"When the Music's Over" then "Dancing with a Partner Will Help You Find the Beat".

Responses to brain injury sit in the intersection between neuroscience and an ethic of care, and require sensitive and dynamic indicators of how an individual with brain injury can learn how to live in the context of a changing environment and multiple timescales. Therapeutic relationships and rhythms underpinning such a dynamic approach are currently obscured by existing models of brain function. Something older is required and we put forward narrative types articulating outcomes of brain injury over various periods and starting points in time. Such storytelling challenges a static neuropsychological paradigm and moves from an ethics that focuses on patient autonomy into one that is reflective of the cognitive supports and therapeutic relationships that underpin ways that the patient can re-find the beat that proves the music is not over.

COVID-19 Ethics-Looking Down the Muzzle.

Public health and pandemic ethics frequently concern themselves with organizing principles, utility, and public policy. But the effects of pandemics, and the impact of measures to control them, are experienced by individuals and families. This is particularly true for those who are most vulnerable to COVID-19-the elderly and "infirm." So while ethics must assist in articulating the policies that will determine the allocation of resources during this and future pandemics, it must, at the same time, be alert to the intimate narratives of the infection. This is an account from someone looking down the muzzle of COVID-19.

Concussion in Sport: The Unheeded Evidence.

Patients with repeated minor head injury are a challenge to our clinical skills of neurodiagnosis because the relevant evidence objectively demonstrating their impairment was collected in New Zealand (although published in the BMJ and Lancet) and, at the time, was mired in controversy. The effects of repeated closed diffuse head injury are increasingly recognized worldwide, but now suffer from the relentless advance of imaging technology as the dominant form of neurodiagnosis and the considerable financial interests that underpin the refusal to recognize that acute accelerational injury is the most subtle and insidiously damaging (especially when seen in the light of biopsychosocial medicine), and potentially one of the most financially momentous (given the large incomes impacted and needing compensation) phenomena in modern sports medicine. The vested interests in downplaying this phenomenon are considerable and concentrated in North America where diffuse head injury is a widespread feature of the dominant winter sports code: Gridiron or American Rules football. The relationship of this to shattered lives among the brightest and best of young men and the relatively dated objective evidence are a toxic mix in terms of ethical analysis and, therefore, there is a malignant confluence of social forces that tends toward minimizing the injury.

Long-term outcome following decompressive craniectomy: an inconvenient truth?

PURPOSE OF REVIEW: There is little doubt that decompressive craniectomy can reduce mortality following malignant middle cerebral infarction or severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability. RECENT FINDINGS: There has been a number of large multicentre randomized trials investigating surgical efficacy of the procedure. These trials have clearly demonstrated a survival benefit in those patients randomized to surgical decompression. However, it is only possible to demonstrate an improvement in outcome if the definition of favourable is changed such that it includes patients with either a modified Rankin score of 4 or upper severe disability. Without this recategorization, the results of these trials have confirmed the 'Inconvenient truth' that surgery reduces mortality at the expense of survival with severe disability. SUMMARY: Given these results, the time may have come for a nuanced examination of the value society places on an individual life, and the acceptability or otherwise of performing a procedure that converts death into survival with severe disability.

The crisis of patient-physician trust and bioethics: lessons and inspirations from China.

Trust is indispensable not only for interpersonal relationships and social life, but for good quality healthcare. As manifested in the increasing violence and tension in patient-physician relationships, China has been experiencing a widespread and profound crisis of patient-physician trust. And globally, the crisis of trust is an issue that every society, either developing or developed, has to face in one way or another. Yet, in spite of some pioneering works, the subject of patient-physician trust and mistrust - a crucial matter in healthcare especially because there are numerous ethical implications - has largely been marginalized in bioethics as a global discourse. Drawing lessons as well as inspirations from China, this paper demonstrates the necessity of a trust-oriented bioethics and presents some key theoretical, methodological and philosophical elements of such a bioethics. A trust-oriented bioethics moves beyond the current dominant bioethical paradigms through putting the subject of trust and mistrust in the central agenda of the field, learning from the social sciences, and reviving indigenous moral resources. In order for global bioethics to claim its relevance to the things that truly matter in social life and healthcare, trust should be as vital as such central norms like autonomy and justice and can serve as a potent theoretical framework.

Effaced Enigmata.

Severe head injury or brain injury presents clinical neuroscientists with a unique challenge. Based on an objective assessment of cognitive and neurological function, it is sometimes hard to recognize our patients as members of our moral community (actually or potentially) but we treat them as if that were is the case, and, therefore, as if they need rescuing. Thus their existences as enigmata-beings who may or may not reveal themselves to us through social and personal function realized in conversations and relationships-are in doubt. However, the objective mode of assessing individuals and their mental functions needs to be bracketed here, as we reconnect with them and offer them our help in the restorative journey that they need to take. The journey has many tortuous paths comprising it, not the least of which is the existential question of whether the damaged human being with whom we are engaged actually can be restored to a meaningful life. A negative answer to that question can bring the whole process to an abrupt end. Neuroscience cannot answer some of these questions, as they are ethical. Is this a life worth living and are our commitments going to go the distance that must be traversed here. Therefore, this is an area where ethics take priority over neuroscience, and it is on our ethical response that everything else hinges. Understanding the light this throws on the nature of a human being takes us to the heart of the value of every human being and the nexus of mutuality that is the moral community.

