Introduction	Part 2	Part 3	Appendices
Part 1	Introduction to Part 2	Introduction to Part 3	Appendix A
Introduction to Part 1	Chapter 6	Chapter 9	Appendix B
Chapter 1	Chapter 7	Chapter 10	Appendix C
Chapter 2	Chapter 8	Chapter 11	Appendix D
Chapter 3	Conclusions to Part 2	Thesis Conclusions	Appendix E
Chapter 4			Appendix F
Chapter 5			Bibliography
Conclusions to Part 1			Books and Articles
			Legal Cases

Chapter 1: Difficulties in judging ‘consciousness’

The discussion in this chapter proceeds by first showing (in Section 1) that there is an assumption, widespread in both in the medical literature and in the legal cases which involve PVS, that PVS patients have no consciousness and cannot feel pain.

In Section 2 the arguments offered from philosophy and science, for the proposition that PVS patients have no consciousness[i] are considered.

In Section 3 a number of possible meanings of the term ‘consciousness’ are examined. It is argued that many of the purported conclusions concerning the consciousness of PVS patients rely on the existence of ambiguities most particularly in the equation of ‘consciousness’ with ‘reflexive consciousness’.[ii]

In Section 4 it is suggested that there is a clear and demonstrable congruence between the Medical Conceptual Framework and the Cartesian philosophy of consciousness and reflex action and, furthermore, that ideas of consciousness are, in Cartesian philosophy, intimately connected with ideas of personhood. To this end the philosophy of Descartes - in so far as it is relevant to this discussion - is briefly sketched. To the extent that the Cartesian analysis is not only admittedly contingent but, more importantly, incorrect in its claims, so too is the current Medical Conceptual Framework. The strongest challenge to the Cartesian position on consciousness and personhood is from Wittgenstein’s ‘Private Language Argument’ [‘PLA’ ] and this is outlined in Section 4 but the main discussion of the ‘PLA’ is reserved until a fuller discussion of the concept of personhood in Chapter 10. The conclusions of the discussion are summarised in Section 5.

Section 1: The pervasiveness of the assertion that PVS patients lack consciousness and cannot experience pain.

In legal judgements

Perhaps the most forthright expression of the view that PVS patients have no consciousness and cannot experience pain, is to be found in the statement of Sir Stephen Brown P., in the Bland Case:

“... [Tony Bland] has remained ever since in a state of complete unawareness. This is known to the medical profession as a “persistent vegetative state” (“P.V.S.”). Although his brain stem is intact he suffered irreparable damage to the cortex. All the higher functions of Anthony Bland’s brain have been destroyed. There is no hope whatsoever of recovery or improvement of any kind. That is the unanimous opinion of all the distinguished doctors who have examined Anthony Bland ... Although Anthony Bland’s body breaths and reacts in a reflex manner to painful stimuli it is quite clear that there is no awareness on his part of anything that is taking place around him. E.E.G. and C.T. scans reveal no evidence or cortical activity. Indeed recent scans ... show that there is more space than substance in the relevant part of Anthony Bland’s brain. ... He is fitted with a catheter which has given rise to infection necessitating surgical intervention. It is to be noted that the necessary surgical incision was made without any anaesthetic because Anthony Bland is utterly devoid of feeling of any kind.” [iii]

In this same case, at the Court of Appeal, Sir Thomas Bingham, M.R., stated:

“Its [PVS’s] distinguishing characteristics are that the brain stem remains alive and functioning while the cortex of the brain loses its function and activity. Thus the P.V.S. patient continues to breath unaided and his digestion continues to function. But although his eyes are open, he cannot see. He cannot hear. Although capable of reflex movement, particularly in response to painful stimuli, the patient is incapable of voluntary movement and can feel no pain. He cannot taste or smell. He cannot speak or communicate in any way. He has no cognitive function and can thus feel no emotion, whether pleasure or distress.” [iv]

This description of PVS was adopted by Lynch J., in the Ward Case[v] in the Irish High Court proceedings, and by Denham J. in the Supreme Court.[vi] Sir Thomas Bingham M.R. continued:

“The absence of cerebral function is not a matter of surmise; it can be scientifically demonstrated. The space which the brain should occupy is full of watery fluid.” [vii]

It is quite clear from the above quotations that the courts entertain no doubts as to the lack of consciousness of PVS patients and their ability to feel pain; it remains to be seen whether this certainty is also found in the writings of medical commentators.

It is important however to recognise that, whilst the courts often may not exhibit the same subtlety of reasoning as is to be found amongst academic commentators, it is the opinions that are prevalent in the courts that have the most immediate and far-reaching effects. Although it is undoubtedly true that the views of the courts on these issues have their origins in medical testimony; these views, because of the doctrine of precedent, take on an independent life of their own in subsequent legal discussion.

In the medical literature

Later, in discussing the definition of PVS in Chapter 4, many examples are given where medical authorities assert that PVS patients have no consciousness and cannot feel pain and, rather than needlessly repeating these here, I will just quote the recent (1996) British Medical Association guidelines which describe, and endorse, the conventional view on these questions:

“It is widely accepted that PVS patients are unconscious and incapable of suffering mental distress or physical pain although many reflex responses remain.” [viii]

Section 2: Arguments for the assertion that PVS patients lack consciousness

Philosophical arguments are considered first and then the question is examined from a scientific perspective, and finally it is sought to draw some conclusions from the discussion.

The Philosophical Path

Philosophy has long wrestled with the difficulties inherent in ascribing consciousness to others; this recurrent problem has become known as the ‘problem of other minds’. Not only has philosophy been unable to satisfactorily settle this issue but it has not been able to resolve the more basic question of whether consciousness is solely a property of ‘living’ things or may be ascribed to ‘inanimate’ matter. Thomas Nagel, for example, concludes his essay on ‘Panpsychism’ with the following words:

“But we know so little about how consciousness arises from matter in our own case and that of the animals in which we can identify it that it would be dogmatic to assume that it does not exist in other complex systems, or even in systems the size of a galaxy, as the result of the same basic properties of matter that are responsible for us.” [ix]

It seems that questions as to the existence of consciousness can be divided into two types. Firstly, general questions such as ‘What are the necessary and sufficient conditions for ascribing consciousness to other entities?” or indeed ‘Has a plant consciousness?”. We can, following Nagel, accept our inability to answer these broad questions, and turning to less esoteric topics we can ask apparently simpler questions of the form ‘Given a class to whom consciousness is normally ascribed [i.e. fellow humans] how can we tell whether an individual member of that class possesses consciousness?’ Our concern in this section is only with questions of this second type as our context is that of determining whether a particular PVS patient has some level of awareness. Recognising the difficulty - indeed impossibility - of solving the general questions can these simpler questions of the second type find a philosophical resolution?

We can begin by asking if it is possible to determine whether other humans who live apparently normal, uneventful, everyday lives, are really conscious? Could they simply be machines or robots? Wittgenstein, amongst many others, considered this question and his answer is illuminating (though more for what it leaves unsaid!):

“But can’t I imagine that the people around me are automata, lack consciousness, even though they behave in the same way as usual? ... But just try to keep hold of this idea in the midst of your ordinary intercourse with others, in the street ... And you will either find the words become quite meaningless; or you will produce in yourself some kind of uncanny feeling ...” [x]

This appears to acknowledge that whilst we may logically hold that others are robots this is - for emotional reasons - an impossible standpoint to consistently adopt. It seems that even by restricting the discussion to questions of the narrower sort little progress is possible.[xi]

The role of philosophy in this discussion of consciousness.

If philosophy cannot establish with certainty the consciousness of other, apparently normal, individuals then it would seem clear that it cannot resolve doubts as to the consciousness of PVS patients. From this it might seem that philosophy has nothing to offer towards a resolution of the problem of PVS patient consciousness; but such a view would be seriously in error. Philosophy can help to:

(i) clarify ambiguities in the use of the term ‘consciousness’ [As discussed in Section 2].

(ii) elucidate the reasons why the ascription of consciousness is considered to have the importance that it does.

(iii) uncover and critically analyse the criteria that are commonly used for the ascription of consciousness.

In relation to the second point, I will argue that consciousness is being used as a surrogate for personhood; more particularly, that the possession of consciousness is implicitly used as a criterion of, if not personhood, then ‘moral objecthood’ [xii] and that it is these concepts that are, and should be, primary in the discussion. This position would be supported by P.F.Strawson who sees the problem of personhood as primary and that of consciousness as derivative:

”So the concept of the pure individual consciousness - the pure ego - is a concept that cannot exist; or, at least, cannot exist as a primary concept in terms of which the concept of a person can be explained or analysed. It can exist only, if at all, as a secondary, non-primitive concept, which itself is to be explained, analysed, in terms of the concept of a person ...The concept of a person is logically prior to that of an individual consciousness. The concept of a person is not to be analysed as that of an animated body or of an embodied anima. This is not to say that the concept of a pure individual consciousness might not have a logically secondary existence, if one thinks, or finds, it desirable. ... A person is not an embodied ego ...” [xiii]

Strawson’s position contrasts with the Cartesian tradition which holds that the individual consciousness is logically prior to, and may exist independently of, all else. To Descartes the isolated - or pre-social - individual can philosophise and, by the famous ‘cogito’ argument, settle his doubts about his own existence and consciousness and go forth and discover the world. This suggests that ‘personhood’ - whatever that may be defined to be - can be ascribed to such an isolated, pre-social, individual. Strawson’s position is that the ascription of personhood is a mutual judgement of individuals following social interaction, and could not be ascribed to an isolated, pre-social, individual; this implies that a necessary condition for the ascription of personhood to an individual is the ability of that individual to communicate to some minimal standard. To Strawson, the isolated pre-social individual could not be a ‘person’ without prior social interaction; and this conclusion is also supported by Wittgenstein’s ‘PLA’ which implies that such an isolated pre-social individual would not be capable of conceptual thought. Surprisingly support for the ‘ability to communicate’ being a necessary condition for the ascription of personhood can also be found in the writings of Descartes. These questions will be considered more fully later in this chapter in discussing the philosophy of Descartes, and in Chapter 10 which discusses personhood.

In relation to the third point, the suggestion that the role of philosophy is to analyse the criteria used to ascribe consciousness and not to speculate on whether or not some mental state actually exists, does not find a ready acceptance from Nagel, though he acknowledges that it would be Wittgenstein’s position:

“[Wittgenstein] holds that all kinds of familiar propositions about the mental states of individual living beings are true, but that there is almost nothing to be said about what property must be possessed by what thing if one of these ascriptions is to be true. All such specifications of truth conditions are trivial. What can be more fully described, however, are the kinds of circumstances, including evidential grounds, that make the ascription appropriate: criteria rather than truth conditions. For third person ascriptions the grounds are behaviour, stimuli, circumstances and testimony (once the subject has learned the relevant mental vocabulary). For self-ascription no evidential grounds are needed. Although facts about the body are among the criteria for ascribing mental state to others ... the mental states are not states of the body. The view is not reductionist. Mental states are no less real than behaviour ... In fact their situation ... is symmetrical, because physical processes have mental (specifically observational) criteria just as mental processes have physical criteria. According to Wittgenstein, everything there is must be systematically connected with other things in a way that permits public agreement, or at least public disagreement, about whether it is there or not. Mental phenomena meet the condition through their connection with behaviour and circumstances, but they are perfectly real in their own right. They cannot be analysed as dispositions to behaviour or properties of the organism, any more than physical phenomena can be analysed as multiple possibilities of sensation or of observation. If asked to say what any of these kinds of things really is, or what statements about them really assert, we can give no reply that is not trivial.” [xiv]

Nagel does not accept Wittgenstein’s view. He believes that it depends too heavily on an analysis of language and that it surrenders, what he believes is, the important question - the consciousness of another - in favour of resolving a subsidiary question - the criteria for the ascription of consciousness to another. To highlight the difference he takes a striking example:

“... if things emerged from a spaceship which we could not be sure were machines or conscious beings, what we were wondering about would have an answer even if the things were so different from anything we were familiar with that we could never discover it. It would depend on whether there was something it was like to be them, not on whether behavioural similarities warranted our saying so ... I believe that the question about whether the things coming out of the spaceship are conscious must have an answer. Wittgenstein would presumably say that this assumption reflects a groundless confidence that a certain picture unambiguously determines its own application. That is the picture of something going on in their heads ... that cannot be observed by dissection.” [xv]

This point is particularly apposite for our purposes in that the question of the consciousness of a PVS patient is often reduced simply to the quite different question as to whether the behaviour of the patient would normally merit application of the term ‘conscious’. It is perhaps worthwhile to formalise the distinction drawn by Nagel between consciousness as it is ‘internally experienced’ - Consciousness _IN , for short - and consciousness as determined by behaviour - Consciousness _B , for short. Wittgenstein’s position would be that the distinction between Consciousness _IN and Consciousness _B could not be sensibly made; Nagel’s is that it must. A simple gesture of introspection would favour Nagel’s perspective; such a gesture will immediately make clear that the existence of one’s own consciousness does not depend on one’s manifesting any particular, or indeed any, behaviour; consciousness being quite compatible with extended periods of physical stillness; in short we can conclude that:

Conclusion _{1 -1} :[xvi] Consciousness _IN and Consciousness _B - though normally found in such a close association as to have a factual interdependence - are, strictly speaking, logically independent. As applied to a PVS patient, this suggests that, although it may be adjudged that Consciousness _B does not exist, no necessary implication follows concerning Consciousness _IN .[xvii]

The contribution of philosophy to the debate on the criteria for ascribing consciousness is not simply restricted to analysing, and criticising, particular criteria but is much more fundamental, it can determine the very boundaries of the debate. To see this it is first necessary to consider the scientific contribution to the debate on consciousness.

