Key points

It’s life, Jim, but not as we know it.

Ethics simply would not exist in the absence of real relationships that either reduce or increase real suffering in others. Therefore, we need to understand both the nature of experience and our connections to others.

In an effort to understand everything in terms of matter and mechanism, I believe that we have indeed made a tragic error in discounting the qualitative experience of life. Subjective experience is all we have, and science itself is built upon it. Instead of fearing the subjective, we need to befriend it . . . the world is pregnant with lived experience, and it is time to turn to that experience and to the essentially subjective character of reality, to accept the infant child some would deny.

Introduction

“Doing the right thing”—realizing the course of conduct that ought to be taken—in the process of enacting ethical decision making when it comes to the challenges posed by acquired brain injury (ABI) presents a broad variety of provocative difficulties and vexations. Furthermore, the process for how to best arrive at a satisfactory solution to an ethical dilemma presented in the context of ABI care is not defined definitively. This paper argues that one of the main reasons that this is so is because we are in critical need of a transformation in the fundamental philosophic paradigm for understanding brain injury and its consequences, particularly when faced with axiological concerns that revolve around subjective meaning and value as distinct from ‘fact,’ in the context of the personal—that is, the experiential—which are central issues for ethical decision making. The physicist, author, and educator, Arthur Zajonc, whose research concerns a reorientation of science toward human life and ethics, asks “Where do mind and morality meet?”, and that is precisely the crux of the matter. Mind and morality meet in the context of subjectivity, a subjectivity that ‘never disappears (but) . . . is our friend, not the enemy science has made it out to be’ ^(p13) —science in the dominant paradigm of mechanistic ‘scientism,’ that is. A study of ethics requires the ability to examine and understand the nature of the experience of the subject— the experiencing human being—and, in that context, to recognize the need to realize the foundational status of dynamic process and relationality, as opposed to the indolent mechanistic materiality attributable to the “unresolved residue of antiquated thinking from the seventeenth century that still pervades the twenty-first century treatment of the mind.” ^(p10) It could well be argued that medicine, as a moral practice, including, in particular, for the purposes of this paper, ABI rehabilitation, requires the same. To be alive is to be a dynamic processual subject—a living, experiencing being coupled to the exterior world through a myriad of different relationships, ranging from relatively simple impassive interactions with inanimate objects—like the keyboard I am typing on—to highly complex and provocative interpersonal connections and exchanges with other living beings including those of particular—although certainly not exclusive—interest, involving other human persons. To be human is to have a unique array of ‘lived’ experiences acquired during a ‘lived’ trajectory that constitute a dynamic ‘life-world’ played out in the culturally propelled context of a species-specific human Umwelt —where the Umwelt is the species-specific external world as known to and understood by the subject in terms of the meaning and relevance of the various features of the surrounding environment and circumstances as self-assessed. Ethics is all about the intersubjective encounter and the navigation of the intrapersonal and interpersonal. It centers on the relationship between persons—both living human and nonhuman subjects—and how to effectively and properly engage with and become engaged in provocative relational situations and value-laden contexts. To be able to do ethics involves the extraction of meaning from experience and the assignment of value to the relational.

