Moll, F. H., Görgen, A., Krischel, M., & Fangerau, H.. (2011). Das Bild der Tuberkulose im Film „Robert Koch – Bekämpfer des Todes“. Der Urologe, 50(11), 1441–1448.
“Summary psychiatrist thomas szasz fought coercion (compulsory detention) and denied that mental illness existed. although he was regarded as a maverick, his ideas are much more plausible when one discovers that between 1939 and 1941, up to 100 000 mentally ill people, including 5000 children, were killed in nazi germany. in the course of the nazi regime, over 400 000 forced sterilisations took place, mainly of people with mental illnesses. other countries, including denmark, norway, sweden and switzerland, had active forced sterilisation programmes and eugenics laws. similar laws were implemented in the usa, with up to 25 000 forced sterilisations. these atrocities were enabled and facilitated by psychiatrists of the time and are only one example of the dark side of the profession. this article reviews some of these aspects of the history of psychiatry, including germany’s eugenics programme and the former ussr’s detention of dissidents under the guise of psychiatric treatment.”
Zeidman, L. A.. (2011). Neuroscience in Nazi Europe Part II: Resistance against the Third Reich. Canadian Journal of Neurological Sciences / Journal Canadien Des Sciences Neurologiques, 38(6), 826–838.
“Previously, i mentioned that not all neuroscientists collaborated with the nazis, who from 1933 to 1945 tried to eliminate neurologic and psychiatric disease from the gene pool. oskar and cécile vogt openly resisted and courageously protested against the nazi regime and its policies, and have been discussed previously in the neurology literature. here i discuss alexander mitscherlich, haakon saethre, walther spielmeyer, jules tinel, and johannes pompe. other neuroscientists had ambivalent roles, including hans creutzfeldt, who has been discussed previously. here, i discuss max nonne, karl bonhoeffer, and oswald bumke. the neuroscientists who resisted had different backgrounds and motivations that likely influenced their behavior, but this group undoubtedly saved lives of colleagues, friends, and patients, or at least prevented forced sterilizations. by recognizing and understanding the actions of these heroes of neuroscience, we pay homage and realize how ethics and morals do not need to be compromised even in dark times.”
Arbia, D., Alam, M., Moullec, Y., & Hamida, E.. (2017). Communication Challenges in on-Body and Body-to-Body Wearable Wireless Networks—A Connectivity Perspective. Technologies, 5(3), 43.
“Wearable wireless networks (wwns) offer innovative ways to connect humans and/or objects anywhere, anytime, within an infinite variety of applications. wwns include three levels of communications: on-body, body-to-body and off-body communication. successful communication in on-body and body-to-body networks is often challenging due to ultra-low power consumption, processing and storage capabilities, which have a significant impact on the achievable throughput and packet reception ratio as well as latency. consequently, all these factors make it difficult to opt for an appropriate technology to optimize communication performance, which predominantly depends on the given application. in particular, this work emphasizes the impact of coarse-grain factors (such as dynamic and diverse mobility, radio-link and signal propagation, interference management, data dissemination schemes, and routing approaches) directly affecting the communication performance in wwns. experiments have been performed on a real testbed to investigate the connectivity behavior on two wireless communication levels: on-body and body-to-body. it is concluded that by considering the impact of above-mentioned factors, the general perception of using specific technologies may not be correct. indeed, for on-body communication, by using the ieee 802.15.6 standard (which is specifically designed for on-body communication), it is observed that while operating at low transmission power under realistic conditions, the connectivity can be significantly low, thus, the transmission power has to be tuned carefully. similarly, for body-to-body communication in an indoor environment, wifi ieee 802.11n also has a high threshold of end-to-end disconnections beyond two hops (approximatively 25 m). therefore, these facts promote the use of novel technologies such as 802.11ac, narrowband-iot (nb-iot) etc. as possible candidates for body-to-body communications as a part of the internet of humans concept.”
Thiry, L. (1970). The Ethical Theory of Saint Thomas Aquinas: Interpretations and Misinterpretations. The Journal of Religion, 50(2), 169–185. www.jstor.org/stable/1201784
What is the natural law? We might attempt to answer this question by considering both the meaning of the term “law” as well as the law’s origin. On Aquinas’s view, a law is “a rule or measure of human acts, whereby a person is induced to act or is restrained from acting” (ST IaIIae 90.1). Elsewhere, he describes a law as a “dictate of practical reason emanating from a ruler” (ST IaIIae 91.1). At a very general level, then, a law is a precept that serves as a guide to and measure of human action. Thus whether an action is good will depend on whether it conforms to or abides by the relevant law. Here we should recall from an earlier section that, for Aquinas, a human action is good or bad depending on whether it conforms to reason. In other words, reason is the measure by which we evaluate human acts. Thus Aquinas thinks that the laws that govern human action are expressive of reason itself (ST IaIIae 90.1).
For Thomas Aquinas, as for Aristotle, doing moral philosophy is thinking as generally as possible about what I should choose to do (and not to do), considering my whole life as a field of opportunity (or misuse of opportunity). Thinking as general as this concerns not merely my own opportunities, but the kinds of good things that any human being can do and achieve, or be deprived of. Thinking about what to do is conveniently labeled “practical”, and is concerned with what and how to choose and do what one intelligently and reasonably can (i) to achieve intelligible goods in one’s own life and the lives of other human beings and their environment, and (ii) to be of good character and live a life that as a whole will have been a reasonable response to such opportunities.
Political philosophy is, in one respect, simply that part or extension of moral philosophy which considers the kinds of choice that should be made by all who share in the responsibility and authority of choosing for a community of the comprehensive kind called political. In another respect, it is a systematic explanatory account of the forms of political arrangement that experience and empirical observation show are available, with their characteristic features, outcomes, and advantages (and disadvantages and bad aspects and consequences). Though in form descriptive and contemplative, and thus non-practical, this aspect of political philosophy remains subordinate, in its systematization or conceptual structure, to the categories one finds necessary or appropriate when doing moral and political philosophy as it should be done, that is, as practical thinking by one whose every choice (even the choice to do nothing now, or the choice to do moral or political philosophy) should be a good use of opportunity.
Moral and political philosophy for Aquinas, then, is (1) the set or sets of concepts and propositions which, as principles and precepts of action, pick out the kinds of conduct (that is, chosen action) that are truly intelligent and reasonable for human individuals and political communities, together with (2) the arguments necessary to justify those concepts and propositions in the face of doubts, or at least to defend them against objections. It is a fundamentally practical philosophy of principles which direct us towards human fulfillment (flourishing) so far as that happier state of affairs is both constituted and achievable by way of the actions (chosen conduct) that both manifest and build up the excellences of character traditionally called virtues. If one must use a post-Kantian jargon, it is both “teleological” and “deontic”, and not more the one than the other.
Aquinas’ moral and political philosophy has to be reconstructed from his theological treatises and commentaries and his commentaries on Aristotle’s Nicomachean Ethics and the first two and half books of Aristotle’s Politics. Its proper interpretation has been a matter of some difficulty from the time of his death in 1274. In recent decades the way to understand some aspects of its foundational concepts and logic has been strenuously disputed, not least among those philosophers who see it as offering a broadly sound answer to radical scepticism about value and obligation, an answer truer and more human than Kant’s or Bentham’s or their (in the broadest sense) successors’. A partial sample of these controversies is given in 1.1 and 1.2 below, which state the more common interpretation on two strategic issues and then elaborate objections to those interpretations. The remainder of this article then proceeds on the basis that there is merit in these objections, and that the study of Aquinas’ ethics as a systematic and strictly philosophical work of practical reason (at its most general and reflective) is still in its infancy. Further textual support, from over 60 of Aquinas’ works, can be found in Finnis 1998. Criticisms of the interpretation of Aquinas’ theory that is proposed in that work can be found in Paterson 2006, Wheatley 2015, Long 2004, and earlier in Lisska 1998 and McInerny 1997. These works argue in various ways that that interpretation denies or neglects the metaphysical foundations of the principles of practical reason that it offers to identify. Support, in general, for the approach in this article will be found in Rhonheimer 2012 and 2000. The first issue underlying this debate is whether the order of inquiry and coming to know (the epistemological order) is the same as the order of metaphysical dependence. The second issue is whether we can settle the first issue by using the epistemological axiom that we come to an (ultimately metaphysical) understanding of dynamic natures by understanding capacities through their actuations – which, in turn, we come to understand by understanding their objects. Does or does not that axiom entail that understanding of objects such as the intelligible goods (the objects of acts of will) precedes an adequate knowledge of nature, notwithstanding that (as is agreed on all sides) in the metaphysical order of intrinsic dependence such objects could not be willed or attained but for the given nature of (in this case) the human person?
1.1 Is the notion of “distinctive human function” foundational for Aquinas?
One line of understanding is exemplified by the section on “moral doctrine” in McInerny and O’Callaghan 2005. It gives a priority to Aristotle’s arguments attempting to identify a “distinctive” or “peculiarly human” function, arguments which proceed on the postulate that, if each kind of craft has its own characteristic function and mode of operation, so must human life as a whole have an “overall” and “distinctively characteristic” function and operatio; and the determination of this should decisively shape the whole of (the rest of) ethics and political theory. To this standard interpretation other interpreters, such as Grisez, Finnis, and Rhonheimer, object on grounds such as these:
(i) Aquinas’ austerely self-disciplined purposes as an Aristotelian commentator make quite insecure any assumption that he treats as fundamental to his own thinking any and every proposition which is treated by Aristotle as fundamental and expounded in Aquinas’ relevant commentary without adverse comment.
(ii) The “distinctive function” argument is not prominent or adduced as fundamental (or at all) in Aquinas’ more free-standing treatments of morality.
(iii) The argument is treated by Aquinas’ commentary as yielding the conclusion that felicitas (human happiness or flourishing) consists in a complete life lived in accordance with reason and hence, by entailment, with virtue. But in the Summa Theologiae this is argued to be only an imperfect and incomplete felicitas, and the problematic character of such a concept is apparent from the Summa’s definition of felicitas (and synonymously beatitudo) as perfect good and complete satisfaction of all desires.
(iv) The “distinctive function” argument is inherently unsatisfying in ways that could hardly have failed to be apparent to so able a philosopher as Aquinas. (a) In Aquinas’ rendering, it depends on the postulate that “nature does nothing in vain”, which in turn depends, according to Aquinas, on the premise that nature is the product of divine creative rationality, a premise which Aquinas himself argues is, though provable, by no means self-evident. (b) It seems arbitrary to assume that, if there is an appropriate function or operatio of human beings, it must be peculiar to them. For peculiarity or distinctiveness has no inherent relationship to practical fittingness, and in fact Aquinas elsewhere denies that rationality is peculiar to human beings since he holds that there are other intelligent creatures (the angels, understood to be created minds unmixed with matter, occupying what would otherwise be a surprising gap in the hierarchy of beings which ascends from the most material and inactive kinds through the vegetative kinds, the animal kinds, and the rational animal humankind, to the one utterly active and intelligent, non-dependent and uncreated divine being).
(v) The root of the weakness of the “peculiar/distinctive function” argument is that it is looking in the wrong direction, towards a metaphysical proposition concerning the nature of things, instead of towards what is intelligibly good as an opportunity, perhaps even the supreme opportunity, for me and anyone like me (any human being). And it is a truly fundamental methodological axiom of Aquinas’s philosophy, from beginning to end of his works, that in coming to understand the nature of a dynamic reality such as human being, one must first understand its capacities, to understand which one must first understand its act(ivities), to understand which one must first come to understand those activities’ objects. But the objects of human activities are intelligible opportunities such as coming to know, being alive and healthy, being in friendship with others, and so forth – objects whose attractiveness, fittingness, opportuneness, or appropriateness is in no way dependent upon, or even much enhanced by, the thought that they are distinctively characteristic of human beings as opposed to other animals.
(vi) The fact that an operatio is distinctive of human beings does not entail that that operatio is truly valuable, still less that it is obligatory, or that it is more valuable than alternative and incompatible ways or objectives of acting. For a premise containing no evaluative or normative term cannot entail a conclusion including such a term. If, on the other hand, the postulate that a certain operatio is the proper (or even a proper) function of human beings is asserted to be itself evaluative and/or normative rather than, or as well as, factual/descriptive, then some account is needed of the postulate’s source or justification (or self-evidence?). Aquinas has a fairly careful account of the self-evidence of a number of foundational evaluative and normative principles, but only one or two of them are said by him to point to kinds of operatio distinctive of human beings; two of the foundational principles are explicitly said by him to direct to goods that are not peculiar to human beings.