The Scientific Path

In order to gain access to the problem of consciousness, science needs to find some point of purchase, otherwise it faces precisely the same difficulties as does philosophy. The simplest assumption that permits this is that all mental processes are, if not just brain processes at least in some sense isomorphic to, or at least reflected in, brain processes.[xviii] This assumption would suggest an investigation of the brain in an attempt to establish correlates of various mental phenomena and this indeed is what has happened in recent years. By identifying firstly those parts of the brain - or brain process - associated with consciousness, and secondly those areas of the brain injury to which is associated with PVS, the hope would be that - by a comparison of these respective areas - the problem of PVS-patient consciousness could be resolved. This hoped for resolution fails for two reasons, firstly there is no one area of the brain, or no particular brain processes, that can be unequivocally associated with consciousness and secondly there is no one area of the brain, damage to which is uniquely associated with PVS.

Any area of the brain uniquely associated with consciousness?

The search to find an area of the brain uniquely associated with consciousness has not been successful. Owen Flanagan notes:

“One mistake to stay away from is positing a centre of consciousness ... Some patterns of neural activity result in phenomenological experience; other patterns do not. The story bottoms out there.” [xix]

He also reports that even in those areas where attempts at a neural mapping have had some success the boundaries of the neural regions themselves are unstable:

“There are precise mappings for certain sensation types (for example, color sensation, taste touch and vibration), but the mapping are coarser and less consistent for other sensation types (for example, pain and temperature). Secondly, there is evidence ... of changing boundaries and intraindividual variation of neural maps. The mappings from the sensory receptors to the cortex are remarkably fluid within a certain range.” [xx]

Some current research suggests that consciousness, rather than being mirrored in some particular area of the brain, is manifested in a non-localised brain activity. Crick and Koch, for example, believe that consciousness is linked to oscillatory patterns in the 40 Hz range resonating across the brain;[xxi] the fact that the experimental research offered in support of this hypothesis relates solely to visual awareness considerably weakens this hypothesis.

Bernard J. Baars, in a recent paper,[xxii] throws even greater doubt on such attempts to find a neural correlate of consciousness:

“A great variety of evidence may have a bearing on consciousness - hypnotizability, perceptual reaction time, memory measures, psychophysical scaling - but the relationships between these measures and ‘consciousness per se’ are probably indirect. Which measures are most relevant to understanding consciousness seems to be a great source of confusion. A review of the vast literature on event-related brain potentials concludes pessimistically that, although there are well-known ERP correlates of perception, decision-making, discrimination, and voluntary action, it is unclear whether any of them say anything about consciousness. (Donchin, McCarthy, Kutas, and Ritter, 1983)! The sticking point seems to be that there is no explicit agreement on what to look for in trying to understand ‘real’ consciousness. But of course raw observations won’t tell us anything until we have some notion of what to look for.” [xxiii]

The conclusion can be drawn that:

Conclusion _{1 -2} : There is no area of the brain, and no specific brain activity, that is uniquely associated with the possession of consciousness.

For brain damaged (including PVS) patients the problem is even more intractable, because - even assuming that a neural correlate of consciousness has been established for normal subjects - we cannot conclude that the same neural correlate would necessarily be valid for brain damaged subjects. This is because, in brain damaged patients, a reorganisation of the brain can occur so that an (undamaged) area of the brain - not normally associated with a particular task - can take over the management of that task from the now damaged part of the brain. Furthermore the brain exhibits a so-called ‘parallelism’. Of this, Richard Gregory states:

“The cortical events underlying complex and cognitive actions are probably so widely dispersed that no brain damage, however great, can either destroy them entirely or leave them wholly unimpaired.” [xxiv]

It seems that to approach the problem of determining PVS patient consciousness from the direction of consciousness is singularly unpromising; the alternative is to approach it from the direction of PVS - i.e. to examine the brain states of PVS patients in the hope that these may exhibit a uniformity of damage to specific areas of the brain; this, in turn, might suggest new methods of resolving the question of PVS patient consciousness. We now examine the correlation of PVS with specific brain damage.

PVS and associated brain damage

An article by Jennett and Plum was the first to name the syndrome ‘Persistent Vegetative State’ as such.[xxv] Its authors were cautious in suggesting links between PVS and damage to any particular location of the brain or to any particular brain activity.[xxvi] They stated:

“... the clinical syndrome we are describing can be produced by lesions which largely spare the cortex structurally, and the E.E.G may even show persistent alpha rhythms. ... the lesion may be in the cortex itself, in subcortical structures of the hemisphere, or in the brain-stem, or in all of these sites. But the exact site and nature of the lesion is unknown to the bedside clinician, and the name for the syndrome should not imply more than is known. ... In the first few weeks after injury the electroencephalogram (E.E.G ) may resolve doubts about whether the patient is really attentive; if there is extensive neocortical death the record will be initially flat ... However this is rare and there is very little information about the significance of E.E.G. changes months after the initial incident; ... However, we cannot yet accurately predict the specific pathological substrate or the precise E.E.G abnormality which will be found in association with the persistent vegetative state.” [xxvii]

The Jennett and Plum paper was published in 1972 and there have been considerable developments since then both in the general study of the brain, and in the relationship between brain damage and PVS. One such study, by Hannah Kinney,[xxviii] concerned a neuropathological analysis of the brain of Karen Quinlan[xxix] in which her entire brain and spinal cord were systematically examined. The Kinney study, which was published in 1994, is of particular interest in that its results were contrary to the expectations of the neuropathologists. This divergence between the expectation and the result is eloquent testimony to the gap that still exists in the understanding of how PVS manifests in the brain. The study states:

“Contrary to expectation the most severe damage was not in the cerebral cortex but in the thalamus, and the brain stem was relatively intact ... The persistent vegetative state raises fundamental questions about the neuroanatomical basis of human consciousness and the nature of brain damage that leads to a dissociation of cognition and awareness from arousal. ... In Quinlan’s case, however, the most extensive and bilateral damage was not in the cerebral cortex or white matter. In other patients in the persistent vegetative state, cerebral cortical damage has varied widely, and as in Quinlan, has sometimes seemed insufficient to cause the global defects.” [xxx]

A more recent study by Dr. Keith Andrews of the London Royal Hospital for Neuro-disability, states:

“It has been pointed out that neurodiagnostic tests can neither confirm the diagnosis of a vegetative state nor predict the potential for recovery.” [xxxi]

Although Ronald Cranford, in responding to the Andrews study, says:

“Both the multi-society task force on the vegetative state in the United States and the working group of the Royal College of Physicians in Britain stated that these neurodiagnostic studies have some use in the diagnosis. It is unfortunate that Andrews et al did not make use of them.” [xxxii]

One point, however, clearly emerges from the Kinney study and from the conflict between Andrews and Cranford, and that is that neurodiagnostic tests are not definitive in diagnosing PVS.

Conclusion _{1 -3} : There is no definitive neurological test for PVS.

It has been argued earlier that, given neural activity, there is no neurological test which will determine the presence of consciousness. We are thus led ineluctably to the conclusion that:

Conclusion _{1 -4} : There is no neurological test which will determine PVS patient consciousness.

This leads us to question the medical practice which has hitherto been used to resolve the problem of determining PVS patient consciousness.

The determining of PVS patient consciousness in medical practice

The 1972 article by Jennett and Plum, referred to earlier, is again a good starting point. This article, particularly in its discussion of patient consciousness, exhibits a precision of language not always found in other discussions of PVS. As is shown in the quotations following, Jennett and Plum were fully aware of the distinction between the existence of patient consciousness as ‘internally experienced’ - ‘Consciousness _IN’, and the existence of patient consciousness as judged by external behaviour - ‘Consciousness _B ‘;

“We propose this[xxxiii] as the most satisfactory term to describe this syndrome, for several reasons. It describes behaviour, and it is only data about behaviour which will always be available, ... What is common to all these patients ... is that, as best can be judged behaviourally, the cerebral cortex is not functioning ... ” [xxxiv]

They acknowledge the tenuous nature of the judgements as to absence of mental activity but see no alternative:

“Although we would not deny that a continuum must exist between this vegetative state and some of the others described, it seems wise to make an absolute distinction between patients who do make a consistently understandable response to those around them, whether by word or gesture, and those who never do. ... the immediate issue is to recognise that there is a group of patients who never show evidence of a working mind. This concept may be criticised on the grounds that observation of behaviour is insufficient evidence on which to base a judgement of mental activity: it is our view that there is no reliable alternative available to the doctor at the bedside, which is where decisions have to be made.” [xxxv]

Their recognition of the tenuous nature of the judgements as to the absence of mental activity in conjunction with their (seemingly) obligatory duty to make such a judgement, raises the pivotal question as to the role this judgement plays in the conceptual structure that they are using. I suggest that it is being implicitly used as a criterion of personhood. The United States President’s Commission for the Study of Ethical Problems[xxxvi] in its discussion of PVS was quite explicit in linking personhood to consciousness; they stated:

“Most of what makes someone a distinctive individual is lost when the person is unconscious, especially if he or she will always remain so. Personality, memory, purposive action, social interaction, sentience, thought and even emotional states are gone. Only vegetative functions and reflexes persist.” [xxxvii]

They also took note of Joseph Fletcher’s criteria for ‘personhood’, [xxxviii] and that these criteria implied that a PVS patient ought not to be considered a ‘person’. Without registering disagreement with Fletcher’s approach, they did not pursue the issue of defining personhood. I wish to leave the issue of personhood to one side for the moment and return to it at a later stage (in Chapter 10) where I will argue that possession of consciousness is not a suitable criterion for ‘personhood’.

Returning to the main question - which is the meaning of the term ‘consciousness’ as used in medical practice - the Commission, whilst noting that: “No one can ever have more than inferential evidence of consciousness in another person.” [xxxix] neatly seeks to resolve the difficulty of determining PVS patient consciousness by making the equation:

Consciousness _IN = Consciousness _B

- an equation which is a relic of a somewhat discredited behaviorist psychology. They continued:

“ Medical science has been unable to detect or postulate neurologic damage to the brain that would result in a functioning cerebrum capable of consciousness but able to perform absolutely no purposeful actions. At the least, to have consciousness a person must have some functioning cerebrum connected to adequate activating structures in the midbrain. Neurological findings indicate that having that much of a functioning central nervous system entails having at least the ability to blink voluntarily or move the eyes deliberately, and usually much more. Patients with the rare neurological syndrome termed ‘locked-in state’ retain only the ability to control movements of the eyes or eyelids.” [xl]

There are three reasons why this proposition is difficult to sustain:

(i) It is not compatible with statements, quoted earlier, showing that the search to find a neural correlate of consciousness has been unsuccessful.

