substance (res cogitans), rather than as an operation, or even a quality of an operation. However, this substantialization of consciousness causes an irresolvable dualism (the problem of the causal bridge) between a spiritual substance (consciousness) and a material substance (physical body). Of course, we could simply call upon God as the direct cause of the perceived causal harmony between such substances – as Descartes, Malebranche, Berkeley and others would eventually have to propose. A similar problem arises if we take consciousness metaphysically as simply a quality of a physical operation. Property dualists are of this persuasion, where a brain operation has both physical (neurophysiological) properties, and mental (conscious) ones. We still fall into the problem of the causal bridge between these two properties, material and spiritual, and a usual solution either sees the mental as a causally inefficacious epiphenomenon of neural activity, or as a panpsychist may assert, any operation whatsoever (be it of a brain or not) is already both material and psychical.

116

The Origins of Consciousness

The hylomorphism of Aristotle, adopted by Aquinas, does not maintain that consciousness is to be considered a substance. Rather consciousness belongs to the human person, and therefore must be categorized metaphysically as an accident, inhering in some way in the substance of the person. Aristotle has done us the favor of carefully categorizing the different types of metaphysical accidents, and among them, there seem to be a number of potentially correct candidates for consciousness: quality, action, habit. For a correct categorization, a keen phenomenal psychology is important. Even Descartes sheds light on the matter, for he rightly observes that all he is conscious of is an action – his own thinking (cogito). Aristotle and Thomas Aquinas start from this same observation though, rather than concluding that thinking directly and immediately reveals a substantial res cogitans à la Descartes (I think, therefore, I am a thinking thing), they correctly discern that it reveals primarily the presence of what is called “an active power” or “faculty” for thinking – the intellect –, which inheres in the substance of the human person. The intellect is not a separate substance, as Aquinas will state perhaps more emphatically than Aristotle, but a rather a faculty of the human person. Could consciousness be this faculty, i.e. the intellect? Not exactly, for consciousness is of something, what psychologists – and philosophers, such as John Searle – have identified as “having intentional nature”, being directed towards something. Consciousness has more of the character of the action of the intellect, rather than the intellect itself. Is consciousness the very operation of thinking then? It certainly relies on thinking, for without thinking, there would be no consciousness; so, it seems to be a kind of thinking. On the other hand, the very Latin etymology “con-scientia” betrays the fact that consciousness merely accompanies thinking, while being distinct from it. In fact, it is only when we reflect upon our thinking (which we seldom do thematically), that we distinguish between “thinking” and “awareness of our thinking”; the first aspect is scientia, knowledge about something and the second con-scientia, awareness or consciousness that I know. In other words, consciousness is a character of certain types of knowledge in which awareness of thinking is “concomitant”.2 2 If knowledge can be distinguished from conscious awareness, we might consider whether knowledge could exist without awareness. Certainly, already in the case of sense knowledge, there are many cases of knowing (sensing) without awareness. Even in the case of intellectual knowledge, one might make the case for the possibility of knowing without awareness, e.g. in habitual knowledge. On the other hand, there does not seem to be consciousness without knowledge. This epistemological clarification – between knowledge as first intention and

Alex Yeung

117

At this point, two further distinctions need to be made so as to clarify the notion of consciousness. The first distinguishes it from the concept of “self”, and the second with distinguishing it from that of “moral conscience”. Regarding the concept of “self”, which many people may mistake for a synonym of consciousness, we need to first distinguish between the ontological referent of the notion of “self”, which is the person him or herself, and the knowledge of self – the psychological self –, which is a type of habitual knowledge. Consciousness is not identical to the psychological self; this is the tendency of substance dualism. Rather, selfknowledge can be accompanied by concomitant awareness, in a manner that such consciousness can be specified as “self-consciousness”. For the second distinction to clarify the notion of consciousness, we should note that the Italian language unfortunately uses the same word for both psychological consciousness (coscienza) and moral conscience (coscienza), even though they are quite different. Moral conscience is a kind of knowledge. In fact, it can be further specified as practical (contrary to theoretical or speculative), habitual (in the sense that it can be formed through repetition of use), and foundational (it is immediately derived from the first knowledge of reality). Moral conscience is called upon to judge our voluntary action, before, during and after such action. The results of its judgment arouse in us sentiments of shame, remorse, and guilt, or moral approval and moral peace. Though it can, psychological consciousness is not moral conscience. Of course the judgments of moral conscience are accompanied by psychological awareness. Now, these distinctions being made, it is perhaps in the case of the acts of self-knowledge and moral conscience that consciousness best reveals its nature and its finality. For it is in practical knowledge – especially when it appeals to our free will – that the reflective awareness that it is I who am judging and acting comes to light. The phenomenon of consciousness, in fact, reveals that it is the thinking and judging self (the ontological person) that is thinking and judging, and therefore the thinking and judging (and eventual acting) is imputable to my “self”, i.e. to me, the ontological person. So, consciousness accompanies certain knowledge acts (speculative and practical) as concomitant awareness. In other words, consciousness reveals that human beings possess a specific mode of knowing and judging, what the Scholastics called “reditio completa”, or complete concomitant reflection. An animal, especially some higher animals, demonstrate some consciousness as concomitant and even as secondary intention – is necessary to avoid falling into epistemological idealism, where consciousness is taken as a sort of “mental space” where ideas and knowledge are located.

118

The Origins of Consciousness

measure of concomitant reflection. Their brains not only process exterior information, but also memory and feedback information. This allows them a greater control and elaboration of the information received in relation to their biological needs. But animal reditio is only incompleta; it is not aware of the nature of this knowledge and reflection nor of the subject of knowledge. An animal is not aware of itself, as a self, and therefore as responsibly imputable for its actions. In human thinking, on the other hand, the person knows an exterior object or event, but concomitantly knows the objectifying and abstractive nature of that knowing. In other words, in the act of knowing, we are aware that the object is “over and against” us as a subject, and that, as a possible good for me, such an object has a contingent and relative value with respect to my ultimate finality. Human beings have the possibility of knowing an object as just an object for me, whose value is just one value for me among many. Again, it should be emphasized that such concomitant knowledge is only possible if the very selfsame act of knowledge simultaneously turns back upon, and includes, the knowledge of the nature of the act as well as the knowing agent.3 The presence of consciousness, therefore, brings us to two metaphysical results. The first is that certain types of knowledge and volitional activity in the human person are spiritual. This is because no material object can exhibit complete reflection due to ontological limitations of time and space, which accompany all matter. And since material things cannot cause spiritual things,4 both the faculties for intellectual knowledge and volition, as well as the substance in which they inhere, must also be spiritual. Aquinas solves the possible dualist implications of such a conclusion by theorizing that the substantial principle (Aristotelian “form”) – that which makes the human person to be a substance and the kind of substance that it is (called by Aristotle “psyche”, translated into English as “soul”) of the human person – is at once metaphysical form and subsistent per se (and thus spiritual). In other words, the human spiritual soul is both the principle of the unity of the human body, as well as metaphysically subsistent in itself 3

Something of an analogy for reditio completa would be like a mirror where we see ourselves seeing. Certainly, in physical mirroring, we do not have a reditio completa, properly speaking, because we can’t physically see ourselves seeing (we only see our eyes). Neither is there reditio completa in the feedback of the brain’s neural activity, for although the results of a neural network are fed back as input information to the same network, there remains material obstacles of time and space to complete reflection. 4 This is the result of another metaphysical principle, wherein what is more perfect cannot be caused by what is less perfect, and matter is ontologically less perfect – less necessary – than spiritual realities.

Alex Yeung

119

(and subsistent even when eventually separated from the material body in physical death)5. The second result is that consciousness reveals that the human person is open to infinite sense-making. The value of objects is relative because we are able to know things as objects, and as having some value. Nothing we can know on this Earth with our natural powers is Value Itself, and yet, this horizon of being, good, and value is implied in every act of knowledge and volition. This means that we are open to the Absolute – whom in religious terms, we call “God” – whether we reflectively acknowledge it or not. Consciousness is thus an indicator of the teleological nature of the human person, as a being open to the Absolute. As recalled in this Chapter’s introduction, in metaphysical terms, any operation flows from the substance and is for the good and perfection of the substance. Intellectual and volitional activity derives from human nature and is for the good of the human person, wherein good is not simply biological survival and reproduction, but also for contemplation and for voluntary (and thus moral) decision-making. Consciousness “serves” the finality of spiritual intentional activity by not only positing known and valued objects as objects, but also as objects in the horizon of the Absolute. It thus is essential to the final fulfilment of the human person.

3. Neuroscientific data for the philosophical problem We have examined how consciousness belongs to the human person, is concomitant to intellectual and volitive (spiritual) activity, and is an indicator of the teleological nature of the human person – ordered as they are, towards the Absolute of truth, goodness, and beauty in a personal and free manner. It is necessary to examine a final aspect of consciousness – the way it is dependent upon a certain complexity of organic organization. Consciousness is (ordinarily) dependent on something material; this phenomenon is experienced by normal human beings. We have already stated that consciousness is of a spiritual nature; thus the dependence upon 5 This metaphysical difference between the principle of subsistence (what makes a substance to be a substance) and the principle of nature or Aristotelian form, is theoretically resolved by Thomas Aquinas at the most basic level of analysis of created being – the real distinction between act-of-being (esse) and essence (essentia). The final solution to the metaphysical composition of the human person is that the principle of subsistence (act of being) belongs per se not to the composite of form and matter – as in all other material beings – but to the form (soul) immediately, and only through the soul to the body (form-matter composite). Cfr. Thomas Aquinas, Summa Theologiae Ia.75.2 ad 1.

120

The Origins of Consciousness

a certain quantity and quality of matter can only be an instrumental dependence. Just as in the case of a carpenter hammering a nail into a wall, although we don’t say the cause of the nail being driven into a wall is the hammer (rather it is the carpenter), the hammer is a necessary instrumental cause for it to effectively take place. The question of the how the organic body (and the brain in particular) is an instrumental cause of consciousness is an interdisciplinary subject. Neuroscientific and psychological data are necessary to specify the precise material conditions for normal conscious development and exercise, and to understand how organic changes can affect the structure and contents of conscious awareness. Neuroscience can try to establish, for example, through brain activation or brain lesion experiments, if conscious experience is well-correlated to certain brain areas, to patterns or intensity of brain activity. A philosophical interpretation of these results may be that without brain activity, sensation and perception are disrupted, and without these, no intellection or the resulting volition is possible (given that in human thinking, reference to sensation is essential, what the Scholastics called conversio ad phantasmata). In this regard, it is not surprising to observe that in some stages of sleep, when the brain decouples itself from external senses, no consciousness is recorded6. Neuroscience is helping us understand different forms and functions of consciousness: wakefulness, awareness of world, awareness of other persons, self-awareness, moral self-awareness, and so on. In other words, we may discover that someone with brain damage could be self-aware but perhaps not morally self-aware; this could be well-explained that without the integration of certain areas of the brain, certain contents of intentional activity are not available to perception, and thus to intellectual consideration and consciousness. Neuroscience also helps us to distinguish between attention and consciousness strictly speaking. Attention levels can be modified, even pharmacologically. While one cannot have intellectual activity (and 6

Note that in some stages of dreaming sleep, a certain amount of consciousness returns, even though the brain is still decoupled from the external senses. This does not show that sense-level brain activity is unnecessary for conscious activity, but rather that what the Scholastics call the “internal senses” (which include memories and imaginations), whose organ is the brain, is the immediate instrument of intellectual activity. In fact, the brain areas that usually are active in wakeful conscious activity become excited in these dream states (of course, whether one is morally responsible in vivid dreams is a different question. One is not in a “real” situation and is not afforded the checks and cues that “real-life” situations give you).

Alex Yeung

121

therefore conscious experience) without some degree of attention, intentional activity is not reducible to attention. Increased levels of attention can alter the precision and concentration of the human person, and therefore, indirectly influence the quality of our knowledge and judgments. Having said all this, the presence of neural correlates of consciousness does not simply mean that consciousness (intellectual activity) is reducible to the sum total of the activity of the brain neurons, and these in turn to the sum total of activity of the atoms that compose them. Such an atomist philosophical position has been countered precisely by the above-mentioned hylomorphic vision of reality. What makes something to be the thing it is, is the form. Any material thing can be further decomposed into its parts, but the whole (at least natural wholes, of which biological organisms are the prime example) is more than the mere sum of the parts. The concrete relationships between the parts are not purely deterministic7. Rather, it is the principle at the level of the whole that “subsumes” the potentiality of the parts for its finality. This formal causality is perhaps unintelligible to someone brought up with the idea of push-pull billiard-ball causality as the only kind of causality that exists in the world. Yet wholistic reality is found on many levels. For example, water is not simply the sum of two hydrogen atoms and one oxygen; in the water molecule, the parts are virtually hydrogen and oxygen atoms, but their relationship in the whole is really changed. Another example is the concrete meaning of a word in a language. A word’s meaning is only defined concretely in relation to all (or at least a good number of) other words in the language. Even in the brain as a whole, a neuron’s function is only concretely realized in relation to all the other neurons, and therefore to the sensible inputs, and thus to the environment in which the organism lives.

