Post-Phenomenological Issue: the Self in a First-Person Perspective in the Locked-In Syndrome

Post-phenomenological issue: The Self in a first-person perspective in the Locked-In Syndrome

Abstract

This study offers a specific point of view on the matter of self and self-consciousness because of its philosophical background applied to an original clinical experimentexploring a specific self-disorder: the Locked-In Syndrome (LIS). This syndrome is described as the massive loss of motor control associated with full consciousness of the patient. Cognitive functions remain intact but the patient is unable to make contact with others. Because of the major impact of this syndrome on personal identity, we designed an experiment to investigate the patients’ first person experience of their selves. Results suggest that the philosophical concept of the self should be acknowledged to include a more phenomenological ground. In this paper, we claim that the self refers to a first-person very flexible construction, requiring – among others – memory, a sense of body-ownership and a subjective feeling of “meaning”. This conception stands against the very traditional one in continental philosophy according to which the self is a separated entity from the body and has to remain one and the same all lifetime. That conception raised many famous questions such as the impossible interaction between an immaterial self and the body in Descartes’ dualism. Famous phenomenologists like Dilthey tried to propose a more subjective concept of the self. In an interdisciplinary approach linking philosophy, psychology and neuroscience, we claim that the philosophical concept of the self will benefit from our experiment on LIS patients to evolve towards a post-phenomenological concept. Self would then be considered as a dynamic and adaptable process rather than a separated entity.

Key words: self, self-consciousness, identity, Locked-In Syndrome

1)Introduction

In this study, we investigate the importance of two elements (body-representation and meaning) in the persistence of the self in the Locked-In Syndrome (LIS). Patients with the Locked-In Syndrome suffer a full body paralysis without any cognitive impairment. Often due to a vascular cerebral accident touching the brain stem, these patients remain fully conscious of themselves and their environment but have no means of expression or communication with others (Schnakers and Laureys, 2008). In this study we focus on their subjective experience of self-consciousness in the first person perspective (Perin, 2006; Bretard et als., 2006; Laureys, 2007) to evaluate how the self endures major changes in personal identity.

This experiment was designed around three dimensions of the phenomenological self in LIS: each part (A, B, C) targets a specific aspect. Our first goal is to question the traditional concept of self in continental philosophy, according to which the self is an immutable center that grants personal identity despite the physical injuries. We claim that the feeling of identity is a phenomenological issue that has little to do with the objective handicap of the patient. In other words some LIS patient may report the feeling of a continuous identity before and after the accident whereas some other will report the feeling of a major breach leading them to describe their previous self as a stranger to them. The first part of this test asks patients to evaluate their feeling of identity from continuity to breach.

The second part of this experiment targets another element of the concept of self in continental philosophy according to which the center of the self is the mind compared to which the body is of secondary importance. The LIS implies a total loss of motor skills and therefore creates an extreme situation for the patients regarding their relation to the body. The body acts no longer as a useful tool for will: the mental decision to move the arm no longer leads to the actual movement of the arm. There is a breach between the intact will of these patients and their motor capacities. One may think of the traditional Mind-Body Problem raised by Descartes’ dualism in philosophy. Many continental philosophers claimed that the self was linked to the mind and thought rather than the body. From Plato[1] to Malebranche[2] the body was conceived as disturbing the pure thought of the mind so that someone who wouldn’t have to worry about his body would access the perfection of the mind. In this very theoretical view, LIS patients may offer a chance to question the real importance of the body in the self. We claim that the body is of major importance in the construction of personal identity and therefore is completely part of the phenomenological self.

The third part of the experiment questions the usual way to study the self, which is the scientific third person perspective. Instead, we claim that the phenomenological self benefits from a first person perspective study. In this part (C), we try to investigate the feeling of a meaningful identity that leads us to say “My life means something to me” or not. When asked if they themselves would accept to be kept alive in such a situation, medical teams often answer that they wouldn’t. The patients, on the contrary, are often willing to be resuscitated in case of a new stroke after the accident. They report a complex life but which is nevertheless somehow manageable and therefore a life worth living (Laureys, 2005; Lulé, 2009). We claim that this dimension of the phenomenological self could explain how the self can adapt itself to major physical injuries despite the importance of the body.

2)Methods

The design of our test was based on the questionnaires used in social psychology (Likert) to measure attitudes and the previous quality of life tests (MVQOLI, McGill). 15 items were selected (5 for each part of the test) and patients were asked to tell how much they agreed or disagreed to each item following four degrees: “Totally agree”, “Agree”, “Disagree”, Totally disagree”. Because of the specific problems of these patients, the test was designed to be answer by blinking (only voluntary movement usually preserved) once to four times.