(vii) The analogy comparing one’s life as a whole to arts and crafts, each with its own distinctive function, operatio, seems weak, questionable and indeed question-begging. For life as a whole is open-ended both in having no knowable duration (see 2.2. below) and in requiring judgment about the choice-worthiness of ends as well as means and techniques (see 4.4.1. below). Moreover, Aquinas like Aristotle regularly insists on the irreducibility of the distinction or distinctions between, on the one hand, ars or factio (arts, crafts, techniques) and actio (the precise subject-matter of morality and morally significant choices).
1.2 Is the identification of “man’s last end” foundational for Aquinas?
Along with very many other Thomistic commentators, McInerny and O’Callaghan 2005 and Celano 2003 treat Aquinas’ moral philosophy as founded, like his moral theology, upon his determination of what felicitas (= perfecta beatitudo and Aristotle’s eudaimonia) truly is, a determination made in the opening quaestiones of the Second Part of his Summa Theologiae, where he elaborately argues that complete beatitudo or felicitas consists in an uninterruptible vision of God (and, in God, of the other truths we naturally desire to know), something possible for us only in a life – in many respects another life – after death. But it is possible to regard Aquinas’ argument in those quaestiones as dictated by the needs of a specifically theological pedagogy, as open to telling objections, and as detachable from (or at least as methodologically posterior to) the working and sound foundations of his moral philosophy and his treatment of specific moral issues – detachable, that is to say, in a way that Aquinas would not need to regard as inappropriate in the different context of today’s discourse. This article will treat Aquinas’ ethics and political theory as detachable from his theology of life’s ultimate point, and will take seriously his emphatic and reiterated thesis that, apart from the divinely given and super-natural opportunity of perfecta beatitudo (a gift about which philosophy as such knows nothing), the only ultimate end and beatitudo (fulfillment) for human beings is living in a completely reasonable, morally excellent (virtuosus) way. That thesis entails that philosophy’s main account of morality need and should contain no claim about what perfect happiness consists in.
Despite surface appearances, Aquinas is conscious of Aristotle’s failure to settle whether it is contemplation or political praxis that is the essence of human fulfillment. He therefore attempts, more intently than Aristotle did in any surviving work, to identify what the first principles of ethics and politics are, and to do so without any premises or presuppositions about a unitary “last end of human existence”.
Moreover, when Aquinas does refer to beatitudo as fundamental to identifying the principles of practical reason and the natural (because reasonable) moral law, he in the same breath emphasizes that this is not to be thought of as the happiness of the deliberating and acting individual alone, but rather as the common flourishing of the community, ultimately the whole community of humankind:
The ultimate end of human life is felicitas or beatitudo… So the main concern of law [including the natural (moral) law] must be with directing towards beatitudo. Again, since every part stands to the whole as incomplete stands to complete, and individual human beings are each parts of a complete community, law’s appropriate concern is necessarily with directing towards common felicitas … that is, to common good. (ST I-II q. 90 a. 2.)
The “complete community” mentioned here is the political community, with its laws, but the proposition implicitly refers also to the community of all rational creatures, to whose common good morality (the moral law) directs us.
1.2.1 Philosophy and theology in Aquinas’ theory of morality and politics
Detaching Aquinas’ philosophy from his theology is compatible with distinctions he firmly delineates at the beginning of his two mature theological syntheses, the Summa contra Gentiles and the Summa Theologiae. (i) There are truths, he says, which are accessible to natural reason, that is, to ordinary experience (including the specialized observations of natural scientists), insight, and reflection; and these include practical truths about good and evil, right and wrong. (ii) Many of those truths of natural reason are confirmed, and even clarified, by divine revelation, that is, the propositions communicated directly or inferentially in the life and works of Christ, as transmitted by his immediate followers and prepared for in the Jewish scriptures accepted by those followers as revelatory. (iii) Some of the truths divinely revealed could not have been discovered by natural, philosophical reason, even though, once accepted, their content and significance can be illuminated by the philosophically ordered reflection which he calls theology.
The philosophical positions in ethics and politics (including law) that are explored in this article belong to categories (i) and (ii). The moral and political norms stated, for example, in the biblical Decalogue are, in Aquinas’ view, all knowable independently of that revelation, which confirms and perhaps clarifies them. But the propositions that he holds about what the true last end or ultimate destiny of human beings actually is belong to category (iii) and cannot be affirmed on any philosophical basis, even though philosophy, he thinks, can demonstrate that they are neither incoherent nor contrary to any proposition which philosophy shows must be affirmed.
2. Practical reason’s first principles
Intelligence and reason are not two powers; “reason” and “reasoning” in a narrow sense can be regarded as the extension of one’s “intelligence” (one’s capacity for intelligent insight into the data of experience) into the propositional work of reasoning towards judgment, and “reason” (ratio) in a broader sense refers to this whole capacity, only analytically divisible into aspects or phases. So too, practical reason is not a distinct power. Rather, one’s capacity to think about the way things are can be (and naturally, that is effortlessly and normally, is) “extended” (Aquinas’ metaphor) to thinking intelligently and making reasonable and true judgments about what to do. Thinking and judging of the latter kind is practical, that is, intends to terminate in choice and action (in Greek praxis, in Latin actio). “Practical reason” sometimes refers (i) directly to such thinking, sometimes (ii) to the propositional content or structure which such thinking has when it is done well – and thus to the propositions that pick out what kinds of action one ought to be judging pursuit-worthy, undesirable, right, wrong, etc. – and sometimes (iii) to the capacity to engage in such thinking by understanding such propositions and being guided by them.
2.1 Precondition: capacity for self-determination by free choices
Practical reason’s central activity is deliberation about what to do. One would have no need to deliberate unless one were confronted by alternative attractive possibilities for action (kinds of opportunity) between which one must choose (in the sense that one cannot do both at the same time, if at all) and can choose. The standards that one comes to understand to be the appropriate guides for one’s deliberation, choice and action give such guidance, not by predicting what one will do, but by directing what one should do. (The “should” here may but need not be moral.) There could be no normativity, no practical (choice-guiding) directiveness, unless free choices were really possible.
Aquinas’s position is not that all our activities are freely chosen: there are indeed “acts of the human person”, perhaps quite frequent, which are not “human acts” in the central sense (freely chosen) but rather spontaneous and undeliberated. Nor is it that chosen acts must be immediately preceded by choice: many of one’s acts are the carrying out of choices which were made in the past and need not be now renewed or repeated since no alternative option appears attractive. It is that one can be and often is in such a position that, confronted by two or more attractive possibilities (including perhaps the option of “doing nothing”), there is nothing either within or outside one’s personal constitution that determines (settles) one’s choice, other than the choosing: Mal. q. 6. This conception of free choice (liberum arbitrium or libera electio) is much stronger than Aristotle’s, on whose conception free choices are free only from external determining factors. Aquinas’ conception of free choice is also incompatible with modern notions of soft determinism, or the supposed compatibility of human responsibility (and of the sense [self-understanding] that one is freely choosing) with determination of every event by laws (e.g. physical) of nature. Aquinas understands the freedom of our free choices to be a reality as primary and metaphysically and conceptually irreducible as the reality of physical laws, and he puts all his reflections on morality and practical reason under the heading of “mastery over one’s own acts” (ST I-II, prologue).
He is also insistent that if there were no such freedom and self-determination, there could be no responsibility (fault, merit, etc.), and no sense or content to any ought (normativity) such as ethics is concerned with.
2.1.1 Choice, intention and act-descriptions
Aquinas pulls together into a powerful (though confusingly expounded) synthesis a long tradition of analysis of the elements of understanding (reason) and intelligent response (will) that constitute deliberation, choice, and execution of choice: ST I-II qq. 6–17. The analysis shows the centrality of intention in the assessment of options and actions. In a narrow sense of the word, intention is always of ends and choice is of means; but since every means (save the means most proximate to sheer trying or exertion) is also an end relative to a more proximate means, what is chosen when one adopts one of two or more proposals (for one’s action) that one has shaped in one’s deliberation is rightly, though more broadly, said to be what one intends, what one does intentionally or with intent(ion), and so forth. An act(ion) is paradigmatically what it is intended to be; that is, its morally primary description – prior to any moral evaluation or predicate – is the description it had in the deliberation by which one shaped the proposal to act thus. Aquinas’ way of saying this is: acts are specified by – have their specific character from – their objects, where “objects” has the focal meaning of proximate end as envisaged by the deliberating and acting person. Of course, the behavior involved in that act can be given other descriptions in the light of conventions of description, or expectations and responsibilities, and so forth, and one or other these descriptions may be given priority by law, custom, or some other special interest or perspective. But it is primarily on acts qua intended, or on the acts (e.g. of taking care) that one ought to have intended, that ethical standards (moral principles and precepts) bear. To repeat: in the preceding sentence “intended” is used in the broad sense; Aquinas sometimes employs it this way (e.g. ST II-II q. 64 a. 7), though in his official synthesis the word is used in the narrower sense to signify the (further) intention with which the act’s object was chosen – object being the most proximate of one’s (broad sense) intentions.
This understanding of human action has often been misappropriated by interpreters who have assumed that when Aquinas says that acts are wrongful by reason of their “undue matter” (indebita materia), he refers to an item of behavior specifiable by its physical characteristics and causal structure. So, for example, direct killingof the innocent is taken to refer to behavior whose causally immediate effect is killing, or which has its lethal effect before it has its intended good effect. But this is incompatible with Aquinas’ fundamental and consistent positions about human action. The “matter” of a morally significant act is, for him, its immediate object under the description it has in one’s deliberation: Mal. q. 7 a. 1; q. 2 a. 4 ad 5; a. 6; a. 7 ad 8. It is, in other words, not an item of behavior considered in its observable physicality as such, but rather one’s behavior as one’s objective (or the most proximate of one’s objectives), that is, as one envisages it, adopts it by choice, and causes it by one’s effort to do so. The most objective account of human action is provided by the account that is most subjective. This sound account will, however, set aside any distorted act-descriptions that one may offer others, or even oneself, as rationalizations and exculpations of one’s choice and act, but that do not correspond to what really made the option attractive, as end or as means, and so was treated, in one’s actual course of deliberation, as one’s reason for acting as one did. The immediately and foreseen lethal effect of an act of self-defense may genuinely be a side-effect of one’s choosing to stop the attack by the only available efficacious means (ST II-II q. 64 a. 7), or it may be one’s precise object (and the “matter” of one’s choice and act) because one’s (further) intent was to take lethal revenge on an old enemy, or to deter potential assailants by the prospect of their death, or to win a reward. Behaviorally identical items of behavior may thus be very different human acts, discernible only by knowing the acting person’s reasons for acting.
2.2 Context: the open horizon of human life as a whole
Ethical standards, for which practical reason’s first principles provide the foundations or sources, concern actions as choosable and self-determining. They are thus to be distinguished clearly, as Aristotle already emphasized, from standards which are practical, rational, and normative in a different way, namely the technical or technological standards internal to every art, craft, or other system for mastering matter. Aquinas locates the significant and irreducible difference between ethics and all these forms of “art” in three features: (i) Moral thought, even when most unselfishly concerned with helping others through the good effects of physical effort and causality, is fundamentally concerned with the problem of bringing order into one’s own will, action, and character, rather than the problem of how to bring order into the world beyond one’s will. (ii) Correspondingly, the effects of morally significant free choices (good or evil) are in the first instance intransitive (i.e., effects on the will and character of the acting person). Only secondarily are they transitive effects on the world, even when that person’s intentions are focused, as they normally should be, on the benefits of those external effects. (iii) Whereas every art and technique has a more or less limited objective (end) which can be accomplished by skillful deployment of the art, moral thought has in view an unlimited and common (shared) horizon or point, that of “human life as a whole [finis communis totius humanae vitae]” (ST I-II q. 21 a. 2 ad 2), for each of one’s morally significant choices (for good or evil) is a choice to devote a part of one’s single life to a purpose which could have been any of the whole open-ended range of purposes open to human pursuit for the sake of benefiting all or any human being(s).