4. Origin and development of consciousness As was suggested in the introduction to this article, the question of the origin and development of human consciousness is ultimately philosophical because it relies on the philosophical analysis of the nature of consciousness. Consciousness is concomitant intentional activity of an intelligent being. We saw above that this requires the presence of a spiritual subsistent form. Now metaphysically speaking, nothing ontologically inferior can give rise to something superior: nemo dat quod non habet. So, the immediate 7

Chaos theory has shown that even knowing the deterministic laws of nature does not allow us to determine the final results of real-world events. This is true even in the most simple cases, such as the Three-Body Problem.

122

The Origins of Consciousness

conclusion is that subsistent spiritual form has its immediate creative source in God, who is the only one who has the metaphysical power to bring spiritual form into being. This seemingly simplistic solution seems to sidestep the whole question of origins, which seems more to do with the question of when does consciousness begin in the life of a human person, and what are the biological causes of this beginning and subsequent development of consciousness. Instead of scientifically dealing with more proximate causes, this solution also seems to unnecessarily introduce the First Cause into the mix. Firstly, in replying to the question of when, we must distinguish two moments: when the intellectual soul is present and therefore directing biological growth towards the exercise of intellectual and conscious activity, and the first moment of use8. Secondly, we will see whether any secondary cause could possibly create the human soul. With regards to the first part of the first inquiry, the question is answered biologically: when there is a biological human unity, which grows and develops into an adult, this will be – philosophically speaking – the moment of the presence of the intellectual soul. At the present state of biological science, the moment of conception is taken as the beginning of a new biological unity – a new human person, with a biological program for growth and development distinct from either of the parents. Note a striking conclusion: the presence of intellectual form in the human person is certainly manifest by consciousness, but the contrary is not true: the lack of manifestation of consciousness, or the absence of consciousness, is not in itself a foolproof indicator of the lack of a human soul. Regarding the second part of the first inquiry, or the question of development, we can affirm that there can be no intellectual activity without first having a functioning organism and functioning sense apparatus. The biological development of the sense organs and of the brain is necessary for the functioning of intellectual activity and therefore of consciousness – as the necessary material instrument – even though they are not their per se cause. It is to be emphasized again here that the development of the embryo towards full functioning of all of the human person’s capacities shows the teleology already present at the moment of conception and illustrates how the different organic parts in development are in fact engendered and subsumed by the whole. Full conscious self-awareness, manifest in the possibility of making morally-aware decisions, comes about, it seems to be agreed, after some years, traditionally up to seven years of life. The number 8

A third moment was referred to above with regards to the temporary inactivation of consciousness during sleep.

Alex Yeung

123

of years will depend on a great number of factors, not in the least cultural factors, which can enhance or dampen the growth in moral self-awareness. For the second inquiry, the philosophical conclusion seems insurmountable, that spiritual beings can only be directly created, not from matter, but only from God. In fact, they are not your parents who created you! You could say that parents are the natural generators of their children, but such a process requires the intervention of God, in order to create the human spiritual, subsistent soul. Again, for an evolutionist, this makes no sense, but this is for lack of finalistic imagination. For a “teleologist”, one sees a certain unsurpassed beauty in such a situation. Biological evolution seems to move teleologically towards greater complexity, and towards the creation of a material substrate suitably instrumental for the infusion of an intelligent-human soul. Instead of thinking about biological evolution then as merely chaotic and random, we could think of it as teleological, and therefore, theological. We might not be surprised that at a particular moment in evolutionary history, God may infuse a spiritual soul – as part of the “overall plan” for the evolving universe. This is certainly invoking the anthropic principle for the universe, but more than that, a metaphysical principle that the universe itself is created and returns – intelligently and morally – to its Author. A concluding aside: whether human beings may dispose matter – in robots or in artificial neural networks – to also receive the infusion of an intellectual soul from God, may not be unthinkable in such a teleological and theological scheme for the universe. What is quite certain now, is that for all the talk about artificial “intelligence”, present-day computers and robots are quite dumb, exhibiting only a remarkable functional equivalence, although they can be highly effective machines. Future technological innovation may lead us to the brink of creating artificial organisms of some kind, and maybe God would infuse a spiritual soul in such an organism. Whether this is ethically correct is another question that cannot be dealt with here. It can be simply commented that as long as we can personally and lovingly give rise to new members of the human family through natural reproduction, this other mode would seem aberrant (in the same class of moral actions as in vitro fertilization, where the technological production of a new person poses great problems for the dignity of the human being).

5. Conclusion The answer to the question of the origin of consciousness in the human person depends on the nature of consciousness. Taking the lead from an Aristotelian-Thomistic perspective, enriched by progress in the biological-

124

The Origins of Consciousness

and neuro- sciences, consciousness refers to the concomitant experiential quality of some intentional acts. Knowledge in higher animals has a certain concomitant self-reflection, which allows for planning and ecologicallytuned responses. In human beings, there are strong indications that this selfreflection can be complete, that is, the simultaneous awareness not only of intentional contents, but also of the nature and source of the intentional activity. Ulterior reflection on this source of our thoughts and agency produces the habitual knowledge of one’s self. Note that such an account of consciousness does not identify the human person with consciousness and does not necessarily problematize the thorny relationship between brain activity and conscious activity. Still, advances in neuroscience have narrowed down possible neural pathways and structures that correlate to conscious awareness of perceived objects, their properties and value, and possible coordinated motor responses to the perceptual situation. Neural correlates to conscious features can give insight into the “easy problem” of consciousness, as well as to the origins of consciousness in the human biological development (and thus also to diseases and “errors” in consciousness). The “hard problem” of consciousness, on the other hand, is not resolvable by simply identifying neural correlates, but rather needs to be approached philosophically – or even theologically. In this sense, we propose that (intellectual) consciousness cannot be simply identified with some supervenient or emergent property of the brain, nor with a res cogitans of the Cartesian framework. Metaphysical reflection first centers on the principle of unity of the human person, which being not simply an aggregate of parts, but rather a substantial unity, requires the presence of a soul (Aristotelian form). The biological continuity of this substantial unity, initiated at the moment of union of the sexual gametes, is ordered to intellectual and volitional (and therefore concomitantly conscious) activity. The development of the human being to the stage where first phenomenal, and then reflexive, consciousness are manifest confirms the presence of the human person; their absence on the other hand – during sleep, in embryonic development, or due to disease – is never in and of itself conclusive of the lack of personal presence or dignity.

CONSCIOUSNESS AND THE ACTING PERSON MICHAEL BAGGOT

Abstract The present work addresses how one of the 20th century’s most influential figures, Karol Wojtyáa, placed Thomistic understandings of consciousness in dialogue with 20th century thinkers from other intellectual traditions. Wojtyáa highlights both the mirroring mode of consciousness that captures the objective otherness of the object known and the reflexive consciousness that reveals to the acting person his subjectivity. As an ethicist, Wojtyáa’s metaphysically grounded anthropological reflections were also made in view of helping the acting person achieve perfection through his moral acts. The presentation will thus show how the Thomistic tradition appreciates the relationship between consciousness, moral conscience, intentionality, and moral action in the individual’s self-realization. The present work shows how Karol Wojtyáa’s Thomistic personalism reveals the value of consciousness in the moral life of the acting person. The Polish philosopher offers a relevant model that incorporates the insights of phenomenology’s sensitivity to the subjective experience of consciousness into an ontologically grounded ethics of perfectionism. He shows how consciousness, while not a distinct faculty, is an important concomitant effect of the moral agent’s acts of intellect and will. In turn, such consciousness reveals to the subject his identity as a cause of both changes in the external world and the interior realm of moral character. Consciousness is thus the space in which the human person discovers both the objective morality of his actions through judgments of conscience and the place where he appreciates his subjective actualization in his journey of personal realization. Many thinkers have sought to integrate the traditional metaphysics of the person with phenomenological insights into consciousness and human subjectivity. Karol Wojtyáa is chief among such Thomistic personalists sensitive to the importance of consciousness in the development of the

126

Consciousness and the Acting Person

moral agent. He was a student and practitioner of the phenomenological method, often referred to as the philosophy of consciousness.1 However, Wojtyáa never saw this trend in his thought as hostile to the philosophy of being he had received as part of his seminary formation and his private readings. Unfortunately, a questionable English language translation of his last major philosophical work before his papal election, Osoba i czyn (Person and Act), has obscured many of the Thomistic notions he maintained in his positive assimilation of what he deemed most valuable in the modern phenomenologist thinkers. 2 Thankfully, a recently released critical edition of Wojtyáa’s work in English has helped to avoid some of the misunderstanding related to Wojtyáa’s project.3 The present study will focus on several of Wojtyáa’s most salient points regarding the relationship between consciousness, moral conscience, intentionality, rationality, and the soul in the individual’s self-realization. Without denying Wojtyáa’s fundamental Thomistic approach, the wellknown Wojtyáa expert, Richard A. Spinello, notes that “Wojtyáa readily realized some of the shortcomings of Aquinas’s metaphysical thought, which did not and perhaps could not give enough attention to human subjectivity.” 4 Spinello commented that such concerns about human subjectivity were simply not widespread in Aquinas’s intellectual milieu. Although he was a knowledgeable disciple of the Thomistic tradition, Wojtyáa acknowledged that the tradition’s valuable focus on the objective seems to leave little space for the subjective human experience of consciousness in Aquinas’s system. 5 Wojtyáa recognized that a renewed attention to such subjectivity was essential to face the challenges of Marx’s materialism and Sartre’s radical existentialist freedom.6 The enrichment of 1

For a detailed study of Wojtyáa’s relationship with phenomenology and Thomism, see Piotr JaroszyĔski, “Karol Wojtyáa: A Thomist or a Phenomenologist?,” Studia Gilsoniana 10, no. 1 (2021), https://doi.org/10.26385/SG.100105; Douglas Flippen, “Was John Paul II a Thomist or a Phenomenologist?,” Faith & Reason, Spring (2006). 2 On the significant and controversial editorial liberties taken in the second and third editions of Osoba i czyn, see JaroszyĔski, “Karol Wojtyáa,” 146–48. 3 Karol Wojtyáa, Person and Act and Related Essays, The English critical edition of the works of Karol Wojtyáa/John Paul II Volume 1 (Washington D.C.: The Catholic University of America Press, 2021). 4 Richard A. Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” Logos 17, no. 3 (2014): 19, https://doi.org/10.1353/log.2014.0022. 5 See Karol Wojtyáa, “Thomistic Personalism,” in Person and Community: Selected Essays, Catholic Thought from Lublin Volume 4 (New York: Peter Lang, 1993), 170–71. 6 See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 20.