Literature in social psychology (Fiske, 2008) has demonstrated a tendency for subjects to answer positively so half of the items were presented in a negative way (“I don’t recognize myself”) and half in a positive way (“I still am the same person”). Answers to each item have to be interpreted considering this difference (Annex 1): the more the answer tends to a continuous identity, the more the score will be positive (+1, +2). The more the answer reveals a breach in identity, the more the score will be negative (-1, -2) according to the four possible levels of answer. This gives three partial scores (part A, B, C) and a global score (sum of the score for the 15 items). The importance of each dimension will be interpreted from the correlation between the partial score and the global score.

3)Population

All patients are members of the French association ALIS. 44 LIS patients (14 females, 30 males) between 17 and 71 year old (mean = 49) took the test. Age distribution is reported in Graph 1. Time since the accident is reported in Graph 2.

Graph 1: Age distribution

Graph 2: Time since the accident

4)Procedure

Test is taken at home, with the help of a caregiver instructed not to influence the answers. Same procedure has been used for several years by the Coma Science Group (Laureys, University of Liege) during similar tests so that the situation presented no difficulties for the patients.

Questionnaire presented the 15 items with the following instruction: “Precise for each item if you totally agree (1), agree (2), disagree (3) or totally disagree (4). Blink the suitable number of time to chose the answer.”

5)Variables et Hypothèses opérationnelles

Our three hypotheses are the following:

H1: If the questionnaire targets one and the same concept of self, then one should expect a correlation between the partial score A and the global score.

H2: If the body is an important element of the self, one should expect a strong correlation between the partial score B and the global score.

H3: If the meaning of one’s life is an important element of the self, then one should expect a correlation between the partial score C and the global score.

6)Results

A-Profils from the global score

In order to define the general profile of our patients, we analyzed the global score (15 items, score from -30 to +30). Score repartition shows that 28 of the 44 patients have a positive score, indicating a continuous identity despite the accident. 15 patients have a negative profile; one patent has a neutral score. Mean score is 3, 5 and 75% of the patients have a score superior to -4. According to the four levels of answer, only two patients report a totally discontinuous self (score <-15); 13 patients report a discontinuous self (score between -15 and 0); 21 patients report a continuous self (score between 0 and +15) and 7 patients report a totally continuous self (score >+15). Score repartition is indicated on Graph 3.

Graph 3: Scores’ repartition

A-Correlations’ analyse

To test our first hypothesis, the correlation between score partial A and global score was calculated. Tau Kendall method (t=0.51) indicates a significant correlation at 0.05. This tends to prove that the patients’ global introspective evaluation of the self is coherent with their global judgment. The whole questionnaire seems to investigate one and the same concept of the self, otherwise the partial score A and the global score wouldn’t have been correlated. On Graph 4 you see the repartition of the patients’ profile in blue compared to a perfect correlation (red line).

Graph 4: Correlation between partial score A (Var 1) and global score (Var 4)

To test our second hypothesis, the correlation between partial score B and global score was tested. Tau Kendall method (t=0.72) indicates a significant correlation at 0.05. This tends to prove that the body representation is an important element of the self. A patient with a good appropriation of his body is expected to report a continuous self. We can suggest that the self doesn’t remain untouched (continuous) by ignoring the body but on the contrary patients tend to report a global experience of their self very correlated to their experience of their own body. That is to say that from these results the body is a very good predictor of the quality of the phenomenological self in a first person perspective. On Graph 5 you see the correlation between score partial B and the global score.

Graph 5: Correlation between partial score B (Var 2) and global score (Var 4)

To test our third hypothesis, the correlation between partial score C and global score was tested. Tau Kendall method (t=0.63) indicates a significant correlation at 0.05. This tends to prove that the meaning is an important element of the self. Patients tend to report a continuous self when their lives and choices are experienced as meaningful. On the contrary patients report a breach when they experience a feeling of being passive. This would confirm the importance of the feeling of agency in the constitution of the self as suggested in the philosophical literature (De Vignemont, 2004).

Graph 6: Correlation between partial score C (Var 3) and global score (Var 4)

7-Discussion

The aim of this study was to promote a new conception of the phenomenological self based on a clinical experiment. Locked-In Syndrome was first chosen because it involves a major traumatic event in the personal identity. Despite this fact most of the patients report a preserved self. Further investigation could propose the test to a control group in order to evaluate whether healthy subjects would predict a massive discontinuous profile for LIS patients in a third person perspective. If it was to be the case, as previous studies tend to show (Laureys, 2005; Lulé, 2009), it would greatly encourage first person perspective investigations of the self.

