Commanding or being a simple intermediary: how does it affect moral behavior and related brain mechanisms?

History has shown that fractioning operations between several individuals along a hierarchical chain allows diffusing responsibility between components of the chain, which has the potential to disinhibit antisocial actions. Here, we present two studies, one using fMRI (Study 1) and one using EEG (Study 2), designed to help understand how commanding or being in an intermediary position impacts the sense of agency and empathy for pain. In the age of military drones, we also explored whether commanding a human or robot agent influences these measures. This was done within a single behavioral paradigm in which participants could freely decide whether or not to send painful shocks to another participant in exchange for money. In Study 1, fMRI reveals that activation in social cognition and empathy-related brain regions was equally low when witnessing a victim receive a painful shock while participants were either commander or simple intermediary transmitting an order, compared to being the agent directly delivering the shock. In Study 2, results indicated that the sense of agency did not differ between commanders and intermediary, no matter if the executing agent was a robot or a human. However, we observed that the neural response over P3 was higher when the executing agent was a robot compared to a human. Source reconstruction of the EEG signal revealed that this effect was mediated by areas including the insula and ACC. Results are discussed regarding the interplay between the sense of agency and empathy for pain for decision-making.

Art, craft and science of limb amputation Part 1. Art and craft of amputation: from Hippocrates to Ambroise Pare (V century B.C. – XVI century)

Limb amputation is one of the oldest and most famous operation in surgery. Over the millennia, the tools for its implementation and the technique for its perfomance have been constantly improved. In part 1 of the article, using historical, chronological and dialectical methods, as well as the method of comparative content analysis a number of printed (Hippocrates, V-IV centuries B.C.; Celsus, I century; Abu-alQasim, XI century; A. Paré, XVI century, etc.), material (prostheses, surgical instruments) and visual (engraving, painting, etc.) sources, the circumstances and features of the emergence and development of instruments and techniques for limbs amputation from antiquity to the era were studied and recreated Renaissance. The main indication for amputation was the limb death (gangrene), as well as significant tissue trauma caused by cold or firearms (since the XIV century). The limb was truncated (or isolated) with a circular section along the demarcation line (in ancient times) or within healthy tissues (in the Middle Ages). The operation was carried out under a tourniquet applied above the level of amputation; healthy tissues were shifted proximally; sometimes a second tourniquet was applied - below the cut-off level. Anesthesia was achieved by operating in a state of painful shock, after bloodletting, or by applying a tight ligature (tourniquet). Bleeding was stopped with the surgeon's finger, cauterization or vessel cutting of, ligature of one vessel or the entire bleeding tissue (en masse), suturing of the bleeding vessel (A. Paré), as well as astringents and a bandage. The wound of the stump was left open or brought together with sutures. A major stage in the development of amputation was the work of A. Paré (XVI century), who improved instruments (in particular, clamps for stopping bleeding), the technique of the operation, and pain relief during its performance. If in the Ancient World and in the early Middle Ages amputation was life-threatening, available only to a few of the most skilled doctors, was performed relatively rarely and was akin to art, then after its development in the XIII–XIV centuries. barbers began to perform it everywhere, routinely and gradually turned into a craft. Further development of indications for amputation, techniques for its implementation and the transformation of this operation from a craft into a science from the XVII century. until the middle of the twentieth century will be reflected in part 2 of this article.

Quality dying: An approach to ICD deactivation in the hospital setting

Background: In Canada, cardiovascular disease is the second most common cause of death. A subset of these patients will require a cardiovascular implantable electronic device (CIED). An estimated 200 000 Canadians are living with a CIED. CIEDs can improve life and prevent premature death. However, when patients reach the end of their lives, they can pose a challenge. An example of which is a painful shock delivered from an implantable cardioverter defibrillator (ICD) for an arrhythmia in a dying patient. Receiving a shock at the end of life (EOL) is unacceptable in an age when we aim to ease the suffering of the dying and allow for a comfortable death. Methods: As a quality standard of practice, all clinicians are expected to engage in EOL conversations in patients requiring CIED deactivation. Due to the potential discomfort of an ICD shock, specific conversations about deactivation of an ICD are encouraged. A process improvement approach was developed by our hospital that included an advance care planning simulation lab, electronic documentation and a standardized comfort measures order set that includes addressing the need for ICD deactivation at EOL. Results: EOL conversations are complex. Health care providers have been equally challenged to have conversations about ICD deactivation. Standardization of the process of ICD deactivation ensures an approach to EOL which respects the individuality of patients and promotes quality dying. Conclusion: Our hospital is committed to assisting clinicians to provide quality care by improving conversations about EOL care. On the basis of a synthesis of existing literature, we describe the importance of and the ideal process for having EOL conversations in patients about ICD deactivation at the EOL.

Altruistic behaviors relieve physical pain

Engaging in altruistic behaviors is costly, but it contributes to the health and well-being of the performer of such behaviors. The present research offers a take on how this paradox can be understood. Across 2 pilot studies and 3 experiments, we showed a pain-relieving effect of performing altruistic behaviors. Acting altruistically relieved not only acutely induced physical pain among healthy adults but also chronic pain among cancer patients. Using functional MRI, we found that after individuals performed altruistic actions brain activity in the dorsal anterior cingulate cortex and bilateral insula in response to a painful shock was significantly reduced. This reduced pain-induced activation in the right insula was mediated by the neural activity in the ventral medial prefrontal cortex (VMPFC), while the activation of the VMPFC was positively correlated with the performer’s experienced meaningfulness from his or her altruistic behavior. Our findings suggest that incurring personal costs to help others may buffer the performers from unpleasant conditions.

