Grossi, Antonio This article discusses anaesthesia, the role of the anaesthetist and its ethical challenges. In the current political climate of task substitution and de-professionalisation, it is worth considering the role of the anaesthetist and the relevant ethical issues pertaining to this endeavour.

In general anesthesia, a “cocktail” of drugs renders a patient unconscious, in what has been called a “controlled coma”. Various measures of patient awareness involve overt behavior, autonomic nervous system activity, processed EEG, and event‐related potentials. The incidence of intraoperative awareness is very low, but anecdotal reports suggest that patients might process surgical events unconsciously, leading to unconscious postoperative memories. Careful experimental studies show that priming effects, similar to those observed in implicit memory, can be spared even in the (...) absence of conscious recollection, an outcome which indicates that unconscious perception can occur even in clinically adequate general anesthesia. Deeper planes of amnesia, however, appear to abolish both explicit and implicit perception. (shrink)

For patients under anesthesia, it is extremely important to be able to ascertain from a scientific, third person point of view to what extent consciousness is correlated with specific areas of brain activity. Errors in accurately determining when a patient is having conscious states, such as conscious perceptions or pains, can have catastrophic results. Here, I argue that the effects of (at least some kinds of) anesthesia lend support to the notion that neither basic sensory areas nor the (...) prefrontal cortex (PFC) is sufficient to produce conscious states. I also argue that it this is consistent with and supportive of the higher-order thought (HOT) theory of consciousness. I therefore disagree in some ways with Mehta and Mashour (2013), who argue that evidence from anesthesia mainly favors a first-order representational (FOR) theory, as opposed to HOT theory (and many other theories, for that matter). (shrink)

General anesthesia provides an alternative to typical laboratory paradigms for investigating implicit learning. We assess the evidence that a simple type of learning—priming—can occur without consciousness. Although priming has been shown to be a small but persistent phenomenon in surgical patients there is reason to question whether it occurs implicitly due to problems in detecting awareness using typical clinical signs. This paper reviews the published studies on priming during anesthesia that have included a measure of awareness or of (...) anesthetic depth. We conclude that perceptual priming, but not conceptual priming, takes place in the absence of conscious awareness. (shrink)

Is a painful experience less bad for you if you will not remember it? Do you have less reason to fear it? These questions bear on how we think about medical procedures and surgeries that use an anesthesia regimen that leaves patients conscious – and potentially in pain – but results in complete ‘drug-induced amnesia’ after the fact. I argue that drug-induced amnesia does not render a painful medical procedure a less fitting object of fear, and thus the prospect (...) of amnesia does not give patients a reason not to fear it. I expose three mistakes in reasoning that might explain our tendency to view pain or discomfort as less fearful in virtue of expected amnesia: a mistaken view of personal identity; a mistaken view of the target of anticipation; and a mistaken method of incorporating past evidence into calculations about future experiences. Ultimately my argument has implications for whether particular procedures are justified and how medical professionals should speak with anxious patients about the prospect of drug-induced amnesia. (shrink)

This article analyses problem situations in the context of anaesthesia care. It considers what it means for nurse anaesthetists to be in problematic situations in the anaesthesia care of older patients. Benner’s interpretive phenomenological approach proved useful for this purpose. Paradigm cases are used to aid the analysis of individual nurses’ experiences. Thirty narrated problematic anaesthesia care situations derived from seven interviews were studied. These show that experienced nurse anaesthetists perceive anaesthesia care as problematic and highly demanding when involving older (...) patients. To be in problematic anaesthesia care situations means becoming morally distressed, which arises from the experience or from being prevented from acting according to one’s legal and moral duty of care. An important issue that emerged from this study was the need for an ethical forum to discuss and articulate moral issues, so that moral stress of the kind experienced by these nurse anaesthetists can be dealt with and hopefully reduced. (shrink)

This article engages two fundamentally different kinds of so-called natural law arguments in favor of specific moral absolutes: Elizabeth Anscombe's claim that certain actions are known to be intrinsically wrong through intuition, and John Finnis's claim that such actions are known to be wrong because they involve acting directly against a basic human good. Both authors maintain, for example, that murder and contraceptive sexual acts are known to be wrong, always and everywhere, through their respective epistemological lens. This article uses (...) the counter-example of anesthesia to challenge these two approaches to substantiating natural law claims. The paper concludes by rejecting the view shared by Professors Finnis and Anscombe that once one rejects these foundations for moral absolutes, one is left with moral subjectivism. In fact, one is left with moral absolutes of a more restricted nature, which are known philosophically, and with more robust moral absolutes held on religious grounds. Virtues are needed in the moral life, among other reasons, because such norms require discernment and integrity for their correct application. (shrink)

