This chapter looks at claims to understanding. It begins by looking at the system I have worked on, the lamprey spinal cord locomotor circuit, and claims that circuit function and behaviour can be understood in terms of the interactions of spinal cord nerve cells. I highlight that the claims to experimental confirmation actually reflect various assumptions and extrapolations and that the claimed understanding is lacking. I then look at the Nobel Prize winning work on the Aplysia gill withdrawal reflex, making the same conclusion as the lamprey, various assumptions and extrapolations are used to claim causal links, and in doing this commit various logical fallacies, including confusing correlation for causation and begging the question. I finish by looking at hippocampal long-term potentiation and claims it is the cellular basis of memory, again highlighting that the claimed links have not been made.

An ethics consultation case is presented in which a hospice patient wished to deactivate his Cardiovascular Implantable Electronic Device (CIED), specifically an implantable cardioverter-defibrillator, at the end of life to prevent the prolongation of the dying. The consultants developed an ethical analysis supporting the deactivation of the pacemaker based on authoritative literature and moral reasoning. The consultants’ recommendations to deactivate the pacemaker were ultimately rejected by the medical team based on an alternative assessment which concluded the patient is suicidal, doubts based on the consultants not being physicians, and the healthcare professionals’ sense that deactivating a pacemaker is different from withdrawing other forms of life-sustaining treatment at the end of life. Professional reflections by the consultants and lessons learned are discussed.

Jane was in imminent danger of an impending thyroid storm from her goiter and was experiencing intermittent psychosis. The clinical team was focusing on capacity evaluations as they found Jane to be angry, hostile, and difficult, and believed an involuntary hold was necessary as she was not consistently consenting to the surgery and trying to leave. As soon as Jane had the thyroidectomy she would return to her baseline as if nothing had happened. When I was training, I shared with a few close colleagues and mentors my nervousness about how I would be received as a clinical ethicist. I was cognizant that there would be some patients who may not appreciate my disability or see it as of value. In reality, Jane had a big ally in me and my disability helped me untangle some aspects of the case in a way that validated her experience. Nonetheless, clinical ethicists have a responsibility to actively assess and check for implicit bias within ourselves. As we caution our clinical colleagues not to be paternalistic in their practice, we, too, must not be paternalistic in ours.

Our chapter explores the ethical and systemic challenges faced by healthcare staff when caring for an adolescent patient boarding in the emergency room (ER). We use the case of Samantha, an indigenous adolescent, brought to the ER after trying to elope from her youth treatment center. Samantha’s prolonged stay in the ER highlights significant gaps in healthcare; society’s struggle to address the needs of vulnerable populations; and the healthcare staff’s efforts to fulfill the duties of beneficence, nonmaleficence, and justice. Samantha’s case underscores the need for improved clinical and institutional processes and support systems. We advocate for better access to ethics support, enhanced community resources, and a more inclusive approach to care that considers the unique needs of marginalized individuals. Our case also reflects on the emotional and moral toll experienced by healthcare providers, exacerbated by systemic injustice and an unclear pathway to access our ethics committee at the time. We hope this case provides insights for healthcare systems to develop comprehensive strategies to support adolescents boarding in the ER ensuring their dignity.

This introductory chapter starts by considering the distinction between doubt and denial, and why retaining doubt in science is needed to ensure claims are accurate. It then discusses neuroscience aims and claims, and how the insight obtained is directed at translations to practical use in artificial intelligence, neurology, psychiatry and wider translations to society; for example, education and cognitive enhancement. The chapter highlights the relevance of philosophy and history to science, aspects to which science students are seldom exposed. This includes discussion of science denial by popularist politicians and corporations who try and ignore or dismiss evidence that negates their views or products. These aspects are highlighted as being important to defend science and ensure that scientific claims are as accurate as possible, and that in an age of disinformation we all need to think critically, mirroring the workers’ educational movements of the late nineteenth century.