Post-Structural Methodology at the Quilting Point: Intercultural Encounters.

Lacan's quilting point connects a network of signifiers with the lived world as a place of voices, memory, and adaptation "seen in" the mirror of language. Crossing cultures can obscure the ways we make sense of the world. Some planes of signification, in aiming to be universal in their knowledge (such as the natural sciences), try to track objects and events independent of our thoughts about them and the ways that signifiers may slide past each other. However, cross-structural comparison and the analysis of cross cultural encounters cannot treat its objects of interest that way. Thus we need a theory and methodology that effectively connects the multilayered discourses of subjectivities from diverse cultures and allows triangulation between them in relation to points of shared experience. At such points we need a critical attitude to our own framework and an openness to the uneasy reflective equilibrium that uncovers assumptions and modes of thinking that will hamper us. Quilting points are such points where different discourses converge on a single event or set of events so as to mark "vertical" connections allowing tentative alignments between ways of meaning so that we can begin to build real cross-cultural understanding.

Culture, the Crack'd Mirror, and the Neuroethics of Disease.

Human beings are sensorimotor coupled to the actual world and also attuned to the symbolic world of culture and the techniques of adaptation that culture provides. The self-image and self-shaping mediated by that mirror directly affects the neurocognitive structures that integrate human neural activity and reshape its processing capacities through top-down or autopoietic effects. Thus a crack'd mirror, which disrupts the processes of enactive self-configuration, can be disabling for an individual. That is exactly what happens in postcolonial or immigration contexts in which individuals' cultural adaptations are marginalized and disconnected in diverse and often painful and disorienting ways. The crack'd mirror is therefore a powerful trope for neuroethics and helps us understand the social and moral pathologies of many indigenous and immigrant communities.

Uncertainty, conflict and consent: revisiting the futility debate in neurotrauma.

The concept of futility has been debated for many years, and a precise definition remains elusive. This is not entirely unsurprising given the increasingly complex and evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions. Allocating resources appropriately amongst a population whose expectations continue to increase raises a number of ethical issues not least of which are the difficulties encountered when consideration is being given to withholding "life-preserving" treatment. In this discussion we have used decompressive craniectomy for severe traumatic brain injury as a clinical example with which to frame an approach to the concept. We have defined those issues that initially lead us to consider futility and thereafter actually provoke a significant discussion. We contend that these issues are uncertainty, conflict and consent. We then examine recent scientific advances in outcome prediction that may address some of the uncertainty and perhaps help achieve consensus amongst stakeholders. Whilst we do not anticipate that this re-framing of the idea of futility is applicable to all medical situations, the approach to specify patient-centred benefit may assist those making such decisions when patients are incompetent to participate.

Minding and Caring about Ethics in Brain Injury.

Joseph Fins's book Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness (Cambridge UP, 2015) is a considerable addition to the literature on disorders of consciousness and the murky area of minimally conscious states. Fins brings to this fraught area of clinical practice and neuroethical analysis a series of stories and reflections resulting in a pressing and sustained ethical challenge both to clinicians and to health care systems. The challenge is multifaceted, with diagnostic and therapeutic demands to be met by clinicians and a mix of moral, scientific-economic, and political resonances for health care analysts. Everything in the book resonates with my own clinical experience and the often messy and emotionally wrenching business of providing ongoing care for patients with severe brain injuries and disorders, people who frequently resist the categorizations that well-organized health care systems prefer and that can dictate terms of patient management.

Psychosurgery Reduces Uncertainty and Increases Free Will? A Review.

OBJECTIVE: A definition of free will is the ability to select for or against a course of action to fulfill a desire, without extrinsic or intrinsic constraints that compel the choice. Free will has been linked to the evolutionary development of flexible decision making. In order to develop flexibility in thoughts and behavioral responses, learning mechanisms have evolved as a modification of reflexive behavioral strategies. The ultimate goal of the brain is to reduce uncertainty inherently present in a changing environment. A way to reduce the uncertainty, which is encoded by the rostral anterior cingulate, is to make multiple predictions about the environment which are updated in parallel by sensory inputs. The prediction/behavioral strategy that fits the sensory input best is then selected, becomes the next percept/behavioral strategy, and is stored as a basis for future predictions. Acceptance of predictions (positive feedback) is mediated via the accumbens, and switching to other predictions by the dorsal anterior cingulate cortex (ACC) (negative feedback). Maintenance of a prediction is encoded by the pregenual ACC. Different cingulate territories are involved in rejection, acceptance and maintenance of predictions. Free will is known to be decreased in multiple psychopathologies, including obsessive compulsive disorder and addictions. METHODOLOGY: In modern psychosurgery three target structures exist for obsessive compulsive disorder and addiction: the dorsal ACC, the nucleus accumbens, and/or the anterior limb of the internal capsula. Research in all three areas reports favorable results with acceptable side effects. Psychosurgical interventions seem to exert their effect by a common final common pathway mediated via the pregenual ACC. CONCLUSION: Successful neuromodulation increases the capacity to choose from different options for the affected individual, as well as inhibiting unwanted options, therefore increasing free will and free won't.