Michael Baggot

127

Thomism was not, however, an abandonment of the school. Wojtyáa finds in the Thomistic suppositum the indispensable ontological foundation for the existence of a personal subject who endures the varied changes of conscious states that accompany the person throughout his life.7 The Polish philosopher’s appeal to a metaphysics of being to ground the experience of consciousness is not a nostalgic attachment to the past but rather the response to his desire to understand better the drama of the moral life and the experience of the moral agent as a responsible author of his acts and character.8 Wojtyáa reproves non-metaphysically-grounded phenomenologists for the grave error of “failure to realize that acts have the person as their efficient cause.” 9 He contends that it is precisely such conscious lived experience of the person as cause of his own acts that enables true perfection of the person through adherence to values in freely chosen acts. Consciousness opens the person to experience his moral conscience in the evaluation of actions. Thus, consciousness is foundational to the moral responsibility, which is the basis for the entire ethical life of the person and society. Wojtyáa thus preserves the reality of consciousness more thoroughly than the Marxian approach that would risk explaining away so direct a human experience of human subjectivity in fidelity to its reductive materialism. Yet, his modern appreciation for subjectivity does not aggrandize consciousness into the self-inventing existence unbound from essence found in Sartre thought. Similarly, Wojtyla concludes that his phenomenological master, Max Scheler, is “incapable of giving an account of moral perfectionism” because of the German’s “identification of person and consciousness.” 10 At first glance, Scheler seems to adopt a richer anthropology that could provide a modern foundation for a realist ethic. The German thinker embraces a tripartite vision of the person that harkens back to St. Paul’s references to 7

See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 21. See Kenneth L. Schmitz, At the Center of the Human Drama: The Philosophy of Karol Wojtyla/Pope John Paul II (Washington, D.C.: The Catholic University of America Press, 1993), 44. 9 Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 21. 10 Angel P. López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” The Thomist 79, no. 3 (2015): 410–11, https://doi.org/10.1353/tho.2015.0002. The author goes on to explore some of the bioethical implications of Scheler’s reduction of the person to consciousness. For instance, non-conscious embryos are nonpersonal humans. Thus, abortion presents no moral problem in Scheler’s ethical system. See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 414–16. 8

128

Consciousness and the Acting Person

body, soul, and spirit. 11 However, for the phenomenologist philosopher, spirit alone points to personal identity, while body and soul are relegated to vital dimensions. Truly personal acts must be fully spiritual and independent of the vital. 12 For the German philosopher, Scheler, spirituality entails a pure intentionality and actuality without any reactivity or passivity. Scheler explains that the person enjoys an independence from vital acts that allows the agent to objectify such acts and assign meaning to them. For example, he argues that masturbation can take on different moral qualities depending upon the intentional meaning the agent assigns to it.13 While the vital act could involve a negative autoerotism, it could also be an expression of love if the agent fixes his intention on the absent beloved made present through his fantasies. Thus, Scheler “reduces the person to consciousness of spiritual acts.”14 Scheler excludes the vital body from the person and his human acts in a way that, Wojtyáa contends, betrays the person’s lived experience as a moral agent. Scheler’s failure to sustain an adequate ethical foundation seems to come not from the phenomenology per se. Wojtyáa finds in such phenomenological description a privileged point of access to the interiority of the unique and irreducible subject that a strictly metaphysical analysis of common human nature could not offer. Thus, the Polish thinker does not target the phenomenological method as the source of the limits of Scheler’s ethics. Instead, Wojtyáa chides the German philosopher for an unnecessary bracketing of causal agency in his approach.15 Scheler was understandably wary of the disproportionate influence Kant’s system of willful reverence for duty had acquired in ethics.16 Yet, Scheler’s cleansing of morality of duty in favor of emotionally-felt values leaves the agent as a passive recipient of experiences and ignores the experience of the self as the conscious causal author of actions.17 Thus, a methodological limit imposed due to understandable polemic with the flaws of Kant’s system hinders

11

See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 411. See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 412. 13 See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 413. 14 López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 411. 15 See Schmitz, At the Center of the Human Drama, 45; Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 21; JaroszyĔski, “Karol Wojtyáa,” 141. 16 See JaroszyĔski, “Karol Wojtyáa,” 140–45 for a helpful discussion of Wojtyáa’s engagement with Kant and Scheler. See also Richard A. Spinello, The Genius of John Paul II: The Great Pope's Moral Wisdom (Lanham, MD: Sheed & Ward, 2007), 220. 17 See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 26. 12

Michael Baggot

129

Scheler from appreciating key aspects of lived experience that phenomenology should respect. Wojtyáa highlights how the free efficient causality is experientially revealed to actors through consciousness. In particular, he singles out the consciousness of being able to do A or B without being constrained to either. The agent consciously chooses an option and knows that he could have chosen another option or refrained altogether. 18 Yet, the consciousness of value also pulls the agent out of a pure indifference before a set of options. The pull of value also reveals to the agent that a teleological final causality guides his conscious experience of efficient causality. The experience of value indicates how the agent subjectively appropriates the goods of his life. For Wojtyáa, such considerations are essential to avoid the formalism of duty-centered Kantian ethics. Kant’s view promotes an agent indifferent to the attractions of goods recognized as values through experience. While the experience of value involves important affective dimensions, Wojtyáa also wants to avoid Scheler’s overemphasis on feelings in value identification. Thus, Wojtyáa emphasizes how truth must guide and shape our affective responses to reality so that values can be experienced.19 He also highlights such values as normogenic, in the sense that they point to rationallyknowable moral norms that guide the agent to perfection.20 Thus, the lived experience of the moral ought presents itself to consciousness and is only later articulated intellectually as moral norms. Wojtyáa is therefore able to unite value and duty in a model more faithful to the full moral experience. “In summary, the actus personae is a self-initiated, conscious causal action whereby, thanks to the cooperation of will and intellect, the person acts through himself to intentionally achieve a certain value end.”21 Wojtyáa’s vision is careful to protect the insights of Thomism from some of the partial pictures of human action that emerge in the modern period. Yet, Wojtyáa also emphasizes that Aquinas’ analytic study of human action risks neglecting the role of “consciousness and lived experience of causal efficacy” if a phenomenological approach is neglected.22 Angel Lopez comments that Thomism is fundamental for Wojtyáa’s analysis of the role of consciousness in the moral life of the agent because 18

See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 29. See Schmitz, At the Center of the Human Drama, 81–82; Mary Shivanandan, Crossing the Threshold of Love: A New Vision of Marriage in the Light of John Paul II's Anthropology (Washington D.C.: The Catholic University of America Press, 1999), 65. 20 Schmitz, At the Center of the Human Drama, 82. 21 Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 31. 22 Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 25. 19

130

Consciousness and the Acting Person

the tradition “places consciousness in the accidental order, and identifies consciousness neither with the human person nor with one of his faculties.”23 For Wojtyáa, acts of the intellect and will entail an actualization of the distinctly spiritual human potencies of the human soul. As Lopez observes, consciousness, for Wojtyáa, is not an act of distinct faculty but rather an aspect of the acts of the intellect and will.24 The moral agent first has a direct, lived experience of personal causation. Only in a second phase does the awareness shift to intellectual knowledge. It is precisely this dynamic of consciousness that reveals the nature of the underlying ontological subject or suppositium. 25 Since “Wojtyáa distinguishes the intentional act of the intellect, whereby one objectifies something (reaching in this manner an essential induction), from the awareness one has of this very intellectual action,” he departs from a standard phenomenologist view of consciousness as naturally intentional.26 As Lopez clarifies, “consciousness is not intentional because it does not make the knower in act one with the thing known in act, nor does it confer intentional being to the representation through which one knows the res significata.”27 Wojtyáa also wants to avoid the absolutization of consciousness found in the phenomenological literature he admires and makes it clear that consciousness does not actively construct the objects presented to it. 28 As Schmitz summarizes, “a consciousness whose essential trait is intentional would be one that, in constituting its world, would absorb that world into itself as an absolute subject.” 29 Wojtyáa instead positions consciousness within a larger framework that orders the real but relative dimension of consciousness toward an ethics of action grounded in a realist metaphysics of being. The 23

López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 434. See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 424. 25 See López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 424– 25. 26 López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 425. On the intentionally of intellectual acts as distinct from non-intentional experiences of consciousness, see López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 423. 27 López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 426. 28 See Schmitz, At the Center of the Human Drama, 69, note 24 As another author explains “Whereas for the phenomenologists consciousness is always intentional— which is to say constituting the object to be experienced—for Wojtyáa, this process is left to cognition itself, which identifies and grasps the object experienced.” Thomas Petri, Aquinas and the Theology of the Body: The Thomistic Foundations of John Paul II’s Anthropology (Washington D.C.: The Catholic University of America Press, 2016), 118. 29 Schmitz, At the Center of the Human Drama, 76. 24

Michael Baggot

131

will directs the moral agent’s intentional actions, but only according to the good or value that the intellect knows and presents to the person. 30 Ultimately, through an appeal to an Aristotelian-Thomistic act-potency model, the 20th century Polish philosopher finds the resources for explaining how the agent is perfected in his faculties through a conscious choice of the good. Wojtyáa also helps elaborate upon the role of consciousness in the person’s moral development by distinguishing between the two-fold function of the rational mode of human consciousness. First, in the mirroring function, the subject experiences the otherness of what prompts the conscious experience. Consciousness thus reflects back what has previously been cognized.31 Moreover, Wojtyáa points to the interiorization of what it has received according to the proper mode of the human subject. As Schmitz notes, this process entails an awareness distinct from cognitive objectification.32 Self-knowledge arises through the union of consciousness and cognition through which that person comes to objectivize the initial awareness of his agency and its impact on his character.33 Thus, the function opens to an objective understanding of the world and the self. Second, the reflexive function enables the subject to “experience that I am the subject doing the knowing, the willing, or the feeling.” 34 While Wojtyáa has already battled against the idealist tendency to absolutive consciousness, he also ensures that consciousness maintains a prominent role in his anthropology as more than the epiphenomenon of a materialist approach.35 Reflexive consciousness gives the person an admissions ticket to the experience of the dramatic dimension of his life enacted principally on the stage of human interiority. I use the theater metaphor purposefully given that many themes of Wojtyáa’s action-centered philosophy were first explored in poetry and, in particular, in the plays he composed as a youth.36 Through reflexive consciousness, the subject can take on personal possession of various experiences that enter his consciousness. Such possession is an essential element of the experience of moral responsibility that characterizes moral life. Spinello explicates the moral implications for both functions of consciousness.37 While the mirroring function allows the moral conscience 30

See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 29–30. See Schmitz, At the Center of the Human Drama, 71. 32 Schmitz, At the Center of the Human Drama, 72. 33 See Schmitz, At the Center of the Human Drama, 73. 34 López, “Karol Wojtyáa’s Thomistic Understanding of Consciousness,” 427. 35 See Schmitz, At the Center of the Human Drama, 75. 36 See Schmitz, At the Center of the Human Drama, 1–29. 37 See Spinello, “The Enduring Relevance of Karol Wojtyáa’s Philosophy,” 28. 31

132

Consciousness and the Acting Person

to judge the objective conformity of the act with the natural moral law, the reflexive function enables the moral agent to appreciate himself as the selfdefining subject who himself becomes good or evil through his choices. Thus, while the agent is beholden to a law he did not invent, he does not stand as an outside observer of the moral life but as an involved subject who is constantly deciding who he is and who he will become. Since consciousness is a concomitant aspect of intellectual knowledge, the person whose intellect is overwhelmed by strong emotions loses the lived experience of his own efficient causality as well. 38 The agent experiences his unruly emotions as foreign events happening in him rather than dimensions of his person integrated into his quest for the good. Virtue formation thus brings a great self-possession and self-knowledge rather than a suppressive inauthenticity. While metaphysics shows man as a suppositum (a substantial subject of being and action), and cognition can present man as the object of knowledge, only consciousness can grant the person experience of being a responsible agent of causal acts and a self-determining author of his character. 39 Approaches that seek to exalt the role of consciousness, such as that of Sartre or Scheler’s, sadly fail to appreciate consciousness’s role as a signpost for the moral values that perfect the suppositum in all its richness. An ethical life as a path to authentic self-realization is, according to Wojtyáa, unsustainable if such distorted anthropologies are embraced.

Bibliography Flippen, Douglas. “Was John Paul II a Thomist or a Phenomenologist?” Faith & Reason, Spring (2006): 65–106. Hoáub, Grzegorz. “The Relation Between Consciousness and Emotions in the Thought of Karol Wojtyáa.” The Person and the Challenges 5, no. 2 (2015): 149–64. https://doi.org/10.15633/pch.1528. JaroszyĔski, Piotr. “Karol Wojtyáa: A Thomist or a Phenomenologist?” Studia Gilsoniana 10, no. 1 (2021): 135–52. https://doi.org/10.26385/SG.100105. López, Angel Pérez. “Karol Wojtyáa’s Thomistic Understanding of Consciousness.” The Thomist 79, no. 3 (2015): 407–37. https://doi.org/10.1353/tho.2015.0002. 38 See Grzegorz Hoáub, “The Relation Between Consciousness and Emotions in the Thought of Karol Wojtyáa,” The Person and the Challenges 5, no. 2 (2015): 153– 56, https://doi.org/10.15633/pch.1528. 39 See Schmitz, At the Center of the Human Drama, 74–75 See also Spinello, The Genius of John Paul II, 75–76.

