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 2: Distinguishing between ‘reflex’ and ‘non-reflex’ action

In Chapter 1 it was noted that, with few exceptions,[i] the term ‘consciousness’ is interpreted in the Medical Conceptual Framework as ‘consciousness as judged by behaviour’; this identity was expressed symbolically as:

Consciousness = Consciousness _B

The analysis in Chapter 1 concentrated on the left hand side of this identity and concluded that - because the term ‘consciousness’ was capable of a multiplicity of meanings - the identity was erroneous. This chapter focuses on the right hand side of the purported identity - on Consciousness _B - and asks whether it is a coherent concept. It asks:

‘Is the concept ‘consciousness _B’ well defined, and if not, what consequences follow?’

The concept of ‘behaviour’ is not transparent; it has connotations of ‘purpose’ and ‘intention’ which are unclear. In order to draw out these connotations, the question can be phrased in term of the less opaque concept of ‘action’,[ii] either by using the concept of ‘intentional action’,[iii] or the concept of ‘reflex action’.[iv] Expressed in terms of ‘intentional action’ our question becomes:

‘Can intentional action be clearly distinguished from non-intentional action?’

Expressed in terms of ‘reflex action’ the question is:

‘Are reflex actions well defined; and can reflex actions be clearly distinguished from non-reflex actions?’ - That is, given any action is it possible to state unequivocally whether it is a ‘reflex’ action or a ‘non-reflex’ action?

A further question is immediately suggested:

‘Is the distinction between ‘reflex’ and ‘non-reflex’ actions logically equivalent to that between ‘intentional’ and ‘non-intentional’ actions ? That is, is an action ‘reflex’ if, and only if, it is ‘non-intentional’?’

This last question is not as otiose as it might appear principally because, as we shall see, the term ‘reflex’ is capable of being used with a number of different meanings not all of which are synonymous with ‘intentional’; furthermore the term ‘intention’ is itself problematic in that its domain of applicability is closely associated with the concept of ‘personhood’.

_________

At first sight the distinctions between ‘reflex’ and ‘non-reflex’ actions might seem to be of only slight interest and the questions posed above to be purely philosophical questions, of no relevance to everyday clinical decision-making. This view is seriously mistaken. Clinical decisions are made on the basis of categorising a patient’s behaviour as ‘reflex’ or ‘non-reflex’. Actions are taken based on these distinctions, actions which can have life and death consequences for a patient.[v] To the extent that these distinctions are dubious or lack a strong evidential basis, the consequences may well be humanly tragic.

In this regard it is important to realise that, even if the reflex/non-reflex distinction is theoretically sound, the distinction may be prone to error in practice. This difficulty was recognised by Jennett and Plum who noted that, amongst PVS patients:

“A significant grasp reflex often appears, and this may be provoked by chance touch of the bedclothes; to the inexperienced observer ... the resulting movement may look as though it was initiated by the patient and may even be regarded as purposeful or voluntary. Sometimes fragments of coordinated movements may be seen such as scratching, ...” [vi]

The difficulty can be more clearly seen by considering a specific case - that of ‘Miss D’ provides a good example; in this case the court was told that the patient did not meet the strict guidelines for diagnosis of PVS in that:

“Her eyes appeared to track moving objects, she flinches if a gesture is made and reacts to the feeling of ice on her body.” [vii]

However, an expert medical witness disagreed and regarded these responses simply as “primitive reflexes" which "existed within the nervous system at a lower level than consciousness". Yet in discussing similar responses the ‘The Multi-Society Task Force on PVS’ felt constrained to state that:

“In rare cases, patients who have no other evidence of consciousness ... have some degree of briefly sustained visual pursuit or fixation, which is believed to be mediated through brain-stem structures. Nevertheless one should be extremely cautious in making a diagnosis of the vegetative state when there is any degree of sustained visual pursuit, consistent and reproducible visual fixation, or response to threatening gestures.” [viii]

The recent (1995) case of Jean-Dominique Bauby[ix] is also relevant as had Bauby’s nurse been less perceptive, or had Bauby’s eyelid been subject to a slight twitch, his eye responses might easily have been regarded as either chaotic, or reflex, actions.

___________

The discussion in this chapter is structured into five Sections. In Section 1 the reflex/non-reflex distinction is considered both as it is manifested in Cartesian philosophy and in the Medical Conceptual Framework; it is suggested that the term ‘reflex’ is open to ambiguity; a notation is introduced for the differing meanings. Section 2 considers scientific challenges, and Section 3 considers philosophical challenges, to the distinction between ‘reflex’ and ’non-reflex’. In Section 4 Dennett’s analysis of the concept of ‘intention’ is considered; his analysis is of considerable assistance in disentangling the link between ‘intention’ and ‘personhood’.[x] Section 5 seeks to draw some conclusions from the earlier discussion.

Section 1: The distinction between ‘reflex’ and ‘non-reflex’.

The distinction has value only insofar as it is embedded in a specific framework.

The distinction between ‘reflex’ and ‘non-reflex’ has, like all distinctions, importance only because of the theoretical framework within which it is embedded; without the theoretical framework the distinction is pointless. Given an action, the theoretical framework permits differing implications to be drawn concerning this action depending on whether it is classified as being either ‘reflex’ or ‘non-reflex’.

There are two theoretical frameworks of interest that utilise the distinction between ‘reflex actions’ and ‘non-reflex actions’; they are Cartesian philosophy and medicine. It was pointed out earlier that Western culture, and in particular Western medicine, is greatly indebted to the intellectual framework provided by Cartesian philosophy; indeed the influence is so widespread and all-pervasive as to be generally unrecognised. Our very language embodies Cartesian distinctions so that the terms ‘will’ and the ‘mind/body’ distinction have a naturalness that makes alternative philosophies seem forced. However, the distinction between ‘reflex’ and ‘non-reflex’ actions can also find an interpretation within other philosophical systems which differ considerably from Cartesian philosophy. These other systems - some of which are discussed in Section 3 - provide a true point of contrast to Cartesianism and, most importantly, allow those conclusions which are often considered to follow by logical necessity[xi] to be seen for the contingent propositions that they really are.

The role played by the concept of ‘reflex action’ in both Cartesian philosophy and the Medical Conceptual Framework will be considered shortly, before doing so it is convenient to isolate some different meanings of the term ‘reflex’.

Ambiguities in the term ‘reflex’ [xii]

The ‘reflex actions’ of a human are often described as those actions which are purely mechanical - in the sense of predictable - responses to outside stimuli. There are many such actions - the knee jerk,[xiii] the sneeze, the cough, the yawn, the laughter response to tickling, the involuntary blink[xiv] to a threatening gesture. Descartes instanced[xv] the response of the pupil when a light is shone in the eye. These actions are described as automatic responses to stimuli, not requiring any awareness, or act of will, to occur.

It could, however, be argued that only the broad outlines of these responses is predictable and that around this broad outline there is a penumbra within which individual responses lie but such that each individual response is not strictly predictable and is thus not mechanical - that, for example, though each may laugh in response to tickling each individual’s laugh is different. To address this objection it is useful to consider the example of a ball bouncing on a horizontal surface - the very epitome of a mechanical system. Newtonian mechanics can predict the movement of the ball in general terms, however there will always be slight individual differences between bounces due to the individual nature of the system. However, the Newtonian model of the bouncing ball can be widened to accommodate increasing levels of complication - the roughness of the ground, the imperfections of the ball, and the air resistance can be included - so that theoretically the variations can be completely predicted. Is this theoretically possible for human reflexes? If not, can they be correctly categorised as mechanical?[xvi]

The objection to describing ‘reflex actions’ as simply the mechanical responses of the human body can also be approached from a different direction. A human, in that he has a body, is subject to precisely the same physical laws as an inert object; however, under certain conditions he may influence the physical system of which he is a part and the resultant response of his body to an outside stimulus is different from that of an inert body. An example may help explain. A man, whilst crossing the street, is hit by a bicycle. As he falls to the ground he twists his body to avoid an oncoming car. His motion is obviously different from that of an inert body, as is evident if one imagines a circumstance where he had lost consciousness on being hit by the bicycle. Dennett would consider the man moving to avoid the car as manifesting an intention to avoid the car - to be, in Dennett’s words, an ‘intentional system’[xvii] - whereas he would regard the unconscious man falling to the ground as purely a physical system in that the man’s motion is completely determined by the laws of physics; accordingly, his response is a purely mechanical, or ‘reflex’, response. In short, to Dennett, the unconscious man has a mechanistic or reflex response, whereas the conscious man has an intentional response even though he would, perhaps, deny that he had a conscious intention to avoid the car.

This example is analysed quite differently when viewed from the perspective of the Medical Conceptual Framework. Medical practice - as we shall see - applies the term ‘reflex’ to all actions which are not consciously determined or, alternatively it categorises the actions according to the nervous system required for their execution.[xviii] Thus, the response of the conscious man (‘unconsciously’) moving to avoid the car is classified, medically, as a reflex response because it was performed without (conscious) intention, the response of the unconscious man being beneath categorisation, because no specific brain activity is required for this response.