This chapter presents a complex case of clinical ethics consultation involving a patient with end-stage renal disease, frailty, and severe dementia. It explores the ethical challenges faced by the healthcare team, particularly regarding the designation of dialysis as a "nonbeneficial" intervention. The narrative focuses on the tension between medical decision-making, rooted in evidence-based practice, and the values and spiritual beliefs of the patient and her family, especially in light of systemic inequities. By examining the patient’s historical context, including implicit racial bias and structural barriers, the chapter highlights the need for ethics consultations to acknowledge these factors when navigating difficult medical decisions. The case ultimately illustrates the limitations of standard ethical frameworks in addressing the long-standing harms experienced by some patients and calls for a more nuanced approach that incorporates systemic injustices into ethical deliberations.

This chapter dives into one of the most difficult clinical ethics consultations in the author’s career. A vibrant patient suffers a cardiac arrest and severe anoxic brain injury on their way to dialysis. After weeks of ICU treatment, the family came when the patient was liberated from the ventilator. The daily spontaneous breathing trials made everyone think (and prepare) that the patient would only have minutes to live after extubation. Yet, the patient began to breath. When the minutes turned into an hour, the yelling began. The ethics pager went off moments later, and no one could have be prepared for journey ahead. Trust was gone, and the current course of comfort care would bring an irreversible outcome. The effort to buy time in the face of uncertainty resulted in a complex sequence of events that unfolded over months. The author reflects on the case and shares the opportunity to learn by failing forward.

Clinicians have a duty to care for patients whose injuries or illness may appear self-inflicted. However, in some cases, the self-inflicted element of these injuries makes this care especially difficult. Repeated self-inflicted injuries raise ethical dilemmas including issues of allocation of scarce resources, how to justly care for patients in the context that led them to self-injury, so-called "care contracts" with patients, and whether it is ever appropriate to violate a patient’s autonomy to protect them from further self-harm (either during acute recovery or long-term). They also raise issues of frustration for caregivers seeing patients at medical risk that feels avoidable, and caregivers who feel that by providing immediate medical care they are likely not addressing the root of the problem for the patient.

We examine these issues via a clinical ethics case study of a patient representing a case of Repeated Foreign Body Ingestion (RFBI). RFBI occurs among a small number of patients, but occurs frequently for those affected, and often requires emergency surgery to resolve. In many cases, RFBI is extremely dangerous for patients who experience it, and caregivers find themselves haunted by wondering what they could have done differently for patients when the RFBI does repeat.

This chapter looks specifically at neural circuits, assemblies of neurons that influence sensory, motor and cognitive functions. I discuss the conventional criteria for understanding these circuits, which are reductionist in their approach, and highlight various caveats in experimental and conceptual approaches that are routinely followed. I also consider the use of motifs, arrangements of component parts of a circuit that serve specific functions like electronic components. I follow others in highlighting the utility of appealing to motifs, but again highlight caveats of these motifs that mean we cannot assume their presence or the function when we know they are present. I finish by discussing aspects that have been identified over the last few decades that may add to the aspects we need to study, including plasticity, glial cells, variability and ephaptic signals.

This chapter considers reductionism, a major aspect of neuroscience research. I consider reductionist claims that we can only understand nervous systems from knowledge of their component parts. I then consider reductionist approaches and what we have learnt by following them, highlighting that a complete reductionist account of any nervous system region hasn’t been and is probably impossible to achieve. I then discuss decomposable hierarchical and non-decomposable heterarchical systems, and how relational aspects suggest we cannot understand the latter systems from cataloguing their individual components. I then discuss two effects that have received little attention despite being known for decades – volume transmission and ephaptic signalling – that highlight the need to consider component parts in relation to the whole system. I finish by discussing non-reductionist views, equipotentiality, cybernetics, the holonomic brain and embodied cognition, highlighting, as many have in the past, that debating between reductionist and non-reductionist approaches is a false dichotomy.

This chapter looks at social influences on neuroscience. It outlines that science is a social system, and subject to various social pressures that can affect what we study, how we study it, and how we interpret the data we obtain. This includes financial conflicts of interest, claims to priority, scientific prizes, peer review, ‘scientmanship’ that attempts to promote or suppress certain scientific views and scientists, and the recent quantification of social pressures in science from surveys that suggest that social pressures and career structures introduce behaviours that make science a difficult career for those lower in the scientific hierarchy, including racial and sexual biases, and can see those higher up using their prominence to affect how science is done and the claims made. I highlight that awareness of these negative social influences is starting to lead to approaches that aim to address these issues.