Michael Baggot

133

Petri, Thomas. Aquinas and the Theology of the Body: The Thomistic Foundations of John Paul II’s Anthropology. Washington D.C.: The Catholic University of America Press, 2016. Schmitz, Kenneth L. At the Center of the Human Drama: The Philosophy of Karol Wojtyla/Pope John Paul II. Washington, D.C.: The Catholic University of America Press, 1993. Shivanandan, Mary. Crossing the Threshold of Love: A New Vision of Marriage in the Light of John Paul II’s Anthropology. Washington D.C.: The Catholic University of America Press, 1999. Spinello, Richard A. The Genius of John Paul II: The Great Pope’s Moral Wisdom. Lanham, MD: Sheed & Ward, 2007. Spinello, Richard A. “The Enduring Relevance of Karol Wojtyáa’s Philosophy.” Logos 17, no. 3 (2014): 17–48. https://doi.org/10.1353/log.2014.0022. Wojtyáa, Karol. “Thomistic Personalism.” In Person and Community: Selected Essays, 165–75. Catholic Thought from Lublin Volume 4. New York: Peter Lang, 1993. Wojtyáa, Karol. Person and Act and Related Essays. The English critical edition of the works of Karol Wojtyáa/John Paul II Volume 1. Washington D.C.: The Catholic University of America Press, 2021.

CONSCIOUSNESS IN THE AESTHETIC VISION MELISSA MAIONI

Abstract Is there a neural basis for the aesthetic experience? Is there a relationship between states of consciousness and the perception of beauty? What is scientific, measurable, universal, and objective about beauty, which is considered intangible, subjective, depending on individual taste or codified by the culture of reference? By bringing the philosophical and bioethical spheres into dialogue with contemporary neurological and psychobiological theories, an attempt will be made to assemble all the available evidence to identify the relationship between consciousness and art, to grasp the truth of beauty more fully and enhance aesthetic experience as the driving force behind a moral experience oriented towards the good and the beautiful, without therefore falling into reductionism or a transhumanist vision.

1. Introduction Contemporary research devotes ample space to the theme of consciousness in all its facets. Medicine, biomedical engineering, and philosophy pull together to unravel consciousness, one of the most fascinating mysteries that characterize the human being. Certainly, it is partly due to the rapid development of artificial intelligence, as the result of many intellectual and economic investments made by researchers all over the world. New technical possibilities and new questions of meaning ensue, competing to be the first to reach a hypothetical future goal, laden with the expectation of answers capable of always better revealing to humans their own identities. By virtue of this ongoing research, new and original interdisciplinary fields of knowledge are emerging, aimed at choosing two or more elements related to the theme of consciousness, in order to investigate how they relate

Melissa Maioni

135

to each other. In the new “neuroculture1“, today it is often referred to as neuroethics, neurotheology, neuroeconomics, and neuroaesthetics. We will briefly reflect on neuroaesthetics and in particular, we will attempt to answer the following questions: 1. Is there a neural basis for the aesthetic experience? 2. Is there a relationship between states of consciousness and the perception of beauty? 3. What is scientific, measurable, universal, and objective about beauty, which is considered intangible, subjective, depending on individual taste or codified by the culture of reference? 4. What is the relationship between consciousness, art, and bioethics? How can philosophy and bioethics engage with contemporary neurological and psychobiological theories? 5. Can aesthetic experience be a driving force for moral experience, oriented towards the good and the beautiful, without falling into reductionism or a transhumanist vision, to help human beings reach the truth?

2. Is there a neural basis for aesthetic experience? 2.a. The perception of beauty A prelude on “neuroaesthetics” is necessary when reflecting on the knowledge of cognitive science and the neuroscientific approach, on the one hand, and the knowledge of aesthetic speculation, on the other. Importantly, we must clarify what we mean by “perception of beauty”. There are two elements: a. perception: does it only concern the sensory aspect? Or can we extend it to “all cognitive experiences”? b. beauty: is beauty born within us or does it exist and do we recognise it? Is it the cause or the effect? Examining perception, let us orient ourselves by analysing the distinct elements that make up some definitions of perception. The term perception derives from the Latin perceptio-onis, extracted from percipƟre “to

1 Cf. F. MORA, “Neuroculture: A New Cultural Revolution”, in Art, Aesthetics, and the Brain, J.P. HUSTON et al. (Eds.), Oxford University Press, (2015) pp. 3-18

136

Consciousness in the Aesthetic Vision

perceive”. According to the Treccani dictionary, different meanings are ascribed to perception, of which a few are: a) First meaning: “the act of perceiving, i.e. becoming aware of a reality that is considered external, through sensory stimuli, analysed, and interpreted by means of intuitive, psychic, intellectual processes; also, the faculty of perceiving: [...] Sometimes with a meaning not different from sensation, as the sensitive acquisition of external phenomena2“. Analysis: with regard to the first meaning we can point out that perception is defined as action, sensation, ability. b) Second meaning: “in psychology, in the strict sense, sensation accompanied by variously perceived forms of consciousness; more generally, the whole sequence of events that goes from the presentation of a stimulus, through the realisation and objectification of the sensation, up to its being perceived, therefore the basis of knowledge and interaction with reality inside and outside the organism. The set of organic and mental processes that make up this sequence can be specifically analysed and studied according to whether the physical, physiological, cognitive, and affective components are considered3“. Analysis: with regard to the second meaning we can consider how perception is related to cognitive processes and the senses, in the action of knowing events or external objects. c) Third meaning: “in philosophical language, the term can designate any cognitive experience and intellectual activity in antithesis to the operations of the will (for example, the meaning of perceptio in Descartes’ terminology) and the cognitive act by which the reality of a given object is felt, and which is distinct, according to some, from simple sensation, because it implies, even in its rapidity, a process of organisation and interpretation (also on the basis of memories and past experiences) of different sensations: internal p., relative to one’s own acts or states of consciousness; external p., relative to the external world; small perceptions (or insensible perceptions), in the philosophy of Leibniz, those which the subject has no awareness of4“.

2 Cf. ONLINE TRECCANI DICTIONARY under the entry: “perception”, at https://www.treccani.it/vocabolario/percezione/ [28/09/2021], translation by the author of this article 3 Cf. Idem, translation by the author of this article 4 Cf. Idem, translation by the author of this article

Melissa Maioni

137

Analysis: with regard to the third meaning, the processes relating to the organisation and interpretation of any intellectual experience are highlighted. In all three definitions, however, the link between the term perception and the meaning of sensation remains clear. This relationship, for the purposes of our reflection, is relevant considering that the word “aesthetica” originates from the Greek word Į੅ıșȘıȚȢ (aisthêsis), which means “sensation5“, and from the verb ĮੁıșȐȞȠȝĮȚ (aisthánomai), which means “to perceive through the mediation of “sense6“. Perception (which can be traced back to the lexicon of neuroscience) and aesthetics thus seem to have more in common than we might think. Precisely this commonality of interest has led to the creation of a new discipline referred to as neuroaesthetics or neuroscience of aesthetics and combines the neurobiological approach with aesthetics in the philosophical sense. Nadal and Pearce defined it in 2011 as: “The study of the neural and evolutionary basis of the cognitive and affective processes engaged when an individual takes an aesthetic or artistic approach towards a (western or non-western) work of art (used in the broad sense to include music, film, theater, poetry, literature, architecture and so on), a non-artistic object or a natural phenomenon7“. According to Carmelo Mario Vicario, “the term “neuroaesthetics” instinctively activates a concept that brings the brain into play in order to explain how man can experience the beautiful and the ugly8“. Echoing the definitions and the distinguishing studies of Changeux, Zeki, and Lamb,

5

Cf. OLIVETTI ANCIENT GREEK DICTIONARY, under the entry: Į੅ıșȘıȚȢ, at https://www.grecoantico.com/dizionario-grecoantico.php?parola=%CE%B1%E1%BC%B4%CF%83%CE%B8%CE%B7%CF% 83%CE%B9%CF%82+, [26/09/2021], translation by the author of this article 6 Cf. OLIVETTI ANCIENT GREEK DICTIONARY, under the entry: ĮੁıșȐȞȠȝĮȚ, at https://www.grecoantico.com/dizionario-grecoantico.php?lemma=AISQANOMAI100, [26/09/2021], translation by the author of this article 7 M. NADAL, M.T. PEARCE, “The Copenhagen Neuroaesthetics Conference: Prospects and Pitfalls for an Emerging Field”, in Brain and cognition, 76/1 (2011), pp. 172-183 8 M. C. VICARIO, “Neuroestetica: una riflessione sulle basi neurobiologiche della bruttezza”, in Reti, saperi, linguaggi, Ed. il Mulino, Bologna, 2 (2019) a. 8 (16) p. 359, translation by the author of this article

138

Consciousness in the Aesthetic Vision

neuroaesthetics can also be broadly defined as the study of the neural basis of the production and appreciation of the arts9. Darwin had already studied the perception of beauty in humans, but the real reflection about the term began with Fechner and Wundt, psychologists who began to study sensory perception in the early 19th century. The flowering of scientific and philosophical speculation, however, can be traced back to the development of neuroimaging techniques, which made it possible to gather data and experimental studies on the subject10. The definition is not a fringe element, as different paradigms of thought can be configured on the basis of it. In the early stages of neuroaesthetic reflection, considerable space was given to the cognitive dimension of the observer contemplating the work of art. However, later on, other visions, such as parallelism and embodied simulation gained ground. According to the parallelism hypothesis, the production of artworks and the organisation of the brain share some fundamental properties. According to Zeki, artists and the nervous system share the drive to understand the essential visual attributes of the world 11 . This assumption has led to a development of empirical research concerning the production of artistic works (see the studies of Conway and Livingston12) and their appreciation (see the study of Kawabata and Zeki13). Referring to the parallelism between artistic activity and Zeki´s neurobiological science, Paolo D’Angelo states: “It is as if the different artistic movements were oriented towards different areas of the brain, just as the neurologist does in his research on the brain functioning”. For example, there are areas of the brain that are responsible for selectively responding to the orientation of lines. Painters such as Cézanne, Malevic, 9

Cf. the studies of J.P. CHANGEUX, “Art and Neuroscience”, in Leonardo, 27, (1994), pp. 89-201 e S. ZEKI, M. LAMB, “The Neurology of Kinetic Art”, in Brain, 117 (1994), pp.607-636 using techniques such as electroencephalography (EEG), functional magnetic resonance imaging (fMRI), magnetoencephalography (MEG), positron emission tomography (PET) 10 Cf. the interesting review on the history of the term and related studies N. DI STEFANO, “Neuroaesthetics”, in International Lexicon of Aesthetics, Autumn 2020 Edition, at https://lexicon.mimesisjournals.com/archive/2020/autumn/Neuroaesthetics.pdf, DOI: 10.7413/18258630098 [26/09/20201] 11 Cf. S. ZEKI, “Art and the Brain”, in Journal of Consciousness Studies, 6, (1999), pp.76-96 12 Cf. B.R. CONWAY, M.S. LIVINGSTONE, “Perspectives on Science and Art”, in Current opinion in neurobiology, 17/4 (2007), pp. 476–482 13 Cf. H. KAWABATA, S. ZEKI, “Neural Correlates of Beauty”, in Journal of neurophysiology, 91 (2004), pp. 1699-1705

Melissa Maioni

139

and Mondrian are said to have exploited this brain capacity by giving particular importance to lines and their orientation. Something similar happens with shape perception; certain brain cells react to square and rectangular shapes. How can we think that Malevic, Mondrian, Theo van Doesburg etc. did not exploit them? Considering motion, there are motionselective brain cells that stay inactive for static stimuli. The art that Zeki calls ‘kinetic’ (and which is broader than what is usually called so in art history) is oriented towards them by aiming at the representation of movement14. Another paradigm in vogue today is that of “embodied simulation”, according to which, the crucial element of aesthetic experience consists in the ability to embody actions, emotions, and bodily sensations represented in works of art. Gallese defines it as: “An automatic and pre-reflective mechanism that is fundamental for determining that intentional correspondence that, in the other person, shows me not a different representational system but an alter ego, that is, an-other person who shares with me a whole series of mechanisms that make us human beings15“. This definitional extension has made it possible to broaden the scope of research, not concentrating neuroscientific investigation solely on the visual, but also on the non-visual arts: research has sought to investigate how music generates aesthetic experience and what the neural basis of dance is. The studies of Brattico, Pearce 16 , Cross, and Ticini 17 are particularly interesting in this regard.