Empirical work is reviewed which correlates the presence or absence of various parts of the auditory evoked potential with the disappearance and reemergence of auditory sensation during induction of and recovery from anesthesia. As a result, the hypothesis is generated that the electrophysiological correlate of auditory sensation is whatever neural activity generates the middle latency waves of the auditory evoked potential. This activity occurs from 20 to 80 ms poststimulus in the primary and secondary areas of the auditory cortex. (...) Evidence is presented suggesting that earlier or later waves in the auditory evoked potential do not covary with auditory sensation (as opposed to auditory perception) and it is therefore suggested that they are possibly not the electrophysiological correlates of sensation. (shrink)

Research on learning under anesthesia has focused on showing that learning is possible in the absence of awareness. However, a simple dissociation between learning and awareness is conclusive only under strong additional assumptions, and the actual state of consciousness of an anesthetized person is difficult to determine. Instead of trying to establish complete unconsciousness, one might employ gradual anesthesia to experimentally vary the level of consciousness in a controlled fashion, checking whether cognitive processes exist that can change in (...) opposite direction to measures of awareness. (shrink)

This paper presents research regarding the monitoring of the brain and the adequacy of anesthesia during surgery. Particular variables are derived from EEG and ECG signals and are correlated to anesthetic gas (sevoflurane) concentration, in pediatric anesthesia. The methods used for parameter extraction are based on change detection theory and time-frequency representation. Preliminary results show that the expired anesthetic gas concentration modulates both the heart rate variability and the duration of the burst suppression. Monitors of the central nervous (...) system and autonomic nervous system activities can be expected to be based on these variables. (shrink)

Possible systemic effects of general anesthetic agents on neural information processing are discussed in the context of the thalamocortical suppression hypothesis presented by Drs. Alkire, Haier, and Fallon (this issue) in their PET study of the anesthetized state. Accounts of the neural requisites of consciousness fall into two broad categories. Neuronal-specificity theories postulate that activity in particular neural populations is sufficient for conscious awareness, while process-coherence theories postulate that particular organizations of neural activity are sufficient. Accounts of anesthetic narcosis, on (...) the other hand, explain losses of consciousness in terms of neural signal-suppressions, transmission blocks, and the disruptions of signal interpretation. While signal-suppression may account for the actions of some anesthetic agents, the existence of anesthetics, such as choralose, that cause both loss of consciousness and elevated discharge rates, is problematic for a general theory of narcosis that is based purely on signal suppression and transmission-block. However, anesthetic agents also alter relative firing rates and temporal discharge patterns that may disrupt the coherence of neural signals and the functioning of the neural networks that interpret them. It is difficult at present, solely on the basis of regional brain metabolic rates, to test process-coherence hypotheses regarding organizational requisites for conscious awareness. While these pioneering PET studies have great merit as panoramic windows of mind-brain correlates, wider ranges of theory and empirical evidence need to be brought into the formulation of truly comprehensive theories of consciousness and anesthesia. (shrink)

Consciousness, Awareness, and Anesthesia is a multidisciplinary approach to both the scientific problem of consciousness and the clinical problem of awareness during general anesthesia.

It is no accident that white privilege designed to be both be invisible and weightless to white people. Alison Bailey’s “On White Privilege and Anesthesia: Why Does Peggy McIntosh’s Knapsack Feel Weightless?” extends a weighty invitation white readers to complete the unpacking task McIntosh (1988) began when she compared white privilege to an “invisible and weightless knapsack.” McIntosh focuses primarily making white privilege visible to white people. Bailey’s project continues the conversation by extending a ‘weighty invitation’ to white readers (...) to explore why the metaphorical knapsack, despite the weight of its contents, feels weightless. Here’s the short answer. The knapsack only feels weightless because white people have become anesthetized us to our own brokenness. We are more comfortable considering what white privilege does for us than what it does to us. People of color feel the weight of whiteness every day. The weighty invitation invites white readers to become sensitive to our own insensitivity. To do this Bailey (1) explores white resistance to unpacking the weight; (2) people of color’s testimonies to the daily impact of the weight on their bodies; and (3) how the anesthesia of white privilege distorts our humanity. The article concludes with a McIntosh style list of that the anesthesia of privilege distorts white people’s humanity. (shrink)

Reflecting recent findings by anaesthesiologists and psychologists, these proceedings discuss: implicit memory function, the use of therapeutic suggestion during anaesthesia, effective drug combinations to achieve maximum impact, monitoring the depth of anaesthesia and patient awareness.