In this paper, it will be argued that the dominant ‘modern’ philosophic paradigm in which the Western world is so deeply saturated and on which the Newtonian scientific paradigm, since the beginning of the ‘Age of Enlightenment,’ has been grounded—its dualism, nominalism, depersonalization, and the intentional deletion and bracketing out of the subjective being—the experience of the observer—along with bracketing out of each and every nonhuman organism populating the planet, and its inability to address the crucial and foundational nature of relationality and communication —including cultural influences—in the quest to understand conscious experience and, with it, the nature of personhood—makes it very difficult, if not impossible, to recognize and fully understand the deep nature of the ‘personal’—that is, subjective being —in the context of fully nuanced human existence. In the context of modern nominalistic philosophy wherein relation is considered an illusory imposed invention of the mind, real ethics is effectively precluded. Ethics cannot be performed adequately without an understanding that emanates from the personal, an understanding that begins with subjectivity—with the direct experience of the subject—and necessarily incorporates the relational. Ethics is not possible in an impersonal world of encasketed and effectively sequestered and insular ‘thinking machines’—the scenario laid out by Cartesian nominalism that denies the reality of the relational, including the influence of the cultural—assuming that the mind ‘makes it all up’ and imposes its own relational structure—and places an impenetrable wall separating the subjective mind-dependent realm generated inside the head (‘ ens rationis ’) from the objective mind-independent world outside (‘ ens reale ’), the true existence of which can only be inferred in the context of the modern worldview. For the modern philosophic paradigm, the world seems to be organized because it is the human mind that is endowed with the ability to generate the organizing structure, the overlaid logical order that it imposes on reality. But what if it really works the other way around? What if the human mind is logically ordered the way it is because it is a product of the discoverable logic of the reality of the natural world—the mind that pervades nature—from whence it emerged over eons through an expansive and long-enduring evolutionary process? That really would change everything. We now have clues from relativity and quantum mechanics indicating that the logic of the Newtonian paradigm—the logic of hard-core scientific materialism—with its effective elimination of the subjective observer from the system studied, leads to a false objectivism. Instead, what the ‘new physics’ of relativity and quantum mechanics indicates is that the presence of the subject matters—“subjectivity is real, and real at every level of analysis” ^(p13) —and that it is a necessary and integral element of the scientific worldview whose presence and participation cannot be discounted or eliminated. In the new physics, observations are subject to the subject.

A new postmodern framework, indeed, an emerging ‘new age’ of human understanding is entailed—a ‘postmodern’ framework that recognizes and incorporates the fundamental importance of communication, sociality, and intersubjective collaboration throughout the natural world—but particularly for the self-reflecting human species for which ethics, as the capacity to perceive what is happening, imagine what could be, and then reflect on what ought to be done, is not only a possibility, but an obligation —a new nonnominalistic view that recognizes that relations, although invisible and essentially incapable of being detected directly by the senses, are nevertheless very real existents discoverable through inquiry. Furthermore, relations operate at a suprasubjective level, over and above the entities linked together by the relation, making possible a context-dependent flexible interaction between the mind-dependent—that is, what cannot be without the participation of mind—and the mind-independent—that is, the ‘things’ that constitute the real world regardless of whether or not they are ‘objectified’—that is, ‘known’ to a finite mind. In this new postmodern worldview, these two fundamental realms can interpenetrate freely and openly in accordance with relational context.

To be a human person is directly and intimately connected to the process through which the human brain and nervous system, in the context of its embodiment as situated in the further context of our immediate and larger environment with all its complexity (populated with ‘objects’—that is, known entities—many of whom—certainly the living organisms including fellow humans—are also themselves subjects) and affordances for agency, gives rise to and makes possible subjective experience. Therefore, recovering the subjective and having a philosophic framework that honors and allows for the full understanding and appreciation of the subjective, of the phenomena that occur in the experience of the human person, is a necessary prerequisite for engaging in the quest for acceptable ethical decision making in the context of caring for the brain-injured human person.