(ii) Consider the example of a ‘locked-in syndrome’ patient unable to move any part of his body except for one eye.[xli] Imagine that such a patient develops a persistent and permanent twitch in his eye rendering it incapable of voluntary control. The proposition that the existence of this twitch necessarily implies his losing consciousness seems quite absurd. Borthwick’s papers, considered later, urge a similar conclusion.

(iii) On a purely methodological level, the attempt to establish that a PVS patient has no consciousness seems beset by difficulties of such a nature as to render the problem theoretically unsolvable. We will return to this topic shortly.

A more recent (1994) US study by the Multi-Society Task Force on PVS[xlii] again considers the question of PVS patient consciousness. They, however, retreat somewhat from the equation Consciousness _IN = Consciousness _B as asserted in the 1983 President’s Commission report. They state:

“Patients in a coma are unconscious because they lack both wakefulness and awareness.[xliii] Patients in a vegetative state are unconscious because, although they are wakeful, they lack awareness. ... By definition, patients in a persistent vegetative state are unaware of themselves or their environment. They are noncognitive, nonsentient, and incapable of conscious experience. There is, however, a biologic limitation to the certainty of this definition, since we can only infer the presence or absence of consciousness in another person. A false positive diagnosis of a persistent vegetative state could occur if it was concluded that a person lacked awareness when, in fact, he or she was aware. Such an error might occur if a patient in a locked-in state (i.e., conscious yet unable to communicate because of severe paralysis) was wrongly judged to be unaware. Thus it is theoretically possible that a patient who appears to be in a persistent vegetative state retains awareness but shows no evidence of it.” [xliv]

The study then turns to the evidence for the assertion that PVS patients lack consciousness:

”At present, three lines of evidence based on careful clinical and laboratory studies support the conclusion that patients in a persistent vegetative state are unaware of their environment. First, motor or eye movements and facial expressions in response to various stimuli occur in stereotyped patterns that indicate reflexive responses integrated at deep subcortical levels rather than learned voluntary acts. The presence of these responses is consistent with complete unawareness. Second, positron-emission tomagraphic studies of regional cerebral glucose metabolism show levels far lower than those in patients who are aware or in a locked-in state. These low metabolic rates are comparable to those reported during deep general anesthesia in normal subjects whom all would agree are unaware and insensate. Finally, all available neuropathological examinations of the brains of patients with a clinical diagnosis of a persistent vegetative state show lesions so severe and diffuse that awareness would have been highly improbable, given our biologic understanding of how the anatomy and physiology of the brain contribute to consciousness.” [xlv]

Three reasons are offered to support the judgement that PVS patients lack consciousness. Let us isolate and consider each reason separately:

(i) “ eye movements ... indicate reflexive responses ... The presence of these responses is consistent with complete unawareness.”

It need only be pointed out that, as a simple gesture of introspection will prove, they are equally consistent with awareness.

(ii) The second reason draws on the evidence of positron-emission tomagraphic (PET) studies. Two assertions are made.

The first is:

“ ... positron-emission tomagraphic studies show levels far lower than those in patients who are aware or in a locked-in state.”

This clearly begs the very question that it seeks to answer for it presumes that PVS patients are not aware. However leaving the circularity aside, obviously there are many differences between PVS and non-PVS patients, one such is that the responses of PVS patients to stimuli are of a lower order of complexity than are those of locked-in syndrome, or other, non-PVS, patients. It would surely not be unexpected that this lower level of complexity be reflected in lower levels of cerebral activity.

Secondly, the Andrews 1996 study on misdiagnosis, referred to earlier, made no reported use of such PET scans as a diagnostic tool.

Thirdly, the statement is difficult to reconcile with the high rate of misdiagnoses of PVS which exists. The extent and nature of this misdiagnosis is discussed later.

The second assertion is that:

“The low metabolic rates are comparable to those reported during deep general anesthesia ... who all would agree are unaware and insensate.”

This is open to two objections:

Firstly, recent studies of some patients undergoing surgery show that they were aware of what was happening even though they were supposedly in a deep general anaesthesia.[xlvi] This was shown by their being able, subsequently, to report on the conversations of the medical staff which occurred during the surgery.

Secondly, it assumes that consciousness is a unitary phenomenon.[xlvii] Studies[xlviii] of yogic mediators show EEG patterns considerably different from those found in ‘normal’ consciousness. Of these Charles Tart notes:

“The adept practitioners of both forms of meditation [i.e. Zen and Yoga] show almost continuous alpha waves (normally associated with a state of relaxed alertness in ordinary subjects) during meditation. This is particularly startling in the case of Zen monks because their eyes are open: one almost never sees alpha rhythm in the eyes-open condition in ordinary subjects.[xlix] ... The Yogis ... show no response to stimulation at all.” [l]

(iii) “... neuropathological investigations of the brains [of PVS patients] ... show lesions so severe that awareness would have been highly improbable, given our ... understanding of how the anatomy and physiology of the brain contribute to consciousness.”

Firstly, the neuropathology report on the brain of Karen Quinlan, quoted earlier, is difficult to reconcile with this statement. It had stated:

“In Quinlan’s case, however, the most extensive and bilateral damage was not in the cerebral cortex or white matter. In other patients in the persistent vegetative state, cerebral cortical damage has varied widely, and as in Quinlan, has sometimes seemed insufficient to cause the global defects.” [li]

Secondly, as is evident from the 1996 BMA Guidelines,[lii] the very fact that post-mortems are not carried out on PVS patients as a matter of routine lessens the authority of the statement.

Lastly, as has been shown earlier, the understanding of how consciousness manifests in the brain is still in its infancy a fact which further militates against the evidence base of the 1994 US Study on PVS.

The conclusion to be drawn is that:

Conclusion _{1 - 5} : In relation to the problem of PVS patient consciousness, medical practice has assumed that Consciousness _IN = Consciousness _B. Furthermore, it has used the ‘reflex test’ as the criterion for establishing Consciousness _B.

A number of conclusions have been drawn in the course of this discussion concerning the validity of the methods used for determining the consciousness of PVS patients. We have seen that, as yet, science has not been able to penetrate the concept of Consciousness _IN. It has restricted itself to Consciousness _B. Without doubt, the current situation is unsatisfactory. There are problems[liii] associated with the concept of Consciousness _B and with the equation of Consciousness _B to Consciousness _IN which (pace Wittgenstein) is something of a ‘logical sleight-of-hand’.

Certainly the results of scientific studies on how consciousness is manifested in the brain have been less than encouraging. An optimist may well hope that this will soon be rectified. Can we hope that sometime in the future, science can penetrate directly to a study of Consciousness _IN or are there theoretical reasons why Consciousness _IN can never be made amenable to a scientific approach? It is to this question that we now turn.

Science and Consciousness_IN

I wish to suggest that a philosophical approach can offer good theoretical reasons why Consciousness _IN can never be made amenable to a scientific approach and that this is particularly so in relation to PVS patients.

First consider how experiments to establish a neural correlate of, say, visual consciousness are carried out. A subject is presented with various images whilst his brain is being monitored for activity; he is questioned as to the images of which he was conscious, he is further questioned to see if certain images of which he was not conscious were perceived by the brain (the phenomenon of ‘blindsight’[liv]); the subsequent correlation of these three sets of images (the ones consciously perceived, the ones unconsciously perceived in ‘blindsight’, and the ones not perceived) with the corresponding brain states, yield a tentative neural map for visual consciousness. It is clear that a communication with the subject to establish that of which they were conscious, is an essential part of this investigation.

Can the same methodology be used in relation to consciousness? Let us return to first principles. From the minimal assumption that any level of consciousness manifests in some level of activity in the brain [either electrical or chemical] what follows? Certainly the conclusion can be drawn that if no such activity manifests in the brain then consciousness is absent, in other words that brain activity is a necessary condition for consciousness. Is it, however, a sufficient condition? If some activity remains in the brain what type of conclusions can be drawn?

To best resolve this problem imagine that brain studies are performed on people in their normal state of waking, communicating consciousness. Let us assume that there is a common brainstate found amongst all such subjects and let us call it BrainState_C. Furthermore let us assume that BrainState_C is found to be absent in subjects who are asleep or anaesthetised. Can the conclusion be drawn that the existence of BrainState_C is a necessary and sufficient condition for ascribing consciousness (i.e. consciousness_IN)? The answer is no! - a subject after recovering from anaesthesia reports that he was conscious; the medical team consult the records of his brain scans made during the procedure and find that he was indeed in BrainState_C. They doubt his story. However he is able to report details of conversations between the medical team held whilst he was supposedly unconscious. The existence of further such cases, and more experimental studies, suggest that the definition of BrainState_C was too coarse and a distinction is introduced which has the effect of dividing it into two sub-states BrainState_C1 and BrainState_C2. The presence of BrainState_C1 now being regarded as the test for consciousness. This process can continue with no limit to its refinements. It is clear however that although there may be a pretence at completeness and an assertion that BrainState_C1 is both a necessary and sufficient condition for consciousness, in actuality only its sufficiency can be established.

It is clear that the mechanism which enables the scientific processes of correlation to continue is the ability to communicate with the subject of the investigation. However this is exactly what is not available in cases of PVS. One avenue of investigation might appear to lie in the questioning of recovered PVS patients. Herein is the ‘Catch 22’ - for if such patients assert that they were conscious during the time when they were diagnosed as PVS then this, of itself, invalidates the original diagnosis. Indeed simply the bare fact of their recovery is sufficient to render null the original diagnosis.[lv] Had they been in BrainState_C3 during their period of apparent PVS this has no consequences for the proposition that PVS patients lack consciousness[lvi] although it may have repercussions on the sufficiency test elaborated above. Of course in the extreme case of all brain activity having ceased, then clearly consciousness could be assumed to be absent but such does not obtain in cases of PVS. Thus, in summary, we have a sufficient condition for ascribing consciousness - BrainState_C1 - and a necessary condition for the absence of consciousness - some brain activity. The conclusion is that, unless the presence of any brain activity is taken as a sufficient condition for ascribing consciousness, there is necessarily a lacuna.

Others also urge the conclusion that there are theoretical reasons why science cannot ‘lay hold of’ consciousness. Drury, for example, writes:

“The data of every natural science are data for consciousness. You cannot then bring consciousness in as one of the items of the hypothesis. The material used in the foundation cannot at the same time form the coping stone on the roof. Consciousness is not just one of the things we are conscious of.” [lvii]

An interesting parallel to these issues concerns scientific studies on ‘dreaming’. It has been argued[lviii] that scientists who use the existence of eye movements as a criterion for dreaming are using quite a different concept than is normally used. They are redefining the concept of ‘dreaming’ and are pretending by experimental methods to establish facts concerning what is normally called ‘dreaming’. This is an observation which finds a ready counterpart in statements concerning consciousness[lix] and brings to mind Karl Jaspers’ admonition that there must be freedom from ‘scientific superstition, i.e. from false absolutes and pseudo-knowledge.’ [lx]

The conclusion to be drawn is that:

Conclusion _{1 - 6} : There are theoretical limits to the determination of necessary and sufficient conditions for the ascription of consciousness. Any attempt by science to assert that particular criteria are both necessary and sufficient for ascribing consciousness is unwarranted.

Section 3: Ambiguities in the term ‘consciousness’ .

In this section a number of different meanings of the term ‘consciousness’ are identified, in the hope that this will permit some of the problems often found in discussions on ‘consciousness’ to be disentangled.