2.3 At the origin of Ought
Practical reason, in Aquinas’ view, has both one absolutely first principle and many truly first principles: ST I-II q. 94 a. 2. The absolutely first principle is formal and in a sense contentless. Like the logical principle of non-contradiction which controls all rational thought, it expresses, one might say, the pressure of reason and is so far from being empty of significance and force that its form may be regarded as the frame, and its normativity the source, for all the normativity of the substantive first principles and of the moral principles which are inferable from them. Aquinas articulates it as “Good is to be done and pursued, and bad avoided” (ibid.).
This has often been truncated to (i) “Good is to be done, and evil avoided” or even, more drastically, (iia) “Do good and avoid evil” or yet more drastically (iib) “Avoid evil and seek the good”. But Grisez 1963 gave reason to think these abbreviations both exegetically and philosophically unsound. The first practical principle is not a command or imperative as (ii) would have it, nor is it a moral principle as all these formulae suggest by omitting “to be pursued” (see 2.7 below). Both in grammar and in propositional content, the principle’s gerundive “is-to-be” is neither imperative nor predictive, but rationally directive – an ought – in the way that gets its fully developed and central sense and normativity in the more specified ought of moral standards.
Against a Kantian or neo-Kantian primacy or ultimacy of “structures of mind”, Aquinas would say that just as the pressure of reason articulated in the principle of non-contradiction has its source in the structure of reality – in the real opposition between being and not being – so the source of the equivalently first practical principle is the real desirability of intelligible goods, and the true undesirability of what is not good.
2.4 First principles of practical reason
If Plato and Aristotle fail to articulate substantive first principles of practical reason, and if Kant overlooks them in favor of the quasi-Humeian notions of motivation that dominate ethics during the Enlightenment (and ever since), the articulation of such principles by Aquinas deserves attention.
2.4.1 First principles are insights into the data of experience and understood possibility
Each of the several substantive first principles of practical reason picks out and directs one towards a distinct intelligible good which, in line with the primariness of the principle identifying it, can be called “basic” (not a term used by Aquinas). Aquinas regards each of the first practical principles as self-evident (per se notum: known through itself) and undeduced (primum and indemonstrabile). He does not, however, mean that they are data-less “intuitions”; even the indemonstrable first principles in any field of human knowledge are knowable only by insight (intellectus) into data of experience (here, of causality and inclination).
Moreover, when describing the first practical principles as self-evident, Aquinas emphasises that self-evidence is relative: what is not obvious to some will be self-evident to those who have more ample experience and a better understanding of other aspects of the matter. And we should expect our understanding of first principles to grow as we come to understand more about the objects to which they refer and direct (e.g. knowledge, human life, marriage, etc.).
2.4.2 Their Oughts are not inferred from any Is
Aquinas’s repeated affirmation that practical reason’s first principles are undeduced refutes the common accusation or assumption that his ethics invalidly attempts to deduce or infer ought from is, for his affirmation entails that the sources of all relevant oughts cannot be deduced from any is. There remain, however, a number of contemporary Thomists who deny that such a deduction or inference need be fallacious, and regard Aquinas as postulating some such deduction or inference. They are challenged., however, by others (such as Rhonheimer, Boyle, and Finnis) who, while sharing the view that his ethics is in these respects fundamentally sound, deny that Aquinas attempted or postulated any such deduction or inference, and ask for some demonstration (i) that he did and (ii) that he or anyone else could make such a deduction or inference.
These critics reinforce their denial by pointing out that in his prologue to his commentary on Aristotle’s Ethics, Aquinas teaches that knowledge of things that are what they are independently of our thought (i.e. of nature) is fundamentally distinct both from logic and from practical knowledge, one of whose two species is philosophia moralis (whose first principles or fundamental oughts are under discussion here)
2.4.3 A sample first principle: Knowledge is pursuit-worthy
Aquinas neglects to spell out how these first principles come to be understood. But he holds that they are understood and accepted by everyone who has enough experience to understand their terms. The process of coming to understand a first practical principle may be exemplified as follows, in relation to the basic good of knowledge. As a child one experiences the inclination to ask questions, and to greet apparently satisfactory answers with satisfaction and failure to answer as a disappointment. At some point one comes to understand – has the insight – that such answers are instances of a quite general standing possibility, namely knowledge, coming to know and overcoming ignorance. By a distinct though often well nigh simultaneous further insight one comes to understand that this – knowledge – is not merely a possibility but also a good [bonum], that is to say an opportunity, a benefit, something desirable as a kind of improvement (a perfectio) of one’s or anyone’s condition, and as to be pursued.
2.5 The other basic goods
The basic human goods which first practical principles identify and direct us to are identified by Aquinas as (i) life, (ii) “marriage between man and woman and bringing up of children [coniunctio maris et feminae et educatio liberorum]” (not at all reducible to “procreation”), (iii) knowledge, (iv) living in fellowship (societas and amicitia) with others, (v) practical reasonableness (bonum rationis) itself, and (vi) knowing and relating appropriately to the transcendent cause of all being, value, normativity and efficacious action (ST I-II q. 94 aa. 2 & 3). His lists are always explicitly open-ended. They sketch the outlines and elements of the flourishing of the human persons in whom they can be actualized. Even complete fulfillment – the beatitudo perfecta that Aquinas places firmly outside our natural capacities and this mortal life – could not be regarded as a further good, but rather as a synthesis and heightened actualization of these basic goods in the manner appropriate to a form of life free from both immaturity (and other incidents of procreation) and decay.
Similarly, as is entailed by the epistemological principle that nature is known by capacities, capacities by acts, and acts by their objects (see 1.1(v) above), these basic goods, being the basic objects of will and free action, are the outline of human nature. The is of an adequate account of human nature is dependent upon prior grasp of the oughts of practical reason’s first, good-identifying principles, even though that prior grasp was made possible by that partial understanding of human nature which comes with an understanding of certain lines of causality and possibility. But defending the epistemological priority of the intelligible objects of will in explanations of practical reason does not entail (contrast McInerny 1992) any denial of the metaphysical priority of the naturally given facts about the human makeup.
2.6 Known by (or from) inclination?
Many modern accounts of Aquinas’ theory of natural law give explanatory primacy to the naturalness of the inclinations (to live, to know, etc.) that correspond to these basic goods. But others regard this as a fundamental misunderstanding of Aquinas’ conception of will, and of the epistemological relationship between nature and reason. Will is for him intelligent response to intelligible good: one’s will is “in” one’s reason [voluntas in ratione]. He makes it very explicit both that human actions are rightly said to be natural (in the morally relevant sense of “natural”) when and because they are intelligent and reasonable (ST I-II q. 71 a. 2), and that there are inclinations which are natural, in the sense that they are commonly found or characterize some or even most individuals, yet are unnatural because lacking any intelligibly good object. So explanatory priority must be accorded to the basic human goods themselves, and to the self-evident desirability which makes each of them the object of an inclination in the will of anyone sufficiently intelligent and mature to understand their goodness (that is, the way they make human beings more fulfilled, more “perfect” [complete]). An inclination of that kind is relevant in practical reason because its object is desirable, and desirable because it would contribute to anyone’s flourishing. To say this is not to say that our natural inclinations to what contributes to our flourishing are mere accident or happenstance.
2.7 Only incipiently moral
Many nineteenth- and early twentieth century accounts of Aquinas took it that the first principles of practical reason, which he regularly calls first principles of natural law or natural right, are moral principles picking out kinds of human act as to be done (e.g. alms-giving to the poor) or not done (e.g. murder, adultery), in the manner of the Commandments. But though there are a few passages in which Aquinas himself speaks in that way, they can be read down so as to make them consistent with the more strategic passages in which he speaks of such moral principles or norms as “derived” conclusions from first principles. (See also 3.3 below.) Even immoral people so blinded by culture or disposition that they do not make these inferences nevertheless can and normally do understand the first principles of practical reason and are guided by them, though imperfectly, in their deliberations.
Against Kant’s assumption that, since the ends toward which one wishes to act are subjective because projected, and established in one’s deliberating and willingness (as Hume proposed), by one’s subrational desires, practical reason’s function is to limit and channel one’s pursuit of those ends, Aquinas considers that practical reason’s first and fundamental operation is not limiting, confining or negative but rather facilitating and positive: finding and constructing intelligible ends to be pursued (prosequenda), ends that give intelligent point to our behavior.
The thesis that the first practical principles are only incipiently moral should not be confused with the widespread modern opinion that practical reason’s default position is self-interest or “prudential” reason, so that there is a puzzle about how one transits from this to morality. In Aquinas’ classical view, one’s reason (as distinct from some of one’s customary ways of thinking) naturally understands the primary or basic goods as good for anyone, and further understands that it is good to participate in the many forms of friendship which require that one set aside all merely emotionally motivated self-preference.
3. Moral principles
The discerning, inferring and elaborating of moral principles is a task for practical reasonableness. The judgments one makes in doing this are together called one’s conscience, in a sense prior to the sense in which conscience is the judgments one passes or could pass on one’s own acts considered retrospectively. Someone whose conscience is sound has in place the basic elements of sound judgment and practical reasonableness, that is of the intellectual and moral virtue which Aquinas calls prudentia. Full prudentia requires that one put one’s sound judgment into effect all the way down, i.e. into the particulars of choice and action in the face of temptations to unreasonable but perhaps not unintelligent alternatives.
3.1 Conscience
Conscience in Aquinas’ view is not a special power or presence within us, but is our practical intelligence at work, primarily in the form of a stock of judgments about the reasonableness (rightness) or unreasonableness (wrongness) of kinds of action (kinds of option). Since each such judgment is of the form “[It is true that] action of the kind phi is always [or generally] wrong [or: is generally to be done, etc.]” or “phi is [always] [or: generally] required [or forbidden] by reason”, it must be the case – as Aquinas stresses very forcefully – that one’s conscience is binding upon oneself even when it is utterly mistaken and directs or licenses awful misdeeds. For since it is logically impossible that one could be aware that one’s present judgment of conscience is mistaken, setting oneself against one’s own firm judgment of conscience is setting oneself against the goods of truth and reasonableness, and that cannot fail to be wrong: ST I-II q. 19 a. 5; Ver. q. 17 a. 4. The fact that, if one has formed one’s judgment corruptly, one will also be acting wrongly if one follows it (ST I-II q. 19 a. 6) does not affect the obligatoriness (for oneself) of one’s conscience. This teaching about conscience was rather novel in his day and to this day is often misrepresented or misapplied as a kind of relativism or subjectivism. But it is actually an implication of Aquinas’ clarity about the implications of regarding moral judgments as true (or false) and of thus rejecting subjectivism and relativism.
3.2 The supreme moral principle
Aquinas is regrettably inexplicit about how the first practical principles yield moral principles, precepts or rules that have the combined generality and specificity of the precepts found in the portion of the biblical Decalogue (Exod. 20.1–17; Deut. 5.6–21) traditionally called moral (the last seven precepts, e.g. parents should be reverenced, murder is wrong, adultery is wrong, etc.). But a reconstruction of his scattered statements makes it clear enough that in his view a first implication of the array of first principles, each directing us to goods actualisable as much in others as in oneself, is this: that one should love one’s neighbor as oneself.
Since he considers this principle, like the set of first principles mentioned in I-II q. 94 a. 2, to be self-evident (per se notum), he must regard the principle of love-of-neighbor-as-self not so much as an inference from, or even specification of, but rather a redescriptive summary of that set. This in turn suggests the further reflection that the first principles, and the goods (bona) to which they direct us, are transparent, so to speak, for the flesh-and-blood persons in whom they are and can be instantiated. Moreover, it may be thought that the primary moral principle of love of neighbor as oneself is another reason to doubt (despite appearances) the strategic role of eudemonism in his ethics. Aristotelianising interpretations of Aquinas’ ethics normally make central the notion of fulfillment, understood (it seems) as the fulfillment of the deliberating and acting person – to which the requirement of neighbor love does not have a perspicuous relationship. Grisez and others, on the other hand, take it that the role of fulfillment (eudaimonia, beatitudo) in ethical thought’s unfolding from the first principles of practical reason is best captured by a “master moral principle” close though perhaps not identical to Aquinas’s supreme moral principle: that all one’s acts of will be open to integral human fulfillment, that is to the fulfillment of all human persons and communities now and in future.