Based on the differing analyses of the example just given, I wish to suggest a number of distinctions. Firstly, there is a distinction between the medical usage of the term reflex - I call it ‘reflex_M’ - and its use in relation to a purely physical system -‘reflex_P’. Secondly, within the medical usage there is a further distinction between ‘reflex’ as defined in terms of the brain level required for the implementation of the response - called ‘reflex_MB’ - and as defined in terms of the absence of intention required to produce the response - ‘reflex_MI’. Returning to our example of the man turning to avoid the oncoming car; medically speaking this is a reflex action. If this assertion is based on the presumed lack of (conscious) intention of the man then it is a ‘reflex_MI’ action; whereas if it is based on the areas of the brain required to orchestrate the response it is a ‘reflex _MB’ action.

Perhaps these are distinctions without a difference? This will be so if:

(i) ‘reflex_MB’ and ‘reflex_MI’ are identical. If the areas of the brain uniquely associated with intention can be identified so that it is then possible to say of an action which does not ‘activate’ these areas, that it is ‘non-intentional’; and if, furthermore, these areas associated with ‘non-intentionality’ are identical to those associated with ‘reflex _MB’ actions; then the distinction is indeed unnecessary. Can areas of the brain be uniquely identified with intentionality?

To answer this it need only be pointed out that the theoretical grounds offered in the previous chapter against assuming that certain areas of the brain can be uniquely associated with consciousness, are equally valid in relation to intention.

(ii) ‘reflex_P’ and ‘reflex_M’ are identical. This will be so if it can be shown that all (medically) reflex actions can be predicted in precisely the same manner as if the system was regarded as a purely physical system. It may well be that there is a class of human actions which are unambiguously reflex - i.e. both ‘reflex_P’ and ‘reflex_M’. The reflex action of the tendon - the ‘tendon jerk’ - is a paradigm example of such actions which are unambiguously those of a physical system. The extent and full movement of the jerk is predictable. There are, however, many other responses - particularly as seen in PVS patients where eye-tracking movements and the ‘pulling away from’ painful stimuli are common - which are often described medically as reflex actions - i.e. ‘reflex_M’. These actions, however, are of a complexity such that they cannot be precisely predicted if considered simply as the response of a physical system.[xix] This is particularly so in relation to those situations - as occurred to the subject of the Ward case - where a patient exhibits fear in the presence of strangers. Such actions can be much more readily understood as intentional actions. The example, just given, of the man avoiding the oncoming car supports a similar conclusion.

Until these equivalencies have been shown, it seem a wise precaution to accept the distinctions suggested. The following conclusions may be draw:

Conclusion _{2 - 1} : There is a distinction between the medical usage of the term ‘reflex’ - ‘reflex_M’ - and its use in relation to a purely physical system - ‘reflex_P’.

and:

Conclusion _{2 - 2} : Medically the term ‘reflex’ is used in two senses; as actions performed without (conscious) intention - ‘reflex_MI’ - and as actions which require only limited areas of the brain for their completion - ‘reflex_MB’. ‘Reflex_MI’ and ‘reflex_MB’ are not necessarily equivalent concepts.

The distinction as manifested in Cartesian philosophy.

We have seen[xx] how Descartes sought to draw a clear distinction between man and the animals by his assertion that animals were just machines,[xxi] perhaps more complicated than, but essentially of the same nature as, the mechanism of a clock. Man, by contrast, had a ‘consciousness’ and a ‘will’. This ‘will’ allowed man to be the originator of his own actions[xxii] in contrast to animals whose actions were rigidly determined by stimulus and environment. Man, however, could not be defined solely as a self-determining entity for such could not explain the many involuntary behaviours - such as sneezing or blinking - to which he was prone. Descartes explained these involuntary actions by suggesting that man also partook of an ‘animal nature’; that aspects of his behaviour were determined mechanistically - these are the ‘reflex’ actions.

Thus, Descartes conceived of the human as composed of two autonomous parts - the animal part which does not involve the mind and whose outward manifestation is in ‘reflex’ actions; and a mind or ‘soul’ which, in an interior sense, is manifested in consciousness and the exercise of will and whose outward manifestation is in ‘non-reflex’ actions. To Descartes all actions were either willed or mechanical, there could be no other. Furthermore, the categorisation into ‘reflex’ and ‘non-reflex’ was mutually exclusive - to accept otherwise would be to put the distinction between man and animal in jeopardy.

Conclusion _{2 - 3} : In Cartesian philosophy the term ‘reflex’ is used to refer to the purely physical, or mechanistic responses, of a physical system. This meaning of the term ‘reflex’ is denoted by ‘reflex_P’. Furthermore the terms ‘reflex_P’ and ‘non-reflex_P’ are mutually exclusive.

Williams is critical of the coherence of such a strict dichotomy:

“However, Descartes’s specification of this class of movements or actions suffers considerably from vagueness and from his appealing to what seem to be several non-equivalent criteria. ... It is hardly surprising that Descartes’s account is unclear on this point, since he is engaged in an impossible task, of sorting all human movements 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.” [xxiii]

Before considering objections to the Cartesian approach let us note that two conclusions follow from it. Firstly, if an individual exhibits only ‘reflex_P’ actions, then he is to be regarded as a machine. There is no more reason to attribute consciousness, or mind or intention to him than to an animal. Secondly, irrespective of how personhood is defined, the individual - being just as a ‘machine’ - is not a ‘person’.

Conclusion _{2 -4} : In Cartesian philosophy an individual who manifests only ‘reflex_P’ actions lacks ‘consciousness’, ‘mind’ and ‘intention’. Such an individual is not to be considered a ‘person’, howsoever that is defined.

In Cartesian philosophy the assertion that a ‘non-reflex action’ is intentional, is a tautology - the very fact that it is ‘non-reflex_P’ implies that it is ‘willed’.

Conclusion _{2 -5} : In Cartesian philosophy a non-reflex_P action is necessarily an intentional action.

The distinction as manifested in the Medical Conceptual Framework.[xxiv]

The medical usage of the term ‘reflex’ was introduced by the 19^th century neurologist Marshall Hall[xxv] to describe certain muscle responses. He considered that these muscle responses reflected a stimulus much as a wall reflects a thrown ball. He suggested that the anatomical pathway used in the generation of the reflex action - which he called the ‘reflex arc’ and which linked the motor and the sensory nerves - was through the spinal cord. Details of the connections between these nerves, in the grey matter of the spinal cord, dates only from experiments by Eccles in 1951.

Descartes had suggested the existence of ‘animal spirits’ as the explanatory mechanism for those actions which he considered mechanical. However, it was not until the discovery of electricity and subsequently Galvanis’ experiments with frogs, that the theory of a nervous system as we now know it - i.e. with electricity as one of the mechanisms of communication - was developed.

Up to the 19^th century the term ‘reflex response’ was restricted to actions routed through the spinal cord. Orthodox medicine insisted on a clear distinction between the spinal cord and the brain. This is evidenced in the statement by Marshall Hall that:

“The cerebrum itself may be viewed as an organ of mind. It is an the organ on which the psyche sits, as it were enthroned. All its functions are psychical. They imply consciousness ... How different from. ... the functions which belong to the true spinal nervous system. In these there is no sensation, no volition, no consciousness, nothing psychical at all.” [xxvi]

Jonathan Miller comments that:

“Like Descartes, almost two hundred years earlier, Hall was prepared to make a large territorial concession to materialism in exchange for a treaty which recognised the local sovereignty of the soul and the brain. The only difference was that whereas Descartes’ soul was confined to the somewhat cramped premises of the pineal gland, Hall furnished the spiritual monarch with the large upholstered apartments of the brain as a whole.” [xxvii]

The mind/body dualism of Cartesian philosophy was replaced with the body/brain dualism of theoretical medicine. However, this sideways translation of the Cartesian ideas into medicine is not as seamless as it might appear. In Cartesian philosophy a ‘non-reflex’ action was necessarily intentional, however, once the mind is identified with the activity of the brain then it is theoretically possible to empirically verify the existence of ‘mind’ - i.e. brain activity. Thus an action which requires a physical manifestation in the brain is ‘non-reflex’; one that does not so require, is ‘reflex’. But what of intentional actions? It is no longer obvious that those actions which require the use of the brain are necessarily intentional actions.[xxviii] If actions which were normally categorised as intentional were found not to necessitate any brain activity this would indeed destroy the equation of mind and brain activity (because intentional actions obviously involve mind); however, the corollary is not obvious - an action might necessitate the use of the brain, and hence be a ‘non-reflex action’ but not, in fact, be intentional. A thought experiment may help to clarify. Consider a sleep walker; imagine that it could be established that sleepwalking necessitated the use of the brain and was accordingly to be categorised as ‘non-reflex’; but such an action is obviously not intentional!

Thus, once mind is identified with some physical process then there is no longer a necessary identity between mind activities - non-reflex actions - and intentional activities. Hence, as mentioned earlier,[xxix] it is necessary to distinguish between various senses of the term ‘reflex’ - ‘reflex_MB‘ and ‘reflex_MI’. The conclusion is that, once mind is equated to brain activity, the simplicity of the Cartesian system is no longer sustainable.

Conclusion _{2 -6} : Within the Classical[xxx] Medical Conceptual Framework the presence of brain activity is both a necessary, and a sufficient, condition for the ascription of consciousness. This identification ‘mind’ = ‘brain activity’ = ‘consciousness’ readily enables the further identification ‘consciousness’ = ‘personhood’. However, within this framework, though an intentional action is necessarily non-reflex, a non-reflex action is not necessarily intentional.

