[A] man does not consist of memory alone. He has feeling, will, sensibilities, moral being…. And it is here … that you may find ways to touch him.—A. R. Luria1.

According to the hypotheses of distributed and extended cognition, remembering does not always occur entirely inside the brain but is often distributed across heterogeneous systems combining neural, bodily, social, and technological resources. These ideas have been intensely debated in philosophy, but the philosophical debate has often remained at some distance from relevant empirical research, while empirical memory research, in particular, has been somewhat slow to incorporate distributed/extended ideas. This situation, however, appears to be changing, as we witness an increasing level (...) of interaction between the philosophy and the empirical research. In this editorial, we provide a high-level historical overview of the development of the debates around the hypotheses of distributed and extended cognition, as well as relevant theory and empirical research on memory, considering both the role of memory in theoretical debates around distributed/extended ideas and strands of memory research that resonate with those ideas; we emphasize recent trends towards increased interaction, including new empirical paradigms for investigating distributed memory systems. We then provide an overview of the special issue itself, drawing out a number of general implications from the contributions, and conclude by sketching promising directions for future research on distributed memory. (shrink)

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

How can black feminist and women of color feminist theoretical interventions help create frameworks for discerning agentic action in the context of power, oppression, and violence? In this paper, I explore the social dimension of agency and argue that intention is not just authored by the agent as a function of practical reasoning, but is also socially authored through others' discernment and translation of her action. Further, when facilitated by reasoning designed to reinforce and rationalize systems of domination, social authoring (...) systematically distorts the intentions of some agents. Although some theorists have argued that those agents whose intentions are not recognized by others are forced to exercise a diminished agency, I contend that this account obscures agency that is practiced despite or through conditions of oppression. As an alternative, I propose that feminist of color theory that examines the structural and existential erasures of women of color maps a conceptual space to help us better discern agentic action that is practiced by those subjects whose acts are defined away from them. (shrink)

Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies in (...) the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patients self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality. (shrink)

This essay examines the goals of care and the exercise of guardianship authority in the long-term care of persons with Alzheimer's disease and other forms of chronic, progressive dementia. It counters philosophical views that deny both agency and personhood to individuals with Alzheimer's on definitional or analytic conceptual grounds. It develops a specific conception of the quality of life and offers a critique of hedonic conceptions of quality of life and models of guardianship that are based on a hedonic legal (...) standard of “best interests.” As an alternative, it proposes a conception of quality of life based on the notions of “semantic agency” and “memorial personhood.”. (shrink)

This chapter contains sections titled: Introduction: Liberalism and Inclusiveness Liberalism: Political and Metaphysical Collaborating on Ideas of the Good Powers of Self‐Control Conclusion References.

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

This essay takes a close look at a species of care that is particularly needed by people with progressive dementias but that has not been much discussed in the bioethics literature: the activity of holding the person in her or his identity. It presses the claim that close family members have a special responsibility to hold on to the demented person's identity for her or him, and offers some criteria for doing this morally well or badly. Finally, it considers how (...) even those with dementia can hold others in their identities, and suggests that this kind of holding too can have great moral worth. (shrink)

Deep-brain stimulation has been used to treat advanced Parkinson disease and other neurological and psychiatric disorders that have not responded to other treatments. While deep-brain stimulation can modulate overactive or underactive regions of the brain and thereby improve motor function, it can also cause changes in a patient’s thought and personality. This paper discusses the trade-offs between the physiological benefit of this technique and the potential psychological harm.

Beverly Beckham writes in the Boston Globe in praise of Lisa Genova’s Still Alice: “You have to get this book. … I couldn’t put it down. …” After I read Still Alice, a book of fiction about an accomplished Harvard professor with early-onset Alzheimer’s disease, I too wanted to tell everyone to get this book, but not because “I couldn’t put it down.” The first time I read it, I put it down several times to cry. It was too painful (...) to read in one stretch. Years back, my mother, Gloria Baylis,1 had been diagnosed with vascular dementia, and recently there had been findings suggestive of an atypical presentation of Alzheimer’s disease. The story of Alice Howland, the Alice of Still Alice, was both too... (shrink)

