Preface

Less than 50 years ago, neuroscientific understanding was in its infancy by millennial standards, with no consensus on such basic cell features as signal transduction, membrane channels, most neurotransmitters, synaptic circuits, and the like. In this early milieu there was little need for an ethical discipline that would be uniquely concerned with the nervous system. By 2013, in contrast, neuroscience has advanced well beyond single neuron functions, often touching on the global properties that emerge from central nervous system operation. This new era has seen, for example, the launching of national and continental initiatives in the BRAIN and Human Brain Projects, respectively, not to mention Asian and Latin American initiatives. These projects intend not only to elucidate disease mechanisms, but also to create wholly new technological approaches for exploring higher order function.

Core ethical concerns, in consequence, now touch on such significant and nervous system specific issues as the global regulation of organismal performance, an evolution in intervention that is breaching therapeutic boundaries, supraphysical notions of systemic and organizational reality, and the ontological and anthropological ground for human nature, among others. A frequent ethical theme raised by evergreater knowledge and technical prowess over organismal regulation, for instance, is the manipulation by and interaction with technological devices, not just in regard to the potential harm that may be incurred by such devices, but also with respect to the very nature of technology and its relation to the human being. New interventional modes, accordingly, need to consider not only traditional ethical principles of medical practice, but also what is meant by health and normality. In this environment, ethical questions related to the nervous system have assumed an immediacy and significance matching the centrality of neural function in biological behavior.

Contributing to this immediacy is the fundamental value of the human being, which lends normative weight to questions, interventions, and practices influencing him or her. Additionally, the value of human well-being—or eudomaia—is of increasing normative significance. In recognition of these twin normative concerns, parallel metaethical principles invoked in such advanced technical fields as artificial intelligence, for example, place primacy on the human being and prioritize the increase of human flourishing.

On the other hand, despite a recognition of the relevance of fundamental human value, the derivation of metaethical principles that underwrite this value is by no means uniformly agreed to and reflects a turbulence in broader metaphysical notions of material reality, among other factors. This dissonance is singularly and uniquely acute in ethical issues related to the nervous system, seen, for example, in the normatively charged issue of death determinations. On the one hand, the human being is regarded as individuated and holistic, with invested value contingent to the human being in his entire corporality. Such a view is adopted in Karol Wojtyla's ethical perspective, and ascribed to in a number of religious traditions. Here the ground for value contingency emerges from the capacity for the performance of the "good," which thereby establishes the personal agent as a value locus, validating the wholly referential status of the person:

"The reality of the person inheres in morality, that morality is a thoroughly specific and connatural reality with respect to the person—with respect precisely to the person and only to the person [...] man as a man, becomes good or evil through the act."

This capacity extends, crucially, to the whole individual by virtue of an integral metaphysical unity that grounds the corporal reality of the personalist subject. Death determinations in this view, for example, reference the whole individual; hence, medical criteria need to encompass the individual as a biological whole. In other perspectives, value contingent properties emerge reductively, where they relate to the function of discrete brain operations. This latter view broadly privileges the value of the brain over that of the body, thereby creating an intrinsic dichotomy within the individual. Death determinations here thus resort to criteria that philosophically equate the human being with the organ of the brain.

Why and how the human being is normatively privileged, accordingly, emerge as core questions that ground questions of ethical praxis related to the nervous system. At its extremes this foundation is characterized by a diametric polarity, where value, on the one hand, is seen to intrinsically emerge from an integral global order that is normatively endowed from above, and, on the other hand, where human value is invested by consensus discourse in the absence of recognition of a unified corporal reality that can anchor metanorms. The introductory chapter explains the philosophical origin of the current dissonance between these extremes. Chapter 2 reflects on the former approach, in which the global order is constituted by a metaphysical principle of unity, which is grounded in a norm-oriented teleology. By adopting postmetaphysical presuppositions in Chapter 3, by contrast, value investment emerges externally from collective accession.

The challenge for developing normative praxis given this philosophical polarity is evidenced by the adjustment in weight given to traditional medical principles, e.g., non-malfeasance and beneficence vs. autonomy, and expressed in documents like Advanced Directives (ADs) that alter the balance among these principles by placing greater emphasis on the right to individual autonomy. Chapter 4 illustrates such a shift in current legislative initiatives for ADs now undertaken in Brazil. Chapter 5 returns this emphasis somewhat to value primacy in the individual by advancing a case for values-based medical care of cognitive disease, in opposition to the functionalist objectives often characterizing evidence-based medicine. Finally, Chapter 6 considers the implication for ethical praxis that occurs when subdomains of the body, e.g., nervous system vs. body, are treated as distinct ethical spheres, rather than mutually and functionally integrated systems.

It is hoped that these chapters will spur greater recognition of the relationship between the philosophical foundations of value contingency in the human body and the neuroethical praxis that flows from this relationship.

> **Denis Larrivee** Loyola University Chicago, Chicago, USA, University of Navarra Medical School, Pamplona, Spain

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Section 1

Introduction and Origins

of Neuroethical Tension