It remains to see what aspects of the Classical Medical Conceptual Framework still survive.

Section 2: Scientific challenges to the Classical Medical Conceptual Framework.

Hypnosis

Hypnosis[xxxi] presented the first challenge to the 19^th century orthodoxy. The behaviour of subjects under hypnosis was so complex - and so close to quintessentially human activity - that it was precluded from being described as ‘simply mechanical’; neither could it be considered as ‘willed’ and it thus fell outside the Cartesian categories.[xxxii] It was not a ‘primitive’ behaviour and accordingly could not be related solely to the spinal cord, nor was it a willed product of the human control centre, the brain, and thus it fell outside the medical categories.

Originally hypnosis - then known as ‘mesmerism’ - was believed to be associated with magnetism. However Carpenter and Laycock, eminent medical academics of the mid-19^th century, argued that hypnotism functioned by means of a cerebral process analogous to the automatic reflexes of the spinal cord. This was the first acceptance of a reflex mechanism above the spinal cord. Carpenter gave the name ‘unconscious cerebration’ to this process but Laycock preferred the term ‘reflex functions of the brain’. The existence of such reflex actions destroyed the previously accepted identity ‘mind’ = ‘brain activity’ = ‘consciousness’ = ‘intentional action’.

Sir William Hamilton had also made the observation[xxxiii] that the mind has aspects which cannot be described as ‘conscious’, or ‘willed’. He credited Leibniz with the original insight that it is often possible to recall having perceived something at a particular time, though unaware of perceiving it at that time. Hamilton said:

“What we are conscious of is constructed out of what we are not conscious of. ... We are thus constrained to admit, as modifications of mind, what are not phenomena of consciousness.” [xxxiv]

This aspect of the unconscious - the ‘enabling aspect’ in Miller’s apt phrase - is only now reappearing in scientific discourse. Until recently the Freudian aspect of the unconscious - i.e. its withholding or repressive nature - has held sway. This enabling view of the unconscious is resurfacing in academic discussion principally because of the discovery of the phenomenon of ‘blindsight’ but also because of the recognition that a very high proportion of the actions that would usually be considered as quintessentially human, occur automatically and not as the result of a conscious act of will. This recognition has been reinforced by Libet’s experiment, one reading of which suggests that consciousness rather than being understood as the originator of action[xxxv] is in fact just a blocking mechanism - the action emerges from the unconscious as an appropriate response to an environmental stimulus; the role of consciousness often being at most to impede this response before it is manifested in action. This perspective also helps explain hypnosis as the inhibiting of the blocking action of consciousness, thus allowing the unconscious to respond in an unfettered fashion to the stimuli presented to it.

The phenomenon of hypnosis shatters the Cartesian simplicities. An unavoidable dilemma is posed. Either hypnotic behaviour is ‘reflex’ or ‘non-reflex’, there are no other possibilities, yet behaviour under hypnosis is just as complex as normal behaviour.[xxxvi] If it is to be judged to be ‘reflex’, then ‘reflex’ cannot be distinguished from ‘non-reflex’ actions simply by their complexity. If it is judged non-reflex then this is an acknowledgement of the existence of non-reflex behaviour which is non-intentional. Either way the categorisation of reflex actions as non-intentional ‘mechanical’ actions cannot be sustained.

Modern accounts[xxxvii] of the concept of ‘reflex action’ no longer restrict its use to actions whose ‘reflex arcs’ are routed through the spinal cord; it is now accepted that there are many reflexes whose pathway is through the cerebral cortex - the blink response is one, as are the conditioned - or learned - responses. The term is now taken to mean a certain kind of inborn central nervous activity in which a stimulus, by exciting an afferent nerve, produces an immediate, stereotyped, response of a muscle or a gland. Yet even this description does not meet the challenge posed by hypnosis. Furthermore, modern accounts now longer consider the categories ‘reflex_M’ and ‘non-reflex_M’ as mutually exclusive:

“The point at which an animal’s responses to stimuli cease to be regarded as reflex and are called deliberate or voluntary, or by some similar term, is ill-defined. A mild cough can be suppressed by an effort of will during a concert; but such coughing would be regarded as reflex.” [xxxviii]

Conclusion _{2 - 7} : The phenomenon of hypnosis challenges the coherence of the distinction reflex/non-reflex and leads to the conclusion that, either reflex actions must be regarded as possessing a complexity comparable to non-reflex actions, or some non-reflex actions must be regarded as non-intentional.

Conclusion _{2 - 8} : : The categories of actions, ‘reflex’ and ‘non-reflex’, can no longer be regarded as being mutually exclusive.

Conclusion _{2 -9} : The cerebral cortex can no longer be regarded as the exclusive domain of non-reflex actions.

Indeed the exclusive identification of ‘mind’ and ‘brain’ - which is a cornerstone of the Medical Conceptual Framework - has come under threat. A report in the Journal of Consciousness Studies of a recent conference on blindsight states:

“... we too easily assume that the mind just is the brain, and that mental processes just are the processes being carried out by the neural computer. From such a perspective, the fact that many of these processes are not consciously experienced is at first puzzling ... it leads to a bootless search for the mysterious ‘X’ factor that raises some select few of these processes to conscious level. Perhaps there is no such factor; ...” [xxxix]

Let us now examine the phenomenon of ‘blindsight’, automaticity and Libet’s experiment.

Blindsight

During experimentation on animals it was noticed that if the region of the cerebral cortex to which nerve fibres of the eye are connected, is removed, then the ability of the animal to discriminate between visual events was not destroyed. Humans, however, who had suffered brain damage to a similar area of the brain were, when questioned, unable to discriminate between visual events. This led to the theory of ‘encephalization of function’ - the belief that, despite the close anatomical similarity between them, the brains of animals were organised in a different fashion to those of humans. However, when the research on humans was refocused from a direct interrogation of subjects as to their perceptions, to a more indirect approach - which asked the subjects to ‘guess’ the objects that were in their field of vision - a paradox became apparent. It was discovered that these subjects were able, with great accuracy and consistency, to correctly guess - whilst simultaneously denying any conscious knowledge of - the identity of those objects which were in their field of vision.

This phenomenon became known as ‘blindsight’ and it bears witness to mental activity of which the individual has no explicit awareness. This indicates a perceptual competence operating well below the level of overt conscious perception. It also shows that the primary visual cortex, which had previously been thought necessary to vision, is not so; the visual signals can bypass the cortex and be processed by more ‘primitive’ parts of the brain. Phenomena similar to blindsight occur in relation to other senses, such as hearing and touch, and also in relation to ‘implicit memory’- which is when a subject has no conscious memory of particular facts but acts in such a fashion as is only consistent with the possession of those facts.

The phenomenon of blindsight forces a recognition that the concept of ‘mind’ - which was regarded as coextensive with ‘consciousness’ in Cartesian philosophy - is considerably broader. This conclusion is reinforced by a consideration of the phenomenon of automaticity.

Automaticity and Inspiration

There are many occasions[xl] when an individual performs quite complex tasks without an awareness of what he is doing. A distinction may be helpful between true automatism, such as sleepwalking where there is no awareness of what is occurring, and situations where there is a broad awareness of what is happening but no conscious intent to perform the individual actions.

A skilled concert pianist, whilst learning a piece of music, requires total awareness, concentration and deliberation as to the fingering of individual notes; as he becomes more and more proficient the playing is, as it were, ‘handed over‘ to his unconscious so that finally, when in the concert hall, he is fully aware of the music that he is playing but oblivious to the individual fingerings, so that to say he ‘willed’ each of his actions would be incorrect.[xli]

Riding a bicycle, driving a car, learning to type, are similar in that, in the beginning, each action is individually willed but with experience the action is performed not only without will but often indeed without awareness. This latter occurs, for example, when in driving a car, one suddenly realises that for the last few miles one’s thoughts have been elsewhere. In typing a letter, if sufficiently proficient, we can lapse into daydream only to suddenly see that we are about to press an incorrect key but without sufficient time to stop the mistake being made.[xlii] This last experience reinforces the interpretation of the role of consciousness as a blocking mechanism.

Artistic inspiration or creative activity generally is also beyond the realm of conscious intent.[xliii] The creative idea is a ‘given’ as exemplified in the tradition of the artistic muse; the role of the conscious mind is limited to the working out of the implications of this given inspiration. This limited role for the conscious mind is well expressed in Schopenhauer’s observation[xliv] that:

"We find ourselves like a hollow glass globe, from whose vacancy a voice speaks."

and Benoit’s noting[xlv] that man, despite his pretensions, is not the artisan of either his thoughts or his emotions, and he deceives himself in seeing his conscious developed sensibility as self-sufficient.[xlvi] This point is also emphasised by Miller who ends his essay with the observation that:

“Experimental results from an ever-widening range of psychological functions tell the same story, that what we are conscious of is a relatively small proportion of what we know and that we are the unwitting beneficiaries of a mind that is, in a sense, only partly our own.” [xlvii]

The recognition that the locus of that which is most valuable in the human - their creativity, their source of inspiration and the groundswell of their actions - lies outside the realm of consciousness forces a reassessment of any attempt to identify ‘consciousness’ and ‘personhood’.[xlviii] The ‘centre of gravity’ of the human can no longer be defined solely in terms of in their consciousness but must acknowledge the unconscious as the source of that which is of greatest value in human endeavour. The full flowering of an individual is only possible through the capacity to access and make manifest the fruits of their unconscious.[xlix]

Conclusion _{2 -10} : The phenomena of blindsight and automaticity challenge the identification of ‘mind’ with ‘consciousness’. Mind is a broader phenomenon than consciousness.