It will be argued that the process of extracting meaning from subjective experience in the personal context—the ability to understand and infer what is ‘significant’ or meaningful—ultimately involves ‘semiosis’—the ‘action of signs’—that makes possible the flexible context-dependent interaction between ens rationis and ens reale spanning past, future, and the here-and-now in such an interpretation, and makes experience, itself, possible. Furthermore, the scientific foundation of the emerging field of biosemiotics —the study of semiosis as the process through which meaning is extracted from subjective experience in the context of living organisms viewed as complex purposive systems with intentionality that function in the embedded framework of their environmental context—offers a scientific theory of meaning based on the interaction between living things and their inner and outer worlds—the Innenwelt and the Umwelt —meaning that is mediated through semiosis. If what really matters in the ethical context is the axiological—the determination and understanding of value and meaning—then biosemiotics can be viewed as a scientific enterprise capable of grounding a theory of moral valuation, thus providing a philosophic foundation for an ethics capable of bridging the gap between fact and value, the natural and the cultural, reconciling science and morality and enabling progress of our societal ethic. Cobley has recently provided a detailed and cogent 3-fold argument for precisely how the possibility of an ontology of ethics is linked to biosemiotics in the context of the species-specific features—including linguistic capacity—of the human Umwelt :

• 1.
  

  Through the capacity of language to displace, in both time and space, through semiosis, events in other times and places, events that have not yet occurred (ie, as ‘fictions’), as well as in the anticipation of how things could become , referenced to how they currently are (ie, conditions can get better—or get worse).

  
  
• 2.
  

  Through the aspects of the Umwelt that actively contribute to affective experience, from suffering to satisfaction to joy.

  
  
• 3.
  

  Through the specific experience of ‘otherness’ or ‘alterity’ distinguished from but referenced to the experience of ‘self’ that develops in the context of the human Umwelt .

Cobley maintains that ethics, as opposed to being “the idea of . . . a moral system” that arose from the “sound moral judgment of a rational, unified consciousness,” is the result of the circumstances of the species-specific human Umwelt that emphasize the difference in “kind and degree” between the functionality and disposition of the human versus other natural organisms, as well as what specifically characterizes the human being as a “natural subject.” ^(p61)

Brain injury, because the human brain effectively is the bodily organ most intimately involved with subjective human experience, self-identity, and awareness, and the extraction of generalizable meaning from experience, is “an assault on the personal,” ^(p34) a fundamental transformation of the central functions of the subject with ABI both in terms of how they experience themselves and how they experience their world, as well as how they function as a conscious agent within the context of their life-world. ABI can have a powerful influence on self-identity and the process of recovery can entail a complex process of phenomenologically oriented personal narrative reconstruction. Correspondingly, we need to have a new postmodern philosophic paradigm that helps us to recover a deep understanding of what it truly means “to be a person” —to understand what constitutes a human person—an approach that allows us to engage in ordered and systematic scientific discourse regarding pragmatic ethical concerns with regard to such “persons,” especially under the significantly transfiguring circumstances of ABI and its life-altering impact on the subjectivity and selfhood—that is, self-awareness and agency—of the person affected.

Not only does brain injury deeply affect the subjectivity of the person injured—that is, their existence as a human person—because of the potentially significant aspects of personhood impacted (eg, personality, self-identity, capacity to communicate, emote, perceive, act, empathize, and function as a moral agent, to identify only a few of the myriad ways that ABI can alter subjective being), it can also produce significant problematic impairment of self-awareness. In addition, the injured human person can initiate self-protective adaptive strategies “in attempts of the organism to come to terms with” ^(p245) the effects of the injury as self-perceived and understood, schemes that may unintentionally exacerbate the impairment of functionality and precipitate an existential emotional decompensation that Kurt Goldstein termed a “catastrophic reaction.” Because subjectivity is defined through its relations to objects and other subjects—including other human persons—that constitute the Umwelt of the injured person, it also affects all those other human persons who are engaged relationally with the injured person (ie, all those human others who find themselves entangled in the injured person’s ‘semiotic web’)—their family, their employer, their friends, and everyone else in their relational network. In addition, in the context of treatment, everyone involved in their medical care becomes a part of this intersubjective relational network in which the injured individual is embedded. In the process of addressing the challenges of ethical decision making, members of an ethics committee who may be specially consulted to assist with this process are further added into this intricate extended network. This group rapidly becomes a very complex web of dynamic communication and ongoing relational interaction, through which information as well as affective coloration can pulse—involving channels that are both linguistic and extralinguistic.