14

P. D’ANGELO, “La sfida delle neuroscienze”, in Rivista Internazionale di Filosofia Contemporanea – Vol. VI, nº 1, (2018), p.188, translation by the author of this article 15 V. GALLESE, “Neuroni specchio e intersoggettività” in Neuroni Specchio. La relazione empatica tra Scienza, Filosofia, Arte, Cura, L. GAROFANI, G. PIERINI (eds.), Ferrara, Azienda USL Ferrara, (2008), p. 18. Proceedings of the first national conference on mirror neurons. See also V. GALLESE, “Embodied Simulation: From Neurons to Phenomenal Experience”, in Phenomenology and the cognitive sciences, 4/1 (2005), pp. 23-48, translation by the author of this article 16 Cf. E. BRATTICO, M. PEARCE, “The Neuroaesthetics of Music”, in Psychology of Aesthetics, Creativity, and the Arts, 7/1 (2013), pp. 48-61 17 Cf. E.S. CROSS, L.F. TICINI, “Neuroaesthetics and Beyond: New Horizons in Applying the Science of the Brain to the Art of Dance”, in Phenomenology and the cognitive sciences, 11/ 1 (2012), pp. 5-16

140

Consciousness in the Aesthetic Vision

2.b. Tomohiro Ishizu and Semir Zeki’s attempt to create a neuroscientific theory of beauty In 2004, Kawabata and Zeki 18 showed that the visual aesthetic experience provokes a reaction in certain parts of the brain. The researchers observed 10 adults contemplating different categories of paintings, who evaluated and rated the paintings as beautiful, neutral or ugly. They showed that the perception of beautiful and ugly paintings elicited a certain activity in the medial orbitofrontal cortex (mOFC), and also in the anterior cingulate for beautiful or neutral stimuli. The real “neuroscientific theory of beauty”, however, emerged in 2011, when Tomohiro Ishizu and Semir Zeki published their landmark article entitled, “Toward a brain-based theory of beauty”19, which we will present here. Ishizu and Zeki wanted to ascertain whether the experience of beauty derived from different sources (visual, auditive, etc.) has any connection to the same areas of the brain, i.e. whether there is any correlation between certain specific areas of the brain and the experience of beauty, irrespective of the source causing the beauty. This basically means answering the question: does the experience of beauty derived from different senses, e.g. visual and auditive, correlate with the activity of the same or different brain areas? There are two hypotheses, according to Ishizu and Zeki: the first is that there is a single faculty of beauty, and the second is that there is no single faculty, which would mean stating that the brain systems related to the experience of beauty are functionally specialised, i.e. that the experience of visual beauty is correlated with one or more areas, while the experience of beauty from another source (the auditive one, for example) is correlated with other areas. Lending credence to the multidisciplinary literature on the subject, Ishizu and Zeki try to demonstrate the first hypothesis, namely that there is a single faculty of beauty in which different senses are nourished, accepting the definition of beauty given by Burke, according to whom: “for the greater part, some quality in bodies, acting mechanically upon the human mind by the intervention of the senses20“. In their study, Ishizu and Zeki took a sample of 21 right-handed subjects (9 males, 12 females, average age 27.5 years) of different nationalities with 18

Cf. H. KAWABATA, S. ZEKI, “Neural Correlates of Beauty”, in Journal of neurophysiology, 91 (2004), pp. 1699-1705 19 T. ISHIZU, S. ZEKI, “Toward a Brain-Based Theory of Beauty”, in PloS One, 6/7 (2011), e21852 20 E. BURKE, A Philosophical Enquiry into the Origin of Our Ideas of the Sublime and Beautiful, Oxford University Press UK, 1764, p.208

Melissa Maioni

141

no history of neurological or psychiatric disorders and no particular artistic background (except for one of the participants). The researchers performed a human brain imaging experiment using functional magnetic resonance imaging (fMRI): the subjects’ brain activity was recorded when they were asked to view pictures of paintings and listen to short pieces of music that were rated on a scale of 1 (bad) to 9 (good). The study led to the following conclusions: of the several areas that were activated by each type of stimulus, only one cortical area (A1), located in the mOFC, was activated while experiencing beauty, derived from both sources (visual and auditive), which almost completely overlapped within it. The researchers observed that there was a certain proportionality between the strength of activation in that part of the mOFC and the strength of the stated intensity of the experience of beauty (the more something was considered beautiful, the more the reference area was activated). On the one hand, these results allowed the researchers to modify Burke’s definition of beauty taken as a premise and to redefine it as follows: “Beauty is, for the greater part, some quality in bodies that correlates with activity in the mOFC by the intervention of the senses21“ and on the other hand, to affirm that there is a faculty of beauty that does not depend on how it is conveyed but that, at the brain level, can be activated by at least two sources – musical and visual – and probably by other sources as well. However, one problem still remains: investigating the relationship between brain activity and value. Many authors in the literature consider beauty as something that is located within the perceiving subject rather than the object, which means assuming that beauty has links to the axiological realm. Thus, if philosophical evidence connects value, judgement, beauty, and desire, according to those authors, it could be hypothesised that there is a value-assignment system in the brain that is either supra-modal (where by supra-modal we mean the ability to focus attention on stimulus information from multiple modalities at the same time22), which does not mean it is value-bound within a particular domain or that it has specialisations within it related to different values. In this sense, they noted that the A1 activity of mOFC is almost co-terminus with the activity reported in previous studies about the neural correlates of desire and value judgements. Is beauty, then, in the perceiving subject? Since all artworks considered beautiful by a subject have in common the fact that they increase the activity of the A1 field within the mOFC, one could shift the definition of beauty 21 T. ISHIZU, S. ZEKI, “Toward a Brain-Based Theory of Beauty”, in PloS One, 6/7 (2011), e21852, p.7 22 Cf. D. Purves, R. Cabeza, S.A. Huettel, K. S. LaBar, M. L. Platt, M.G. Woldorff, Neuroscienze cognitive, Zanichelli Ed., Bologna (2014)

142

Consciousness in the Aesthetic Vision

more in favour of the perceiving subject rather than relating it to the characteristics of the object contemplated, thus supporting the hypothesis that “De gustibus non est disputandum” (In matters of taste, there can be no disputes). According to this model, although the fact that some characteristics of the object leading the subject to define it as beautiful is not investigated, the proposed definition of beauty focuses on the activity that the aesthetic experience provokes in mOFC: what triggers this activity can be defined as “beautiful art”. Here, the authors do not investigate whether the stimulus is really the result of an artistic process, but consider as “beautiful art” all experiences that provoke this cerebral reaction. A painting of great artistic value, for example, might not be qualified as “beautiful” by an individual, since the contemplative experience does not correspond to any kind of activity in the mOFC. The definition of beauty is therefore subjective, albeit quantifiable, and also susceptible to change: the theory can only be applied to an individual at a specific time and place, since what is judged and experienced as “beautiful” at a specific time and in a specific context by one subject may not be experienced by another subject or by the same subject in a different context. This paradigm clearly ignores factors such as education, culture, context, knowledge, and monetary value in defining what constitutes the aesthetic appeal of a work of art, although all of these factors can contribute to the experience of beauty. Certain works of art will certainly be appreciated by people from different cultures and ethnic groups, which the authors explain using Immanuel Kant’s theory used in his Critique of Judgment23, assuming the existence of a sensus communis, i.e. a similar organisation of the brain between individuals and cultures, which such works of art stimulate. Interestingly, the experiment failed to identify a brain area where activity correlated with the experience of musical and visual ugliness. We must also beware to avoid reductionism: according to the authors, it is not the activation of the mOFC alone that is decisive for beauty; rather, it is the co-activation of the A1 field of the mOFC with the specialized sensory and perceptual area, or areas, and possibly (in case of visual stimuli) also with the caudate nucleus.24 This is the reason that leads them to expand the boundaries of the neurobiological definition of beauty: it includes not merely the activation of the mOFC but also its co-activation with the sensory areas that feed it. 23

Cf. I. KANT, The Critique of Judgment, Clarendon Press, Oxford, (1952), p. 180 T. ISHIZU, S. ZEKI, “Toward a Brain-Based Theory of Beauty”, in PloS One, 6/7 (2011), e21852 24

Melissa Maioni

143

In the context of our discussion, Ishizu and Zeki provided some positive and some negative points in their study that must be emphasized. On the positive side, the study has the merit of proving that the same area of the brain is activated by something considered beautiful, regardless of the stimulus’ nature. It thus seems that the brain has a specific faculty for grasping beauty, regardless of the stimulus. Based on this, it is therefore not wrong to assert that there is a neural basis for the experience of beauty, which follows, in a certain sense, a direction, a purpose, a “universal law”, something intelligible. “Beautiful” is something that goes beyond the contingency of the stimulus itself. On the other hand, the study places beauty in the perceiver’s capacity, contradicting the more classical view of beauty as a property of objects. Although it embraces a certain universality, this is linked to subjectivity. So why do many subjects consider the same thing to be “beautiful”? Perhaps “beautiful” is something independent of the individual, but some are able to grasp beauty and others are not. Thus, the relationship between universal and particular elements cannot be explained.

2.c. Artistic universals: a hypothesis There are some attempts in the literature to frame the perceptual process of appreciating beauty according to the hypothesis of artistic universals. Ramachandran, for example, proposes to address the problem of understanding art, again starting from the proposal of a neurobiological explanation of cognition that encompasses the universally shared abilities of producing artistic works and contemplating them, but, unlike the theory outlined above, according to an evolutionary paradigm of art. Since art is subject to great variability in artistic forms and styles depending on historical epoch and geographical location, Ramachandran attempts to establish universal laws, which “account for the constant core of this cultural variability, compatible with the theory of evolution and for which the causal mechanism must be identified at the neurological or psychophysical level25“. As Bianca Zaccaglini states: “Zeki looks at art as a product of the brain that allows us to investigate its functioning - the work of art tells me something about specialised visual areas - here the opposite is true: starting from what we already know about this complex organ, we try to explain a phenomenon that is no less important, namely art, not so much as a mere

25

C. CALÌ, “Neuroestetica e fenomenologia della percezione pittorica e musicale”, in Rivista di estetica, 37, (2008), pp. 21-42, translation by the author of this article

144

Consciousness in the Aesthetic Vision

product of the brain but rather of the human spirit, and we recognise a biological basis and an evolutionary component in it26“. Ramachandran, in order to present a theory of the human artistic experience and the neural mechanisms that mediate it, therefore looks for artistic universals and proposes a list of eight laws of artistic experience - a set of laws that artists, consciously or unconsciously, use to best stimulate the visual areas of the brain27. According to the author, any theory of art must ideally have three components. x The logic of art: whether there are universal rules or principles; x The evolutionary logic: why these rules have evolved and why they have the form they have? x What is the brain circuitry involved? Along with the principles of order and regularity and that of balance, eight principles that guide different manifestations of human artistic experience are: 1. Peak Shift Principle: not only for form, but also for more abstract dimensions, such as female/male posture, colour (e.g. skin tones), etc. Just as the gull chick responds particularly well to a super beak that does not resemble a real beak, there may be classes of stimuli that optimally excite neurons encoding shape primitives in the brain. 2. Isolating a single module helps the organism to allocate attention to the output of a single module, thus allowing it to more effectively enjoy the shift of the peak along the dimensions represented in that module. Modular isolation is the law whereby the artist strongly emphasises one feature of the represented individual (e.g. colour), over-emphasising the relevant visual area (in this case, V4), and depresses or completely cancels out the others. 3. Perceptual grouping to outline the figure. Our brain will strive to group the patches into a single defined object, which emerges clearly (obvious enough that it will be difficult to go back to seeing just a

26

B. ZACCAGNINI, Neuroestetica. Dialoghi fra arte e cervello, diss. University of Pisa (2015), at https://etd.adm.unipi.it/t/etd-03242015-110755/ [26/09/2021], translation by the author of this article 27 Cf. V.S. RAMACHANDRAN and W. HIRSTEIN, “The Science of Art A Neurological Theory of Aesthetic Experience”, in Journal of Consciousness Studies 6(6-7), (1999), pp. 15-51

Melissa Maioni

4.

5.

6.

7. 8.

145

cluster of patches afterwards). Every time we do this successfully, we feel pleasure. Contrast Extraction: is an abrupt change in brightness, colour, texture or depth between two spatially contiguous regions. The greater the difference between the two areas, the stronger the contrast; it is reinforcing, since regions of contrast are usually information-rich regions that deserve the allocation of attention. Mimicry, in nature, is partly based on this principle. Perceptual problem-solving: an image in which the meaning is implicit rather than explicit may paradoxically be more attractive than one in which the message is obvious. There seems to be an element of “peekaboo”‘ in some types of art: by ensuring that the visual system “fights” for a solution and does not give up too easily, it attracts attention. Abhorrence of unique vantage points: our visual system rejects all those images whose interpretation is based on a single vantage point, preferring those that are more general, visible from multiple viewpoints and therefore liable to multiple interpretations, because they are much more common. Metaphor in art: Such visual metaphors are probably effective because discovering hidden similarities between superficially dissimilar entities is an essential part of all visual pattern recognition. Symmetry whose relevance to identifying prey, predators or healthy mates is obvious.