Libet’s Experiment[l]

In 1985 Benjamin Libet performed a number of experiments in an attempt to determine the order in which

(i) the consciousness of the intent to perform an action

(ii) the activation of the brain area normally associated with the action, and

(iii) the activation of the muscles necessary for the action.

occurred. The expectation was that these occurred in the order just given. The experiments were performed on subjects whose brain and arm muscles were monitored electrically, and who were told to flex their arms whenever they felt like it.

It was found that the consciousness of the intention to flex their muscles occurred after the muscle had already begun to flex. Libet was lead to the conclusion that “cerebral initiation of the kind studied ... can and usually does begin unconsciously.” Paradoxically, the subjects felt that they were consciously causing their muscles to flex. In essence, Libet’s conclusion was that consciousness, though not exercising an originating power, exercised a veto power over actions which originated elsewhere. Philip Dorrell[li] suggests that rather than concluding that consciousness is deluded into thinking itself responsible for behaviour that is actually performed unconsciously, the unconscious behaviour that does occur is the result of imitating previously initiated conscious behaviour. This view would see the role of consciousness as the generator of responses only in those situations which were novel in the sense that an apt and appropriate response had not been already found - a view similar to Schrödinger’s which is discussed below.

For our purposes, the conclusion to be drawn from Libet’s experiment is that actions which are paradigms of non-reflex actions are not preceded by an act of conscious will. The experiment also reinforces the distinction, suggested earlier, between ‘reflex_MB’ and ‘reflex_MI’ actions.

Conclusion _{2 -11} : Libet’s experiment implies that some non-reflex actions are non-intentional.

We now turn to consider some alternative philosophical perspectives on the cluster of concepts consciousness, intention, reflex and non-reflex, action.

Section 3: Philosophical challenges to the coherence of the reflex/non-reflex distinction.

Schrödinger’s view of the role of ‘consciousness’ and ‘reflex’ action

Erwin Schrödinger in his essay ‘Mind and Matter’[lii] criticised the approach of those he called the ‘rationalists’ to the subject of consciousness. These rationalists had, he suggested, argued that the study of consciousness was not a worthy subject of study because of the unprovability of propositions concerning it. Schrödinger conceded that asking whether consciousness was to be found in other than nervous processes led to unprovable speculation. Instead he suggested that an understanding of the role of consciousness could be found by first recognising that not every cerebral process was accompanied by consciousness and then by analysing those processes which were so accompanied.[liii]

Schrödinger first examined the reflexes and noted that:

“... many reflexive processes exist that do pass through the brain, yet do not fall into consciousness at all or have very nearly ceased to do so. For in the latter case the distinction is not sharp; intermediate degrees between fully conscious and completely unconscious occur.” [liv]

He argued that any succession of events involving sensations, perceptions and actions gradually drops out of consciousness when the same string of events occurs very often.[lv] Consciousness of these strings only re-arises when differences to the normal established pattern occur and then it is only of these differentials. Consciousness is then required for the establishment of a response appropriate to the new circumstances.

Schrödinger suggested that consciousness is, metaphorically speaking, “... the tutor who supervises the education of the living substance, but leaves his pupil alone to deal with all those tasks for which he is already sufficiently well trained.” [lvi]

He summarised his hypothesis in the words

“Consciousness is associated with the learning of the living substance; its knowing how is unconscious.” [lvii]

His hypothesis accommodates automaticity with ease and Libet’s experiment presents no challenge. Gregory, who noted that much of the autonomic nervous system can be brought under voluntary control, had posed the question:

“The fact that much behaviour is involuntary and unconscious raises such questions as: why is some behaviour voluntary, and under conscious control? It seems that high rates of information processing in unusual situations require consciousness and are voluntary.” [lviii]

This problem is also elegantly resolved by using Schrödinger’s hypothesis. Furthermore the strict dichotomy between animals and humans, which was such a feature of Cartesian thought falls away; humans and animals, although they have differing abilities to learn and accordingly differing levels of consciousness, are on the same continuum.

The ‘reflex action’ in Spinoza’s philosophy

Spinoza developed his philosophy partly out of a dissatisfaction with Cartesianism. Descartes had conceived of the human mind and the body as being distinct substances thus creating the necessity for an explanation of how these substances might interact. Descartes’ theory, as we have seen, was that certain bodily processes - the reflex actions - could be explained mechanistically, entirely within the confines of the body and with no involvement of the mind; whereas all other bodily actions were to be explained by the doctrine of ‘will’ - the mind acting on the body by means of the pineal gland.

Spinoza, in contrast, postulated that there was only one substance in the universe. This substance - called ‘God’ or ‘Nature’ - could be conceived under different aspects - called ‘attributes’ - of which we humans were aware of two, the mental and the physical.[lix] Since these attributes were aspects of the same underlying phenomenon, it was not to be expected that they were to be explained in terms of each other. Thus the problem of interaction of mind and body encountered by Descartes, is elegantly avoided.

Any phenomenon in the universe could be viewed, and explained, either through the aspect of mind or through that of body; these being equivalent but different explanations, much as a physicist and a musician might both give different but equivalent[lx] explanations of a piece of music. However, the mental aspect could not be reduced to the physical nor could the physical be reduced to the mental; the explanations move in parallel, as bodily injury has its mental parallel in pain. In particular the ‘mechanical actions’ - the reflexes - of the Cartesian system could be interpreted mentally just as the non-reflex action could be interpreted physically. The fact that we utilise ideas of ‘choice’, ‘will’ and ‘purpose’ in explaining the non-reflex actions is:

“... simply because purely physical explanations are not yet available; the use of these words ‘will’ and ‘purpose’ confesses that we do not in fact generally possess clear and adequate ideas of causes; they are confessions of ignorance.” [lxi]

Descartes’ concept of the ‘will’ reflected prevailing Christian ideas of freedom and the moral responsibility of the individual for his actions. To Spinoza, such ideas of freedom were illusory; he regarded men as in bondage in so far as they are under the control of external things and ‘inadequate ideas’. The Cartesian ‘will’ was the paradigm of such an inadequate idea:

“... men are mistaken in thinking themselves free; and this opinion depends on this alone, that they are conscious of their actions and ignorant of the causes by which they are determined. This, therefore, is their idea of liberty, that they should know no causes of their actions. For that which they say, that human actions depend on the will, are words of which they have no idea. For none of them know what is will and how it moves the body; those who boast otherwise and feign dwellings and habitations of the soul, provoke either laughter or disgust.” [lxii]

Hampshire comments[lxiii] that Spinoza is not denying that there is anything within the human experience corresponding to ‘will’ or ‘choice’ for such would be absurd. Spinoza indeed recognises the conscious state of indecision and the ‘choosing between alternatives’ and that from this state a decision arises; what he does deny is that we are the conscious authors of this decision, despite our beliefs to the contrary.[lxiv] To state of another ‘that he could have acted otherwise’ is, to Spinoza, necessarily a ‘sign of the incompleteness of our scientific knowledge, or an expression of our present state of ignorance.’ [lxv]

With so many aspects of his philosophy unmentioned it is left to end this sketch by saying that Spinoza created a philosophy of extraordinary beauty and power which has a surprisingly modern resonance. This is seen particularly in its ability to accommodate many of the ideas of both contemporary science and psychology. In so far as there is one universal substance in his philosophy it follows that the rigid boundaries of objects and substances, as found in Cartesian philosophy, must yield to a more fluid view of the universe where ideas of ‘process’ and ‘change’ replace ideas of ‘substance’ and ‘fixity’ - a startlingly modern perspective when the theories of modern physics are considered. Yet it is in his treatment of the ‘human bondage’ to emotion, false understanding and ‘inadequate ideas’ and his idea of a ‘lived philosophy’ that his true genius becomes apparent; and if his philosophy is a source of wonder in its ability to accommodate many of the ideas of modern physics, how more so is it that his philosophy of the emotions can incorporate the insights of modern psychoanalysis.

Conclusion _{2 -12} : Some philosophers, for example, Spinoza and Schrödinger, have understood the complex of concepts ‘consciousness / intention / reflex and non-reflex action’ in a manner radically different to the Cartesian understanding. Spinoza believes that all actions are determined by their environment and that the distinction between reflex and non-reflex actions rests simply on our present ignorance of the causes of those actions we categorise as non-reflex. Schrödinger argues that consciousness - understood as intent - is needed only if a novel situation is encountered needing a response. To him, reflex responses are simply the responses deemed adequate to a situation which has been previously encountered. They do not imply a lack of consciousness (understood as awareness) in fact they presume such a consciousness.

However, there is one modern philosopher - Daniel Dennett - also standing outside the Cartesian tradition, who has given a particularly clear and fruitful analysis of the concept of ‘intention’.[lxvi] It is to his analysis that we now turn.