This article presents a brief sketch of a recommended approach to ethical decision making in the context of ABI care with all of these considerations in mind. Various reasons why ABI poses significant ethical challenges have been briefly touched on here and a limited sample of the sources of these challenges are itemized in Box 1 .

Introduction

“Doing the right thing”—realizing the course of conduct that ought to be taken—in the process of enacting ethical decision making when it comes to the challenges posed by acquired brain injury (ABI) presents a broad variety of provocative difficulties and vexations. Furthermore, the process for how to best arrive at a satisfactory solution to an ethical dilemma presented in the context of ABI care is not defined definitively. This paper argues that one of the main reasons that this is so is because we are in critical need of a transformation in the fundamental philosophic paradigm for understanding brain injury and its consequences, particularly when faced with axiological concerns that revolve around subjective meaning and value as distinct from ‘fact,’ in the context of the personal—that is, the experiential—which are central issues for ethical decision making. The physicist, author, and educator, Arthur Zajonc, whose research concerns a reorientation of science toward human life and ethics, asks “Where do mind and morality meet?”, and that is precisely the crux of the matter. Mind and morality meet in the context of subjectivity, a subjectivity that ‘never disappears (but) . . . is our friend, not the enemy science has made it out to be’ ^(p13) —science in the dominant paradigm of mechanistic ‘scientism,’ that is. A study of ethics requires the ability to examine and understand the nature of the experience of the subject— the experiencing human being—and, in that context, to recognize the need to realize the foundational status of dynamic process and relationality, as opposed to the indolent mechanistic materiality attributable to the “unresolved residue of antiquated thinking from the seventeenth century that still pervades the twenty-first century treatment of the mind.” ^(p10) It could well be argued that medicine, as a moral practice, including, in particular, for the purposes of this paper, ABI rehabilitation, requires the same. To be alive is to be a dynamic processual subject—a living, experiencing being coupled to the exterior world through a myriad of different relationships, ranging from relatively simple impassive interactions with inanimate objects—like the keyboard I am typing on—to highly complex and provocative interpersonal connections and exchanges with other living beings including those of particular—although certainly not exclusive—interest, involving other human persons. To be human is to have a unique array of ‘lived’ experiences acquired during a ‘lived’ trajectory that constitute a dynamic ‘life-world’ played out in the culturally propelled context of a species-specific human Umwelt —where the Umwelt is the species-specific external world as known to and understood by the subject in terms of the meaning and relevance of the various features of the surrounding environment and circumstances as self-assessed. Ethics is all about the intersubjective encounter and the navigation of the intrapersonal and interpersonal. It centers on the relationship between persons—both living human and nonhuman subjects—and how to effectively and properly engage with and become engaged in provocative relational situations and value-laden contexts. To be able to do ethics involves the extraction of meaning from experience and the assignment of value to the relational.