With Ramachandran, the focus is more on the artist, on the one who makes art rather than on the spectator, on creation rather than on fruition, which becomes the test bench for the success of the “neuroartist’s” work: the more “There!” of pleasure28 he arouses, the more he will have created a work that is pleasing to the brain of the beholder, since he will have respected the laws of art innate in both their brains. Ramachandran’s studies have received much criticism regarding the essence of art and the individuality of the artist, his ignorance of art history and the main aesthetic theories, the lack of a universally shared judgement of taste, the originality of the ideas, reductionism, functionalism, the completeness and totality of the theory29. 28

Cf. V.S. RAMACHANDRAN, L'uomo che credeva di essere morto, Ed. Mondadori, Milano, 2012 29 There are other specific studies on some of these universals: the 2007 DI DIO, MACALUSO, RIZZOLATTI studies, for example, showed that symmetrical, wellproportioned and regular images (especially of human figures) are judged more

146

Consciousness in the Aesthetic Vision

Beyond Ramachandran’s theories, combining elements of evolutionary psychology with neuroaesthetics, contemporary empirical literature supports the existence of aesthetic universals in the appreciation of natural beauty and suggests the biological reasons why humans have naturally developed for such universals. From this, we can therefore conclude that there is a certain universality in the process of perception, supported just by empirical literature. This notion could later lead us back to the philosophical concept of intelligibility. Changeux’s well-known evolutionary neuroaesthetic view is characterised by his abandonment of field research in comparison with his colleagues and his propensity to digress into aesthetics, the humanities such as philosophy and anthropology, in favour of a focus on other functions of art as a product of the human (social cohesion, for example). This aspect allows the author to take a broader global view, capable of fully grasping the mystery of art and of blurring the boundary that separates the artist-neurologist from the art beneficiary, highlighting how the same subject can play both roles at the same time. Changeux states: “I define art as an intersubjective symbolic communication with variable and multiple emotional contents, for which empathy is an essential characteristic. There is empathy between the figures within a work of art, but also between the viewer and those figures, and between the artist and the viewer. The neuronal bases of empathy [...] are many. Besides the neurons in the temporal cortex that are responsible for the expression of emotions, the limbic system contributes importantly to the neurology of emotions [...]. Brain visualisation highlights the close relationship between the limbic system [...] and the prefrontal cortex30“.

beautiful than asymmetrical and irregular ones. Judgments of symmetry activated areas linked to visuospatial analysis, such as the superior parietal lobule and intraparietal sulcus as well as dorsal premotor cortex, while aesthetic judgments activated the medial wall and bilateral ventral prefrontal cortex, the same areas linked to social or moral evaluative judgments. Other studies have focused on natural, human physical and landscape beauty: see CHATTERJEE 2014, RHODES 2006, ETCOFF 1999; PERRETT, MAY, YOSHIKAWA 1994, LANGLOIS ET AL. 2000, ORIANS AND HEERWAGEN 1992. 30 J.P. CHANGEUX, Ragione e piacere. Dalla scienza all'arte (Raison et plaisir, 1994), Raffaello Cortina, Milano, (2013), pp. 34-35, translation by the author of this article

Melissa Maioni

147

2.d. Boundaries of existence of the neuroaesthetic field of investigation According to Brown and Dissayanake31, neuroaesthetic research may be influenced by a narrow, culture-bound aesthetic sense. It applies to a much wider range of objects than works of art; actually, the aesthetic experience is much more pervasive, fundamental, and free than the experience of contemplating works of art. Conversely, authors such as Noë32 argue that the neuroaesthetic approach is too broad and therefore ineffective in treating art as an object of investigation33. Our proposal is not to dissociate the empirical datum from philosophical speculations, but according to our bioethical reference apparatus, to seize the opportunity that the scientific datum offers us to read the metaphysical and anthropological reality that is part of the human being, and then attempt to grasp the whole truth.

3. Is there a relationship between states of consciousness and the perception of beauty? It seems obvious, but it is worth repeating: when we speak of consciousness here, we are not referring to consciousness in the moral sense, but to awareness of oneself or one’s surroundings. In this sense, before attempting to answer the question, it is appropriate to introduce the topic with some medical definitions. Consciousness, defined as: “awareness of oneself, others and one’s surroundings, thus being present for oneself and others and responding to stimuli34“, is characterised by two elements: -

The level of consciousness (AROUSAL): it concerns the general state of attention, which is not always constant throughout the day (it involves the reticular formation and the cerebral hemispheres),

31 Cf. S. BROWN, E. DISSANAYAKE, “The arts are more than aesthetics: Neuroaesthetics as narrow aesthetics”, in Neuroaesthetics, M. SKOV & O. VARTANIAN (Eds.), Baywood Publishing Co., (2009) pp. 43–57 32 Cf. A. NOË, Strange Tools. Art and Human Nature, Hill and Wang Ed., New York, (2015) 33 For example, results suggest that emotions and internalisation also reflect very general mechanisms that influence visual perception (e.g. VARTANIAN, SKOV 2014). The risk of any reductionist approach is to hide the object of investigation behind methodological criteria 34 F. COHADON, G. SALVI, Uscire dal coma, Libreria Cortina, Milano, (2003), translation by the author of this article

Consciousness in the Aesthetic Vision

148

-

vigilance, the ability to respond to external stimuli. It represents a necessary support to consciousness, but not sufficient for performing mental activities. The content of consciousness: it concerns the sum of mental activities (perceptions, thoughts, dream activity); it involves the cerebral cortex.

There are disorders and particular states of consciousness: -

-

-

35

Disorders of content: confusion, confused delirium, akinetic mutism, apallic syndrome, coma. Disorders of the consciousness level: stupor, drowsiness, locked-in syndrome35 (man awake, but able to move basically only his eyes because of a lesion in a certain part of the brainstem), coma. Vegetative state: characterised by the absence of responsiveness and consciousness due to severe dysfunction of the cerebral hemispheres, with sufficient preservation of the diencephalon and brainstem to maintain neurovegetative and motor reflexes and the normal sleepwake cycle. Patients may have complex reflexes, including eye movements, yawning, and involuntary movements in response to painful stimuli, but show no awareness of themselves or their environment36. Minimally conscious state: unlike a vegetative state, it is characterised by some evidence of self and/or environmental awareness, and patients tend to improve. Diagnosis is clinical and treatment is mainly supportive. The prognosis for patients with persistent deficits is usually poor37. Coma: impairment (reduction or abolition of consciousness and social life or somatic functions, associated with alterations in

Cf. MSD MANUAL, under the entry: “Sindrome locked-in”, at https://www.msdmanuals.com/it-it/professionale/malattie-neurologiche/coma-edeterioramento-della-coscienza/locked-in-syndrome [26/09/2021] 36 Cf. MSD MANUAL, under the entry: “Stato vegetativo e stato di minima coscienza”, at https://www.msdmanuals.com/it-it/professionale/malattie-neurologiche/coma-edeterioramento-della-coscienza/stato-vegetativo-e-stato-di-minimacoscienza#:~:text=Lo%20stato%20vegetativo%20%C3%A8%20caratterizzato,il% 20normale%20ciclo%20sonno%2Dveglia. [26/09/2021] 37 Cf. Ibidem.

Melissa Maioni

149

vegetative and vital functions, due to brain metabolic or structural suffering38). Under “special” states, one must certainly also consider unformed consciousness, such as that of foetuses, and states of consciousness altered by drugs or certain diseases. An interesting case for our debate is the Near-Death Experience (NDE). The Dutch cardiologist Pim Van Lommel for some years has been carrying out scientific studies on patients who survived a cardiac arrest. In an interview with the Italian news agency Adnkronos, Van Lommel, known for the world’s first study on premature death concluded “Death is not the end of consciousness but only a change in the state of consciousness39“. Among several thought-provoking stories is an example from the Italian newspaper “La Stampa” that reported the testimony of an intensive care nurse: “During the night shift, the ambulance brings to my ward a 44-year-old man, cyanotic and comatose: they had found him in a coma in a meadow half an hour before. We are about to intubate him when we realise he has dentures. We remove his upper dentures and put them on the crash cart. It takes another hour and a half for the patient to regain sufficient heart rhythm and blood pressure, but he is still intubated and ventilated, and still in a coma. We transfer him to the intensive care unit to continue the necessary artificial respiration. The patient comes out of the coma a week later, and I see him back in the cardiology ward. As soon as he sees me, he says: “Ah, this is the nurse who knows where my dentures are”. I am really very surprised, but the patient explains: “She was there when they rushed me to the hospital, she took my dentures out of my mouth and put them in the sliding drawer under the shelf of the trolley, loaded with bottles40”.

38

Cf. MSD MANUAL, under the entry: “Panoramica su coma e deterioramento della coscienza inquadramento”, at : https://www.msdmanuals.com/it-it/professionale/malattie-neurologiche/coma-edeterioramento-della-coscienza/panoramica-su-coma-e-deterioramento-dellacoscienza-inquadramento [26/09/2021] 39 P. VAN LOMMEL in “Oltre la vita, parla lo scienziato che indaga sulla premorte” in ADNKronos 14/04/2017 at https://www.adnkronos.com/lo-scienziato-cheindaga-sulla-premorte-possibile-per-2-5-mln-italiani_3687n27hjvwtbRiDIINn9e [26/09/2021], translation by the author of this article 40 P. VAN LOMMEL in C. GALLO, “Cosa significa tornare alla vita dopo la “premorte”: parla il cardiologo che studia la “quasi morte”. Intervista all’olandese Pim van Lommel” in La Stampa 26/03/2017 at

150

Consciousness in the Aesthetic Vision

We ask ourselves: where was the subject’s consciousness? Perhaps the subject somehow, even if he has a problem with consciousness, can somehow have other kinds of experiences? There is an interesting 2020 study that addresses the NDE as a test to explore disconnected consciousness. The study reports: “A more recent framework has been suggested by Sanders and colleagues to study different states in which the individual is not awake but can nevertheless experience some episodes of consciousness. Within this framework, the concept of responsiveness, connectedness, and consciousness are distinguished. Responsiveness corresponds to behavioral interactions with the outside world (excluding reflex behavior). Observing behavioral responsiveness does not necessarily inform the state of consciousness, as demonstrated in anesthesia and disorders of consciousness studies. The very concept of connectedness allows the distinction between two episodes of consciousness: connected and disconnected consciousness. Connected consciousness is defined as the connection to the external world allowing experience of external stimuli and is close to the concept of external awareness used by Steven Laureys.41 The isolated forearm technique (IFT) provides evidence of connected consciousness during general anesthesia. In such a setup, the patient may respond to verbal commands with the isolated forearm that remains nonparalyzed. By contrast, disconnected consciousness corresponds to a subjective experience without experiencing the external world. In other words, it is the presence of internal awareness while being disconnected from the environment, like when one dreams during rapid eye movement (REM) sleep42“. In most cases, the narratives of near-death experiences (NDEs) are described with positive connotations, in terms of “beauty”, love, and all sensations that are wonderful to the point of being irresistible, leading the person to wish to never go back, as so many recount43. Given this, we could hypothesize that the experience of pre-mortality could be considered as an experience of disconnected consciousness,

https://www.lastampa.it/scienza/2017/03/26/news/cosa-significa-tornare-alla-vitadopo-la-premorte-parla-il-cardiologo-che-studia-la-quasi-morte-1.34642597 [26/09/2021], translation by the author of this article 41 C. MARTIAL, H. CASSOL, S. LAUREYS, O. GOSSERIES, Near-Death Experience as a Probe to Explore (Disconnected) Consciousness, Trends Cogn Sci 24(3), (2020), 42 Ibidem, pp. 173-183 43 Cf. the video testimony “Vi racconto cosa ho visto nella mia esperienza di morte” in youtube channel TV2000it, 17/01/2017 at https://www.youtube.com/watch?v=c-sAm7mtMA8 [26/09/2021].

Melissa Maioni

151

thinking of it as a first neuroscientific clue that the experience of beauty is possible in altered states of consciousness too. Basically, in response to the question: “Can a person suffering from pathological states of consciousness experience beauty?”, it seems reasonable, under a “disconnected consciousness” perspective, to answer that the person can, beyond pure empirical science. Sergio Contiero states: “The demonstration of the irreducibility of consciousness, and much less of free will, to chemical and electrical laws alone occurs when intellectual and complex performances expressions are consciously and autonomously determined and in constant creative development. Moreover, given the complexity of nature and the impossibility of experimentally grasping the origin and essence of matter, subjective consciousness, i.e. the “ego” experience escapes all empirical investigation. Therefore, responsibility arises not only in social interaction, but is based on personal freedom, which is as much a mysterious and enigmatic spiritual activity as consciousness. From this it follows that consciousness should not be interpreted as a mere instinct and in a deterministic way44“.