The supreme moral principle of love of neighbor as self has, Aquinas thinks, an immediately proximate specification in the Golden Rule: Others are to be treated by me as I would wish them to treat me. The tight relation between the love principle and the Golden Rule suggests that love and justice, though analytically distinguishable, certainly cannot be contrasted as other and other. “Neighbor” excludes no human being anywhere, insofar as anyone could be benefited by one’s choices and actions. To love someone is essentially to will that person’s good. The reasonable priorities among all these persons as objects of one’s love, goodwill and care are discussed by Aquinas both as an “order of love(s)” [ordo amoris] and as a matter of right and justice.
3.2.1 The fuller version: the place of the transcendent
Since Aquinas thinks that the existence and providence of God, as the transcendent source of all persons and benefits, is certain, his usual statement of the master moral principle affirms that one should love God and one’s-neighbor-as-oneself. But since he accepts that the existence of God is not self-evident, he can allow that the more strictly self-evident form of the master moral principle refers only to love of human persons (self and neighbors). He would add that, once the existence and nature of God is accepted, as it philosophically should be, the rational requirement of loving God, and thus the fuller version of the master moral principle, is self-evident. He also holds that one does not offend against this requirement of loving God except by making choices contrary to human good, that is, to love of self or neighbor: ScG III c. 122 n. 2.
3.3 Moral precepts are further specifications of this master principle and its immediate specifications
All moral principles and norms, Aquinas thinks, can be inferred – as either implicit in, or “referable to” as conclusions from – the moral first principle of love of neighbor as self: ST I-II q. 99 a. 1 ad 2 with q. 91 a. 4c and q. 100 a. 2 ad 2; q. 100 aa. 3 and 11c. But he never displays an example or schema of these deduction-like inferences. Consequently, as noted in 2.7 above, his would-be successors have sometimes proposed that moral principles and norms have the self-evidence of first principles, and sometimes, equally desperately, have offered premises which, though suggested by some of Aquinas’s argumentation or remarks, are incoherent with his general theory – e.g. that natural functions are not to be frustrated.
The main lines of Aquinas’ theory of moral principles strongly suggest that moral norms (precepts, standards) are specifications of “Good is to be done and pursued, and evil avoided”, specifications which so direct choice and action that each of the primary goods (elements of human fulfillment) will be respected and promoted to the extent required by the good of practical reasonableness (bonum rationis). And what practical reasonableness requires seems to be that each of the basic human goods be treated as what it truly is: a basic reason for action amongst other basic reasons whose integral directiveness is not to be cut down or deflected by subrational passions. The principle of love of neighbor as self and the Golden Rule immediately pick out one element in that integral directiveness. The other framework moral rules give moral direction by stating ways in which more or less specific types of choice are immediately or mediately contrary to some basic good. This appears to be Aquinas’s implicit method, as illustrated below (3.4).
An adequate exposition and defence of the moral norms upheld by Aquinas requires a critique, only hints for which can be found in his work, of theories which claim that choice can and should rationally be guided by a utilitarian, consequentialist or proportionalist master principle calling for maximizing of overall net good (or, some say, incompatibly, for minimizing net evils). In developments of Aquinas’s moral theory such as are proposed by Grisez and Finnis, that critique is treated as an indispensable preliminary to any reflective non-question-begging identification of the route from first principles to specific moral norms.
3.4 Some examples
The three examples or sets of examples considered in this section are only examples of the kinds of moral norms (praecepta) which Aquinas considers are excluded by any sound conscience from one’s deliberations about what to choose. Other examples are more complex, such as theft and various other wrongful deprivations of property, and the form of charging for loans which is named usury and judged by Aquinas (not implausibly, though with little direct applicability to developed financial markets: see Finnis 1998, 204–210) to be always contrary to just equality. Aquinas also treats in some detail scores, indeed hundreds of other moral issues, touching the life of judges, advocates, merchants, the rich, the poor, or everyone.
3.4.1 Homicide
Some types of act are intrinsically and immediately contrary to the basic human good of life, that is to a human being’s very being. Every act which is intended, whether as end or as means, to kill an innocent human being, and every act done by a private person which is intended to kill any human being, is to be excluded from deliberation as wrongful because contrary to love of neighbor as self (or self as neighbor). Public persons, Aquinas thinks, can rightfully intend to kill in carrying out needful acts of war, suppression of serious wrongdoing, and punishment (see also 6.3 below).
As a private person one may rightfully use force in defense of oneself or others even if the force is such that one foresees it is likely or even certain to kill; but one’s intention in using such lethal force must not be to kill, but only to disable and block the attack (and less lethal force would not have met the need for defensive blocking of the assault). Aquinas’ discussion of this (ST II-II q. 64 a.7) is the locus classicus for what later became known, unhappily, as the “principle” of double effect, whose real core is the thought that moral principles bear differently on kinds of action specified by intention (e.g. to kill) from the way they bear on behavior chosen with foresight that it will (probably or even certainly) kill as a side-effect (praeter intentionem – outside the acting person’s intention).
Aquinas wavers between suggesting that the use of lethal public force, e.g. in capital punishment, intends (“is referred to”) justice rather than killing, and plainly accepting that in such cases death is indeed intended. The latter is his dominant position; his arguments to justify a kind of choice which, whatever its beneficial consequences, is so immediately against the good of life have come increasingly to seem insufficient: the Catechism of the Catholic Church (1993), paras. 2263–67 expounds its whole teaching on war, lethal police action, and capital punishment on the basis of the thought that these can be justified only so far as they amount to causing death as a side-effect, and not as killing with intent to kill. The thought is formulated by appeal to Aquinas’ reference to acts with “double effect” in his discussion of private defence in ST II-II q. 64 a. 7.
3.4.2 Adultery and other kinds of act contrary to the good of marriage
Marriage is, Aquinas says, a primary human good and, philosophically considered, it has a dual point (end, finis): (i) the procreation and bringing up of children is a manner suited to their good, and (ii) fides, which goes far beyond the literal translation “faithfulness” and includes not only exclusivity and permanence but also the positive readiness and commitment to being united with one’s spouse in mind, body and a mutually assisting domestic life. Aquinas neither subordinates one of these two “ends” to the other, nor regards it as appropriate to choose to divide them. Fides is a good and sufficient reason for engaging in the usus matrimonii, the kind of sexual act that is intended to enable both husband and wife to experience and in a particular way actualize and express the good of their marriage, so that the act’s giving and receiving of delight is token of their commitment.
Consequently the kind of wrongful sexual choice most often considered by Aquinas is engaging in intercourse with one’s spouse without fides, because one either (i) is thinking of one’s spouse in the way one would think of a prostitute, or (significantly worse) (ii) would be willing to have sex with somebody else if some other attractive person were to be available. Such depersonalized sex acts are instances of willing against the good of marriage (contra bonum matrimonii). This reiterated analysis should be regarded as the key to Aquinas’ sex ethics. Another paradigmatic kind of instance, in itself much more serious, is a married person’s choice to have intercourse with some third party (perhaps with the other spouse’s consent). These and all other wrongful kinds of sex act have their wrongfulness, according to Aquinas, not because they are unnatural in some biological or sociological sense of “unnatural”, but because they are against reason’s directive to respect, if not also pursue, the good of marriage, a respect that calls for reserving to marriage (and within marriage to truly marital intercourse) all uses of one’s capacity to engage in the intentional pursuit of sexual satisfaction. For unless one regards such reservation as required, one’s stance about human sex acts is contra bonum matrimonii and unreasonable because one cannot coherently maintain that the intercourse of the married enables them to actualize and experience their fides and their marriage, a thought essential to the flourishing (bonum) of marriage and thus of children and thus of the wider community as a whole. One measure of the gravity of morally bad sex acts is applicable to some kinds but not others: injustice (as in rape or seduction of the vulnerable). Another measure, applicable to all such acts, is the extent of the deviance (“distance”) between acts of that kind and truly marital acts.
As in ours, many in Aquinas’ milieu found it difficult to understand how mutually agreeable sex could be a serious moral issue, or indeed a moral issue at all. Aquinas noted this, but was clear that every kind of conduct that acts out and thus confirms and reinforces a disposition of will contra bonum matrimonii is seriously wrong because so many aspects of individual and social flourishing profoundly depend upon the health of the institution of marriage, as it exists in the real lives of adults and children. It is worth repeating, since the point is so often misunderstood and misreported, that Aquinas’ moral arguments for distinguishing good from bad sex never run from “natural” to “therefore good/reasonable/right”, but always from “good/reasonable/right” to therefore “natural” (and similarly, of course, for unreasonable and unnatural): see II-II q. 153 a. 2c, a. 3c, q. 154 a. 1c, a. 2 ad 2, a. 11.
3.4.3 Lying
Aquinas’ thesis is that lying, properly defined, is always to be excluded as to some extent wrong. The thesis is often misunderstood as being premised on the thought that lying is contrary to the natural function of tongue or speech, a thought that has often been transposed into an effort to explain his theses about the wrong kinds of sex act. But, as has been seen, his sex ethics has another and more plausible basis, and so, it seems (albeit less clearly), has his ethics of lying. Though all his treatments include something like “words are naturally signs of what one understand” (ST II-II q. 110 a. 3) or “speech was invented for expressing the conceptions in one’s heart” (Sent. III d. 38 a. 3c), this statement is pointing to a more explanatory and prior premise, discernible though never adequately articulated so as to show its relation to basic human goods. This prior premise turns on his definition of lying as one’s assertion of what one believes to be false. Whenever one asserts, one affirms as true two propositions: explicitly the proposition one articulates as true despite one’s belief that it is not, and implicitly the proposition that one believes what one is assertively articulating. So Aquinas seems to locate the essential wrongfulness of lying in this intentional dissonance between the self presented or reported and one’s real self: a duplicitas. It is often reasonable and even morally necessary to hide one’s beliefs, and this, not “deception”, is what Aquinas means by the “prudent dissimulatio” he thinks justifiable in appropriate contexts. But one should not do so by the spurious self-projection entailed by asserting what one believes false. Pretended flight as a device for luring an unjust enemy into an ambush can be right in a just war, but lying to the enemy is wrong, although its gravity is much diminished by the duty not to reveal the truth to the enemy, a duty compatible with the coexisting duty not to lie. Subsequent scholars in his tradition have wondered whether the conditions of discourse with an unjust opponent do not, at least in many circumstances, defeat the presumption that a grammatically indicative statement asserts what it is put forward to seem to assert.
3.4.4 Exceptionless negative norms: more urgent though not all or always more important
Negative norms such as the three sets of norms just discussed are more urgent and direct as implications of love of self and neighbor, but are not necessarily more important in other dimensions of importance. That is to say, they are applicable and to be followed semper et ad semper, always and in all circumstances, whereas the applicability of affirmative norms (requiring one to act in a specified kind of way) is semper sed non ad semper: always applicable subject to there being (as is not always the case) suitable circumstances. Kinds of conduct that are contrary to a negative moral norm of this type are “intrinsically wrongful” (intrinsece mala).
Only negative norms can be exceptionless (and not all negative moral norms are). If affirmative norms could be exceptionless, there would be inescapable conflicts of obligation, but since morality is simply (the set of standards of) full reasonableness, there can be no conflict of duties each truly and inescapably obligatory in one and the same situation: one cannot truly be perplexus simpliciter – that is, in a dilemma such that, through no fault of one’s own, any choice one makes will be immoral. (It is, however, possible that my prior wrongful choices or my culpable negligence in forming my conscience put me into a situation such that I have applicable and irreconcilable duties and will be in breach of one or more of them whatever I choose or do or omit: I am then perplexus secundum quid, that is, in a dilemma but of a qualified, derivative kind, only in a weak sense unavoidable.)
4. Virtues
A virtue is an aspect of, or constitutive element in, being a person of good character. To have the virtues is to have a stable and ready willingness to make choices that are morally good because in line with the bonum rationis, the basic good of practical reasonableness.