Several general anesthetics produce their sedative effect by activating endogenous sleep pathways. We propose that general anesthesia is a two‐step process targeting sleep circuits at low doses, and synaptic release mechanisms across the entire brain at the higher doses required for surgery. Our hypothesis synthesizes data from a variety of model systems, some which require sleep (e.g. rodents and adult flies) and others that probably do not sleep (e.g. adult nematodes and cultured cell lines). Non‐sleeping systems can be made (...) insensitive (or hypersensitive) to some anesthetics by modifying a single pre‐synaptic protein, syntaxin1A. This suggests that the synaptic release machinery, centered on the highly conserved SNARE complex, is an important target of general anesthetics in all animals. A careful consideration of SNARE architecture uncovers a potential mechanism for general anesthesia, which may be the primary target in animals that do not sleep, but a secondary target in animals that sleep. (shrink)

Professional directives are unwavering: educational intimate exams should only ever occur with patients’ explicit consent. This article describes the current clinical, educational, and ethical landscape of educational pelvic examinations under anesthesia, underscores the imperative that these exams only ever occur with patients’ explicit consent, and offers accessible modifications to students’ involvement in these exams.

Evil should be characterised as a specific constellation, which results from destructive connections between individual activities and systemic influences. The article shows some important aspects of the structure of evil and prefers the terms of wickedness and obscene coincidences to describe its own character. Therefore, also the division between rationality and affectivity appears as inadequate, because evil has on the one side an intrinsic attractiveness for individuals and is on the other side in modern societies more and more a product (...) of a rationality, which is free from passion. Especially the emotional impoverishment is responsible for the increase of evil, which is demonstrated by two examples. Based on Paul Ricoeur, the evolution of malum can be developed by a short analyse of the relationship between Ethics and Emotions. (shrink)

It has frequently been suggested that science and religion are innately in conflict. One example from the history of medicine is the introduction of anaesthesia into obstetrics in 1847, which is commonly said to have stimulated massive religious opposition. Historians have almost unanimously averred that such opposition arose from the belief that obstetric anaesthesia interfered with the primeval curse— ‘In sorrow thou shalt bring forth children’ . Despite considerable opposition to obstetric anaesthesia upon medical, physiological, and general moral grounds, evidence (...) of genuine religious opposition in contemporary sources has proved to be virtually non-existent. On examination, this particular ‘conflict’ appears to be an artifact of historiography based upon a contemporary defence prepared against an attack which never materialized. (shrink)

Philosophical (p-) zombies are constructs that possess all of the behavioral features and responses of a sentient human being, yet are not conscious. P-zombies are intimately linked to the hard problem of consciousness and have been invoked as arguments against physicalist approaches. But what if we were to invert the characteristics of p-zombies? Such an inverse (i-) zombie would possess all of the behavioral features and responses of an insensate being yet would nonetheless be conscious. While p-zombies are logically possible (...) but naturally improbable, an approximation of i-zombies actually exists: individuals experiencing what is referred to as “anesthesia awareness.” Patients under general anesthesia may be intubated (preventing speech), paralyzed (preventing movement), and narcotized (minimizing response to nociceptive stimuli). Thus, they appear—and typically are—unconscious. In 1-2 cases/1000, however, patients may be aware of intraoperative events, sometimes without any objective indices. Furthermore, a much higher percentage of patients (22% in a recent study) may have the subjective experience of dreaming during general anesthesia. P-zombies confront us with the hard problem of consciousness—how do we explain the presence of qualia? I-zombies present a more practical problem—how do we detect the presence of qualia? The current investigation compares p-zombies to i-zombies and explores the “hard problem” of unconsciousness with a focus on anesthesia awareness. (shrink)

Cataract surgery has evolved rapidly over the last decade. Previously such cases required admission for prolonged postoperative convalescence. However, currently such procedures are carried out as day cases. An area where significant change has evolved is the role of anaesthesia in cataract surgery.Recently, a growing number of surgeons have been performing cataract surgery using topical drops to achieve anaesthesia. However, case selection and operator experience impose a limit on the use of topical anaesthesia.1 Other local techniques for delivering ….