Subjective value then confidence in human ventromedial prefrontal cortex

Two fundamental goals of decision making are to select actions that maximize rewards while minimizing costs and to have strong confidence in the accuracy of a judgment. Neural signatures of these two forms of value: the subjective value (SV) of choice alternatives and the value of the judgment (confidence), have both been observed in ventromedial prefrontal cortex (vmPFC). However, the relationship between these dual value signals and their relative time courses are unknown. We recorded fMRI while 28 men and women performed a two-phase Ap-Av task with mixed-outcomes of monetary rewards paired with painful shock stimuli. Neural responses were measured during offer valuation (offer phase) and choice valuation (commit phase) and analyzed with respect to observed decision outcomes, model-estimated SV and confidence. During the offer phase, vmPFC tracked SV and decision outcomes, but it not confidence. During the commit phase, vmPFC tracked confidence, computed as the quadratic extension of SV, but it bore no significant relationship with the offer valuation itself, nor the decision. In fact, vmPFC responses from the commit phase were selective for confidence even for rejected offers, wherein confidence and SV were inversely related. Conversely, activation of the cognitive control network, including within lateral prefrontal cortex (lPFC) and dorsal anterior cingulate cortex (dACC) was associated with ambivalence, during both the offer and commit phases. Taken together, our results reveal complementary representations in vmPFC during value-based decision making that temporally dissociate such that offer valuation (SV) emerges before decision valuation (confidence).

The Body of Thersites

‘Satire is a sort of glass, wherein beholders do generally discover everyone’s face but their own.’ The preface to Swift’s ‘The Battle of the Books’ (1704) articulates a uniquely human paradox of universal error and individual delusion that inspires the genre’s violent attempts to reform by replacing self-love with the painful shock of self-recognition. Evoking both Thersites and Achilles, the monster and the hero, the satirist strives to humble human pride by holding up a beastly mirror, undermining both dominant protocols of representation and standard ethical categories. The reader of satire thus is forced to embrace madmen, monsters, and savage others as herself, at once humbled by and freed from the limits of the human. The liberating potential and visceral power of these inhumanely human texts offer joy in rage and freedom of fellowship with the abject other, while providing no escape from one’s own monstrosity.

Conducting Large Groups

When a conductor steps in to conduct a large group she steps into a singular place: a nodal point, that carries with it many unconscious expectations that need decoding in order to understand what is happening. This paper gives an impression of my experience of conducting large groups in Finland. It has been written in close cooperation with Aila Kauranen, a Finnish group psychotherapist. I paid 10 visits to Finland: one to the Arctic Circle and nine to Helsinki. On two occasions, after a regular pattern of visiting every six months, the expected return invitation did not arrive. Both times this break occurred I felt it as a painful shock. It led me into some deep thinking about why this had happened. After studying Finland’s history and connecting my experience to the events both in and around the group, I realised that the unexpected and sudden breaks in continuity were perhaps the only way in which those associated with the workshops could let me know something of the deep social trauma they carried. Waitara Inā hīkoi he kaitaki ki te taki ropū matarahi, ka hīkoi ia ki tētahi tūnga takitahi: he pūpeka, kawenga wawata o te mano mauri moe e mate pukuana kia mōhio ai he aha te aha. Mai i tēnei tuhinga ka hoatu he hāraunga o aku wheako taki rōpū matarahi i Hinerangi. He mea tuhi i raro i te mahitahitanga ki a Aila Kauranen, he kaiwhakaora hinengaro rōpū Hinerangi. Tekau ngā wāhanga i haere au ki Hinerangi: kotahi ki te Awhio Raki e iwa ki Heretiniki. E rua ngā wā, i muri mai o te haerenga ia ono marama, kāre i puta mai te pōhiri hoki atu. Ia wā i whātia, tino kaha te taunga hihiko pōuri ki ahua. Ka huri ki te whaiwhakaaro hōhōnu mō tēnei take. I te mutunga o te whai mātauranga mō te whakapapa o Hinerangi me te whakahāngaitanga atu i aku wheako i waenga i te rōpū, ka kite au ko ngā whatinga whakahaere ohotata, ohorere hoki, te momo whakamōhio mai a ngā tāngata o nga rōpū awheawhe rā i te taumaha o te mamae e maua ana e rātou.

Antitachycardia pacing: an overview

Ventricular tachycardia is the most common life-threatening tachyarrhythmia seen in patients with structural heart disease. In the past 10 years, many thousands of lives have been saved by the addition of the implantable cardioverter-defibrillator to the armamentarium of treatment options. Yet, despite the success of these devices in the prevention of sudden cardiac death, many patients felt that the psychological cost was too high. Loss or restriction of some of the most basic activities such as driving and working and not knowing when they would receive the life-saving but painful shock took a toll on patients' perceptions of the quality of their lives. When antitachycardia pacing was demonstrated to provide about half of these patients a life-saving, yet comfortable, means of controlling episodes of ventricular tachycardia, physicians and patients were eager to try it. None of the many ways to provide antitachycardia pacing has proved overwhelmingly more effective than the others. This paper describes and illustrates each type of antitachycardia pacing and demonstrates their programmed parameters. Several clinical case illustrations are included.

Effects of “Neutral Hypnosis” on a Conditioned Physiological Response

The objective of the present experiment was to determine whether hypnosis without explicit suggestion of analgesia would diminish physiological responses to an operationally defined painful shock stimulus. Muscle tension (EMG) was significantly lower during hypnosis than pre- or posthypnosis. Pulse rate remained stable throughout all conditions. Also, the question of whether a tone paired with shock might acquire some unique property because of that association was investigated. It was found that EMG response to the tone alone was significantly greater than to the tone-shock combination, in prehypnosis and posthypnosis, but not during hypnosis.