Section 4: Dennett’s analysis of ‘intention’

Dennett locates his discussion of whether behaviour can be classed as ‘intentional’ in quite an abstract setting. He first considers an abstract system - i.e. to include any system whether it be human, animal, computer or even weather system - and considers the problem of what it means to understand - in the sense of being able to predict - the development, or unfolding, of such a system. He believes three types of attitudes or ‘stances’ [lxvii] are available in confronting such a system:

(i) a ‘design stance’ - such as is adopted in relation to a computer which one has designed. One’s predictions will come true provided only that the computer behaves as designed.

(ii) a ‘physical stance’ - such as is adopted when we base our predictions on the physical state of the system and the laws of nature as, for example, in the movement of a pendulum.

(iii) an ‘intentional stance’ - such as is adopted when we base our predictions on imputing intentions to a system. The intentional stance is often used when a system is too complex to permit the other stances to be adopted;[lxviii] it is, Dennett argues, equivalent to imputing rationality to the system. Intentional activity is not the sole prerogative of persons, it is found amongst animals - Dennett considers the example of the hunter stalking a tiger, and considering what he would do if he were the tiger. It can even be applied to prediction of the behaviour of plants[lxix] or inanimate objects - Dennett gives the example of a chess playing computer; the earlier versions of such computers were amenable to prediction using a design stance but:

“... today, with evolving programmes capable of self-improvement, designers are no longer capable of maintaining the design stance in playing against their own programs, and must resort, as any outsider would, to the intentional stance in trying to outwit their own machines.” [lxx]

Dennett considers it important that we do not attempt to ask whether a system really has beliefs, desires, or intentions, as such is an inappropriate question. The appropriate question relates to the choice of stance, and this is to be answered pragmatically by virtue of the success, or otherwise, of the stance adopted.[lxxi] If the intentional stance is the most successful then this implies that the system has beliefs desires and intentions; according to Dennett there is no other meaningful method of assigning the terms ‘belief’, 'desire' or 'intention'.

What stance is appropriate to humans? Dennett argues that there is a ‘tolerant assumption of rationality’ which exists normally in our dealing with our fellow humans. This presumption implies that the intentional stance is appropriate in all but the most exceptional circumstances, such as, for example, when in relation to the insane the ‘design stance’ is occasionally adopted. Of the possible application of the ‘physical stance’ to humans Dennett says:

“It need hardly be added that in the area of behaviour (as opposed to the operation of internal organs, for instance) we hardly ever know enough about the physiology of individuals to adopt the physical stance effectively, except for a few dramatic areas, like surgical cure of epileptic seizures.” [lxxii]

Conclusion _{2 -13} : To assert that a human manifests only reflex behaviour is - to Dennett - to adopt a ‘physical stance’ to that individual;[lxxiii] this requires that laws of physics and chemistry are sufficient to fully predict the behaviour of that individual. It is a necessary consequence of the adoption of the physical stance that ‘consciousness’, ‘intention’, ‘mind’ and ‘personhood’ are not to be ascribed to that individual.

Section 5: Conclusions

Questions

A number of questions were posed at the beginning of this chapter:

(i) ‘Are reflex actions well defined; and can reflex actions be clearly distinguished from non-reflex actions’?

(ii) ‘Is an action ‘reflex’ if, and only if, it is ‘non-intentional’?

A third question is also fundamental to this thesis:

(iii) ‘In relation to an individual all of whose actions are judged to be reflex, what conclusions can be drawn pertaining to the complex of concepts consciousness / mind / intention / personhood’?

As a preliminary to addressing these questions it is first necessary[lxxiv] to adopt some theoretical framework; without such a framework the questions are meaningless. Cartesian philosophy is usually the framework within which these questions are considered; however, because the Cartesian perspective is so all-pervasive in Western culture, it is often not recognised that a choice of framework is actually being made. By using other philosophical systems - such as, for example, Spinoza’s and Schrödinger’s - a counterpoint is provided which enables us to see that a choice is indeed being made. Because these questions are not just philosophical questions but address issues at the forefront of modern science, Schrödinger’s views - in that they are those of one of the most eminent theoretical physicists of the 20th century - are worthy of especial consideration.

I will now summarise the various answers to these questions; first, as answered by Cartesian philosophy then by Spinoza, by Schrödinger, by the Classical Medical Conceptual Framework and, finally, by the Medical Conceptual Framework as it is currently found.

Answers: Descartes

The existence of a strict dichotomy between body and mind is a cornerstone of Cartesian philosophy. The mind is synonymous with ‘soul’, ‘consciousness’, ‘intention’ and ‘will’; the existence of the mind is manifested through non-reflex actions; all other actions were purely mechanical - i.e. ‘reflex_P’ actions.

To answer the questions posed above:

(i) Theoretically, there is a clear and unambiguous distinction between reflex and non-reflex actions; the categories are, by definition, mutually exclusive.

Practically, the situation is far from clear; for example, to Descartes, the behaviour of animals was a paradigm of reflex activity, yet even current scientific knowledge is incapable of adequately predicting their behaviour.

(ii) It follows, as a matter of strict logical deduction, from Descartes’ philosophy that an action is reflex if, and only if, it is non-intentional.

(iii) An individual who manifest only reflex actions is, to Descartes, a machine - necessarily without mind, consciousness, or intention. Being just a machine, personhood - irrespective of its definition - is obviously excluded.

Answers: Spinoza

Spinoza, writing to a correspondent who had difficulties in accepting Spinoza’s theories of the will, suggested a thought experiment. Imagine, he said, a stone set in motion by an external cause, thinking, and knowing that as far as it can, it strives to continue to move:

“Of course since the stone is conscious only of its striving, and not at all indifferent, it will believe itself to be free, and to persevere in motion for no other cause than because it wills to. ... And this is that famous human freedom which everyone brags of having, and which consists only in this: that men are conscious of their appetites and ignorant of the causes by which they are determined.” [lxxv]

To answer our specific questions:

(i) Non-reflex actions are simply those actions of whose causes we are presently unaware. The reflex /non-reflex distinction is not intrinsic to actions but only mirrors our present state of ignorance; as scientific research progresses, actions which were once thought to be non-reflex, will be clearly seen to be reflex.

(ii) Non-reflex actions are usually perceived as being intentional but such views are founded on ignorance. In view of Libet’s experiment - where the volunteers believed that, despite evidence to the contrary, they were responsible for the movements of their arm - Spinoza’s prescience is uncanny.

(iii) To Spinoza, whilst the individual who manifests (what are usually judged to be) only reflex actions certainly has more limited responses than other individuals, his capacity to act on intention is in reality no more or no less than other individuals. The judgement as to whether such an individual could be considered to be a ‘person’[lxxvi] is unclear; it can, however, be stated that Spinoza’ human ideal lies in the achievement state of ‘freedom’, by which he means not one whose actions have no cause - for such is impossible - but one whose actions are caused by himself alone; hence, the more an individual’s actions are a response to circumstances outside of himself - i.e. are reflex actions - the less is he fully human.[lxxvii]

Answers: Schrödinger

(i) To Schrödinger, reflex responses are simply learned responses. A strict distinction is not to be drawn between reflex and non-reflex actions, rather they are to be viewed as different extremes on a continuum.

(ii) The role assigned to consciousness by Schrödinger appears to be threefold; firstly, in being aware of responses which are being (unconsciously) generated; secondly, the blocking of these if they are considered inappropriate and thirdly, the generation of more appropriate responses. It could be argued that the second category envisages actions which are both intentional and reflex.

(iii) A manifestation of only reflex actions would, to Schrödinger, imply either that they were sufficiently appropriate to the situation, or that the individual was incapable of making more appropriate responses. This inability might be caused by either informational deficiencies (those asleep cannot escape a fire) or operative reasons (those paralysed cannot escape a fire). Consciousness - understood as awareness - cannot be excluded.

To Schrödinger, the strict dichotomy between animals and humans disappears; they both lie on the same continuum; this would suggest that an individual who manifested only reflex responses would not be considered truly human because of the paucity of their response vocabulary.

Answers: Classical Medical Conceptual Framework

To Descartes, mind, consciousness, soul, and personhood were synonyms; the Classical Medical Conceptual Framework included ‘brain activity’ as an additional equivalence. Non-reflex actions were the outward manifestation of brain activity whereas reflex actions were the province of the spinal cord. Hitherto the Cartesian framework was a closed theoretical system, self-validating and immune from experimental challenge. However, the identification of mind (= consciousness) with brain activity, and the fact that brain activity could be independently monitored, opened a bridge with science, and caused some fundamental realignments amongst the cluster of concepts ‘mind/consciousness/intention’. In particular the linking of consciousness with brain activity rather than with the soul dispensed with the ‘all or nothing’ nature of consciousness; so that it was now possible to speak of greater or lesser degrees of consciousness. Thus Bernard Williams’ criticism[lxxviii] of the Cartesian account of mind - which was recently echoed by Susan Greenfield in her suggestion that consciousness is not an ‘all of nothing’ condition but is more like a dimmer switch - did not apply to the Classical Medical Conceptual Framework. There were also (in relation to our specific questions) some other consequences:

(i) It was possible to investigate, experimentally, whether the ‘reflex arc’ corresponding to a particular action was confined to the spinal cord, or whether it was routed through the brain. Hence, necessary and sufficient conditions for describing an action as reflex, could be experimentally determined.