“Informed consent” is a legal instrument that allows individuals to define their own interests and to protect their bodily privacy. In current medical practice, patients who have consented to surgery are considered to have implied consent to anaesthesia, even though anaesthesia is associated with its own particular set of risks and consequences that are quite separate from those associated with surgery. In addition, anaesthetists often perform interventions that are the only medical treatment received by a patient. Anaesthetists, therefore, should always (...) obtain separate consent for anaesthesia, and should regard the process of consent as a stimulus for active, fluid reciprocal discussion with patients about treatment options. (shrink)

This is a response to James Dubois’ “Is anesthesia intrinsically wrong?” I do not address many of the claims in this article but only DuBois’ use of the moral evaluation of the medical use of anesthesia as a counter example to two lines of reasoning developed to defend the traditional Catholic prohibition of contraception. Elizabeth Anscombe's dialectical defense of this teaching does not imply that such a defense must logically apply to the use of anesthesia. John Finnis’ (...) defense of this teaching on the basis of a natural law argument does not imply that consciousness is a basic human good. (shrink)

Evidence coming from several studies into memory and awareness during general anesthesia suggests that in surgical patients who seem to be adequately anesthetized , some form of cognitive functioning is preserved. This finding has important implications both for clinical practice and for memory research. In order to give the methodological background of the present situation in this field of research, this article deals, on the basis of recent experiments, with important methodological aspects of studies into perception and memory during (...) general anesthesia. (shrink)

IntroductionPreoperative neurocognitive disorder is a common condition affecting 14–51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder, specifically, a deficit in executive function, measured by the Trail Making Test B, but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia in general preoperative cognitive status [measured via (...) the Montreal Cognitive Assessment ] and/or in executive functioning.MethodsIn this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected.ResultsWe discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood and education with a decreased likelihood of general cognitive impairment, but only education was significantly associated with a decreased likelihood of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment.ConclusionWe found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age. However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population. (shrink)

This current study aims to examine the importance of anesthesia for humans. Secondly, what are the types of anesthesia currently used in operations, and what is the role of anesthesia in preserving human life. A questionnaire was prepared via Google Drive and distributed to residents aged 25-55 years, men and women, in the city of Mecca. As for the questionnaire, it was distributed via the social media program (WhatsApp) for the purpose of distancing for fear of the (...) presence of the Corona virus. 380 questionnaires were distributed, and 370 responses were obtained via email to the main researcher. it concluded that requires continuing to work on continuous on advanced anesthesia methods. (shrink)

This paper explores the changes in cognitive function which occur as someone "loses consciousness" under anesthesia. Seven volunteers attempted a categorization task and a within-list recognition test while inhaling air, 0.2% isoflurane, and 0.4% isoflurane. In general, performance on these tests declined as the dose of anesthetic was increased and returned to baseline after 10 min of breathing air. A measure of auditory evoked responding termed "coherent frequency" showed parallel changes. At 0.2% isoflurane, subjects could still identify and respond (...) to category exemplars but showed impaired short-term memory function. Electrical stimulation at 0.4% isoflurane, intended to mimic the arousing effects of surgery, had a small, beneficial effect on performance. A mean of 63% of category exemplars was identified at this stage, but recognition memory for those exemplars was at chance on recovery. There was no evidence for learning of words presented at 0.8% isoflurane. (shrink)

A theory of anaesthesia is presented. It consists of four hypotheses: (1) The occurrence of states of consciousness causally depends on the formation of transient higher-order, self-referential mental representations. The occurrence of such states is identical with the appearance of conscious phenomena. Loss of consciousness will occur, if and only if the brain's representational activity falls below a critical threshold. (2) Mental representations are instantiated by neural cell assemblies. (3) The formation of assemblies involves the activation of the NMDA receptor (...) channel complex. The activation state of this receptor determines the rate at which assemblies are generated. (4) General anaesthetics have a common operative mechanism: they directly or indirectly affect the function of the NMDA system. (shrink)