4. What is scientific, measurable, universal and objective about beauty, which is considered intangible, subjective, dependent on individual taste or codified by the culture of reference? Rodolfo Papa states: “Although the classic definition of beauty is now supported by several psychological and anthropological researches that confirm how, since childhood and regardless of culture, we tend to recognize as beautiful and pleasant what is harmonious and proportioned, however, in recent decades, a concept of beauty completely divorced from sensory and rational knowledge, completely detached from aesthetic pleasure and common experience has been taking hold. It is precisely a “concept” of beauty developed by some theorists that has no connection with reality and vision. Based on this assumption, various types of contemporary art have come into being, united by this esoteric conception of beauty (beauty as absence, as disharmony, as estrangement...). Before

44

S. CONTIERO, Il «difficile problema» della coscienza nelle neuroscienze, (2019), at https://www.terapiacognitiva.eu/tc/il-difficile-problema-della-coscienza-nelleneuroscienze/ [26/09/2021], translation by the author of this article

152

Consciousness in the Aesthetic Vision

such contemporary works of art, it is impossible to perceive their beauty, but some experts guarantee that there is beauty in them45“. Certainly, beauty has an aim and a subjective component. Let us inspect the theories of some authors. To support the objective elements, Saint Thomas Aquinas argues that beauty46 comprises elements such as: x “integrity or perfection” (integritas sive perfectio) - completeness and lack of deformity of any kind x “due proportion or harmony” (debita proportio sive consonantia) proportion and harmonious relationship x “splendour” (claritas) – manifestation of beauty These elements must be read using the interpretative key of Thomistic metaphysics, which relates them to the being, to the human intellect and to spiritual realities, above all because of their “ontological perfection”, and not only to the objects themselves. The sought proportion seems to link every entity to God himself. In the Thomistic model, the “universal aspect” of beauty can be found in the studies seen above: beauty has a connection with intelligibility and rationality. It is something we can grasp through our faculties. A question remains, though: is beauty what pleases? To support the subjective elements, Aquinas states: “pulchra dicuntur quae visa placent47“, “beautiful things as those which, when seen, give pleasure”. In her analysis of Aquinas, Miriam Savarese claims: “The pulchrum has a privileged relationship with pleasure (delectatio), perhaps more than the good, and a constitutive relationship: beauty satisfies desire (technically, Aquinas writes “appetite”) just by looking at it, without it being necessary reachable or appropriate it in any other way. Note that it is intellectual pleasure, which in this case is involved as it derives from intellectual beauty, that has greater dignity: for Aquinas, it is not a simple delectatio, which is also characteristic of animals, but more properly consists in gaudium48“. For Plato as well, objective and subjective elements coexist. He believed that beauty has an existence of its own, independent of the individual. As 45

R. PAPA, “Bellezza, natura e arte nel pensiero di san Tommaso” in Espíritu LXVI, n. 154, (2017), p. 439, translation by the author of this article 46 Cf. THOMAS AQUINAS, Summa Theologiae, I, q. 5. a. 4 47 THOMAS AQUINAS, Summa Theologiae, I, q. 5, a. 4, ad 1 48 M. SAVARESE, La nozione trascendentale di bello in Tommaso d’Aquino, (2015) at https://disf.org/editoriali/2015-02 [26/09/2021], translation by the author of this article

Melissa Maioni

153

seen in his Phaedrus and Symposium, beauty is understood as an eternal presence outside the individual. On the other hand, the individual’s participation in it remains a critical element: in Hippias Major, Plato states that beauty is what “pleases the eye and the ear”, i.e. participation. In the Critique of Judgement: Analytic of the Beautiful49, Kant combines objective and subjective elements in a relational model. He argues that beauty does not properly belong to the object, but arises from the relationship between subject and object. Beauty, therefore, takes the form of a property that we attribute to things, defined according to the feeling of pleasure or displeasure that their images produce in us: “Beautiful is therefore what is pleasing according to the judgement of taste”. This is a true Copernican revolution in aesthetics. On the basis of what we have analysed, we offer the following points for reflection. x Beauty as a relationship Thinking of beauty as a relation has its advantages: it means conceiving beauty as a correspondence of the mind to the objective beauty of an object, similar to what we do with the concept of truth. Depending on the degree of correspondence, we could hypothesise two scenarios: •

•

If there is a true correspondence between subject and object, objective beauty and taste correspond. We would then have an authentic experience of contemplation, a “complete” aesthetic experience. Perhaps “almost complete” would be more appropriate, since we must always come up against the transient nature of existence. If there is no correspondence, objective beauty and taste differ. We would then have a superficial, dissociated aesthetic experience of

49 To the question: “What are the conditions implied by the existence of the beauty phenomenon, and what are the assumptions that validate our aesthetic judgements?” Kant answers by elaborating four characteristics of beauty: i) Taste is the faculty of estimating an object or a mode of representation by means of a delight or aversion apart from any interest. The object of such a delight is called beautiful. ii) Beautiful is what, without a concept, is liked universally. iii) Beauty is the form of the purposiveness of an object, insofar as it is perceived in it without representation of an end. iv) Beauty is what is recognised without concept as the object of a necessary satisfaction.

Consciousness in the Aesthetic Vision

154

reality. Taste is configured as a non-adhesion to the reality of the object. x Beauty as the search for a single principle that unites subject and object. If we think of beauty as a single principle common to subject and object, we might suppose that the subject, as beautiful, perceives as beautiful what resembles his own beauty, or that he perceives as beautiful something, which reveals his own beauty to him. Beauty is what tells me something about my being, the truth about myself, something that makes me feel loved, understood, and comprehended. Here we can hypothesise a relationship between beauty and truth, in the transcendental sense: “something is beautiful if it leads back to truth”. Beautiful if gifted

x

When the subject says: “This thing is beautiful for me”, we can understand the preposition “For” by assigning it a meaning of “purpose”, of “gift”: “This object was made for me, and I like that”. Taste (“it is beautiful for me”) thus becomes the recognition of this “gift”.

5. What is the relationship between consciousness, art and bioethics? How can the philosophical/bioethical field dialogue with contemporary neurological and psychobiological theories? Ethics and art have a historically troubled relationship, made up of phases of hate and love. Carole Talon-Hugonin identifies an evolution of three phases in the relationship between art and ethics: until the 18th century, ethics prevailed over art; until the 19th century, art became independent of ethics; in contemporary times, the relationship between art and ethics is liquid, played out through the confusion of terms, amid conflicts, and transgressions. The author also remarks that the 20th century has seen the relationship between art and morality configured according to three typologies: extraneousness of art and morality; submission of morality to art; superiority of morality over art50.

50

Cf. C. TALON-HUGON, Morales de l’art, Éditeur: Presses Universitaires de France, (2009)

Melissa Maioni

155

Specific currents of thought, such as artistic ethicism, artistic autonomism and artistic contextualism or immoralism, have also emerged in the aesthetic landscape. “Artistic ethicism is the theory according to which the moral value of a work of art, when relevant to the evaluation of the work in question, uniquely influences its artistic value: every moral defect in a work also constitutes an artistic defect and every moral merit constitutes an artistic merit. This does not mean that every immoral work of art must, by virtue of its immorality, be considered an artistic failure tout court. Similarly, not every morally meritorious work is, for this same reason, an artistic masterpiece. Other considerations can be made in favour of a general positive or negative assessment of the work itself51“. It goes without saying that it is quite reasonable to ask whether a work of art can be considered both an artistic masterpiece and an example of immorality. In order to answer this question, a field of research has been structured in the sphere of literature and fiction: “ethical art criticism”. In particular, Wayne Booth and Martha Nussbaum focused their studies on the ethical role of literature, while Noël Carroll has written about the role of works of art in moral education52. Sauchelli writes: “Since some works of art have a cognitive value and this value is relevant to the artistic value of the work in question, when a work of art contains a positive moral message, the work also has a positive cognitive content. If a work of art has a cognitive value, this constitutes an artistic value. It follows that works of art with a positive ethical value have an artistic value for this very reason. If a work of art prescribes an immoral attitude as appropriate, this cannot represent a positive cognitive value because a work of art has nothing to teach, or if we learn something from the work of art in question, the merit is not to be attributed to the work of art, but to the person who learns from it. The implicit idea is that, for example, if a plumber makes a mistake while repairing a sink, and we learn something from it (specifically, how not to fix a sink), we cannot credit the plumber with teaching us something. Similarly, if we learn something morally positive from an immoral work of art, a work through which an artist intended to convey or suggest a negative moral point of view, we must not credit the work. On the contrary, it is the

51 A. SAUCHELLI, “La critica etica dell’arte”, in V. TRIPODI (ed.), APhEx 8, (2013), p.2, translation by the author of this article 52 Cf. R. PAPA, “Bellezza, natura e arte nel pensiero di san Tommaso” in Espíritu LXVI, n. 154, (2017), pp. 427-442, translation by the author of this article

156

Consciousness in the Aesthetic Vision

reader (if this were a novel) who must be credited with having learned a lesson from the work in question53“. Artistic autonomism can be defined as the theory that moral value does not influence the artistic value of a work of art54. Harold, on the other hand, defines it as the theory that an observer does not make an error of judgement by not revising his artistic judgement of a work of art in the light of a negative moral assessment55. Artistic contextualism or immoralism argues that its moral value can influence the artistic value of a work of art56. The difference with ethicism lies in the connection’s nature between art and morality, which here may vary in relation to the particular work under consideration57. According to the Thomistic, and generally Christian, view, the contemplation of beauty is regarded as a precept of natural moral law and sees the connection between beauty, goodness, and truth as central. Aquinas states: “Beauty and good in a subject are the same, for they are based upon the same reality, that is form, and for this reason what is good is praised as beautiful58“. Taking up Aquinas, Pope John Paul II reminds us: “The natural law involves universality. Inasmuch as it is inscribed in the rational nature of the person, it makes itself felt to all beings endowed with reason and living in history. In order to perfect himself in his specific order, the person must do good and avoid evil, be concerned for the transmission and preservation of life, refine and develop the riches of the material world, cultivate social life, seek truth, practise good and contemplate beauty”. Knowing beauty is an activity certainly linked to the experience of the senses, but it is not exhausted in it: aesthetic experience is a specifically human phenomenon, involving the rational faculties, and the higher spheres that make man sublime in relation to other beings.

53 A. SAUCHELLI, “La critica etica dell’arte”, in V. TRIPODI (ed.), APhEx 8, (2013), p. 8, translation by the author of this article 54 Cf. J. ANDERSON, J. DEAN, “Moderate Autonomism”, in British Journal of Aesthetics 38, 2, (1998), pp. 150-66 55 J. HAROLD, “Autonomism Reconsidered”, in British Journal of Aesthetics 51, 2, (2011), pp. 137-147 56 Cf. A. SAUCHELLI, “La critica etica dell’arte”, in V. TRIPODI (ed.), APhEx 8, (2013), p. 8, translation by the author of this article 57 For example, a work of art may have an artistic merit by virtue of its immorality, or an artistic defect by virtue of its morality 58 THOMAS AQUINAS, Summa Theologiae, I, q. 5. a. 4, translation by the author of this article

Melissa Maioni

157

Moreover, the enjoyment of beauty, whatever the source that provokes it, is accompanied by pleasure that involves the whole individual, his passions and emotions, but also his intellect. This pleasure has no useful end, but is an end in itself: this makes the nature of aesthetic experience as an authentic cultural activity clear, as it nurtures the whole person, i.e. “paideia”. We can therefore conclude that the contemplation of beauty is certainly a potential route to the knowledge of goodness, including moral goodness, the basis for bioethical discernment. It inevitably involves man’s senses and cognitive capacities, but more precisely, it involves the whole individual.