Is it ethically justifiable to honor a patient’s request for ongoing blood transfusions for an incurable, relapsed leukemia, particularly in the context of scarcity? Our patient was a thirty-two-year-old Black man who had been hospitalized for six months. Despite daily blood and platelet transfusions, he remained too frail for cancer-directed therapy or discharge home. The clinical team considered ongoing transfusions to be a futile endeavor, especially given their state’s acute shortages of blood products. For the patient however, these transfusions were anything but futile: they were a form of life support, akin to hemodialysis, that allowed him to spend as much time as possible with his young family.

While this case initially appeared relatively straightforward using a utilitarian approach, the consultants have been haunted by our eschewing of alternative viewpoints, particularly in the context of the patient’s race and socioeconomic status. Should we have set aside our “usual commitments to professional polish and position” in favor of a more robust appreciation of the ethical, social, cultural, and economic dimensions of this case? By ignoring or downplaying important social considerations and our patient’s unique attributes, we actually may have tipped the balance towards less fairness and equity.

This chapter focuses on aspects of the philosophy of science, in particular the twentieth century views of Karl Popper and Thomas Kuhn. It briefly covers earlier aspects, including Francis Bacon and William Whewell who highlighted the need for, and influence of, subjective factors in science. In discussing Popper, it considers inductive and deductive reasoning and his falsification approach, while discussion of Kuhn focuses on his view of scientific paradigms, normal science, anomalies and crises, and paradigm shifts and scientific revolutions. It highlights both Popper’s and Kuhn’s views using neuroscience examples, including chemical synaptic transmission, animal electricity and adult neurogenesis. The conclusion is that there is no formal scientific method, no formula for discovery: scientists use, and need to use, a diversity of approaches.

When a patient is developmentally and intellectually disabled, nonverbal, never competent, without a legal guardian; who speaks for him when urgent medical care is needed? In this case, a twenty-five-year-old patient with a mental age of two presented with a history of frequent bowel obstructions and constant abdominal pain with feeding. Upon admission, he was physically restrained and sedated to enable the treatment team to provide tube feeding. The treating physician requested an ethics consult, asking whether artificially nutrition should be continued, and who should make this decision? His biological parents relinquished him at birth. A foster family provided care for twenty-five years but could no longer manage his care. The state caseworker could not make medical decisions. The patient did not have a legal guardian, and urgent medical decisions needed to be made. The Ethics Committee along with many key stakeholders, gathered to discern this morally complex case. After much discussion, a recommendation was made to discontinue artificial nutrition and provide comfort care. This recommendation was grounded in a best interest standard. The treatment team agreed with the recommendation. Following consultation with the biological and foster families, feeding was discontinued, and the patient died.

A sixty-nine-year-old man with severe necrotizing fasciitis in the setting of a newly diagnosed, metastatic cancer is transferred from an outside hospital for further evaluation of treatment options, including surgical debridement. His family indicates he is a member of a small, adherent religious community that holds the belief that all life-sustaining measures should be pursued and that any breath he takes constitutes meaningful life, even if it causes severe suffering. The patient’s altered mental status due to brain metastases prevents him from verbally communicating with the team, but he intermittently tracks movement of the healthcare team and grimaces in response to painful stimuli. This case narrative explores surgical ethics and moral distress evoked by this haunting case, with analysis from a consulting clinical ethicist who supported communication with family about treatment options and a clinical ethicist who provided guidance on code status and led nursing ethics rounds with the care team.

The patient presented at night. She was at forty-two weeks gestation, in stalled labor, with fetal heart rates in prolonged deceleration. Due to the hour, no records were available from the outside facility where she said she had received prenatal care. An urgent cesarean section was recommended, but she refused. Her husband was passively supportive of her decision. There were some concerns about mental illness, but no clear history was known to the team. Over the next several hours, the obstetric team attempted to respectfully persuade her to accept the cesarean as the fetus was in very serious distress. An ethics consult was requested. The patient acknowledged that her baby could die or suffer grave damage but felt doctors are too eager to deliver by c-section and that the baby would be fine. She also said she would be so traumatized by a cesarean that she did not think she could bear it.

The team considered whether the patient had decision-making capacity and what could be done to assist the fetus without harming the mother. The ethicist questions whether she could have done more to balance the competing vulnerabilities in this case.