4.1 Specified by principles identifying the reasonable “mean”
The virtues, like everything else in one’s will, are a response to reasons. But practical reasons (i.e. reasons for action) are propositional: they can be stated as principles and other standards, more or less specific. So principles, ultimately the first principles of practical reason (that is, of natural law), are more fundamental to ethics than virtues are. Aquinas accepts Aristotle’s notion that every virtue is a mean between too much and too little, and he constantly stresses that it is reason – with the principles and rules (regulae) it understands – that settles the mean and thus determines what is too much or too little. Indeed, the principles of practical reason (natural law) establish the ends of the virtues: ST II-II q. 47 a. 6. And the master virtue of bringing practical reasonableness into all one’s deliberations, choices, and carrying out of choices – the virtue of prudentia, a virtue both intellectual (of one’s intelligence) and moral (of one’s whole will and character) – is part of the definition, content, and influence of every other moral virtue: ST I-II q. 65 a. 1, q. 66 a. 3 ad 3, etc.
Aquinas arranged the Summa Theologiae’s exposition of morality within a classification, not of the goods to which rational acts are directed, nor of types of act, nor of practical reason’s standards, but of the virtues. Explicable as a reflective theological project of depicting the flourishing or deviations of human beings in an account of the whole movement of creature from their origin to their fulfillment, his decision to adopt this superstructure has tended to obscure the real foundations of his ethics. As one would expect from the considerations sketched in the preceding paragraph, his actual arguments about what is right and wrong, virtuous or vicious, get their premises not from analysis of the virtues at stake but rather from the principles and more specific standards, norms, precepts or rules of practical reason(ableness). It is the conclusions of these arguments that are then re-expressed in terms of what is contrary to or in line with one or more of the virtues.
4.2 Virtue can also be a source, rather than conclusion, of moral judgment
One’s affirmative responsibilities are all conditioned by circumstances, and mostly are (conditional) implications of the Golden Rule of doing to or for others what you would wish them to do to or for you. For both these reasons, one cannot make sound judgments about what one should be doing – that is, about what is the “mean” of reasonableness – unless one’s wishes are those of a person who understands the opportunities and the circumstances well, and whose concerns and intentions are those of someone whose reasonableness is not corrupted or deflected either by sub-rational desires and aversions or by deformations of will such as pride or presumption. Such a person has the virtues, intellectual and moral, and virtue is thus, and in these respects, required for sound moral judgment. Sometimes the mean of reason, properly assessed by someone of true virtue, calls for heroic virtue (say, immense courage) far beyond conventional measures or expectations of reasonableness, moderation, and the like.
4.2.1 The interdependence of the virtues
Aquinas firmly holds the Platonic-Aristotelian theses (i) of the connexio virtutum: that to have any of the virtues in its full and proper form one must have all of them, and (ii) of the governing and shaping role of (the good of) practical reasonableness (bonum rationis), that is, of the intellectual and moral virtue of prudentia. For some indication why, see 4.4 below..
4.3 Virtue’s priority not reducible to self-fulfillment
Just as some take Aquinas to hold that concern for one’s own happiness is the source of one’s moral motivation and judgment, so some take him to hold that the point of being virtuous is being virtuous. But a sounder reading may understand him to hold that attaining beatitudo and virtus are more like built-in beneficial side-effects of openness to the beatitudo of everyone – that is, of love of neighbor as oneself, according to a reasonable order of priorities. What virtue (the state of character) is praised for, he says, is its actualizing the good of reason(ableness), and reason is good because it enables one to discern things for what they truly are – and so, in the practical domain, to discern real benefits (bona, opportunities) and direct one’s choices and actions to bringing them about in the real people for whom one thereby makes effective one’s love and respect.
4.4 The cardinal virtues
Aquinas accepts the Platonic-Aristotelian thesis that there are four virtues which are cardinal, that is on which the moral life and all other virtues hinge or depend: prudentia, justice, courage, and temperantia. Each is a strategic element in one’s integrating of the good of practical reasonableness into one’s deliberations, choices and execution of choices (prudentia), in one’s dealings with others justice), and in integrating and governing one’s desires by genuine reasons (temperantia) and enabling one to face down intimidating obstacles (courage, fortitudo).
4.4.1 Prudentia and love
Practical reasonableness involves not only (i) an intelligent and rationally integrated understanding of practical reason’s principles and of the implications that, under the auspices of the master principle of love of neighbor as self, they have in the form of moral standards, but also (ii) the personal self-governance needed to put those conscientious judgments into effect by choices and corresponding action. So prudentia has many phases or, as Aquinas says, parts, and enters into every other virtue. It is far removed from “prudence” in the sense of “rational self-interest”, for by prudentia one is actively aware that self-interest is self-stunting or indeed self-destructive unless one transcends it by one’s dispositions and acts of justice and friendship or love. (And see 2.7 above.)
Although Aquinas subscribes to Aristotle’s thesis that practical reasonableness (phronesis, prudentia) concerns means rather than ends, he eliminates any quasi-Humeian reading of that thesis by emphasizing that what “moves” prudentia is not one’s passions but one’s underivative understanding of the first practical principles and of the intelligible goods to which they point (synderesis movet prudentiam: ST II-II q. 47 a. 6 ad 3). Moreover, since he holds that virtually all means are also ends, the Aristotelian thesis in no way inhibits him from holding that prudentia is what guides one in identifying moral standards and the “mean” of every virtue: prudentia “directs the moral virtues not only in choosing means but also in establishing ends”: I-II q. 66 a. 3 ad 3.
4.4.2 Justice
Justice is the steady and lasting willingness to give to others what they are entitled to (their right: jus [or ius] suum). Aquinas works with this Roman Law definition (ST II-II q. 58 a. 1c), and with Aristotle’s division of justice into (i) distributive (good judgment about how to divide up and parcel out beneficial or burdensome wholes or sets in a way that is fair because guided by appropriate criteria) and (ii) what Aquinas calls commutative justice (good judgment going far wider than Aristotle’s “corrective” justice, and concerned with all other kinds of dealings between persons). His prioritizing of the concept of right (jus), conceived as something that belongs to another, brings him to the brink of articulating a concept of human rights, a concept certainly implicit in his thesis that there are precepts of justice each imposing, on me and my communities, a duty to everyone without discrimination (indifferenter omnibus debitum: ST II-II q. 122 a. 6). For his definition of justice immediately entails that correlative to such duties of justice there must be rights that belong to everyone indifferenter. Many duties of justice are positive (affirmative duties to give, do, etc.), and Aquinas treats the duties of relieving poverty both under justice and under love (of neighbor, for God’s sake). The duties in either case are essentially the same, and Aquinas’ understanding of them strongly affects his understanding of justified private property rights, which are valid because needed for prosperity and development, but are subject to a duty to distribute, directly or indirectly, one’s superflua – that is, everything beyond what one needs to keep oneself and one’s family in the state of life appropriate to one’s (and their) vocation(s). For the natural resources of the world are “by nature” common; that is, reason’s principles do not identify anyone as having a prior claim to them other than under some customary or other socially posited scheme for division and appropriation of such resources, and such schemes could not be morally authoritative unless they acknowledged some such duty to distribute one’s superflua.
4.4.3 Fortitudo and temperantia
Though one’s passions, that is one’s emotional desires and aversions, support one’s reason in deliberation, choice and action, they are also always capable of deflecting one from reasonable and right choice. So the ready disposition to keep these passions in their proper role is an essential element of a virtuous character and life. By temperantia one integrates one’s desires, particularly but not only for sexual pleasure, with reason, lest reason be enslaved by passion and become its ingenious servant, as it readily can. Temperantia is the mean, for example, between lust and frigidity or apathy (Aquinas everywhere rejecting any “Stoic” ideal of passionlessness, and holding that there is good as well as bad concupiscentia).
By fortitudo one keeps one’s aversions, particularly but not only fear, in check lest one shirk one’s moral responsibilities in situations of danger or other adversity. It is the mean between recklessness or over-boldness and cowardice or defeatism.
4.5 “Virtue ethics”
In recent decades various philosophers and theologians have proposed that ethics done well is virtue ethics, not an ethics of rules and principles. An ethics of the latter kind is denounced as legalistic. As should be clear from the foregoing, Aquinas rejects the proposed contrast and gives systematic prominence both to standards, such as principles and rules, and to virtues. He holds, in effect, that they are interdefined. Nor does he have any time for the view that there are no exceptionless moral norms and that moral norms or other standards are no more than a kind of anticipation, shadow or approximation of the judgments which in each situation need to be made by a person of virtue, and which could never exclude in advance any kind of act as always wrongful by reason of its object and regardless of its further intentions or the circumstances of the situation. On the contrary, he holds that no human act is morally good (right, in the sense of not wrong) unless it is in line with love of self and neighbor (and thus with respect for the basic aspects of the wellbeing of each and all human beings) not only (i) in the motives or intentions with which it is chosen, and (ii) in the appropriateness of the circumstances, but also (iii) in its object (more precisely the object, or closest-in intention of the choosing person) (see 2.1.1 above). This is the primary sense of the axiom he frequently articulates by quoting an old tag: bonum ex integra causa, malum ex quocumque defectu (good from an unflawed set of contributing factors, bad from any defect in the set). That is, there is a fundamental asymmetry between moral good and moral evil – a notion very foreign to any version of utilitarian or post-utilitarian consequentialist or “proportionalist” ethics.
5. Political community
Love of neighbor as oneself requires one to live in political community with others. For the wellbeing and right(s) of all or almost all of us are dependent upon there being in place institutions of government and law of the relatively comprehensive kind we call “political” and “state”.
5.1 Common good
“Common good” is very often a safer translation of bonum commune than “the common good”. For there is the common good of a team, but equally the common good of a university class, of a university, of a family, of a neighborhood, of a city, of a state, of a church and of human kind throughout the world. The difference in each case between the group’s common good and an aggregate of the wellbeing of each of its members can be understood by considering how, in a real friendship, A wills B’s wellbeing for B’s sake, while B wills A’s wellbeing for A’s sake, and each therefore has reason to will his or her own wellbeing for the other’s sake, with the result that neither envisages his or her own wellbeing as the source (the object) of the friendship’s value, and each has in view a truly common good, not reducible to the good of either taken separately or merely summed. Inasmuch as there is possible and appropriate a kind of friendship between the members of each of the kinds of group listed (non-exhaustively) above, each such group has its own common good.
5.1.1 Groups
Communities such as those just mentioned are groups, each of them a whole [totum] made up of persons (and perhaps of other groups), their unity being not merely one of composition or conjunction or continuity, but rather of order, in two dimensions: (i) of the parts (members) as coordinating with each other, and (ii) of the group and its members to its organizing purpose or end (finis). Of these, (ii) is the more explanatory, as Aquinas argues at the very beginning of his commentary on Aristotle’s Ethics.
5.2 Political common good and political community relativized
Some of the above-listed kinds of group have, in Aquinas’ view, a significance that is in a sense strategic. In particular, the family-cum-household, the political group, and the church established to transmit divine revelation and salvation each have such significance. The benefits made possible by political community, with its state government and law, are such that its common good is both extensive and intensive in its reach and implications (e.g. the legitimacy of securing it by coercion). So on those occasions when “the common good” is the best translation of bonum commune, the referent will normally be the good of the political community in question (or of political communities generically), often called by Aquinas public good.
Nevertheless, Aquinas’s use of the Aristotelian axiom, “human beings are naturally political animals” almost always takes it as asserting our social, not solitary, nature – our need for interpersonal relationships both for friendship and for such necessities as food, clothing, speech, and so forth. So the axiom should not be made to mean that Aquinas thinks there is a distinct basic inclination towards, or a distinct basic good, of political community, to put alongside the distinct basic good of marriage and family. He accepts that we are naturally parts of a political community, but also that we are more naturally conjugal than political (in the narrow sense), and that political community does not properly have the ultimacy it has for Aristotle. For Aquinas, political communities have been irrevocably relativized by the appropriateness for (in principle) everyone of belonging to the Church which is, in its own way, as complete [perfecta] a kind of community as any state.
Moreover, Aristotle’s claim that the polis is “greater and more godlike” than any other human community is put by Aquinas into a horizon which contains not merely the one civitas (Latin for polis) of which I am a member but rather the whole plurality of peoples and civitates (states, political communities): Eth. VIII.4.11–12. So for him the common good that is the ultimate concern of political philosophy, and thus of the reasonable person, is nothing less than the fulfillment of all human persons and communities (and see 3.2 above).