6. Can aesthetic experience be a driving force for moral experience, oriented towards the good and the beautiful, without falling into reductionism or a transhumanist vision, in order to help man reach the truth? Based on our descriptions, we can affirm that aesthetic experience can be considered a universal language, also endorsed by neuroscientific studies, which unite human beings, regardless of culture or religion. There are certain risks to be guarded against. The first, which is the most fashionable one today, is that of reductionism. Man cannot be solely defined as such by virtue of his neurological dimension. Beauty is more than a reaction to certain stimuli. It is not irrational to claim, as we have seen, that aesthetic experience is possible even in altered states of consciousness. Man is more than his strictly physical dimension. The second risk is that of making beauty an absolute, detached from a “healthy” anthropology. Beauty exists for man, it cannot be contrary to his possibility of existing or to his good. There is no need to create a superbeauty for a super-man: the very concept of beauty as balance and harmony would fall apart. Think of the risks of transhumanism and all extreme experiences. Aesthetic experience, instead, is the product of contemplation, which can be inserted within the via pulchretudinis, which is the way that each man can attempt to pursue: it arouses wonder, curiosity about the artwork and the artist who created it. Contemplation leads to the elevation of our intellect, encourages us to nourish an ever-increasing thirst for love, truth, and beauty, which in its growth, paradoxically satiates our being and can therefore be the door to our openness to the transcendent. Beauty, declined as a relationship, according to the examined meanings, becomes an encounter between subject and object, but also the possibility of an encounter with God, artist par excellence, creator of beauty. In this

158

Consciousness in the Aesthetic Vision

sense, contemplation becomes religion and the unambiguous and shareable goal of the journey undertaken by each man, regardless of his religious belief. As Monica Quirico claims: “Tov occurs 741 times in the Old Testament with the meaning of beautiful, good, but also truth, affection, the pleasure of contemplating a landscape or the tenderness of a feeling of love... and tov refers to kabod, the glory of God (where history, nature and God’s work come together). In glory, we might say, the beauty of God, the beauty that is God, shines. Deeper still, there is the reference to the beautiful work of God, the beautiful image: man. Thus the reference to Christ, the beautiful shepherd, icon of the Father (Col 1:17) acquires and gives even more light: “This Son who is the radiance of God’s glory” (Heb 3:13). The beautiful, the aesthetic, therefore, has an original reference to the Just and the Holy that no veil of sin can erase. Beauty is a work, a movement, a “for” that radiates, that comes forth, that ad-venit. This is how it is portrayed throughout the Scriptures: from Creation through the Incarnation to the Parousia there is an epiphany of beauty, the only non-ephemeral Beauty. In this sense, it is easy to see how the Scriptures reject a static Beauty, something that always comes “out of the hands of the creator” is taking form, is a work that experiences movement59“.

Bibliography ANDERSON J., DEAN J., “Moderate Autonomism”, in British Journal of Aesthetics 38, 2, (1998), pp. 150-66 BRATTICO E., M. PEARCE, “The Neuroaesthetics of Music”, in Psychology of Aesthetics, Creativity, and the Arts, 7/1 (2013), pp. 48-61 BROWN S., DISSANAYAKE E., “The arts are more than aesthetics: Neuroaesthetics as narrow aesthetics”, in Neuroaesthetics, M. SKOV & O. VARTANIAN (Eds.), Baywood Publishing Co., (2009) pp. 43–57 BURKE E., A Philosophical Enquiry into the Origin of Our Ideas of the Sublime and Beautiful, Oxford University Press UK, 1764, p.208 CALÌ C., “Neuroestetica e fenomenologia della percezione pittorica e musicale”, in Rivista di estetica, 37, (2008), pp. 21-42 CHANGEUX J.P., “Art and Neuroscience”, in Leonardo, 27, (1994), pp. 89201

59

M. QUIRICO, Bellezza come compito, in https://www.diocesi.torino.it/wpcontent/uploads/2017/07/Quirico-scheda.pdf [26/09/2021], translation by the author of this article

Melissa Maioni

159

CHANGEUX J.P., Ragione e piacere. Dalla scienza all’arte (Raison et plaisir, 1994), Raffaello Cortina, Milano, (2013), pp. 34-35 CHATTERJEE A., “Scientific aesthetics: Three steps forward”, in British Journal of Psychology, 105, 4, (2014), pp.465-467 COHADON F., SALVI G., Uscire dal coma, Libreria Cortina, Milano, (2003) CONTIERO S., Il «difficile problema» della coscienza nelle neuroscienze, (2019), at https://www.terapiacognitiva.eu/tc/il-difficile-problemadella-coscienza-nelle-neuroscienze/ [26/09/2021], CONWAY B.R., LIVINGSTONE M.S., “Perspectives on Science and Art”, in Current opinion in neurobiology, 17/4 (2007), pp. 476–482 CROSS E.S., TICINI L.F., “Neuroaesthetics and Beyond: New Horizons in Applying the Science of the Brain to the Art of Dance”, in Phenomenology and the cognitive sciences, 11/ 1 (2012), pp. 5-16 D’ANGELO P., “La sfida delle neuroscienze”, in Rivista Internazionale di Filosofia Contemporanea – Vol. VI, nº 1, (2018), p.188 DI DIO C., MACALUSO E., RIZZOLATTI G., “The Golden Beauty: Brain Response to Classical and Renaissance Sculptures” in PloS one. 2. (2007), e1201 DI STEFANO N., “Neuroaesthetics”, in International Lexicon of Aesthetics, Autumn 2020 Edition, at https://lexicon.mimesisjournals.com/archive/2020/autumn/Neuroaesthe tics.pdf, DOI: 10.7413/18258630098 [26/09/20201] ETCOFF N., Survival of the prettiest: The science of beauty, Anchor Books/Doubleday (1999) GALLESE V., “Embodied Simulation: From Neurons to Phenomenal Experience”, in Phenomenology and the cognitive sciences, 4/1 (2005), pp. 23-48 GALLESE V., “Neuroni specchio e intersoggettività” in Neuroni Specchio. La relazione empatica tra Scienza, Filosofia, Arte, Cura, L. GAROFANI, G. PIERINI (eds.), Ferrara, Azienda USL Ferrara, (2008), p. 18. Proceedings of the first national conference on mirror neurons HAROLD J., “Autonomism Reconsidered”, in British Journal of Aesthetics 51, 2, (2011), pp. 137-147 ISHIZU T., ZEKI S., “Toward a Brain-Based Theory of Beauty”, in PloS One, 6/7 (2011), e21852 KANT I., The Critique of Judgment, Clarendon Press, Oxford, (1952), p. 180 KAWABATA H., ZEKI S., “Neural Correlates of Beauty”, in Journal of neurophysiology, 91 (2004), pp. 1699-1705 LANGLOIS J. H., KALAKANIS L., RUBENSTEIN A. J., LARSON A., HALLAM M., & SMOOT M, “Maxims or myths of beauty? A meta-analytic and

160

Consciousness in the Aesthetic Vision

theoretical review” in Psychological Bulletin, 126(3), (2000), pp. 390– 423 MARTIAL C., CASSOL H., LAUREYS S., GOSSERIES O., Near-Death Experience as a Probe to Explore (Disconnected) Consciousness, Trends Cogn Sci 24(3), (2020), pp. 173-183 MORA F., “Neuroculture: A New Cultural Revolution”, in Art, Aesthetics, and the Brain, J.P. HUSTON et al. (Eds.), Oxford University Press, (2015) pp. 3-18 MSD MANUAL, under the entry: “Panoramica su coma e deterioramento della coscienza inquadramento”, at : https://www.msdmanuals.com/itit/professionale/malattie-neurologiche/coma-e-deterioramento-dellacoscienza/panoramica-su-coma-e-deterioramento-della-coscienzainquadramento [26/09/2021] MSD MANUAL, under the entry: “Sindrome locked-in”, at https://www.msdmanuals.com/it-it/professionale/malattieneurologiche/coma-e-deterioramento-della-coscienza/locked-insyndrome [26/09/2021] MSD MANUAL, under the entry: “Stato vegetativo e stato di minima coscienza”, at https://www.msdmanuals.com/it-it/professionale/malattieneurologiche/coma-e-deterioramento-della-coscienza/stato-vegetativoe-stato-di-minimacoscienza#:~:text=Lo%20stato%20vegetativo%20%C3%A8%20caratt erizzato,il%20normale%20ciclo%20sonno%2Dveglia. [26/09/2021] NADAL M., PEARCE M.T., “The Copenhagen Neuroaesthetics Conference: Prospects and Pitfalls for an Emerging Field”, in Brain and cognition, 76/1 (2011), pp. 172-183 NOË A., Strange Tools. Art and Human Nature, Hill and Wang Ed., New York, (2015) OLIVETTI ANCIENT GREEK DICTIONARY, under the entry: ĮੁıșȐȞȠȝĮȚ, at https://www.grecoantico.com/dizionario-grecoantico.php?lemma=AISQANOMAI100, [26/09/2021] OLIVETTI ANCIENT GREEK DICTIONARY, under the entry: Į੅ıșȘıȚȢ, at https://www.grecoantico.com/dizionario-grecoantico.php?parola=%CE%B1%E1%BC%B4%CF%83%CE%B8%CE %B7%CF%83%CE%B9%CF%82+, [26/09/2021]

Melissa Maioni ONLINE TRECCANI DICTIONARY under

161

the entry: “perception”, at https://www.treccani.it/vocabolario/percezione/ [28/09/2021] ORIANS G. H., HEERWAGEN J. H., “Evolved responses to landscapes”, in BARKOW J. H., COSMIDES L., TOOBY J. (Eds.), The adapted mind: Evolutionary psychology and the generation of culture, Oxford University Press, (1992), pp. 555–579 PAPA R., “Bellezza, natura e arte nel pensiero di san Tommaso” in Espíritu LXVI, n. 154, (2017), p. 439 PERRETT D. I., MAY K. A., YOSHIKAWA, S., “Facial shape and judgements of female attractiveness”, in Nature, 368(6468), (1994), pp. 239–242 PURVES D., Cabeza R., Huettel S.A., LaBar K. S., Platt M. L., Woldorff M.G., Neuroscienze cognitive, Zanichelli Ed., Bologna (2014) QUIRICO M., Bellezza come compito, in https://www.diocesi.torino.it/wpcontent/uploads/2017/07/Quirico-scheda.pdf [26/09/2021] RAMACHANDRAN V.S. and HIRSTEIN W., “The Science of Art A Neurological Theory of Aesthetic Experience”, in Journal of Consciousness Studies 6(6-7), (1999), pp. 15-51 RAMACHANDRAN V.S., L’uomo che credeva di essere morto, Ed. Mondadori, Milano, 2012 RHODES G., “The Evolutionary Psychology of Facial Beauty”, in Annual Review of Psychology, Vol. 57, (2006), pp. 199-226 SAUCHELLI A., “La critica etica dell’arte”, in V. TRIPODI (ed.), APhEx 8, (2013), p.2 SAVARESE M., La nozione trascendentale di bello in Tommaso d’Aquino, (2015) at https://disf.org/editoriali/2015-02 [26/09/2021] TALON-HUGON C., Morales de l’art, Éditeur: Presses Universitaires de France, (2009) THOMAS AQUINAS, Summa Theologiae, I, q. 5. a. 4 VAN LOMMEL P. in “Oltre la vita, parla lo scienziato che indaga sulla premorte” in ADNKronos 14/04/2017 at https://www.adnkronos.com/lo-scienziato-che-indaga-sulla-premortepossibile-per-2-5-mln-italiani_3687n27hjvwtbRiDIINn9e [26/09/2021] VAN LOMMEL P. in C. GALLO, “Cosa significa tornare alla vita dopo la “premorte”: parla il cardiologo che studia la “quasi morte”. Intervista all’olandese Pim van Lommel” in La Stampa 26/03/2017 at https://www.lastampa.it/scienza/2017/03/26/news/cosa-significatornare-alla-vita-dopo-la-premorte-parla-il-cardiologo-che-studia-laquasi-morte-1.34642597 [26/09/2021] VARTANIAN O., SKOV M., “Neural correlates of viewing paintings: evidence from a quantitative meta-analysis of functional magnetic resonance imaging data” in Brain Cogn. (2014 Jun); 87:52-6

162

Consciousness in the Aesthetic Vision

VICARIO M. C., “Neuroestetica: una riflessione sulle basi neurobiologiche della bruttezza”, in Reti, saperi, linguaggi, Ed. il Mulino, Bologna, 2 (2019) a. 8 (16) p. 359 ZACCAGNINI B., Neuroestetica. Dialoghi fra arte e cervello, diss. University of Pisa (2015), at https://etd.adm.unipi.it/t/etd-03242015-110755/ [26/09/2021] ZEKI S., “Art and the Brain”, in Journal of Consciousness Studies, 6, (1999), pp.76-96 ZEKI S., LAMB M., “The Neurology of Kinetic Art”, in Brain, 117 (1994), pp.607-636

Sitography “Vi racconto cosa ho visto nella mia esperienza di morte” in youtube channel TV2000it, 17/01/2017 at https://www.youtube.com/watch?v=c-sAm7mtMA8 [26/09/2021