I begin with the report of “The Multi-Society Task Force on PVS” [lxi] which adopted William James’s definition of consciousness as ‘awareness of the self ’, and suggested that it has two dimensions: ‘wakefulness’ and ‘awareness’. However, they made no distinction between ‘awareness’ and ‘consciousness’.[lxii] Can such a distinction be made and are there other ambiguities in the term ‘consciousness’?

There is considerable academic support for the view that the term ‘consciousness’ is open to ambiguity. Ned Block, for example, states:

“The concept of consciousness is a hybrid or better, a mongrel concept: the word ‘consciousness’ connotes a number of different concepts and denotes a number of different phenomena. We reason about ‘consciousness’ using some premises that apply to one of the phenomena that fall under ‘consciousness’, other premises that apply to other ‘consciousnesses’ and we end up with trouble. There are many parallels in the history of science. Aristotle used ‘velocity’ sometimes to mean average velocity and sometimes to mean instantaneous velocity ... very different concepts are treated as a single concept. I think we all have some tendency to make this mistake in the case of ‘consciousness’. ” [lxiii]

Bernard Williams notes the confusion of ‘consciousness’ and ‘consciousness of’ in the writings of Descartes:

“If Descartes was disposed to see all conscious experience as consisting of some kind of conceptual thought, this will also help to explain the notorious confusion to which he is subject between mere consciousness and reflexive consciousness; the confusion that we found him making ... between consciousness in seeing and consciousness of seeing.” [lxiv]

This conclusion is also supported by others.[lxv] However, this awareness of the many meanings of ‘consciousness’ [lxvi] has not penetrated into the medical and legal discussions of PVS, and there appears to be a confusion between at least three distinct concepts: ‘consciousness’, ‘awareness’, and ‘intentionality’. Often indeed the term ‘consciousness’ is used as a conflation of all three. I will proceed by first contrasting ‘consciousness’ with ‘awareness’ and then contrasting it with ‘intentionality’ and finally by offering some conclusions.

‘Consciousness’ contrasted with ‘awareness’

A distinction can be made between consciousness and awareness in that one can have awareness without consciousness; this occurs, for example, in the phenomenon of ‘blindsight’ - which is when subjects are not aware of perceiving - i.e. they do not ‘see’ - certain stimuli yet it can be shown, by implication, either from questioning or by their subsequent conduct, that they have indeed perceived them. Thus awareness and consciousness are distinct concepts. Furthermore, since it seems contradictory to speak of consciousness without awareness, it is possible to treat consciousness as a ‘subcategory’ of awareness - i.e. to take awareness as the primary concept and to define consciousness in terms of it.

At least four different types of awareness can be considered. ‘Informational awareness’ which is of two types - conscious and unconscious; the former I term ‘Experiential awareness’ and the concept of ‘Blindsight’ covers the latter. The third type is ‘Conceptual awareness’ and the last is ‘Intentional awareness’.

‘Informational awareness’

‘Informational awareness’ occurs when a system operates in a fashion consistent only with certain information having passed into that system. Thus, for example, a robot can be (informationally) aware that an object is blocking its way and move to avoid it, or indeed a snail can be informationally aware that cabbage is close by and move towards it.

As mentioned informational awareness can either be conscious or unconscious. The informational awareness of the robot is (presumably) unconscious, as is that of the ‘blindsighted’ awareness of the human subject. In subsequent discussions the term ‘informational awareness’ [lxvii] is used to cover just such unconscious awareness and the term ‘experiential awareness’ is used to describe cases of conscious informational awareness.

‘Experiential awareness’

‘Experiential awareness’ is an existential concept; a conscious awareness of an experience, fully in the present and thus unmediated by concepts or language. It can be contrasted with ‘conceptual awareness’ - or ‘awareness of ’, or ‘consciousness of’, or ‘reflexive consciousness’. ‘Conceptual awareness’ implies an awareness of the experience as one happening within a larger context, either of past and future, or of personal and other, or some such. Such ‘conceptual awareness’ is necessarily dependent on language. It is what we mean by ‘conceptual thought’ and is a precondition for ‘cognition’. However, is the distinction between ‘consciousness’ and ‘consciousness of’ a valid distinction - i.e. is it a distinction without a difference?

Some have suggested - most notably Descartes - that ‘consciousness’ is equivalent to ‘consciousness of’; i.e. that there cannot be ‘consciousness’ without the ability to think conceptually. For example, the proposition that it is not possible to experience pain without the ability to think conceptually has been advanced as an argument to suggest that neither animals nor newborn infants can experience pain. The refusal to distinguish between ‘having an experience’ and ‘having an experience and knowing it was an experience of a particular type’ would also imply, for example, that a dog could not be hungry since it has no concept of hunger. The argument will be considered in detail in Chapter 3.[lxviii] Suffice to say at this stage that it is fallacious and rests on a refusal to distinguish between ‘conceptual awareness’ and ‘experiential awareness’. The error can be readily seen by performing a simple thought experiment.[lxix] Imagine a child born to an extended family all of whom were blind, but not so the child. Imagine further the child growing up only amongst such adults so that the concept of ‘seeing’ was not utilised in everyday conversation and not available to the child. Certainly the child would not have the concept of seeing but surely it could see? A more realistic, but less striking, example could be constructed from the actual experience of the neurologist Oliver Sachs outlined in his Island of the Colour Blind by imagining a child born with perfect sight but living in a village populated only by the colour blind. The child’s lack of the concept of colour would surely not affect the nature of the image presented to the brain.

Accepting that a distinction can be drawn between ‘consciousness’ and ‘consciousness of’, must ‘consciousness of’ be manifested in action of some sort? A simple gesture of introspection will show that such ‘conceptual awareness’ is independent of action and that it is possible to be conceptually aware of one’s circumstances and to take no action as a result of this awareness. It follows that ‘conceptual awareness’ has no logically necessary connection to Consciousness _B .

‘Consciousness’ contrasted with ‘intentionality’

A recent article by K. Ramakrishna Rao in the Journal of Consciousness Studies[lxx] distinguishes between Eastern and Western conceptions of consciousness. Rao notes that in the Western tradition intentionality is regarded as a defining characteristic of consciousness which itself is regarded as being synonymous with mind. In the Eastern tradition consciousness is believed to be non-intentional whilst the mind is regarded as intentional. Rao’s suggestion raises the question as to whether ‘consciousness’ can be considered as distinct from ‘intention’ and, if so, how can intention be characterised. [lxxi]

It seems clear that experiential consciousness can exist without intention. A gesture of introspection will show that one can rest in the fullness of an experience and be, at that moment, without dissatisfaction, or intention to move out of that experience. Anything experienced fully in the present precludes a further intention; the existence of intention being possible only in context of contemplating ‘future’ and such is incompatible with experiencing ‘fully in the present’. Assuming then that consciousness can be distinguished from intention, how do we characterise intention?

Intention is distinct from ‘goal directed behaviour’. Goal directed behaviour is obviously a necessary constituent of intentional behaviour yet ‘intentionality’ is more than goal directed behaviour as can be seen by considering the example of a robot programmed to reach a certain point and to avoid any obstructions that it encounters. The robot exhibits goal directed behaviour with informational awareness of the obstacles; yet it could hardly be said that it had intentions. Neither can goal directed behaviour with experiential consciousness, or indeed with conceptual awareness, be considered as necessarily intentional. Consider a person acting under an ‘irresistible impulse’ or whilst under the spell of hypnosis; such subjects are both experientially aware and conceptually aware of their actions but they would not consider themselves, nor be considered as, ‘intending’ these actions. They are not the ‘author’ of their actions. This idea of authorship, or ownership, of one’s actions seems fundamental to ‘intentional awareness’; this ownership necessarily requires a reflexive consciousness but that alone is not sufficient. What else is required? The concept of ‘ownership’ of actions has as a corollary the proposition that the subject is ‘responsible’ for his actions;[lxxii] this is a concept closely connected with ideas of ‘personhood’. Thus again we find the concept of personhood playing an unstated but important role in the discussion. It was suggested earlier that consciousness was sometimes used as a surrogate for ‘personhood’, ‘ability to act intentionally’ is another.

Is intention separable from behaviour? Can we distinguish between ‘executable/executed intentionality’ - involving some act referable to the intention - and ‘pure intentionality’ unconnected with any overt act. In other words can there be ‘pure intention’? Some accept the distinction. Williams[lxxiii] for example - distinguishes between ‘willing that my arm move’ and ‘moving my arm’. Others, such as William James do not. James considered that the act is the intention. The example of a paralysed person might suggest the contrary; such a person might first have the ‘pure intention’ to walk though be unable to execute any action referable to that intention, but may slowly regain the ability to walk.

Before finishing this section we consider an example, taken from the medical literature on PVS, of misuse of the term ‘consciousness’.

An example of ambiguity in the use of the term ‘consciousness’

The Multi-Society Task Force on PVS [‘MSTF’] state:

“None of these[lxxiv] however, can evoke the experience of pain and suffering if the brain has lost its capacity for self-awareness. The perceptions of pain and suffering are conscious experiences: unconsciousness, by definition, precludes these experiences.” [lxxv]

This is clearly a nonsequitur.

Firstly, the term ‘self-awareness’ means the possession of a concept of self; it is often used as a criterion to distinguish between humans and other animals - man having a concept of self unlike, it is said, other animals. When it is said of such animals that they do not have a concept of self this does not imply that they do not have an existential awareness of their own body and can thus not experience its sufferings - such a suggestion would be bizarre. The term relates to the possession of a concept of self which is a particular type of ‘Conceptual awareness’, and the lack of conceptual awareness does not necessarily imply a lack of experiential awareness.

Secondly, the MSTF uses lack of ‘executed intentional awareness’ - i.e. lack of purposeful actions - as the criterion for ‘unconsciousness’ in relation to PVS patients. The proffered conclusion - i.e. that unconsciousness, by definition, precludes experience - is something of a sleight of hand in that it relies on two senses of the term ‘unconscious’ - its normal sense and the sense used by the MSTF.

Conclusions - the link between behaviour and the many meanings of consciousness.

Of the many meanings of consciousness that we have discussed - ‘Informational awareness’ , ‘Experiential awareness’ , ‘Conceptual awareness’ , ‘Pure Intentional awareness’ - all can exist without any outward expression, it is only ‘executed intentional awareness’ that logically requires a behavioural manifestation. However, the Medical Conceptual Framework ignores all meanings other than that of ‘executed/executable intentional awareness’.[lxxvi] The PVS patient who does not show evidence of actions executed with intentional awareness - purposeful actions - is considered to have no consciousness.

Conclusion _{1 -7} : The term ‘consciousness’ has a number of meanings. These various meanings can be arranged as a hierarchy with each succeeding level incorporating the levels beneath and with only the topmost level requiring a behavioural manifestation:

Level ₁ : Informational awareness

Level ₂ : Experiential awareness

Level ₃ : Conceptual awareness

Level ₄ : Awareness with pure intention

Level ₅ : Awareness with executable/executed intention

The Medical Conceptual Framework, in discussing ‘consciousness’, recognises only Level ₅.

Passing mention has already been made of the Cartesian view of consciousness; its role in creating the confusion between ‘consciousness’ and ‘consciousness of’ has been noted. A digression is necessary so that certain aspects of Cartesian philosophy can be outlined. This is of assistance because Cartesian philosophy acts in many ways as a foundation for the Medical Conceptual Framework, and the most fundamental attack on any structure is achieved by first laying bare its foundations.

There are a number of congruences between Cartesian philosophy and the Medical Conceptual Framework and in order that the following discussion be more clearly focused, these correspondences are now listed:

* ‘Consciousness’ and ‘consciousness of’ are considered to be equivalent.

* Pain cannot be experienced in the absence of reflexive consciousness.

* Possession of consciousness is regarded as the criterion of being a person.[lxxvii]

* Once an individual’s behaviour can be given a fully mechanistic explanation - such as, for example, when all the behaviour is considered to be ‘reflex’ in nature - then that individual is not a person.