Still, this wider perspective does not lead Aquinas to develop a theory of international community; this had to be developed by his sixteenth-century followers. Indeed, he takes remarkably little interest in a number of important issues related to the plurality of states and the dynamics of state-formation, and the appropriate relationship between a people [populus, gens, etc.] and a state (should each people presumptively have a state?). His political philosophy explores with subtlety and care the state [civitas, regnum, etc.], almost as if there were simply a single permanent political community.
6. The state a “complete community” with “mixed” and “limited” government
The state is a “complete community”, whose members, in the central case, are also members of another “complete community”, the Church. So this completeness is, in each case, relative and delimited. Correspondingly, the state’s governing structures (which Aquinas does not call “the state”) are – again in the central, morally proper case – limited in four distinct ways.
6.1 Four kinds of limitation on state government and law
(i) State governments and laws are subject to moral standards, especially but not only the principles and norms of justice. This does not mean that moral principles all apply to public authority in the way they do to private persons; they do not, yet there is no exemption of public authorities from the exceptionless moral norms against intentionally killing the innocent, lying, rape and other extra-marital sex, and so forth. Moreover, this limitation has no bearing on the distinct question which moral standards should, or can properly, be legally enforced by the state’s government and law (see (iii) below).
(ii) State governments are subject to laws governing election or other appointment to and tenure and rotation of office, and the jurisdiction of particular offices. Even supreme rulers not subject to the coercive authority of anyone else cannot dispense themselves from the obligation of their own laws unless that is for the common good and free from favoritism. If they defy these moral restrictions they show themselves to be tyrants, and may be resisted and deposed by the concerted (“public”) action of their people. The best form of government (or as we would now say, constitution) is one in which, “well mixed”, are found “monarchy”, “aristocracy” and “democracy”, that is, the rule of one person (whose “monarchy” is probably better elective rather than hereditary), governing in concert with a few high officials chosen for their excellence of character and aptitude, by an electorate comprising the many who are entitled both to vote and to stand for election: ST I-II q. 105 a. 1. Establishing and maintaining such an arrangement is a matter for laws which delimit the competences of all concerned.
(iii) State governments and laws have the authority and duty to promote and defend the common good, including the good of virtue. This responsibility brings with it the authority to use coercion for the suppression of crime and enemy attack. This coercive jurisdiction extends to defending persons and property both by force and by the credible threat of punishment for criminal or other unjust appropriation or damage. But it does not extend to enforcing any part of morality other than the requirements of justice insofar as they can be violated by acts external to the choosing and acting person’s will. Acts of virtues (or vices) other than such external acts of inter-personal (in)justice cannot rightly be prohibited unless they involve (in)justice. For, unlike divine law’s, “human law’s purpose is the temporal tranquility of the state, a purpose which the law attains by coercively prohibiting external acts to the extent that these evils can disturb the peaceful state of the state.” ST I-II q. 98 a. 1c; likewise q. 100 a. 2c: “human law does not put forward precepts about anything other than acts of justice [and injustice]”. State law’s justifiedly coercive domain is not private good as such, nor the whole of the community’s common good. Rather, it is those aspects of the political community’s common good that can be called public good, and that are affected by external acts directly or indirectly affecting other members of the community.
(iv) The morally significant authority of the state’s government and law is limited by the rights of the Church, though when that government and law are within their proper domain, one ought to comply with their directives rather than any purported act of administration or government (apart from general moral teaching) by Pope or bishops.
The last three kinds of limitation can be considered here in a little more detail.
6.2 Limited government’s forms: “political” and “regal”
Government is properly speaking “political” when the supreme person or body “has power which is limited [potestas coarctata or limitata] by certain laws of the state”: Pol. I.1.5. Such rulers govern in accordance with the laws concerning the establishment of their office, their appointment and their responsibilities. When power is, by contrast, “plenary”, the government is said to be “regal” in kind. But even regal government, in its proper forms, is the government of free and equal people who have in some sense (never made quite clear by Aquinas) the “right to resist [ius repugnandi]” the ruler(s). Even regal rulers are subject to the directive force of the laws, though there is no-one who has the legal authority to coerce them.
Aquinas sees no need for any “social contract” to explain or justify the origins of government or of any particular regime. But he does think that, even in regal as distinct from political rule, the enacted laws constitute “a kind of covenant [pactum] between king and people” (In Rom. 13.1 v. 6), and violation of this by the ruler can entail that subjects are released from their covenantal obligation.
In principle, Aquinas thinks, the supreme legislative powers are held either by the whole people [tota multitudo], a free people [libera multitudo], or by some public persona who has responsibility [cura] for them and represents them [gerit personam multitudinis: bears their persona]: I-II q. 97 a. 3 ad 3; II-II q. 57 a. 2. Neither the meaning of this “representation” nor the practicalities of designating a representative are explored in any depth by Aquinas. Nor does he discuss how it gets settled whether a particular people is (i) simply free and self-governing, or (ii) free but subject to the legislative authority of some princeps, or (iii) unfree (perhaps because conquered).
6.3 State authority is neither paternalistic nor divine
Though he never openly confronts them, Aquinas sets aside the sayings at the end of Aristotle’s Ethics which seem to mean that the polis has the responsibility and role of coercively leading all its citizens, of every age, towards all-round virtue. Aquinas plainly rejects the idea that the state is a surrogate for paternal authority, or has God’s authority over morally significant conduct. Though he frequently states that the political rulers have a proper concern to lead people to virtue, these statements turn out to refer to the appropriate aspirations of rulers, not to their coercive jurisdiction or authority. In the context of the surrounding argument, the statements do not commit him to any wider governmental or legal authority than to require and foster the public good and the virtue of justice, that is, the willingness to perform one’s duties to others: 6.1(iii) above. The other virtues can be legally required of citizens only so far as they impact on justice: ST I-II q. 96 a. 3. Moreover, he holds the classic position that doing justice does not require that one’s motivations and character be just. And when it comes to coercive measures, he holds that they can bear only upon conduct that is external and immediately or mediately affects other people unjustly or disturbs the peace of the political community: ST I-II q. 98 a. 1. Really private vices are outside the coercive jurisdiction of the state’s government and law. Though political authority is ultimately derived from divine authority, it is not to be exercised in the same all-encompassing way as God does when directing one (like every other human individual) to the complete and heavenly fulfillment gratuitously and supernaturally offered to us all by God. Absolute political authority of the kind later claimed by rulers such as James I of England is contrary to Aquinas’ constant teaching.
This reading of Aquinas as, in a nineteenth and twentieth century jargon, “a liberal” (or “the first Whig”) is often disputed, for there are statements in his writings which taken acontextually seem to assert the simpler and paternalistic Aristotelian position.
6.4 The state shares its authority with another “complete community”
One of the reasons why Aquinas’ political theory departs significantly from Aristotle’s is that Aquinas believes he has access to facts and considerations unavailable to Aristotle, namely to the public divine revelation completed in the works and sayings of Christ, founder of a spiritual community, the (Catholic = “universal”) Church. When political life is really well-ordered, therefore, each member (citizen) of a state will be also a member of this other “complete community” and subject to its laws as well as to the state’s. The function of this other community is to transmit the divine promise or offer of eternal life, and to help people help each other, through their own individual free choices, to become ready for that life. With the establishing of this community (in continuity and discontinuity with the older religious community of Israel), human associations are henceforth of two fundamentally distinct types: (i) temporal or secular, worldly, civil, or political, and (ii) spiritual. Correspondingly, responsibility for human affairs is divided between (i) secular societies, especially states and families, and (ii) the Church. The distinction between secular and spiritual tracks that between natural and revealed knowledge.
6.4.1 Non-dependence and non-subjection of secular authority
Accordingly, the Church’s leaders have no jurisdiction over secular matters, although they can declare that the choice of a member of the Church, albeit in a secular matter, is seriously immoral. A parent has no jurisdiction over a child’s free choices except in so far as they violate the moral rights of other members of the family or the parents’ responsibility for the child’s education and moral upbringing. State government and law have no right to direct the Church’s leaders, or its members in their religious affairs, except in so far as the state’s peace and justice would otherwise be violated. “In those matters which pertain to political good [bonum civile], secular rather than spiritual authority should be obeyed.” Sent. II d. 44 ex. ad 4.
Neither those who adhere to the old, incomplete revelation (Jews), nor those people and peoples who simply do not accept the truth of the full revelation, are subject to the authority of the Church. Nor is the legitimacy and authority of a government negated by the fact that its members (officials) are unbelievers.
Beyond this, Aquinas works within the constitutional assumptions of the Christendom of his era. His positions imply that if ecclesiastical authorities expel members from the Church for their misdeeds as rulers, the consequences under their particular state’s own constitutional arrangement could include the rulers’ deposition (loss of secular legal authority); but Aquinas blurs or elides this distinction of jurisdictions, and loosely says that the Church “has the authority of curbing secular rulers” (ST II-II q. 12 a. 2 ad 1).
6.4.2 Heresy, unbelief and religious freedom
Aquinas accepts the teaching of the Church of his era that no one can rightly be compelled to accept the Christian faith or membership of the Church, but that those who are members can and should be compelled by both ecclesiastical and state law to abstain from any public denial or renunciation of it. He treats such renunciation as an actionable breach of promise (passing silently over the fact that in most cases the promise was made not by the persons concerned but rather, in their early infancy, by their parents). And he regards public teaching of heresy as comparable to counterfeiting coin of the realm and therefore rightly punishable capitally by the secular authorities (the fact of false teaching having been ascertained by an ecclesiastical trial). His views about this matter are explicitly based on the evolving tradition of the Church and on what historical experience suggested were the effects of more permissive political or legal arrangements. So there are no theoretical obstacles to his ready acceptance of the judgment of later theologians and Church teachers that, as experience shows, it is more compatible with basic positions in his moral and political philosophy to hold that authentically personal judgment and freely chosen commitment are so important in relation to ultimate questions that all persons (even those whose beliefs about religion are false or ill-formed) have a moral right, and should have the corresponding legal right, to be free from state (and ecclesiastical) coercion in religious belief or action except in so far as their conduct would be contrary to the rights of others or to public peace or to public morality (that is, morality so far as it is publicly communicated or concerns actions which impact on the public) (Second Vatican Council, Declaration on Religious Liberty (1965)). Nor is it clear how he could resist the objection that, even if those baptized in infancy ratify the promises made on their behalf at baptism, the subscription of faith is not an undertaking to other people or the community, but rather is a matter which, as he says in a neglected passage elsewhere in his major writings (ScG III c. 80 n. 15), “pertains to that person alone as an individual [secundum se ipsum].”
7. Law
The best developed part of Aquinas’ political theory is his account of law. That account’s main features may be summarized in four propositions about the central case and focal meaning of law. It is a matter of intelligent direction addressed to the intelligence and reason of those whom it directs. It is for the common good of a political community. It is made (positum, put in place) by the ruler(s) responsible for the community in question. It needs to be coercive.
7.1 Law is an appeal to reason
Aquinas’ well-known discussion of law in ST I-II qq. 90–97 (a discussion which actually extends through the less studied qq. 98–105) has been justly admired by jurists and other thinkers not otherwise much interested in his work. But it is shaped by his concern there (i) to present for beginner students of theology an overview of the universe and of the vast sweep of creatures out from their divine creator and back to the same transcendent being as their ultimate destiny, and (ii) to synthesize the traditional vocabulary and classic theological sources on law. So prominence is there given to the “eternal law” by which God governs even inanimate creatures (as by the laws of physics, etc.), and to the “participation” of natural moral law in that eternal law. But when he is free from these textbookish constraints he emphasizes that law’s most essential feature is something which is not true of the laws of nature (physics, biology, etc.), namely that it is an appeal to the mind, choice, moral strength (virtus) and love of those subject to the law: ScG III cc. 114–117; this is quietly indicated also in ST I-II q. 91 a. 2 ad 3.
Law (in its central case and focal meaning) is thus always a plan for co-ordination through free cooperation. The structure of things being what it is, the principles of practical reason and morality (natural moral law and natural right) can be understood, accepted, and lived by, as fully directive in conscience, without needing to be regarded as (what they really are) an appeal from mind to mind, a plan – freely made to be freely adopted – for integral human fulfillment. As the divine creator was in no way constrained to choose to create this universe as distinct from any other good possible universe, so human legislators have wide moral freedom to choose amongst alternative possible legal arrangements, making one set of provisions legally and (presumptively) morally obligatory by the sheer fact of adopting it – that is, by what Aquinas calls the law-makers’ determinatio: I-II q. 95 a. 2; q. 99 a. 3 ad 2; q. 104 a. 1..