(ii) If the identification of mind and brain activity gave a physical embodiment to ‘mind’, it had the opposite effect on ‘intention’. Three alternatives were possible. Either ‘intention’ was to be defined as mind activities relating to non-reflex actions[lxxix] - in such a case the proposition that non-reflex actions are intentional is a vacuous tautology. A second possibility was that the concept of ‘intention’ was to be banished. A third possibility was to seek a brain correlate for intention. If this was successful it would require that a choice be made between:

a) a redefinition of the concept of ‘reflex’ so that it was no longer confined to actions routed solely through the spinal cord. This would enable the identity between non-reflex actions and intentional actions to be preserved. Or,

b) preserving the definition of reflex actions as those routed through the spinal cord. This would break the identity between reflex actions and non-intentional actions so that it might then become possible to speak of intentional reflex actions, or non-intentional non-reflex actions, without contradiction.

By tampering with the Cartesian scheme the concept of ‘intention’ was necessarily cast adrift.

(iii) In considering an individual who manifested only reflex responses two cases fall to be considered:

a) where the individual manifests no brain activity. In such cases there is no mind, nor consciousness, nor personhood in existence. The situation is identical to the Cartesian position, only a ‘bare machine’ exists.

b) where the individual manifests brain activity. In such cases it is logically possible to assert that consciousness and mind persist.

Answers: Medical Conceptual Framework

The incorporation of behaviour such as ‘habits’ into the Classical Medical Conceptual Framework presented problems but it was the phenomenon of hypnosis that wrought the greatest change. The behaviour patterns seen in hypnosis were, in outward respects, indistinguishable from what would normally be considered purposive behaviour. Hampshire notes:

“Once this is admitted, there remains no a priori justification for drawing a line, and for excluding the possibility of description and explanation in physical terms, at any particular point on the scale of complication; we may in our common sense descriptions fall back on the terminology of will and purpose, simply because purely physical explanations are not yet available.” [lxxx]

Yet the distinction between ‘reflex’ and ‘non-reflex’ was not abandoned; rather the category of reflex was widened so that it included such ‘unintended’ behaviour. Such reflex behaviour was no longer considered to be referable solely to the spinal cord but was seen to involve the cortex. The intent was to preserve the link between intentional and non-reflex action. Yet if this link is regarded as sacrosanct then only one of the concepts ‘intention’ and ‘reflex’ can be defined independently.[lxxxi] In other words, either ‘reflex’ and ‘intention’ are to be defined independently - in which case the proposition ‘All reflex actions are non-intentional’ is an analytic proposition that must be established; or, just one of ‘reflex’ and ‘intention’ is to be defined independently - in which case the proposition ‘All reflex actions are non-intentional’ is an empty truism. Returning to our original questions:

(i) The situation in the Medical Conceptual Framework is confused. There have been attempts to define reflex actions independently of intention - one such is as ‘stereotyped’ actions - yet such a definition cannot include behaviour under hypnosis - which is anything but stereotyped and is generally accepted as being non-intentional.

The fact that the terms ‘reflex’ and ‘non-reflex’ are no longer considered to be mutually exclusive and that reflex behaviour can now include cortical activity might suggest that the concept, whilst it may be useful as rough helpmeet, is no longer fully coherent.

(ii) The proposition that ‘all reflex actions are non-intentional’ can either be an empty tautology or a proposition requiring independent confirmation. All depends on how the terms ‘reflex’ and ‘intention’ are defined. However, because of the fluidity of these concepts the status of the proposition is unclear. Libet’s experiment - which isolated behaviour which subjects believed to be intentional but which in fact was not - further confounds the relationship between the intentional and the non-reflex.

(iii) The recognition that reflex behaviour may involve cortical activity means that no conclusion can be drawn in relation to consciousness of an individual who only manifests reflex behaviour. This conclusion is reinforced by the fact that ‘reflex’ and ‘non-reflex’ are no longer considered to be mutually exclusive categories. Libet’s experiment suggests caution in drawing any conclusion concerning the presence of intention. The recognition that certain behaviour - such as ‘unconscious cerebration’,[lxxxii] musical improvisation and some other artistic and creative processes - which would usually be considered as quintessentially human are in fact outside conscious control - and thus lie in the domain of the reflex - cautions against acceptance of the Cartesian simplicities where the possession of personhood - in the sense of being truly human - is equated with the ability to perform non-reflex actions.

Conclusion _{2 -14} : Whereas the conclusions that:

(i) The reflex/non-reflex distinction is coherent.

(ii) An action is reflex if, and only if, it is non-intentional. And

(iii) ‘Mind’, ‘consciousness’ ‘intention’ and ‘personhood’ cannot be attributed to an individual who manifests only reflex behaviour.

were valid within the bounds of Cartesian philosophy; in the light of current scientific knowledge they can no longer be justified without radical amendment. The nature of such amendment is unclear.

A possible resolution of this impasse

The acceptance of Dennett’s, or some equivalent, analysis of ‘intention’ would at least permit that concept to be used in a meaningful fashion. At present its implicit use is, essentially, as a synonym for non-reflex action; this is a logical ‘sleight of hand’ and cannot be justified. Adopting (rather readopting, or repossessing) such a meaning for ‘intention’ and using the term ‘reflex’ as meaning ‘stereotypical response’ would necessitate breaking the link between ‘intentional action’ and ‘reflex action’. An action might then be both intentional and reflex[lxxxiii] - such as, for example, the movement of a PVS patient when they scratch or move away from a painful stimulus; equally behaviour might be both non-reflex and non-intentional - such as, for example, behaviour under hypnosis. One conclusion that follows from this analysis is that a patient who manifests intentional behaviour is necessarily conscious;[lxxxiv] thus the PVS patient who responds to ice on the skin is to be considered conscious.

What of the link between non-reflex behaviour and personhood[lxxxv] which was such a feature of Cartesian thought? The existence of such a link is evident in the distinction between ‘person’, and ‘automaton’, or ‘zombie’ - i.e. individuals who only display predictable stereotypical responses. ‘Person’ and ‘automaton’ are mutually exclusive categories. Theoretical medicine, following Descartes, had attempted to forge a link between behaviour and ‘personhood’ by using the concept of ‘reflex action’ mediated[lxxxvi] through the concepts of ‘consciousness’ and ‘willed’ or ‘intentional action’. I suggest that it is the method of linking rather than the link which is in error. In Chapter 10 I will argue that:

‘It is a necessary condition for the ascription of personhood to an individual that communication, to some minimal standard, be possible with that individual.’

This, if accepted, would imply that if an attempt at communication - the stimulus - is met with only a predictable stereotypical response, too simplistic to be considered as communication - the reflex - then, if this condition is persistent and believed to be permanent, ‘personhood’ is lost. This would thus re-establish the link between non-stereotypical behaviour and ‘personhood’ but on a more secure footing.

This approach also opens up the possibility of distinguishing between ‘locked-in syndrome’ and PVS in terms of ‘ability to communicate’ and not in terms of ‘possessing consciousness’ as at present.[lxxxvii] This suggests a focus - i.e. attempting to establish communication - for the management of a patient before a diagnosis is made; such a focus will itself be the means of enabling the diagnosis. Furthermore it is in accord with what is in fact the best current medical practice[lxxxviii] used in attempting to distinguish between ‘PVS’ and ‘misdiagnosed PVS’. Most importantly, the making of a diagnosis of PVS using these criteria would not necessitate any judgement being made on the state of consciousness of the patient and their ability to experience pain. The following chapters will argue that a reasonable doubt exists as to whether such patients can experience pain, and that there is an ethical obligation on medical carers to treat such patients as if they can experience pain. However, as medicine presently distinguishes between ‘locked-in syndrome’ and ‘PVS’ by asserting that the former has consciousness whilst the latter has not, the treating of PVS patients as if they could experience pain would cause considerable theoretical confusion. A focusing on the task of establishing communication would permit attempts to definitively determine patient consciousness, to be seen for the chimera that they are.

____________

The conclusions that were established in this Chapter are:

Conclusion _{2 - 1} : There is a distinction between the medical usage of the term ‘reflex’ -‘reflex_M’ - and its use in relation to a purely physical system -‘reflex_P’.

Conclusion _{2 - 2} : Medically the term ‘reflex’ is used in two senses; as actions performed without (conscious) intention - ‘reflex_MI’ - and as actions which require only limited areas of the brain for their completion - ‘reflex_MB’. ‘Reflex_MI’ and ‘reflex_MB’ are not necessarily equivalent concepts.

Conclusion _{2 - 3} : In Cartesian philosophy the term ‘reflex’ is used to refer to the purely physical, or mechanistic responses, of a physical system. This meaning of the term ‘reflex’ is denoted by ‘reflex_P’. Furthermore the terms ‘reflex_P’ and ‘non-reflex_P’ are mutually exclusive.

Conclusion _{2 -4} : In Cartesian philosophy an individual who manifests only ‘reflex_P’ actions lacks ‘consciousness’, ‘mind’ and ‘intention’. Such an individual is not to be considered a ‘person’ howsoever that is defined.

Conclusion _{2 -5} : In Cartesian philosophy a non-reflex_P action is necessarily an intentional action.