Furthermore, the idea that an isolated, pre-social, individual could be considered a person is implicit in Cartesian philosophy. The challenge to this idea - particularly from Wittgenstein ‘PLA’ - is of crucial importance in justifying the necessary condition for personhood which is advocated in Chapter 10. It is convenient at this stage to set out the Cartesian position on these questions as a unit and in a reasonably structured fashion, rather than having to treat it piecemeal as the need arises. It is to this task that we now turn.

Section 4: A brief sketch of some aspects of Cartesian philosophy relevant to the discussion of PVS patient consciousness

Introduction

Much of the discussion of consciousness, of reflex actions and indeed of personhood, is embedded in a landscape fashioned by Cartesian philosophy. The concepts of Cartesian philosophy have become the spectacles which permit us to view, or more accurately to structure, the world. However, this structuring is largely unconscious and the spectacles - which necessarily cast their own shadows - become invisible and the view through the Cartesian ‘conceptual spectacles’ begins to wear the mask of unique, necessary, truth.

In this century modern physics has been the only discipline to present a serious challenge to the Cartesian world view, and the effects of this challenge have been largely restricted to science and the philosophy of science, and have not yet infiltrated the wider society. In physics the reevaluation of Cartesianism has been particularly fruitful though the resistance to such a reassessment has been noted by Heisenberg - one of the founders of quantum mechanics at the beginning of this century - who wrote that:

“The Cartesian partition has penetrated deeply into the human mind during the three centuries following Descartes, and it will take a long time for it to be replaced by a really different attitude towards the problem of reality.” [lxxviii]

Others have been less forgiving of the influence of Cartesian philosophy on the modern mind - Jaspers, for example, says:

“Descartes’ perverted conception of science and philosophy made his influence disastrous. Because of this, and because of the basic fallacy that is obvious in his work, we should study him in order to know the road that is to be avoided.” [lxxix]

P.M.S. Hacker is no less critical:

“The Cartesian myth like all great myths is insidious. It can assume many guises, and even those who think of themselves as liberated from Cartesianism adopt crucial elements of the tale. A striking feature of contemporary philosophers, psychologists and neurophysiologists is that, while rejecting mind/body dualism, they accept the fundamental conceptual structure of the Cartesian picture.” [lxxx]

As mentioned earlier, the Medical Conceptual Framework is one of those theoretical structures which is deeply indebted to Cartesianism. What are the essential features of this Cartesianism?

The Philosophy of Descartes - a brief sketch

Descartes (1596-1650) has been considered the father of modern philosophy; a modernist in his attitude to science and scientific explanation, much impressed with ‘those long chains of very simple and easy reasonings which geometers use to arrive at their most difficult demonstrations’. [lxxxi] He sought to place philosophy on equally secure foundations.

Unlike La Mettrie[lxxxii] - who believed that all nature, including man himself, was amenable to a scientific explanation - Descartes set a limit to the scope of mechanistic explanation; he believed in the necessity of preserving the very clear distinction between the animal and the human which was made by Christianity in its doctrine of the immortal soul. Descartes needed to find some philosophical counterpart for this soul and he found it in the concepts of ‘mind’ or ‘consciousness’.[lxxxiii] This ‘consciousness’ was the sole preserve of man, his essence. Animals, in contrast, had no consciousness, they were just machines.

Before Descartes, the fundamental distinction in any analysis of the world was that between ‘living’ and ‘non-living’ matter. However Descartes, following the Christian doctrine of the soul, saw the distinction between man and all else as providing the fundamental line of cleavage and this change of focus changed the categories of philosophy. The focus of wonder was henceforth to be, not that border between living non-living matter, but that between man and nature.

Descartes’ Method

Descartes’ method was to doubt all. His goal was to find that of which he could entertain no further doubts. This, he believed, would be the certain foundation on which he might build. Applying this method he was lead ultimately to his famous ‘Cogito, ergo sum’ - often translated as ‘I think, therefore I am’. [lxxxiv] Descartes elaborates on this:

“... from the very fact that I thought of doubting the truth of other things, it followed very evidently and very certainly that I was ...” [lxxxv]

The validity of Descartes’ method, i.e. whether the inability to doubt is a valid criterion of truth, is open to question, but is not relevant to our purposes. Descartes, from his own perspective, had found the secure foundation and could now commence to build.

Descartes’ essential characteristics of man

Having found the indubitable 'I', the next question is ‘What is this 'I”? Descartes refused to accept the Aristotelian answer - that he is a rational animal - as this would have lead to an infinite regress of definitions.[lxxxvi]

Descartes believed that:

“... I could pretend that I had no body and that there was no world or place for me to be in, I could not for all that pretend that I did not exist.” [lxxxvii]

which led him to conclude:

“... this ‘I’ - that is, the soul by which I am what I am - is entirely distinct from the body, ... and would not cease to be everything it is even if the body did not exist.” [lxxxviii]

Descartes concluded that ‘mind’ and 'body' were of essentially different natures; he expressed this by saying that they were two distinct substances. These substances interacted in man by means of the pineal gland.

These two substances of which man was composed were by no means of equal importance; the existence of the body could, after all, be doubted but not so the mind. The essential characteristic of man lay in the possession of ‘mind’ or ‘consciousness’.

“I am then, in the strict sense only a thing that thinks; that is, I am a mind, or intelligence , or intellect or reason ...” [lxxxix]

and more emphatically:

“... I was a substance whose whole essence or nature of which is to think, and that for its existence there is no need of any place, nor does it depend on any material thing; ...” [xc]

Descartes’ meaning of the term ‘consciousness’

The consciousness of which Descartes speaks, had its origins in his attempt to doubt his own existence; such a doubt can only exist in the context of conceptual mental activity and the consciousness of which he had such certainty, was necessarily a ‘reflexive consciousness’.

Stephen Gaukroger notes that:

“... awareness of ones own mental states is the key to the difference between creatures with a mind and automata, and that without such awareness the characteristic features of human mental life would not be possible.” [xci]

Does Descartes, however, acknowledge an experiential consciousness distinct from a reflexive consciousness?

Williams thinks not:

“If Descartes was disposed to see all conscious experience as consisting of some kind of conceptual thought, this will also help to explain the notorious confusion to which he is subject between mere consciousness and reflexive consciousness; the confusion that we found him making ... between consciousness in seeing and consciousness of seeing.” [xcii]

To Descartes, not only were the terms ‘consciousness’ and ‘reflexive consciousness’ synonyms, but equally so were the terms 'I', 'soul' and 'mind'. [xciii]

Descartes’ equation of ‘consciousness’ with ‘reflexive consciousness’ has further implications:

* consciousness is a definitive and exhaustive description of the mental, in particular there can be no unconscious mental processes[xciv]

* consciousness is a unitary phenomenon. A reflective consciousness if it is to be a self-consciousness must clearly be unitary; any breach in the unitary nature would be destructive of the self - it would be schizophrenic in the classical sense of the term.

In an attempt to further elucidate Descartes’ view on consciousness an examination of his attitude to animals is instructive[xcv] in that it highlights the role Cartesian philosophy assigns to beings who lack self-consciousness.

Animal Consciousness from a Cartesian standpoint

Descartes considered that there were two methods by which ‘we may recognise the difference that exists between men and brutes.’

The first lay in the human ability to communicate: [xcvi]

“For it a very remarkable fact that there are none so depraved and stupid, without even excepting idiots, that they cannot arrange different words together forming of them a statement by which they make known their thoughts; ...” [xcvii]

The second lay in the breadth of human versatility:

“ ... although there are many animals which exhibit more dexterity than we do in some of their actions, we at the same time observe that they do not manifest any dexterity at all in many others.” [xcviii]

The fact that some animals can do certain tasks better than humans does not prove that they can reason; rather it proves:

“... they [animals] have no reason at all, and that it is nature which acts in them according to the dispositions of their organs, just as a clock, which is composed of wheels and weights is able to tell the hours and measure the time more correctly than we can do with all our wisdom.” [xcix]

An alternative formulation of the argument is:

“... if there had been such machines, possessing the organs and outward form of a monkey or some other animal without reason, we should not have any means of ascertaining that they were not of the same nature as those animals. On the other hand if there were machines which bore a resemblance to our body and imitated our actions ... we should always have two very certain tests by which to recognise that, for all that, they were not real men. The first is, that they could never use speech ... For we can easily understand a machine’s being constituted so that it can utter words ... But it never happens that it arranges its speech ... in order to reply appropriately to everything that may be said in its presence, as even the lowest type of man can do. And the second difference is, that although machines can perform certain tasks ... perhaps better than any of us can do, they infallibly fall short in others, by the which means we may discover that they did not act from knowledge but only from the disposition of their organs.” [c]

Descartes considered animals to have ‘no souls, no thoughts or experiences and to be in fact automata’.[ci] To a commentator who expressed outrage at his ‘snatching away life and sensibility from all the animals’, Descartes replied to the effect that - although we cannot prove there is no thought in animals since our mind ‘does not penetrate their hearts’ - their responses are purely mechanical. The 'passions' of animals are purely physical disturbances in the nervous system which can generate behaviour but are not associated with experiences. Descartes gives the example of the flight of a sheep on seeing a wolf; the flight behaviour is, he believed, mechanically caused by light reflected from the body of the wolf and is performed without consciousness.[cii]

In summary, to Descartes animals can neither be conscious nor experience pain; they are ‘natural automata’ because they have only limited responses and above all have no use of language.

Williams has observed that, to Descartes:

“... some human behaviour is of this type. Quite a lot of human bodily movement and actions, in fact, are thought by Descartes to bypass the soul, and to be products of self-contained mechanical cycles within the body. Such actions or movements are not just analogous to animal behaviour, but are produced in exactly the same way.” [ciii]

These actions ‘which bypass the soul’ are precisely the reflex actions spoken of earlier.[civ] These actions which lie outside the ’will’ - that is are not intentional - are not to be considered as having a mental origin. Descartes, after all, had no conception of an unconscious aspect to the human mind. The choice permitted by Descartes is stark:

“... either a creature has a full range of conscious powers ... or is an automaton, with no experience of any kind.” [cv]

To Descartes, all that lay outside our self-consciousness was to be considered as purely mechanical:

” ... if I consider the body of a man as being a sort of machine so built up and composed of nerves, muscles, veins, blood and skin, that though there were no mind in it at all, it would not cease to have the same motion as at present, exception being made of those movements which are due to the direction of the will, and in consequence depend upon the mind ... I easily recognise that it would be as natural to this body, supposing it to be, for example, dropsical, to suffer the parchedness of the throat which usually signifies to the mind the feeling of thirst, and to be disposed by this parched feeling to move the nerves ... in the way requisite for drinking.” [cvi]

An argument which bears uncanny resemblance to current medical theories of PVS patient responses. Let us now look at this question directly and see how a Cartesian framework would resolve the problem of PVS patient consciousness and ability to experience pain.

The PVS patient from a Cartesian perspective

Let us accept, for the sake of argument, that the actions and responses of a PVS patient are of such a predictable nature as to be correctly classified as purely mechanical or ‘reflex’.[cvii]

Would such a PVS patient be considered conscious?

To one who suggested that an animal might be conscious, Descartes replied (as paraphrased by Williams):

“... we cannot prove there is no thought in animals since our mind ‘does not penetrate their hearts’, but he does think their responses are purely mechanical and that they are ... ’natural automata’. His principle ground for this view ... is that animals ... have ... only limited responses ... and, above all, have no use of language at all, ...” [cviii]

Is it possible, within Cartesian philosophy, to make a distinction between the case of animals and PVS patients, if it is accepted that both manifest purely mechanical behaviour and neither can communicate? A Christian theologian certainly might make a distinction; he could say that the PVS patients has a ‘soul’ and the animal has not. Descartes used the same term ‘soul’;[cix] can he make the same distinction as the theologian without distorting his philosophy? I suggest not. To Descartes ‘soul’ was a manifested soul. It was manifested in either the possession of language or complex behavioural patterns. To permit an unmanifested soul would structurally damage the Cartesian edifice. There is no ‘gap’ where such a distinction[cx] could find a point of purchase.