7.2 Law is for a political community’s common good
The definition of law offered by Aquinas in ST I-II q. 90 a. 4 is: “an ordinance of reason for the common good of a [complete] community, promulgated by the person or body responsible for looking after that community.” It is by being intended for common good that law appeals to its subjects’ reason, and gives them reason for regarding the law as authoritative and obligatory, morally as well as legally. Even when its subjects or some of them would have made or preferred a different determinatio, a different way of pursuing communal benefit, the rulers’ intent to promote common good supports and is supported by their claim to rulership. Only if they have such intent can they instantiate the central case of government.
7.2.1 The Rule of Law
The central case of government is the rule of a free people, and law is centrally instantiated when its fully public character (promulgation: q. 90 a. 4), and its clarity (q. 95 a.3), generality (q. 96 a. 1), stability (q. 97 a. 2), and practicability (q. 95 a. 3), enable government (law-makers and law-maintainers alike) and subjects to be partners in public reason (Aquinas has the concept though not the phrase). The features of law thus itemized by Aquinas amount to the concept of the Rule of Law, which he clearly gives a priority over the “rule of men” in his treatment of judges’ subordination to legislation and of the duty of judges to adhere to law even against the evidence of their own eyes (when that evidence is not legally admissible): II-II q. 67 a. 2; q. 64 a. 6 ad 3.
7.3 Law is posited by the responsible authority
The person or body that “has the care of the community” is entitled to make laws. Aquinas treats all human law as “posited” and (synonymously) “positive”, even those of its rules that are restatements of, or authoritatively promulgated deductions (conclusiones) from, general moral principles or norms. Interpretation, too, Aquinas thinks of as involving, in the last analysis, an appeal to the legislator(s) to declare what the enacted law truly means.
The making of law by custom is not incompatible with this thesis; it amounts to a positing of law by the people, considered as having a diffused authority and responsibility for their own community.
Even in a paradise unflawed by any human vice, there would, Aquinas thinks, have been need for government and for law, though not necessarily “political” government, still less coercive law. For social life needs a considerable amount of common policy and common action which cannot otherwise than by authoritative determinatio be achieved by a group whose members have many ideas – perhaps all of them good – about priorities and ways to proceed: ST I q. 96 a. 4. A determinatio, if it is just and fit to be authoritative, must have a rational connection to principles of practical reasonableness. But that rational connection is like an architect’s decisions about dimensions; they must be rationally connected to the terms of the commission (e.g. to build a maternity hospital, not a lion’s cage) but these terms, while excluding various options, leave many options entirely open (the doors must be more than 1 foot high but as between 7.1 and 7.2 feet the choice is entirely free, and likewise with every dimension, selection of materials, colors, and so forth).
7.4 Law needs to be coercive
In a world (paradise) of saints (completely virtuous persons), there would be need for law but not for coercion; so coercion is not part of Aquinas’s definition of law and law’s directive force can be contrasted with its coercive force (and see 6.1(ii) above). But in our actual world the need for (the threat of) coercion is such that Aquinas will say without qualification that law ought to have coercive force [vis coactiva] as well as directive [vis directiva]; he even says that it is a characteristic of law [de ratione legis] (ST I-II q. 96 a. 5), despite not including it in his official definition of law’s nature [its ratio] (q. 90. a. 3).
It is not quite accurate to say that the state or its government has a monopoly of force, since one can justifiably use force as a citizen to defend oneself or others from an attack or assault that is not itself justified (being criminal or insane), and this requires no authorization. Still, Aquinas insistently draws a distinction between private and public use of force. Only public authority can punish or rightly engage in war, and it is reasonable for public authorities to seek a virtual monopoly on what would now be called police operations for the prevention, suppression, and detection of crime. Private persons can never rightly intend precisely to harm or kill, though they can knowingly bring about harm or death as a proportionate side-effect of intending to block an attack (3.4.1 above). Persons with public authority can, Aquinas thinks, rightly intend to kill (or injure) in the exercise of their duty to suppress the attacks of criminals, pirates, and other public or private enemies. (He does not explore those borderland or badland – “wild west” – situations where the distinction between public and private is indistinct.)
The paradigmatic public use of coercion is judicially imposed punishment, capital or otherwise. At the core of Aquinas’s account of justified punishment is the notion that offenders are punishable because, in choosing to offend, they have excessively indulged their will and thereby (he implies) gained a kind of advantage over those who have retrained their own wills from such excess; a just relationship between themselves and their fellow citizens can fittingly be restored by proportionately imposing upon such offenders something contra voluntatem, contrary to and suppressive of their will: I-II q. 46 a. 6 ad 2. This restoration of a fair balance between offenders and the law-abiding is central to what Aquinas frequently calls the “medicinal” function of punishment, for the medicine of punishment is intended to heal not only offenders (by reforming them) or potential offenders (by deterring them), but also and more centrally the whole community by rectifying the disorder of injustice created by the offender’s self-preferential violation of justice. On capital punishment see 3.4.1 above.
Aquinas regards as legitimate ground for going to war not only the defence of this or another political community, but also the purpose of justly punishing and/or securing compensation. (As justifiable grounds for use of force, it is difficult to distinguish between (i) defence of one’s own community’s (or another’s) territory and constitution, (ii) the recovery or restoration of unjustly taken territory or other possessions, and (iii) exaction of compensation for unjust takings or other injuries.)
7.5 Unjust law and just revolution
If the law purports to require actions that no-one should ever do, it cannot rightly be complied with; one’s moral obligation is not to obey but to disobey: ST I-II q. 96 a. 4. And if it purports to authorize such acts (e.g. rape, theft, or infanticide), its authorization is morally void and of no effect (II-II q. 57 a. 2 ad 2); courts should not guide their adjudications by such laws (II-II q. 60 a. 5 ad 1). But law’s obligatoriness and authority is subject to further conditions, derived from the very nature and rationale of political authority. If the law-makers (i) are motivated not by concern for the community’s common good but by greed or vanity (private motivations that make them tyrants, whatever the content of their legislation), or (ii) act outside the authority granted to them, or (iii) while acting with a view to the common good apportion the necessary burdens unfairly, their laws are unjust and in the forum of reasonable conscience are not so much laws as acts of violence [magis sunt violentiae quam leges]: I-II q. 96 a. 4. Such laws lack moral authority, i.e. do not bind in conscience; one is neither morally obliged to conform nor morally obliged not to conform.
This conclusion is subject to a proviso or exception: laws which are unjust by reason of one or more of these three enumerated types of defect in authority sometimes create an obligation in conscience just to the extent that disobedience would cause disorder or give the kind of ‘example’ that leads others into wrongdoing. To avoid those sorts of unjust harm to public and private good one may have a moral obligation to forgo one’s right(s) [iuri suo debet cedere]. This obligation is not: to comply with the law according to its makers’ intent, and/or to the meaning it has under the particular legal system’s interpretative canons. Rather, it is a kind of collateral obligation: to avoid those acts of non-compliance that would unjustly risk having the bad side-effects of being seen not to comply.
All who govern in the interests of themselves rather than of the common good are tyrants, for that is what a tyrant is in the classical line of thought followed by Aquinas. Tyranny entails treating one’s subjects as slaves – persons used for the benefit of the master. The laws of tyrants are not laws simpliciter, but rather a kind of perversion of law [perversitas legis], and one is, in principle, entitled to treat them as one treats a bandit’s demands: I-II q. 92 a 1 ad 4 & 5; II-II q. 69 a. 4. Against the regime’s efforts to enforce its decrees one has the right of forcible resistance; as a private right this could extend as far as killing the tyrant as a foreseen side-effect of one’s legitimate self-defence. It is the tyrant rather than the subject who is morally guilty of sedition. If one can associate with others to constitute oneself with them a kind of public authority willing and able to assume responsibility for the common good of the state, one is entitled, in Aquinas’ view, to set about overthrowing, and if need be executing, the tyrant, with a view to the liberatio of the people [multitudinis] and the homeland [patriae]. Since rulers who are not tyrants are entitled to hunt down and most severely punish sedition, and both rulers and subjects may fall into error about each other’s moral status, subjects ought to be slow to judge a tyranny so unjust that overthrowing or forcibly resisting it is fair to those likely to be injured as a side-effect of revolutionary struggle; there is a (defeasible) presumption in favor of acquiescence and merely passive disobedience: II-II q. 42 a. 2 ad 3, q. 104 a. 6 ad 3; II Sent. d. 44 q. 2 a. 2; Reg. 1.6.
Bibliography
A. Works of Thomas Aquinas
[Eth] Sententia Libri Ethicorum (Commentary on Aristotle’s Nicomachean Ethics) [1271–2].
[Mal] Quaestiones Disputatae de Malo (Disputed Questions on Evil) [1269–71].
[Reg] De Regno [or De Regimine Principum] ad regem Cyprum (On Government [or Kingship] [or On the Rule of Princes/Political Leaders] to the King of Cyprus) [c. 1265].
[ScG] Summa contra Gentiles (A Treatise against the Unbelievers) [?1259–65].
[Sent] Scriptum super Libros Sententiarum Petri Lombardiensis (A Commentary on Peter Lombard’s Sentences [Collection of Opinions of the Church Fathers]) [1253–7]. Note that this remains untranslated save in small excerpts.
[ST] Summa Theologiae (A Treatise on Theology), Parts I [1265–8], I–II [1271–2], II–II [c.1271], III [1272–3].
[Ver] Quaestiones Disputatae de Veritate (Disputed Questions about Truth) [1256–9].
Dyson, R. W. (ed.), 2002, Thomas Aquinas Political Writings, Cambridge and New York: Cambridge University Press. A selection of texts in a new translation.
Freddoso, Alfred (trans.), 2009, Thomas Aquinas: Treatise on Law. The Complete Text. South Bend: St. Augustine’s Press. A new translation.
Regan, Richard, and Baumgarth, William (eds.), 2003, Thomas Aquinas: On Law, Morality, and Politics, Indianapolis: Hackett. A selection of texts in a new translation.
B. Secondary Literature
Bradley, Denis, 1997, Aquinas on the Twofold Human Good: Reason and Human Happiness in Aquinas’s Moral Science, Washington DC: Catholic University of America Press.
Dyson, R. W., 2003, Normative Theories of Society in Five Medieval Thinkers, Lewiston, NY: Edwin Mellen Press, 187–225
Finnis, John, 1983, Fundamentals of Ethics, Oxford: Oxford University Press; Georgetown: Georgetown University Press.
–––, 1996, “The Truth in Legal Positivism”, in George, R. (ed.), The Autonomy of Law: Essays on Legal Positivism, Oxford: Clarendon Press, 195–214; also in Finnis 2011, IV, 174–188.
–––, 1997, “The Good of Marriage and the Morality of Sexual Relations: Some Philosophical and Historical Observations”, American Journal of Jurisprudence, 42: 97–134; also in Finnis 2011, III, 334–352.
–––, 1998, Aquinas: Moral, Political and Legal Theory, Oxford and New York: Oxford University Press.
–––, 2011, Collected Essays of John Finnis, Oxford and New York: Oxford University Press, five volumes.
Goyette, John, 2013, “On the Transcendence of the Political Common Good: Aquinas versus the New Natural Law Theory”, Catholic Bioethics Quarterly, Spring: 133–55.
Grisez, Germain, 1965, “The First Principle of Practical Reason: A Commentary on the Summa Theologiae, 1–2, Question 94, Article 2”, Natural Law Forum, 10 : 168‑201; reprinted Finnis, J. (ed.), 1991, The International Library of Essays in Law and Legal Theory: Natural Law, vol. 1, Aldershot, England: Dartmouth Publishing; New York: New York University Press, 191–224; reprinted Dunn, J., and Harris, I. (eds.), 1997, Great Political Thinkers 4: Aquinas, Cheltenham, England: Edward Elgar, 393–426.
–––, 1987, “Natural Law and Natural Inclinations: Some Comments and Clarifications,” New Scholasticism 61: 307–20.
–––, 2001, “Natural Law, God, Religion, and Human Fulfillment,” American Journal of Jurisprudence, 46: 3–36.