Conclusion _{2 -6} : Within the Classical Medical Conceptual Framework the presence of brain activity is both a necessary, and a sufficient, condition for the ascription of consciousness. This identification ‘mind’ = ‘brain activity’ = ‘consciousness’ readily enables the further identification ‘consciousness’ = ‘personhood’. However, within this framework, though an intentional action is necessarily non-reflex, a non-reflex action is not necessarily intentional.

Conclusion _{2 - 7} : The phenomenon of hypnosis challenges the coherence of the distinction reflex/non-reflex and leads to the conclusion that, either reflex actions must be regarded as of a complexity comparable to non-reflex actions, or some non-reflex actions must be regarded as non-intentional.

Conclusion _{2 - 8} : The categories of actions, ‘reflex’ and ‘non-reflex’, can no longer be regarded as being mutually exclusive.

Conclusion _{2 -9} : The cerebral cortex can no longer be regarded as the exclusive domain of non-reflex actions.

Conclusion _{2 -10} : The phenomena of blindsight and automaticity challenge the identification of ‘mind’ with ‘consciousness’. Mind is a broader phenomenon than consciousness.

Conclusion _{2 -11} : Libet’s experiment implies that some non-reflex actions are non-intentional.

Conclusion _{2 -12} : Some philosophers, for example, Spinoza and Schrödinger, have understood the complex of concepts ‘consciousness / intention / reflex and non-reflex action’ in a manner radically different to the Cartesian understanding. Spinoza believes that all actions are determined by their environment and that the distinction between reflex and non-reflex actions rests simply on our present ignorance of the causes of those actions we categorise as non-reflex. Schrödinger argues that consciousness - understood as intent - is needed only if a novel situation is encountered needing a response. To him, reflex responses are simply the responses deemed adequate to a situation which has been previously encountered. They do not imply a lack of consciousness (understood as awareness) in fact they presume such a consciousness.

Conclusion _{2 -13} : To assert that a human manifests only reflex behaviour is - to Dennett - to adopt a ‘physical stance’ to that individual; this requires that laws of physics and chemistry are sufficient to fully predict the behaviour of that individual. It is a necessary consequence of the adoption of the physical stance that ‘consciousness’, ‘intention’, ‘mind’ and ‘personhood’ are not to be ascribed to that individual.

Conclusion _{2 -14} : Whereas the conclusions that:

(i) The reflex/non-reflex distinction is coherent.

(ii) An action is reflex if, and only if, it is non-intentional. And

(iii) ‘Mind’, ‘consciousness’ ‘intention’ and ‘personhood’ cannot be attributed to an individual who manifests only reflex behaviour.

were valid within the bounds of Cartesian philosophy; in the light of current scientific knowledge they can no longer be justified without radical amendment. The nature of such amendment is unclear.

---

[i] Most notably Jennett and Plum (1972).

[ii] Passmore (op.cit. p.513) summarises the argument for the distinction between ‘behaviour’ and ‘action’ as follows:

“... there is a distinction between motions of the body, such as the knee reflex, and activities of the person, or ‘behaviour’. Behaviour can never be defined in terms of movements of the body, since the very same set of movements can be present in quite different kinds of behaviour ... The physiologist can explain the motions of a body in terms of causes, but he cannot explain human behaviour. Indeed behaviour has no causes.”

Later, in a footnote to his discussion of Austin’s philosophy, Passmore continues:

“Austin’s work has been particularly interesting to moral and legal philosophers, who have suggested that it is a ‘descriptive fallacy’ to suppose that, for example, in calling something good we are describing it or that in saying that somebody did something we are describing the person’s bodily movements, as distinct from ascribing responsibility to him.” [ibid. p.598]

[iii] ‘Purposive’, or ‘willed’, actions are synonyms for intentional actions.

[iv] The term ‘reflex action’ is used to describe actions which, it is asserted, occur automatically in response to a stimulus and without any intentional awareness or ‘will’. In the Medical Conceptual Framework the absence of ‘non-reflex’ actions indicates the absence of consciousness.

[v] A judgement that all of a patient’s actions are ‘reflex’ can, to some, imply that consciousness - or indeed, personhood - is absent and that medical treatment is pointless.

[vi] Jennett and Plum (1972) p.734.

[vii] The patient, in this case identified as Miss D, was not fully PVS; the application to the court was for permission to withdraw treatment. [The Times 21.3.1997]

[viii] Part 1, p.1501.

[ix] Bauby had suffered a massive stroke which left him in a ‘locked-in syndrome’ - he was speechless and, with the exception of only one eyelid, completely paralysed. He dictated a book, The Diving- Bell And The Butterfly, letter by letter, by using this eyelid as in a system of Morse code.

[x] The term ‘personhood’ is used in this chapter as being synonymous with ‘truly human’ because, in discussing the Cartesian distinction between human ( who has a ‘soul’) and animal, some such term is required and ‘truly human’ is cumbersome. The term ‘personhood’ is discussed more rigorously in Chapter 10 as is the link between it and intentionality.

[xi] Such as the absence of non-reflex actions implying the absence of consciousness.

[xii] The discussion in this subsection presumes, to some degree, on the analysis of ‘reflex’ in Cartesian philosophy, and in the Medical Conceptual Framework, conducted later in this chapter. This order was chosen because it permitted the subsequent discussion to take place in the knowledge that the term ‘reflex’ was ambiguous and, secondly, because it permitted a notation to be introduced which is of assistance in the subsequent discussion.

[xiii] Gregory (op.cit. p.676):

“The tendon below the kneecap is struck sharply with a rubber hammer and the muscles of the kneecap in the thigh are caused to give a brief twitch-like contraction which extends the knee joint and causes a little kick of the foot ... The tendon jerk is the simplest and fastest mammalian reflex known ...”

[xiv] Recent research [see the ARCADI project in the University of Western Australia] on the blink response has shown that its apparent simplicity is deceptive. The research suggests that the strength and timing of the blink is indicative of the speed at which the brain processes information and this has been used as a method of monitoring the development of intelligence in infants under 12 months.

[xv] Gregory op.cit. p.676.

[xvi] The theoretical possibility of completely determining the response is crucial; this is because the broad outlines of human behaviour are a given - we all sleep and eat and, within certain broad parameters, have roughly the same desires. In speaking of ‘free will’, it is never assumed that such is exercisable in any absolute sense; the term ‘free will’ means that within the boundaries of what is given - and predictable - there is a residue that is not so. Thus, free will finds its expression within the crevices, or gaps, of that which is predictable.

[xvii] That is a system which is best explained by imputing an ‘intention’ to it. Dennett’s arguments on the meaning of ‘intention’ will be considered in Section 4 of this chapter and in Chapter 10; in summary, Dennett considers that systems should be classified as intentional or mechanical solely on the grounds of the predictive capacity of this classification. Thus, if when watching a dog chase a rabbit towards a clump of bushes, the unfolding situation is best predicted by assigning an intention to the rabbit - to seek the sanctuary of the bushes - and an intention to the dog - to forestall the rabbit escaping - then this is what should be done. The system of dog + rabbit + bushes is too complex to permit of a purely mechanistic prediction. Dennett eschews questions as to whether the dog really has intentions, finding such questions meaningless. Dennett does not argue that all systems are either mechanistic or intentional; some systems are simply too chaotic to be predictable.

[xviii] i.e. by whether the action is mediated entirely through the spinal cord or whether the lower parts of the brain, or the cerebral cortex, are required.

Some actions classified as reflex do require the participation of the cerebral cortex:

“ ...there are many reflexes whose pathway is through the cerebral cortex. The involuntary blink to a threatening gesture is one.“ Gregory op.cit. p.676.

The relationship between reflexes and the various strata of the brain is discussed later in this chapter.

[xix] The inability to predict does not necessarily imply that an intentional stance be adopted. See the discussion on Dennett, in Section 4 of this chapter and in Chapter 10.

[xx] in Chapter 1.

[xxi] It is said that Descartes was fascinated by the statue of the naked goddess Diana in the gardens of St. Germain which was controlled hydraulically; the approach of an observer activated a concealed switch which caused the statue to disappear into the rosebushes.

[xxii] It follows from this that man - in the Cartesian framework - is characterised by his purposeful ‘doing’ as distinct from his existing or just ‘being’; we shall return to this point in Chapter 10.

[xxiii] Williams op.cit. p.284.

[xxiv] In this section I have drawn on articles from the Encyclopaedia Britannica and from Gregory The Oxford Companion to the Mind. An essay by Jonathan Miller entitled ‘Going Unconscious’ - included in Robert B. Silvers (ed.) Hidden Histories of Science - has been particularly helpful. A lecture by Robert Kentridge of the University of Durham, on ‘Comparative Psychology’ which was accessed through the internet, has also been useful.

[xxv] The Royal Society refused to publish Marshall Hall’s original paper on the subject, denouncing it as absurd (vide Encyclopaedia Britannica).

[xxvi] Quoted in Miller op.cit. p.23.

[xxvii] ibid. p.24

[xxviii] Unless intention is, by a logical sleight of hand, redefined to mean just that.

[xxix] In Conclusion _{1 -1} and Conclusion _{1 -2 .}

[xxx] It is convenient to refer to the Medical Conceptual Framework which encompasses this 19^th century understanding of the reflex/non-reflex distinction as the ‘Classical Medical Conceptual Framework’.