Hence we can conclude that, to Descartes, such a patient would be a mere automaton, without consciousness, and equivalent to one of Descartes’ ‘brutes’. Descartes would not have discriminated between ‘reflexive consciousness’ and ‘experiential consciousness’ and would have concluded that such a patient could not have ‘experiences’ and thus could not suffer pain.

This conclusion calls to mind the quotation given earlier from The Multi-Society Task Force on PVS:

“None of these,[cxi] however, can evoke the experience of pain and suffering if the brain has lost its capacity for self-awareness. The perceptions of pain and suffering are conscious experiences: unconsciousness, by definition, precludes these experiences.” [cxii]

The congruence between the Cartesian attitude to animals and the medical attitude to PVS patients is patent. It is inescapable. Furthermore it is not coincidental. It is based on precisely the same theoretical analysis.

Conclusion _{1 -8} : Both Cartesian philosophy and the Medical Conceptual Framework share a common deductive structure. The progression is from

‘lack of non-reflex movements’ to

‘lack of self-consciousness’ to

‘lack of ability to experience pain’ and

‘the subject is not ‘truly human’ or is not a ‘person’ ’.

This last step requires some further discussion.

The Cartesian criteria for ‘personhood’?

Within Descartes’ philosophy, being a person[cxiii] is equivalent to having a ‘reflexive consciousness’ or ‘soul’. The question arises as to how one determines whether another being possesses such a ‘reflexive consciousness’. Descartes, in his discussion of the ‘cogito’, suggested that mind was not dependent on a body; he stated (as quoted earlier):

“... this ‘I’ - that is the soul by which I am what I am - is entirely distinct from the body ... and would not cease to be everything it is even if the body did not exist.” [cxiv]

This suggests that the soul - or ‘reflexive consciousness’- could continue in the absence of the body; and a fortiori the reflexive consciousness could persist without any physical manifestation in the body. Yet, as discussed earlier, Descartes insisted on a manifestation of ‘soul’.[cxv] Animals, he argued, did not have a reflexive consciousness because their conduct was not sufficiently complex to escape a mechanistic explanation and, secondly, because the they had not a language.[cxvi] In order to lay the groundwork for a subsequent discussion of personhood, it is of interest to pose the question - Can these two conditions be brought under the same rubric?

There are two cases to be considered. Firstly, could there be beings who had a language but whose behaviour was mechanical? If so how should they be characterised? Consider the example of an individual who was so severely paralysed that the only movements possible to him were spasmodic but who could still talk. Surely Descartes would not have doubted the existence of such a man’s ‘soul’ or ‘reflexive consciousness’? This would suggest that the language criterion is primary.

The second case would concern an individual whose behaviour could not be classified as mechanical yet who had not language. Consider the example of a man who is a deaf mute who never learned any language but whose intelligence is beyond doubt because it is continuously manifested in his skills. Surely this man would also be, to Descartes, ‘truly human’.

These conclusions can be summarised as:

Conclusion _{1 -9} : In Cartesian philosophy the ability to use language is a sufficient, but not a necessary, condition for personhood. In the absence of an ability to use language ‘complexity of behaviour’ is both a necessary and a sufficient condition for personhood.

Applying this test to a PVS patient it is clear that the language condition is not met, neither is the behavioural patterns manifested by the patient of a sufficient complexity to warrant the imputation of a reflexive consciousness, and hence of personhood.

In the tests for personhood just outlined the underlying assumption appears to be that an individual who exhibits a sufficiently complex behaviour - without any ability to use or understand language - possesses the ability to think conceptually, and thus have a ‘soul’ or a ‘reflexive consciousness’. Complex behaviour per se is not sufficient. This is because if complex behaviour were alone sufficient then that individual would be unable, on his own behalf, to participate in the cogito argument. He could never - even to himself, assert ‘I think therefore I am’ or even its ‘wordless equivalent’ whatever that might be. Hence, because the cogito argument plays such a fundamental role in Cartesian philosophy, it is reasonable to conclude that the ‘sufficiently complex behaviour’ criterion is of importance not for itself, but because of its evidential value in establishing ‘reflexive consciousness’. However, Wittgenstein’s ‘Private Language Argument’ [ ‘PLA’ ] - which will now be sketched - raises a fundamental challenge to these conclusions.

Wittgenstein’s challenge to the Cartesian conceptual framework

Cartesian philosophy has been attacked from many directions but perhaps the most serious and fundamental challenge to the entire Cartesian edifice is from Wittgenstein’s ‘Private Language Argument’ [‘PLA’]. The ‘PLA’ will be considered in detail in Chapter 10; here I simply wish to outline the Cartesian position in a detail sufficient to enable the challenged posed by the ‘PLA’ to be understood.

Cartesian philosophy posits an isolated, pre-social but language using, individual as its starting point. This individual - by virtue of the cogito argument - establishes that his own existence and consciousness, is beyond doubt. This then becomes the rock on which he builds, or appropriates, the world. Wittgenstein’s ‘PLA’ destroys this project at its base and forces a fundamental reassessment of Descartes’ philosophy and, in particular, of the Cartesian conception of a person.

A slight detour to examine the organisational structure of Newtonian physics, is useful because aspects of its methodology are shared by Cartesian philosophy. Newtonian physics sought to describe the workings of an inanimate universe, but any direct approach to such a complex problem was doomed to failure. The genius of the Newtonian approach was that it first considered isolated particles of matter and sought to describe the laws which governed their motion. From the laws governing the motion of these isolated particles it deduced the motion of rigid bodies - which were after all only groups of such particles - and continued this progression until the motions of the planet fell within its ambit. The essence of the method was isolating the simplest constituent - the particle - and slowly, step by step, adding complexity until the workings of the heavens lay bare. Descartes, faced with an infinitely more complex universe than that sought to be explained by Newtonian mechanics - for Descartes took living and thinking things into his universe - equally sought the simplest constituent which he could find, and that was the individual. Descartes presupposed no environment for this individual - no society, no community of fellows, no governments or nationality, no culture, no history, nothing just a thinking thing. On this basis he began his project and set out to construct his philosophy. However, Wittgenstein in his ‘PLA’ found the Achilles heel of the Cartesian project [cxvii] and indeed of all philosophical systems which sought to explain the individual atomistically.

By a ‘private language’ Wittgenstein means:

“ ... a language in which a person could write down or give vocal expression to his inner experience - his feeling, moods and the rest - for his own private use ...The individual words of this language are to refer to what can only be known to the person speaking; to his immediate private sensations. So another person cannot understand the language.” [cxviii]

Wittgenstein’s ‘PLA’ denies the possibility of such a language existing; it implies that an individual, isolated from all contact with his fellow man, can never develop any language.[cxix] Language is, in essence, a social activity. The existence of language depends on social rules and social interaction. This is crucial for our purposes for it follows from it that an isolated pre-social individual cannot have a ‘reflexive consciousness’ because a reflective consciousness depends on concepts and these cannot exist without language. Conceptual thought is impossible without language. Thus the ‘starting point’ of philosophical analysis cannot be the ‘isolated individual’ but must be the wider society; the language speaking individual is a product of the wider society and not conversely. The analytical method must be ‘top-down’ and not ‘bottom up’. As a heuristic devise, certainly it may be convenient to first consider the individual and then to attempt to explain the society wholly in terms of the individual but this must not be allowed to mask the fact that society is logically prior to the individual. Thus, following immediately from Conclusion _1-9 , we have:

Conclusion _{1 -10} : The Cartesian position, adapted to accommodate Wittgenstein’s ‘PLA’, considers ability to use language as both a necessary, and a sufficient condition, for the ascription of personhood. [cxx]

This has, as a further consequence, that Descartes’ first[cxxi] argument to show that animals did not have a reflexive consciousness[cxxii] can be discarded. The very fact that animals do not have language is sufficient to imply that they do not have a reflexive consciousness.

In Chapter 10 I will argue that the permanent loss of the ability to communicate is a necessary condition for the loss of personhood and that this will provide the basis for an alternative, and more fitting, resolution of the ethical problem posed by PVS. I use the term ‘social definition’ of personhood to contrast this approach with that implicit in definitions based on an ‘isolated individual’ which flow from a traditional Cartesian standpoint. The term is meant to suggest that ‘personhood’ is not a term that can be applied to an isolated individual, rather it is to do with the relationship between that individual and society. [cxxiii]

Section 5: Conclusions

There is widespread acceptance, amongst the medical and legal communities, of the proposition that PVS patients lack consciousness and cannot experience pain. The justifications advanced for the view that they lack consciousness were examined[cxxiv] and it was found that there is no scientific test which can conclusively determine consciousness. Furthermore, there are philosophical grounds for holding that it is not theoretically possible to determine necessary and sufficient conditions for ascribing consciousness, scientifically. Secondly, there is no definitive test for PVS. Hence the conclusion that there is no scientific test for definitively determining PVS patients’ consciousness.

The philosophical grounds for arguing that PVS patients lack consciousness were found to rest on the assumption that:

Consciousness = Consciousness _B

where ‘Consciousness _B’ meant consciousness as determined behaviourally. This assumption is invalid because the term consciousness is capable of being, and is used with, a number of different meanings. Hence the philosophical grounds for asserting that PVS patients have no consciousness are open to serious dispute.

The relationship between aspects of Cartesian philosophy and the Medical Conceptual Framework were examined and it was noted that, in certain areas, there was a congruence between them. In particular, they both asserted that the absence of ‘non-reflex’ movements in conjunction with an inability to communicate implied a lack of consciousness. Cartesian philosophy explicitly - and the Medical Conceptual Framework implicitly - asserted the further conclusion that in such circumstances ‘personhood’[cxxv] was absent. The test for personhood in Cartesian philosophy was either the presence of non-reflex actions or language ability. Under the challenge of Wittgenstein ‘PLA’, it was necessary to refine this to read ‘In Cartesian philosophy, the possession of language is both a necessary, and a sufficient, condition for personhood’.

____________

The conclusions that were established in this Chapter are:

Conclusion _{1 - 1} Consciousness _IN and Consciousness _B - though normally found in such a close association as to have a factual interdependence - are, strictly speaking, logically independent. As applied to a PVS patient, this suggests that, although it may be adjudged that Consciousness _B does not exist, no necessary implication follows concerning Consciousness _IN .

Conclusion _{1 - 2} There is no area of the brain, and no specific brain activity, that is uniquely associated with the possession of consciousness.

Conclusion _{1 - 3} There is no definitive neurological test for PVS.

Conclusion _{1 - 4} There is no neurological test which will determine PVS patient consciousness.

Conclusion _{1 - 5} In relation to the problem of PVS patient consciousness, medical practice has assumed that Consciousness _IN = Consciousness _B. Furthermore it has used the ‘reflex test’ as the criterion for establishing Consciousness _B.

Conclusion _{1 - 6} There are theoretical limits to the determination of necessary and sufficient conditions for the ascription of consciousness. Any attempt by science to assert that particular criteria are both necessary and sufficient for ascribing consciousness is unwarranted.

Conclusion _{1 - 7} The term ‘consciousness’ has a number of meanings. These various meanings can be arranged as a hierarchy with each succeeding level incorporating the levels beneath and with only the topmost level requiring a behavioural manifestation:

Level ₁ : Informational awareness

Level ₂ : Experiential awareness

Level ₃ : Conceptual awareness

Level ₄ : Awareness with pure intention

Level ₅ : Awareness with executable/executed intention

The Medical Conceptual Framework, in discussing ‘consciousness’, recognises only Level ₅.

Conclusion _{1 - 8} Both Cartesian philosophy and the Medical Conceptual Framework share a common deductive structure. The progression is from

‘lack of non-reflex movements’ to

‘lack of self-consciousness’ to

‘lack of ability to experience pain’ and

‘the subject is not ‘truly human’ or is not a ‘person’’.