In the article “On Avoiding Deep Dementia,” Norman Cantor defends a position that I suspect many readers share. In my years writing and speaking on advance directives and dementia, I've found that most people support one of two positions. They are convinced either that advance choices should control the treatment dementia patients receive or that the welfare of a person with dementia should sometimes take priority over earlier choices. As Cantor points out, I support the second position.I agree with several (...) of Cantor's arguments. Where Cantor and I part ways is over the degree of control that advance directives should exert over the care of persons with moderate dementia. Although I don't welcome the prospect of living with dementia, I believe that people with the condition should be represented in the debate over treatment standards. It's not surprising that many, perhaps most, people unaffected by dementia think that their preferences should control the care they would receive as dementia patients. But people taking this position are neglecting the concerns and interests they may have as dementia patients. (shrink)

Liberalism welcomes diversity in substantive ideas of the good but not in the process whereby these ideas are formed. Ideas of the good acquire weight on the presumption that each is a person's own, formed independently. But people differ in their capacities to conceptualize. Some, appropriately characterized as cerebral, are proficient in and profoundly involved with conceptualizing. Others, labeled cognitively disabled, range from individuals with mild limitations to those so unable to express themselves that we cannot be sure whether their (...) behavior is mediated by concepts at all. Constricted cognitive capacities have been thought to prevent participation in the prescribed process for forming personalized ideas of the good. So liberal theory, when formulating principles and practices of justice, often disregards cognitively disabled peoples' perspectives. We put aside metaphysically driven notions about personhood and show how interpersonal processes of “prosthetic” thinking (different from surrogacy) can satisfy liberalism's standards, positioning cognitively disabled individuals as fully participating subjects of justice. (shrink)

Advance directives permit competent adult patients to provide guidance regarding their care in the event that they lose the capacity to make medical decisions. One concern about the use of advance directives is the possibility that, in certain cases in which a patient undergoes massive psychological change, the individual who exists after such change is literally a (numerically) distinct individual from the person who completed the directive. If this is true, there is good reason to question the authority of the (...) directive Ð which is supposed to apply to the individual who completed it, not to someone else. This is `the someone else problem'. After briefly introducing advance directives as a basis for medical decision-making, this paper elaborates `the someone else problem' in the context of severe dementia. The paper then reconstructs the reasoning that leads to this putative problem and exposes the important underlying assumption that we are essentially persons. An alternative view of what we are, one that regards personhood as inessential, is then considered, before several arguments are advanced in favor of that alternative view. The paper next explores implications for advance directives: `The someone else problem' is effectively dissolved, while it is noted that a related problem (one beyond the paper's scope) may persist. A few implications beyond advance directives are also identified. (shrink)

Some people will confront Alzheimer's with a measure of resignation, a determination to struggle against the progressive debilitation and to extract whatever comforts and benefits they can from their remaining existence. They are entitled to pursue that resolute path. For other people, like myself, protracted maintenance during progressive cognitive dysfunction and helplessness is an intolerably degrading prospect. The critical question for those of us seeking to avoid protracted dementia is how best to accomplish that objective.One strategy is to engineer one's (...) own death while still mentally competent to do so (even in the stage of mild dementia). If I were to use a preemptive strategy in the face of a dementia diagnosis, I would probably choose to stop eating and drinking, a process known as voluntarily stopping eating and drinking. An alternative tactic for avoiding prolonged dementia would be to allow oneself to decline into moderate dementia—thus losing capacity to perform self‐deliverance or even to make serious medical decisions—but before getting to that point to provide advance instructions rejecting prospective life‐sustaining medical interventions. These advance instructions would authorize palliative but not curative measures. My current personal instructions define the point of intolerable cognitive decline triggering medical nonintervention as “mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook.” These instructions dictate allowing my demise at a point of moderate dementia when I may not be perceptibly suffering, when I may still be getting some rudimentary satisfaction from my debilitated life, and when I no longer recall the preoccupation with personally intolerable indignity that motivated my instructions. Can I expect that my advance instructions will be implemented in those circumstances? Is it lawful, and is it moral for a surrogate decision‐maker and associated caregivers to allow an uncomprehending, ostensibly content but demented individual to die? My analysis herein contends that it is not only lawful and moral but also legally required to implement clear, considered advance instructions even at a stage of moderate dementia. (shrink)