[xxxi] In discussing how the advent of hypnosis changed the medical view of the brain, I have drawn heavily on Jonathan Millers article ‘Going Unconscious’.

[xxxii] “... for a Cartesian, unconscious mind is a self-contradictory expression.”

Antony Flew, An Introduction to Western Philosophy, p.282.

[xxxiii] in 1842.

[xxxiv] Quoted in Miller op.cit. p.19.

[xxxv] Echoing Thomas Huxley’s statement:

“... [the] soul stands to the body as the bell of a clock to the works, and consciousness answers to the sound which the bell gives out when struck. ....We are conscious automata.”

see: Flanagan Consciousness Reconsidered p.7.

[xxxvi] The behaviour of subjects under stage hypnosis - accepting that only some of these are cases of true hypnosis - amply bears this out.

[xxxvii] Such as in Gregory (supra)

[xxxviii] Gregory op.cit. p.677.

[xxxix] Nigel Thomas ‘What does implicit cognition tell us about consciousness ?’ Journal of Consciousness Studies, (1997) at p.395.

[xl] Gregory notes (op.cit. p.112) that: “... a vast amount of our everyday activity is carried out without direct awareness.”

Thomas reporting on a conference on ‘blindsight’ notes:

“Indeed, it would seem that much of our ordinary functioning depends on implicit cognition; very probably the lion’s share of our behaviour is guided much more by 'implicit' than by conscious knowledge.” [op.cit. at p.394]

The suggestion is that non-conscious systems exist whose function is to protect consciousness from overload and to pass inputs on to consciousness only if they become too problematic. A view which echoes Schrödinger’s concept of the role of consciousness, to be discussed later in this chapter.

Thomas also notes:

“In other experiments, subjects seem implicitly to learn successful strategies for some task, whilst having no idea of what they have learned, or of why it would be relevant.” [op.cit. p.394]

The extent of normal reliance on unconscious perception was made very clear by the case of Charles Friel, who was the subject of a BBC Horizon Documentary (‘Man who lost his body’ 16.10.1997). After a viral infection, Friel, though able to move his limbs, was left without ‘properception’ - awareness of his body. He slowly learned to walk, firstly by visualising each single movement to be performed and then by consciously performing it. Each single act had to be planned as he had no repertoire of automatic actions. It took him four months to learn to put on a sock, his simple gestures had lost all spontaneity and had to be meticulously choreographed.

[xli] See La Mettrie:

“This great chemist [Stahl] has wished to persuade us that the soul is the sole cause of all our movements. But this is to speak as a fanatic and not as a philosopher. ... That is to suppose that a flute player could play brilliant cadences on an infinite number of holes that he could not know, and on which he could not even put his finger!” [op.cit. p.136-7]

A more amusing example concerns recent research on how consumers choose between competing brands; it was found that consumers’ choice was almost entirely subconscious. [Mentioned in an article, by the science correspondent of the Sunday Times (8-8-1999), which discussed recent research by a Professor Zaltman of the Harvard Business School.]

[xlii] Gregory notes:

“Once the impulses are on their way, they cannot be interrupted. You know when you are going to type the wrong letter or the letters in the wrong order, and out they come, wrong; the knowledge comes too late to interrupt the planned movement.” [op.cit. p.520]

[xliii] The Encyclopaedia Britannica gives the following examples:

"The English poet Samuel Taylor Coleridge reported that he had written ‘Kubla Khan’ as the result of creative thinking in a dream. Having fallen asleep while reading about that Mongol conqueror, he woke to write down a fully developed poem he seemed to have composed while dreaming. Novelist Robert Louis Stevenson said that much of his writing was developed by ‘little people’ in his dreams, and specifically cited the story of Dr. Jekyll and Mr. Hyde in this context. The German chemist F. A. Kekulé von Stradonitz attributed his interpretation of the ring structure of the benzene molecule to his dream of a snake with its tail in its mouth. Otto Loewi, the German physiologist, attributed to a dream inspiration for an experiment with a frog's nerve that helped him win the Nobel Prize. In all of these cases the dreamers reported having thought about the same topics over considerable periods while they were awake."

[xliv] Quoted in Bryan Magee Confessions of a Philosopher at p.375

[xlv] Benoit op.cit. p.29.

[xlvi] ibid. p.151

[xlvii] Miller op.cit. p.34.

[xlviii] i.e. whilst the possession of consciousness is doubtlessly a necessary condition for personhood however that is defined, it should not be thought of - as it was in Cartesian philosophy - as a sufficient condition.

[xlix] To such as A.H. Maslow creativity is the essential characteristics of the truly human [ A. H. Maslow The Farther Reaches of Human Nature. p.55 et seq.].

[l] Libet’s experiment is described in Flanagan, Consciousness Reconsidered, pp. 136-8.

[li] Philip Dorrell ‘The Libet Problem - Is Consciousness the Boss?’ - a lecture accessed through the internet.

[lii] Included in Erwin Schrödinger What is Life? & Mind and Matter.

[liii] His suggestions were remarkably prescient in view of the current wealth of research in the area of consciousness.

[liv] ibid. p.101.

[lv] ibid. p.102 et seq.

[lvi] ibid. p.103.

[lvii] ibid. p.105.

[lviii] Gregory op.cit. p.66.

[lix] Each ‘object’ being but a ‘limited mode’ of the universal substance.

[lx] In the sense that each can be recovered from the other.

[lxi] Stuart Hampshire, Spinoza p.104.

[lxii] Baruch Spinoza, Ethics, Part 2, Note to Proposition 35 [Everyman Edition at p.64].

[lxiii] Hampshire op.cit. p.116 et seq.

[lxiv] A proposition which is vindicated by Libet’s experiment.

[lxv] Hampshire op.cit. p.116.

[lxvi] and, by implication, reflex action.

[lxvii] Daniel C. Dennett, Brainstorms especially pp. 237-42.

[lxviii] This does not imply that it can be applied in all cases where other stances fail; for example it is not appropriate in attempting to predict the weather system [Dennett op.cit. p.238].

[lxix] as, for example, when:

“I predict that a particular plant - say a potted ivy - will grow around a corner and up into the light because it ‘seeks’ the light and ‘wants’ to get out of the shade ...” [Dennett op.cit. p.272]

[lxx] ibid. p.238.

[lxxi] Strawson makes a similar point [Individuals, p 109] in relation to judgements of the mental states of another. He argues that if we allow a gap to open between the behaviour of another and their mental state - depression in his example - this forces us to:

“... oscillate between a philosophical scepticism and philosophical behaviourism ... What we do not realise is that if this logical gap is allowed to open, then it swallows not only his depression, but our depression as well. For if the logical gap exists, then depressed behaviour, however much there is of it, is no more than a sign of depression.”

[lxxii] ibid. p.239

[lxxiii] The possible application of the ‘physical stance’ to PVS patients is considered in Chapter 10.

[lxxiv] As discussed at the beginning of Section 1.

[lxxv] Quoted in Genevieve Lloyd, Spinoza and the Ethics, at p.46.

see also Albert Einstein’s comment:

“If the moon, in the act of completing its eternal way around the earth, were gifted with self-consciousness, it would feel thoroughly convinced that it was travelling its way of its own accord on the strength of a resolution taken once and for all. So would a Being, endowed with higher insight and more perfect intelligence, watching man and his doings, smile about man’s illusion that he was acting according to his own free will.”

from Albert Einstein Free Will - quoted in the promotional literature to Benjamin Libet The Volitional Brain [To be published September 2000].

[lxxvi] more properly ‘fully human’.

[lxxvii] See G. H. R. Parkinson, Spinoza: Ethics, (2000), p.45.

[lxxviii] Williams (1978) p.284:

“... ‘all or nothing account’ of mind ... that a creature has a full range of conscious powers or is an automaton with no experience of any kind.”

[lxxix] They, in turn, are defined by their being not confined to the spinal cord.

[lxxx] Hampshire op.cit. p.103. Hampshire was discussing the complicated behaviour of animals and sleepwalkers and he did not advert to hypnosis but the point is all the stronger for this.

[lxxxi] If one considers the concept ‘non-reflex’ and ‘intentional’ as a pair. In the Classical Medical Conceptual Framework ‘reflex’ was the dominant partner; it was defined independently - by being linked with the spinal cord - and the definitions of the other concepts ‘non-reflex’ and ‘intentional’ followed by implication. In the Medical Conceptual Framework the situation is reversed, ‘non-intentional’ action was now the dominant concept.

[lxxxii] i.e. problem solving.

[lxxxiii] reflex in the sense of ‘reflex_M’. In Dennett’s categorisation, if one leaves aside the complication caused by the existence of ‘chaotic’ systems, intentional systems are complementary to reflex - in the sense of ‘reflex_P’ - systems.

[lxxxiv] See the earlier discussion on Dennett in Section 4.

[lxxxv] Again in the sense of ‘truly human’.

[lxxxvi] Through the mechanism:

‘(only reflex action manifested) implies (consciousness and will absent) implies (personhood absent)’.

[lxxxvii] i.e. within the domain of applicability of the two concepts, a patient who could communicate would be diagnosed as ‘Locked-In Syndrome’; one who could not communicate, as PVS.

[lxxxviii] I refer to the work of Keith Andrews which is considered in Chapter 4 when discussing the misdiagnosis of PVS.