Conclusion _{1 - 9} In Cartesian philosophy the ability to use language is a sufficient, but not a necessary, condition for personhood. In the absence of an ability to use language ‘complexity of behaviour’ is both a necessary and a sufficient condition for personhood.

Conclusion _{1 - 10} The Cartesian position, adapted to accommodate Wittgenstein’s ‘PLA’, considers ability to use language as both a necessary, and a sufficient condition, for the ascription of personhood.

---

[i] The arguments, both from science and philosophy, that PVS patients cannot feel pain will be considered in Chapter 3.

[ii] The term ‘reflexive consciousness’ is explained in Section 3.

[iii] The Bland case at p.795 [emphasis added].

[iv] ibid. at p.806.

[v] The Ward case at p.2.

[vi] ibid. at p.446.

[vii] The Bland case at p.807. It is of interest to contrast this statement with one by Lord Donaldson, MR, who, in Re J., stated (at p.933):

“Ultrasound scans of his brain. ... showed a large area of fluid filled cavities where there ought to have been brain tissue ... It is highly unlikely that he will develop even limited intellectual abilities. Most unfortunately of all, there is a likelihood that he will be able to feel pain to the extent of a normal baby, because pain is a very normal response.“

In Re J the court was dealing with the issue of withdrawal of life saving treatment from a baby who was grossly handicapped and it considered that the existence of the ability to feel pain lent support to the argument to withdraw treatment. This is in contrast to the Bland case where the inability to experience pain - in so far as it was further evidence of ‘inability to experience (simpliciter)’ - was considered as an added reason for withdrawing treatment. It was noted earlier that both the presence and the absence of consciousness have been adduced as a reason for withdrawing treatment and it seems that the ability to experience pain is playing a similarly paradoxical role.

[viii] BMA (1996) p.58.

[ix] Thomas Nagel, Mortal Questions, p.195.

[x] Wittgenstein, PI-1 § 240

[xi] However other avenues of approach to the problem - such as Daniel Dennett’s analysis of the meaning of the term ‘intention’; the ‘Turing Test’ enunciated by Alan Turing; and P. F. Strawson’s discussion of the concept of ‘person’ - suggest that this conclusion is unduly pessimistic. These issues are discussed in Chapter 10.

[xii] I use the concept of ‘moral objecthood ’ - with its associated concept ‘Objects of Intrinsic Moral Worth’ [‘OMW’s’ ] - to distinguish those objects which, if affected by a proposed action must be included in a calculus which seeks to determine the ethics of the proposed action, from those that need not be so included. For example, if I propose to assault a man with a stick whilst he is walking his dog, then the man, his dog and the stick would, amongst other things, be affected by my actions; in stating that the stick does not possess ‘moral objecthood’ is meant that damage to it, for its own sake, is considered irrelevant; however the dog might, and most certainly the man would, be considered to possess such ‘moral objecthood’ [and therefore be ‘OMW’s’ ].

The concept of ‘Objects of Intrinsic Moral Worth’ is useful in discussions on ‘Personhood’ in that it allows distinctions to be made which are otherwise not apparent. These topics are discussed in Part 3.

[xiii] P. F. Strawson Individuals at p. 98-100.

[xiv] Thomas Nagel Mortal Questions p.190-1.

[xv] ibid. p.191-2. Dennett’s discussion of ‘intention’ (discussed in Chapter 2) is particularly useful in considering Nagel’s example.

[xvi] Conclusion are numbered first according to the chapter in which they are established and then within the chapter. Thus ‘Conclusion _{5 -7}’ refers to the 7^th conclusion in Chapter 5.

[xvii] Nagel’s argument is interesting for another reason: his initial dichotomy between ‘machines or conscious beings’ echoes a similar Cartesian dichotomy between machines and persons and shows again the intimate relationship that exists between the ascription of personhood and of consciousness; this relationship was crucial to Descartes but has become blurred, in recent times, by the now common ascription of consciousness to animals. To Descartes, animals were literally nothing other than machines - so called bete-machine - dispelling the animal-soul view that had been commonplace since Aristotle. [cf. Justin Leiber An Invitation to Cognitive Science. at p.22]

[xviii] In relation to this assumption, Wittgenstein asks:

“The feeling of an unbridgeable gulf between consciousness and brain-process: how does it come about that this does not come into the consideration of our ordinary life? This idea of a difference in kind is accompanied by a slight giddiness, - which occurs when were performing a piece of logical sleight-of hand.”

His answer appears to be that propositions as to consciousness and as to the existence of brain states usually have quite different contexts - the latter not featuring in everyday experience - and that this difference in context misleads us into thinking that consciousness and brain states are different in kind. cf. Wittgenstein PI-1 § 412.

[xix] Owen Flanagan, Consciousness Reconsidered, (1992) at p.58.

[xx] ibid. p.57.

[xxi] ibid. p.15.

[xxii] Bernard J. Baars, ‘A Thoroughly Empirical Approach to Consciousness’ Psyche (1994) (Internet source).

[xxiii] ibid. p.3 of 14.

[xxiv] Richard L. Gregory (ed.), The Oxford Companion to the Mind at p.438.

An example of such brain reorganisation is given in a report by the science correspondent of ‘The Sunday Times‘: the case concerned a 10 year old boy who was suffering from severe, incapacitating epilepsy and who had been unable to speak since birth (he had been suffering from Stuge-Weber syndrome which caused the blood vessels to the left side of his brain to be constricted during development in the womb). In order to cure his very severe epilepsy, the left hemisphere of his brain was removed. The boy subsequently learned to speak like a normal child but utilising only the right side of the brain; (up until then it was believed that the left side of the brain was uniquely responsible for speech). [The Sunday Times, 4-5-1997.]

[xxv] Jennett and Plum, ‘Persistent Vegetative State after Brain Damage - a syndrome in search of a name,’ The Lancet (1972) at p.734.

[xxvi] such as might be measured by an electroencephalograph (‘E.E.G’).

[xxvii] ibid. pp. 736,734,734-5, and 736.

[xxviii] Hannah Kinney et al ‘Neuropathological Findings in the Brain of Karen Ann Quinlan - The Role of the Thalamus in the Persistent Vegetative State’ New England Journal of Medicine, (1994).

[xxix] Karen Quinlan’s case was the first case involving PVS to come before the US courts. Her breathing had been sustained by a respirator and the court application was for permission to remove the respirator. This the court permitted. However, on the removal of the respirator, Karen Quinlan did not die but continued to breath, unaided. She survived for a further 10 years in a PVS. She died in 1985 of acute pneumonia. Antibiotics had not been given to treat the pneumonia.

The case was decided in 1976 and is reported as In the Matter of Karen Quinlan, An Alleged Incompetent, Supreme Court of New Jersey 355A 2d 647. This case is discussed in, amongst others, Bonnie Steinbock and Alistair Norcross (eds.). Killing and Letting Die. p 51; James Rachels, The End of Life, p.101.

[xxx] Kinney op.cit. p.1469,1472.

[xxxi] Andrews (1996) at p.13.

[xxxii] Ronald Cranford Editorial, British Medical Journal. (1996) at p.5 [emphasis added].

[xxxiii] i.e. ‘Persistent Vegetative State’.

[xxxiv] ibid. at p.736 [emphasis added].

[xxxv]Jennett and Plum (1972) at p.736,737; [emphasis added].

[xxxvi] President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research. Deciding to Forego Life-Sustaining Treatment, (1983).

[xxxvii] ibid. at p. 174-5.

[xxxviii] ibid. at p.175, footnote 10. See Appendix F which discusses Fletcher’s criteria.

[xxxix] ibid. at p.174.

[xl] ibid. at p.175, footnote 12

[xli] The case of Jean-Dominique Bauby (discussed in Chapter 10) is an example of such a patient. Bauby was able to blink and used this to establish a system of communication.

[xlii] Multi-Society Task Force on PVS, The. ‘Medical Aspects of the Persistent Vegetative State’ (First of Two Parts) The New England Journal of Medicine (1994); cited hereafter as ‘Multi-Society Task Force on PVS (a)’

Multi-Society Task Force on PVS, The. ’Medical Aspects of the Persistent Vegetative State’ (Second of Two Parts) The New England Journal of Medicine (1994); cited hereafter as ‘Multi-Society Task Force on PVS (b)’

[xliii] The study had adopted William James’ definition of consciousness as ‘awareness of the self ’ and noted that it has two dimensions ‘wakefulness’ and ‘awareness’.

[xliv] Multi-Society Task Force on PVS (a) p.1501 [emphasis added].

[xlv] ibid. p.1501-2.

[xlvi] A recent press report in ‘The Sunday Times’ ‘Medical Notes’ 22.3.1998, stated:

“Doctors at the Institute for Anaesthesiology in Munich report in the British Journal of Anaesthesia that in about 1% of operations patients are aware to some degree. Of these, 73% recalled their surgeons conversations and 17% were in severe pain.”

This problem is further considered in Chapter 3.

[xlvii] Hypnosis and meditation are examples of so-called altered states of consciousness; the existence of such altered states refutes the unitary view of consciousness. (The 1998 conference on ‘consciousness’ which was held in Tucson, Arizona, devoted considerable time to academic discussions of such states.)

[xlviii] Some such studies are included in Charles Tart (ed.) Altered States of Consciousness, (1990).

[xlix] It may be of interest to note that such alpha activity also occurs in PVS patients and these are also open eyed - see Jennett and Plum (1972), p.736.

[l] Tart op.cit. p.576.

[li] Kinney op.cit. p.1472.

[lii] In 1996 the BMA was reported as considering the advisability of routinely carrying our post-mortems of PVS patients, the implication being that this was not then current practice. [BMA (1996), p.59].

[liii] The coherence of the concept Consciousness_B and the validity of the ‘reflex test’ is the subject of Chapter 3.

[liv] Discussed in Chapter 2.

[lv] Because recovery, if a sufficient time has elapsed, invalidates the diagnosis of PVS:

“In the BMA’s view, recoveries, where they can be verified, indicate an original misdiagnosis.” [BMA (1996) at p.58]

[lvi] Because, by definition, PVS patients cannot possess consciousness. This is fully discussed in Chapter 4.

[lvii] Drury, The Danger of Words at p. 108.

See also Drury’s comments (p.75-6) on a passage in Ranson’s Anatomy of the Nervous System, in which he gives a salutary, but perhaps overstated, reminder of the dangers of using imprecise language when discussing consciousness:

“But then you find, even in Ranson, a reference to the question at what point the nerve impulse ‘enters’ consciousness. Notice the complete change of language here; this is no longer descriptive and verifiable, but metaphorical and speculative. In everyday language if we use the word enter we imply a threshold both sides of which can be observed and entering means passing from one side of this threshold to the other. But in this sense, the common everyday sense, of ‘entering’, you cannot speak of anything entering consciousness. For consciousness has no boundary, no threshold which can be observed. If it had then there would have to be a third from of consciousness which was conscious of both what was conscious and what was not yet so. This is obvious nonsense. Consciousness is not just one of the many things we are conscious of: the mind has no particular place in nature.”

I have suggested that Drury’s comments may be overstated in that a third party observer can ascertain that a subject is informationally - but not consciously - aware of a particular state of affairs, and can thus meaningfully speak of information ‘entering’ consciousness; such a situation does not require that any ‘third type of consciousness’ be assumed. (The concept of ‘informational awareness’ is discussed in the following section.)

[lviii] By Norman Malcolm - see Passmore op.cit. p.513.

[lix] Bernard Baars takes the question ‘When are psychologists entitled to call a certain theoretical construct ‘consciousness’?’ as the focus for his paper ‘A Thoroughly Empirical Approach to Consciousness’

[lx] Karl Jaspers ‘On my Philosophy’ included in Walter Kaufmann Existentialism from Dostoevsky to Sartre, (1956) at p.172

[lxi] Part 1 p.1499.

[lxii] ibid. at p.1501:

“In this report we use the terms awareness and consciousness interchangeably. ”

[lxiii] Ned Block ‘On A Confusion About A Function Of Consciousness’ p.1.