In this paper, it will be argued that the dominant ‘modern’ philosophic paradigm in which the Western world is so deeply saturated and on which the Newtonian scientific paradigm, since the beginning of the ‘Age of Enlightenment,’ has been grounded—its dualism, nominalism, depersonalization, and the intentional deletion and bracketing out of the subjective being—the experience of the observer—along with bracketing out of each and every nonhuman organism populating the planet, and its inability to address the crucial and foundational nature of relationality and communication —including cultural influences—in the quest to understand conscious experience and, with it, the nature of personhood—makes it very difficult, if not impossible, to recognize and fully understand the deep nature of the ‘personal’—that is, subjective being —in the context of fully nuanced human existence. In the context of modern nominalistic philosophy wherein relation is considered an illusory imposed invention of the mind, real ethics is effectively precluded. Ethics cannot be performed adequately without an understanding that emanates from the personal, an understanding that begins with subjectivity—with the direct experience of the subject—and necessarily incorporates the relational. Ethics is not possible in an impersonal world of encasketed and effectively sequestered and insular ‘thinking machines’—the scenario laid out by Cartesian nominalism that denies the reality of the relational, including the influence of the cultural—assuming that the mind ‘makes it all up’ and imposes its own relational structure—and places an impenetrable wall separating the subjective mind-dependent realm generated inside the head (‘ ens rationis ’) from the objective mind-independent world outside (‘ ens reale ’), the true existence of which can only be inferred in the context of the modern worldview. For the modern philosophic paradigm, the world seems to be organized because it is the human mind that is endowed with the ability to generate the organizing structure, the overlaid logical order that it imposes on reality. But what if it really works the other way around? What if the human mind is logically ordered the way it is because it is a product of the discoverable logic of the reality of the natural world—the mind that pervades nature—from whence it emerged over eons through an expansive and long-enduring evolutionary process? That really would change everything. We now have clues from relativity and quantum mechanics indicating that the logic of the Newtonian paradigm—the logic of hard-core scientific materialism—with its effective elimination of the subjective observer from the system studied, leads to a false objectivism. Instead, what the ‘new physics’ of relativity and quantum mechanics indicates is that the presence of the subject matters—“subjectivity is real, and real at every level of analysis” ^(p13) —and that it is a necessary and integral element of the scientific worldview whose presence and participation cannot be discounted or eliminated. In the new physics, observations are subject to the subject.

A new postmodern framework, indeed, an emerging ‘new age’ of human understanding is entailed—a ‘postmodern’ framework that recognizes and incorporates the fundamental importance of communication, sociality, and intersubjective collaboration throughout the natural world—but particularly for the self-reflecting human species for which ethics, as the capacity to perceive what is happening, imagine what could be, and then reflect on what ought to be done, is not only a possibility, but an obligation —a new nonnominalistic view that recognizes that relations, although invisible and essentially incapable of being detected directly by the senses, are nevertheless very real existents discoverable through inquiry. Furthermore, relations operate at a suprasubjective level, over and above the entities linked together by the relation, making possible a context-dependent flexible interaction between the mind-dependent—that is, what cannot be without the participation of mind—and the mind-independent—that is, the ‘things’ that constitute the real world regardless of whether or not they are ‘objectified’—that is, ‘known’ to a finite mind. In this new postmodern worldview, these two fundamental realms can interpenetrate freely and openly in accordance with relational context.

To be a human person is directly and intimately connected to the process through which the human brain and nervous system, in the context of its embodiment as situated in the further context of our immediate and larger environment with all its complexity (populated with ‘objects’—that is, known entities—many of whom—certainly the living organisms including fellow humans—are also themselves subjects) and affordances for agency, gives rise to and makes possible subjective experience. Therefore, recovering the subjective and having a philosophic framework that honors and allows for the full understanding and appreciation of the subjective, of the phenomena that occur in the experience of the human person, is a necessary prerequisite for engaging in the quest for acceptable ethical decision making in the context of caring for the brain-injured human person.

It will be argued that the process of extracting meaning from subjective experience in the personal context—the ability to understand and infer what is ‘significant’ or meaningful—ultimately involves ‘semiosis’—the ‘action of signs’—that makes possible the flexible context-dependent interaction between ens rationis and ens reale spanning past, future, and the here-and-now in such an interpretation, and makes experience, itself, possible. Furthermore, the scientific foundation of the emerging field of biosemiotics —the study of semiosis as the process through which meaning is extracted from subjective experience in the context of living organisms viewed as complex purposive systems with intentionality that function in the embedded framework of their environmental context—offers a scientific theory of meaning based on the interaction between living things and their inner and outer worlds—the Innenwelt and the Umwelt —meaning that is mediated through semiosis. If what really matters in the ethical context is the axiological—the determination and understanding of value and meaning—then biosemiotics can be viewed as a scientific enterprise capable of grounding a theory of moral valuation, thus providing a philosophic foundation for an ethics capable of bridging the gap between fact and value, the natural and the cultural, reconciling science and morality and enabling progress of our societal ethic. Cobley has recently provided a detailed and cogent 3-fold argument for precisely how the possibility of an ontology of ethics is linked to biosemiotics in the context of the species-specific features—including linguistic capacity—of the human Umwelt :

• 1.
  