Second reason why LIS was chosen is the massive impact to the relation to the body as a tool for will. The loss of almost all motor skills allows us to investigate the importance of the body in the constitution and continuity of the self in LIS patients. The idea was to question this evidence in the continental philosophy that the body is of secondary importance to the selfcompared to the mind. Results tend to prove that on the contrary the body constitutes a major element of the self and remains so even after a total motor incapacity. Not only does the self include the body representation of the patient but the phenomenological experience of the self is strongly correlated to the experience of the body. This leads us to a new concept of the self in philosophy. Instead of considering that these patients report a continuous self because their cognitive capacities are preserved, we claim that the continuity of the self is to be interpreted in terms of preserved relation to the body. Such a theoretical change implies also medical consequences. Considering the self as a flexible body-related constructionof the patient might lead us to increase the body-related care at the hospital, not only for rehabilitation but also for body-appropriation, sense of body-ownership and sense of agency (Tsakiris, 2006).

The third part of the test was designed to investigate the very subjective bases of the self considered as a meaningful construction of the patient. The five items are based on several sources. The sense of agency, defined as the subjective experience of being the cause of an action, has for example been studied as a constitutive element of the self in the developmental psychology (Rochat, 2007). One could link this element to the active/passive distinction. It seems difficult to consider a life in which I’m always passive as mine. Items C1 and C4 therefore target the sense of agency as part of a meaningful self. Item C3 targets another well known element of the self in social cognition through the familial integration. This dimension is also investigated in the last part of the Coma Science Group Test that ALIS patients used to take in previous years. Items C2 and C5 are based on the fifth part of a quality of life test (MVQOLI) which targets a very phenomenological aspect of the self (entitled “Degree of experienced meaning and purpose in life”).Results show that patients report a better preserved self when their life, no matter how different, keeps its meaning to them. Further research could develop this new concept of a flexible self. As well as we refer to brain plasticity, we could refer to self plasticity, which is an opposite conception of the self compared to continental philosophy.

This study seems indeed to show that the self is not to be considered as a permanent element that would guarantee personal identity despite physical changes but rather as a subjective construction, flexible enough for the patient to appropriate as his very different lives. Throughout experiment, the self seems to refer to a constant process of adaptation and appropriation rather than any permanent entity like the soul or the mind had to be as immaterial principles of individuality.

References

BRETARD, S., DELCHAMBRE, M., LAUREYS, S. (2006), «One’s own Face is hard to ignore», The Quarterly Journal of experimental Psychology, 59(1), 46-52

DEMERTZI A. and al., (2009), “Dualism persists in the Science of Mind”, Annals of the New York Academy of Sciences, 1157, 1-9

DE VIGNEMONT, F. and FOURNERET, P. (2004), “The sense of agency, a philosophical and empirical review of the Who system”, Consciousness and Cognition

FISKE, ST (2008), Psychologie sociale, Paris, De Boeck

JEANNEROD, M. (2007), L’Homme sans Visage et autres Récits de Neurologie quotidienne, Paris, Odile Jacob

LAUREYS, S. (2005), “What is it like to be conscious but paralyzed and voiceless?” Progress in Brain Research, 150, 495-511

LAUREYS, S. (2007), “Self-Consciousness in non-communicative Patients”, Consciousness and Cognition, 16, 722-41

LULE, D. and al., (2009), “Life can be worth living in locked-in syndrome”, Progress in Brain Research, 177, 339-51

MALEBRANCHE, 1965, Œuvres complètes, dirigé par André Robinet, Paris, Vrin

PERRIN, F. (2006), “Cerebral Response to patient’s own Name in Vegetative State, Minimal conscious State and Locked-In Syndrome”, Archives of Neurology, 63, 562-9

PLATO, 2002, Phedon, 66b-e, Paris, Garnier Flammarion, p216-7

ROCHAT, P. (2005), Le Monde des Bébés, Paris, Odile Jacob

SCHNAKERS, C., LAUREYS, S. (2008), “Cognitive function in the Locked-In Syndrome”, Journal of Neurology, 255, p. 323-330

TSAKIRIS, M., PRABHU, G. and HAGGARD, P. (2006), “Having a body versus moving your body: how agency structures body-ownership”, Consciousness and Cognition

[1] “As long as our soul will be attached to our body, we will never get to the truth because the body causes lots of difficulties, like the need to be fed, or cured… If we ever want to access any pure knowledge, it is demonstrated that we need to get rid of the body and contemplate things through the soul.” Plato, Phedon, 66be

[2] “If the soul was released for a moment from the physical impressions caused by the body, it would then be purer and smarter than any greater saint.” Malebranche, Œuvres III, 116