[lxiv] Bernard Williams Descartes, 1978. at p.286

[lxv] See, for example, Preben Bertelsen ‘Review of Arheim ‘Matter Matters?’’ Journal of Consciousness Studies (1998) at p.375:

“The main thesis is that one has to differentiate between consciousness and cognition, which are not synonymous categories ...”

[lxvi] It has been suggested that Buddhism recognises 89 different types of consciousness.

[lxvii] or, simply, ‘blindsight’.

[lxviii] Chapter 3 discusses pain judgements.

[lxix] The example was mentioned earlier - see Introduction, footnote 23.

[lxx] K. Ramakrishna Rao ‘Two Faces of Consciousness: a look at Eastern and Western Perspectives’, Journal of Consciousness Studies, 1998.

[lxxi] Daniel Dennett’s analysis of intention, which is particularly helpful and enlightening, is summarised in Chapter 2. It clarifies the meaning to be given to the term ‘intention’ when used in relation to machines such as robots.

[lxxii] Even more fundamentally, it is often considered that a ‘person’ is one who has actions i.e. is involved in ‘doing’ rather than just in ‘being’. Owen Flanagan, for example, considers personhood to be intimately linked to the ability to have, and execute, ‘life plans’. Western philosophy - in contrast to Eastern - considers man as essentially a ‘doer’; it would regard a life lived without such ‘doing’ as purposeless and pointless. Such views are often encountered in relation to elderly inactive patients, and are implicitly dependent on judgements which distinguish between the value of ‘being’ and ‘doing’. It is important that the values underlying such judgements be made explicit and subject to scrutiny. In this respect the Eastern philosophical tradition provides a useful counterpoint.

[lxxiii] Williams, Descartes, p.291:

“My moving my arm, on Descartes’s account, just is my willing, plus my willing’s being effective; ... To suppose, then, that the intentional content of the willing - what I will - refers to the action of moving my arm would be to suppose that the intentional content itself refers to an act of willing, so that I will that I will, and that must be wrong ... Put your hand next to some object, such as this book, and ‘will’ your hand to approach the book. Nothing happens. Now ‘will’, in that same way, your hand to approach the book. Still nothing happens. Direct application of psychokinesis is no more effective with my limbs that with anything else.”

[lxxiv] i.e. reflexive responses.

[lxxv] Part 2, p.1576.

[lxxvi] ‘Executed/executable intentional awareness’ is identical to the Consciousness_B spoken of earlier.

[lxxvii] The term ‘person’ is used for convenience; a more accurate term would be ‘(truly) human’. As will be discussed in Chapter 10, the concept of ‘personhood’ owes its origin to John Locke.

[lxxviii] Fritjof Capra, Uncommon Wisdom, (1988) at p.19.

[lxxix] Karl Jaspers, Way to Wisdom, (1954) at p.184. In his essay ‘On My Philosophy’ (Kaufmann op.cit. at p.184) Jaspers says:

“In my Descartes I wanted to present historically typical modern errors at their root, viz. mistaking speculative thought for rationally cogent insight ...”

[lxxx] P.M.S. Hacker, Wittgenstein, (1997), at p.16.

[lxxxi] John Cottingham, Descartes, (1997), at p.13.

[lxxxii] La Mettrie in his Man a Machine (1748) had argued - in what he claimed to be a natural extension of Descartes’ views - that man himself could be explained entirely mechanistically. He even suggested that Descartes had accepted this but concealed it in fear of the Church. Unlike Descartes, La Mettrie did not conceive of the existence of a mechanistic explanation and the individual experience of consciousness, as being mutually exclusive:

“For after all, although he [Descartes] extols the distinctness of the two substances, this is plainly but a trick of skill, a ruse of style, to make the theologians swallow a poison, hidden in the shade of an analogy which strikes everybody else and which they alone fail to notice. ... I believe that thought is so little incompatible with organised matter, that it seems to be one of its properties on a par with electricity, the faculty of motion, impenetrability, extension, etc.”

[Julien Offray De La Mettrie, Man a Machine. p.145]

La Mettrie’s suggestion is bolstered by a remark made by Descartes in a letter to a friend:

“But for all the world I did not want to publish a discourse in which a single word could be found that the Church would have disapproved of: so I preferred to suppress it rather than to publish it in a mutilated form ...”

see Cottingham op.cit. p.15; see also: Leiber, An Invitation to Cognitive Science, p.26.

[lxxxiii] Descartes regarded ‘mind’ and ‘consciousness’ as synonyms.

[lxxxiv] The formulation is unfortunate in that it appears to be an inference. Roger Scruton points out that this formulation was due to a friend of Descartes. Descartes’ own formulation in the Meditations was that ‘the proposition ‘I am, I exist’ is necessarily true each time I pronounce it or ’inwardly affirm it’.‘ [Roger Scruton Modern Philosophy, 1994, at p.34]

The proposition is reminiscent of Augustine:

“For if I am deceived I am. For he who does not exist cannot be deceived; and if I am deceived, by this same token I am.”

Vernon J. Bourke, The Essential Augustine, (1964), at p.33.

[lxxxv] Bernard Williams’s essay The Certainty Of The Cogito, in Willis Doney (ed.) Descartes, (1968), at p. 89.

[lxxxvi] i.e. first as to what is meant by 'animal' and then by 'rational' and then to the terms used to define these, and so forth.

Stephen Priest Theories of Mind, (1991), at p.17.

Accepting such a definition would have redirected his attention ‘outwards’; however, Descartes sought to find the answer through introspection. Had his initial direction been outwards his ideas of what was most essential in man might have reflected more the social characteristics of man rather than just his internal state of consciousness. We will return to this question in discussing ‘personhood’.

[lxxxvii] Descartes Discourse on Method Part 4 [quoted by Cottingham op.cit. p.21].

[lxxxviii] ibid. p.22.

[lxxxix] Descartes Meditations ‘The Second Meditations’ [quoted by Cottingham op.cit. p.28].

[xc] Descartes Discourse on Method, Part 4, Para 33; (trans. Haldane) included in Enrique Chavez-Arvizo (ed.) Descartes: Key Philosophical Writings, (1997).

[xci] Stephen Gaukroger, Descartes: An Intellectual Biography, (1995), p.350.

[xcii] op.cit. p.286 (quoted earlier in this chapter).

[xciii] Priest op.cit. p.31.

[xciv] ibid. p.27

[xcv] In so far as PVS patients are also believed to be individuals without self-consciousness.

[xcvi] In Chapter 10 I will argue that ‘ability to communicate’ is a necessary condition for the ascription of 'personhood'.

[xcvii] Descartes Discourse on Method Part 5 para 57 [Chavez-Arvizo op.cit. p.108]

[xcviii] ibid. p.108

[xcix] ibid. p.109. See also: Desmond M. Clarke, Occult Powers and Hypotheses, (1989) - especially Chapter 6 entitled ‘Mechanical Explanation’ - and Desmond M. Clarke, Descartes’s Philosophy of Science, (1982).

[c] ibid. p.107.

[ci] Williams, Descartes p.282.

[cii] ibid. p.283.

[ciii] ibid. p.283-4.

[civ] Chapter 2 will examine the coherence of the Cartesian claim that all human actions can be split into two quite distinct and mutually exclusive classes, the ‘reflex’ actions and the ‘non-reflex’ actions. Williams is critical of the possibility of such a strict dichotomy:

“However, Descartes’s specification of this class of movements or actions suffers considerably from vagueness ... It is hardly surprising that Descartes’s account is unclear on this point since he is engaged on an impossible task of sorting all human movement into two sharply delimited classes, as having ultimately different causal histories, one which does, and one which does not, involve the ‘intervention of the mind’. It is one product of his ‘all or nothing’ account of mind and consciousness: either a creature has a full range of conscious powers ... or it is an automaton, with no experience of any kind.”

[op.cit. p.284].

[cv] ibid. p.284.

[cvi] Descartes Meditations. Sixth Meditation, Para 84. [Chavez-Arvizo op.cit. p.186].

[cvii] Actions which Cartesian philosophy classifies as ‘purely mechanical’, are classified by the Medical Conceptual Framework as ‘reflex actions’. The two terms are synonyms; for if not, an action must exist which is either a non-mechanical reflex action or a mechanical non-reflex action; such is not possible; though see the discussion - in Chapter 2 - concerning ambiguities in uses of the term ‘reflex’.

[cviii] Williams, Descartes, p.282.

[cix] see earlier discussion at footnote 82.

[cx] i.e. a human with an ‘unmanifested soul’ and an animal.

[cxi] i.e. reflexive responses.

[cxii] Part 2 p.1576.

We have already commented on the fundamental confusion inherent in concluding - from an assumption of lack of reflective consciousness - that the ability to experience pain is absent. The confusion is that between ‘experiencing something’ and ‘experiencing that something as pain’ - the latter obviously requiring use of the concept 'pain' and hence a ‘reflexive consciousness’. Concerning this point Williams states (Descartes p.82):

“An interesting case in this connection is pain. It would be generally agreed that pain is a conscious experience: one who is in pain feels something. Now it may, further, be true that a language user who is in pain will believe that he is in pain, unless perhaps he is such a reduced state that he has lost effective hold on his language use. If one possesses and can use the concept pain, its application to oneself will be elicited by one’s being in pain, and in this pains importantly contrasts with wants. But non-language users can be in pain (though Descartes ... denied it); they have no concept of pain they can apply to themselves, and to them we cannot in all seriousness ascribe, in addition to their pain, a belief that they are in pain.”

Judgements as to the possibility of another experiencing pain are discussed in Chapter 3.

[cxiii] The term ‘person’, owes its philosophical origin to Locke and was not used by Descartes. As mentioned earlier a more appropriate term would be ‘truly human’ however ‘person’ is more convenient.

[cxiv] Cottingham op.cit. p.22.

[cxv] It is clearly possible to conclude here that PVS patients have no such manifestation and accordingly are not persons; this indeed is the conclusion that was arrived at in the previous subsection. The discussion temporarily holds off on this conclusion in order that the Cartesian criteria for personhood be cast in the form of necessary and sufficient conditions.

[cxvi] Williams Descartes p.282 (quoted earlier):

“... but he does think there responses are purely mechanical and that they are ... ’natural automata’ because they have only limited responses or routines and above all have no use of language.”

[cxvii] see Priest op.cit. p.57.

[cxviii] Wittgenstein, PI-1 § 243.

[cxix] Wittgenstein’s reasoning will be considered in detail in Chapter 10.

[cxx] It is of interest to compare this test with Heidegger’s view that language created man and not conversely.

see George Steiner (Heidegger, (1992), at p. xxiv):

”... Heidegger’s theory of a language that speaks man rather than being spoken by him is utterly seminal ...”

and Reinhard May (Heidegger’s Hidden Sources, 1996. at p.39):

“[Heidegger] thus speaks of language as if it were a creature, but of the human being as if it were the work or instrument of language.”

[cxxi] i.e. that their behaviour was not sufficiently complex.

[cxxii] That their conduct could be fully explained mechanically.

[cxxiii] Support for such a ‘social definition’ can be found in the writings of P. F. Strawson and many other philosophers as shown by, for example, the following brief quotations:

"... [this approach] ends the solitariness of the ‘thinking self’, sets man firmly in the world which he knows, and so restores him to a proper existence as a community of persons in relation. It is the purpose of this book to show how the personal relations of persons is constitutive of personal existence; that there can be no man until there are at least two men in communication."

[John Mac Murray, Persons in Relation: Vol 2 of The Form of the Personal, (1961), p.12] Mac Murray also notes that the unit of human life is not the 'I' alone but the ‘you and I’.

Quassim Cassam’s Self and World (1997) was described by Strawson as arguing:

“... for the thesis that a necessary part of being conscious of oneself as a subject of thought and experience is the being conscious of oneself as a corporeal object among others.”

[cxxiv] Arguments advanced for the view that they cannot experience pain are considered in Chapter 3.

[cxxv] in the sense of being ‘truly human’.