  Through the capacity of language to displace, in both time and space, through semiosis, events in other times and places, events that have not yet occurred (ie, as ‘fictions’), as well as in the anticipation of how things could become , referenced to how they currently are (ie, conditions can get better—or get worse).

  
  
• 2.
  

  Through the aspects of the Umwelt that actively contribute to affective experience, from suffering to satisfaction to joy.

  
  
• 3.
  

  Through the specific experience of ‘otherness’ or ‘alterity’ distinguished from but referenced to the experience of ‘self’ that develops in the context of the human Umwelt .

Cobley maintains that ethics, as opposed to being “the idea of . . . a moral system” that arose from the “sound moral judgment of a rational, unified consciousness,” is the result of the circumstances of the species-specific human Umwelt that emphasize the difference in “kind and degree” between the functionality and disposition of the human versus other natural organisms, as well as what specifically characterizes the human being as a “natural subject.” ^(p61)

Brain injury, because the human brain effectively is the bodily organ most intimately involved with subjective human experience, self-identity, and awareness, and the extraction of generalizable meaning from experience, is “an assault on the personal,” ^(p34) a fundamental transformation of the central functions of the subject with ABI both in terms of how they experience themselves and how they experience their world, as well as how they function as a conscious agent within the context of their life-world. ABI can have a powerful influence on self-identity and the process of recovery can entail a complex process of phenomenologically oriented personal narrative reconstruction. Correspondingly, we need to have a new postmodern philosophic paradigm that helps us to recover a deep understanding of what it truly means “to be a person” —to understand what constitutes a human person—an approach that allows us to engage in ordered and systematic scientific discourse regarding pragmatic ethical concerns with regard to such “persons,” especially under the significantly transfiguring circumstances of ABI and its life-altering impact on the subjectivity and selfhood—that is, self-awareness and agency—of the person affected.

Not only does brain injury deeply affect the subjectivity of the person injured—that is, their existence as a human person—because of the potentially significant aspects of personhood impacted (eg, personality, self-identity, capacity to communicate, emote, perceive, act, empathize, and function as a moral agent, to identify only a few of the myriad ways that ABI can alter subjective being), it can also produce significant problematic impairment of self-awareness. In addition, the injured human person can initiate self-protective adaptive strategies “in attempts of the organism to come to terms with” ^(p245) the effects of the injury as self-perceived and understood, schemes that may unintentionally exacerbate the impairment of functionality and precipitate an existential emotional decompensation that Kurt Goldstein termed a “catastrophic reaction.” Because subjectivity is defined through its relations to objects and other subjects—including other human persons—that constitute the Umwelt of the injured person, it also affects all those other human persons who are engaged relationally with the injured person (ie, all those human others who find themselves entangled in the injured person’s ‘semiotic web’)—their family, their employer, their friends, and everyone else in their relational network. In addition, in the context of treatment, everyone involved in their medical care becomes a part of this intersubjective relational network in which the injured individual is embedded. In the process of addressing the challenges of ethical decision making, members of an ethics committee who may be specially consulted to assist with this process are further added into this intricate extended network. This group rapidly becomes a very complex web of dynamic communication and ongoing relational interaction, through which information as well as affective coloration can pulse—involving channels that are both linguistic and extralinguistic.

This article presents a brief sketch of a recommended approach to ethical decision making in the context of ABI care with all of these considerations in mind. Various reasons why ABI poses significant ethical challenges have been briefly touched on here and a limited sample of the sources of these challenges are itemized in Box 1 .

Box 1

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