Grisez, Germain and Finnis, John, 1981, “The Basic Principles of Natural Law: A Reply to Ralph McInerny,” American Journal of Jurisprudence 26: 21–31; reprinted Finnis, J. (ed.), The International Library of Essays in Law and Legal Theory: Natural Law, vol. 1, Aldershot, England: Dartmouth Publishing; New York: New York University Press, 1991, 341–51; reprinted Curran, C., McCormick, R., 1991, Readings in Moral Theology No. 7: Natural Law and Theology, New York: Paulist Press, 157–70.
Kries, Douglas, 1990, “Thomas Aquinas and the Politics of Moses”, Review of Politics, 52: 1–21.
Lee, Patrick, 1981, “Permanence of the Ten Commandments: St Thomas and his Modern Commentators”, Theological Studies, 42: 422.
Lisska, Anthony J., 1998, Aquinas’s Theory of Natural Law: An Analytic Reconstruction, Oxford: Oxford University Press.
Long, Steven A., 2004, “Natural Law or Autonomous Practical Reason: Problems in the New Natural Law Theory”, in John Goyette, Mark Latvic, Richard S. Myers (eds.), St. Thomas Aquinas and the Natural Law Tradition: Contemporary Perspectives, Washington, DC: Catholic University of America Press, 165–91.
MacDonald, Scott, and Stump, Eleonore (eds.), 1998, Aquinas’s Moral Theory: Essays in Honor of Norman Kretzmann, Ithaca: Cornell University Press (essays by a number of contemporary scholars).
McInerny, Ralph, 1980, “The Principles of Natural Law”, American Journal of Jurisprudence, 25: 1–15.
–––, 1992, Aquinas on Human Action: A Theory of Practice, Washington, DC: Catholic University of America Press.
–––, 1997, Ethica Thomistica: The Moral Philosophy of Thomas Aquinas, Washington, DC: Catholic University of America Press, 1997.
McInerny, Ralph, and O’Callaghan, John, 2005, “Saint Thomas Aquinas”, Stanford Encyclopedia of Philosophy (Spring 2005 Edition), Edward N. Zalta (ed.), URL = <plato.stanford.edu/archives/spr2005/entries/aquinas/>.
Macintyre, Alasdair, 1990, First Principles, Final Ends, and Contemporary Philosophical Issues, Milwaukee: Marquette University Press.
Pakaluk, Michael, 2001. “Is the Common Good of Political Society Limited and Instrumental?”, Review of Metaphysics, 55: 57–94.
Paterson, Craig, 2006, “Aquinas, Finnis, and Non-naturalism ” in Craig Paterson and Matthew S. Pugh (eds.), Analytical Thomism: traditions in dialogue, Aldershot: Ashgate, 171–93.
Pope, Stephen (ed.), 2002, The Ethics of Aquinas, Washington D.C.: Georgetown University Press (essays by a number of contemporary scholars).
Rhonheimer, Martin, 2000, Natural Law and Practical Reason: A Thomist View of Moral Autonomy, New York: Fordham University Press.
–––, 2011, The Perspective of Morality: Philosophical Foundations of Thomistic Virtue Ethics, Washington, DC: Catholic University of America Press.
–––, 2012, “Practical Reason, Human Nature, and the Epistemology of Ethics”, Villanova Law Review, 57(5): 873–88.
Wheatley, Anthony Paul, 2015, “In Defence of Neo-Scholastic Ethics: A Critique of Finnis and Grisez’s New Natural Law Theory”, Ph.D. thesis, Manchester, University of Manchester, available online.
Corpus Thomisticum, provides a sound working Latin text of the works of Thomas Aquinas (without annotations or other apparatus, but fully searchable). It is based, so far as they have been completed, on the critically edited Omnia Opera begun by the Leonine Commission in 1879/1882; 13 of the projected 50 volumes remain to be published, and the works thus not yet critically edited are given online in what are thought to be the best existing editions.
What is liberty? What are its foundations, its limits? In this chapter, we explore answers to these and other questions from within the natural law theory articulated by John Finnis. Although Finnis himself seldom uses the language of liberty, the natural law theory that he has expounded over the past 50 years is fully engaged with the concept of liberty, in all its complexity. In our effort to understand and explain Finnis’s account, we distinguish four kinds of liberty at play in his work, which we respectively call ‘existential’, ‘moral’, ‘legal’ and ‘political’. By existential liberty we refer to Finnis’s claim that human beings have the capacity to make choices about courses of action, and his insistence that these choices are free of any form of absolute determinism, whether it be psychological, physiological, social or economic. Moral liberty refers to the related claim that as free moral agents, we have the freedom, and also the responsibility, to make practical choices among a plurality of rationally desirable goods. Legal liberty indicates the freedom to make choices between courses of action unconstrained by positive law, and it encompasses the absence of any countervailing legal duty or legal power to impose a contradictory duty. Legal liberty in both these senses is closely related to Finnis’s conception of what we call political liberty: freedom from legal constraint imposed by the coercive force of government. This freedom is broader than legal liberty, however, because it includes an aspect of moral liberty generated by Finnis’s insistence that political authority is properly constrained, not only by legal or constitutional limitations but also by moral principles and norms. The role of the state, for Finnis, is thus limited both in its purpose and its mode of operation. Finnis affirms the existence of ‘unconditional, exceptionless limitations on government’ and ‘truly inviolable rights’ enjoyed by individuals, suitably protected by legally-enforceable constraints on power. We argue that his account of liberty is best understood by distinguishing these four kinds of liberty and understanding the various subtle but important relationships between them.
Suggested Citation:
Aroney, Nicholas and Miller, Bradley W., Finnis on Liberty. THE JURISPRUDENCE OF LIBERTY, Gabriel Moens, Suri Ratnapala, eds., LexisNexis, 2010, University of Queensland TC Beirne School of Law Research Paper No. 11-07, Available at SSRN: ssrn.com/abstract=1853949
Peter, N., & Kleinjung, T.. (2019). Neuromodulation for tinnitus treatment: an overview of invasive and non-invasive techniques. Journal of Zhejiang University: Science B
“Tinnitus is defined as a perception of sound without any external sound source. chronic tinnitus is a frequent condition that can affect the quality of life. so far, no causal cure for tinnitus has been documented, and most pharmacologic and psychosomatic treatment modalities aim to diminish tinnitus’ impact on the quality of life. neuromodulation, a novel therapeutic modality, which aims at alternating nerve activity through a targeted delivery of a stimulus, has emerged as a potential option in tinnitus treatment. this review provides a brief overview of the current neuromodulation techniques as tinnitus treatment options. the main intention is to provide updated knowledge especially for medical professionals counselling tinnitus patients in this emerging field of medicine. non-invasive methods such as repetitive transcranial magnetic stimulation, transcranial electrical stimulation, neurofeedback, and transcutaneous vagus nerve stimulation were included, as well as invasive methods such as implanted vagus nerve stimulation and invasive brain stimulation. some of these neuromodulation techniques revealed promising results; nevertheless, further research is needed, especially regarding the pathophysiological principle as to how these neuromodulation techniques work and what neuronal change they induce. various studies suggest that individually different brain states and networks are involved in the generation and perception of tinnitus. therefore, in the future, individually tailored neuromodulation strategies could be a promising approach in tinnitus treatment for achieving a more substantial and longer lasting improvement of complaints.”
Fomenko, A., Neudorfer, C., Dallapiazza, R. F., Kalia, S. K., & Lozano, A. M.. (2018). Low-intensity ultrasound neuromodulation: An overview of mechanisms and emerging human applications. Brain Stimulation
“Background: there is an emerging need for noninvasive neuromodulation techniques to improve patient outcomes while minimizing adverse events and morbidity. low-intensity focused ultrasound (lifus) is gaining traction as a non-surgical experimental approach of modulating brain activity. several lifus sonication parameters have been found to potentiate neural firing, suppress cortical and epileptic discharges, and alter behavior when delivered to cortical and subcortical mammalian brain regions. objective: this review introduces the elements of an effective sonication protocol and summarizes key preclinical studies on lifus as a neuromodulation modality. the state of the art in human ultrasound neuromodulation is then comprehensively summarized, and current hypotheses regarding the underlying mechanism of action on neural activity are presented. methods: peer-reviewed literature on human ultrasound neuromodulation was obtained by searching several electronic databases. the abstracts of all reports were read and publications which examined low-intensity transcranial ultrasound applied to human subjects were selected for review. results: lifus can noninvasively influence human brain activity by suppressing cortical evoked potentials, influencing cortical oscillatory dynamics, and altering outcomes of sensory/motor tasks compared to sham sonication. proposed mechanisms include cavitation, direct effects on neural ion channels, and plasma membrane deformation. conclusions: though optimal sonication paradigms and transcranial delivery methods are still being established, future applications may include non-invasive human brain mapping experiments, and nonsurgical treatments for functional neurological disorders.”
Brock, D. G., & Demitrack, M. A.. (2014). Therapeutic neuromodulation: Overview of a novel treatment platform. Psychiatric Annals
Pathak, Y. J., Greenleaf, W., Verhagen Metman, L., Kubben, P., Sarma, S., Pepin, B., … Ross, E.. (2021). Digital Health Integration With Neuromodulation Therapies: The Future of Patient-Centric Innovation in Neuromodulation. Frontiers in Digital Health
“Digital health can drive patient-centric innovation in neuromodulation by leveraging current tools to identify response predictors and digital biomarkers. iterative technological evolution has led us to an ideal point to integrate digital health with neuromodulation. here, we provide an overview of the digital health building-blocks, the status of advanced neuromodulation technologies, and future applications for neuromodulation with digital health integration.”
Velasco, F.. (2000). Neuromodulation: An overview. Archives of Medical Research
“For over two centuries, electricity has been known to induce modification of neural and nerve fiber activity and has been proposed to be used to treat some neurological dysfunctions. the new era of the use of electrical current in the treatment of neurological symptoms began in 1967 with the use of totally implanted devices that deliver a controlled amount of electricity on a precise structure within the nervous systems and was first used to control pain. extensive research has been carried out ever since to elucidate the mechanism of action of this treatment and extend its indication for the treatment of the other neurological symptoms. so far, there is evidence that the treatment is safe and efficient for long periods of time, as it does not induce permanent damage to the stimulated structure. most likely, electrical current at the parameters used for therapeutic purpose induces an inhibition of the structure on which it is applied. however, this may be accompanied by either inhibition or excitation of anatomically related structures. for this reason, it seems more convenient to refer to this type of therapy as neuromodulation.a review of the historical development of this fascinating area is presented, with special attention to the evidence derived from experimental work on the parameters that electrical current must maintain to avoid damage to the underlying tissue. copyright (c) 2000 imss.”
Tanagho, E. A.. (2012). Neuromodulation and neurostimulation: Overview and future potential. Translational Andrology and Urology
“Pediatric movement disorders are heterogeneous and complex disorders with various aetiologies. these are broadly classified as hypo and hyperkinetic disorders. genetic causes of basal ganglia dysfunction or direct injuries to the basal ganglia mark the genesis of these abnormal movements. the management of pediatric movement disorders is multidisciplinary with pharmacotherapy as the first line of management along with physical therapy. patients resistant to medications are candidates for invasive neuromodulation which is an upcoming treatment modality in pediatric movement disorders. deep brain stimulation of basal ganglia and thalamic nuclei are associated with promising symptomatic benefit with reduction in disability and improvement in quality of life of these children. in this article, we have reviewed the management of pediatric movement disorders with emphasis on neuromodulation i.e., deep brain stimulation.”
Roy, H., Offiah, I., & Dua, A.. (2018). Neuromodulation for pelvic and urogenital pain. Brain Sciences
“Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. in cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. however, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. the aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. however, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.”
N., P., & T., K.. (2019). Neuromodulation for tinnitus treatment: an overview of invasive and non-invasive techniques. Journal of Zhejiang University: Science B
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“Tinnitus is defined as a perception of sound without any external sound source. chronic tinnitus is a frequent condition that can affect the quality of life. so far, no causal cure for tinnitus has been documented, and most pharmacologic and psychosomatic treatment modalities aim to diminish tinnitus’ impact on the quality of life. neuromodulation, a novel therapeutic modality, which aims at alternating nerve activity through a targeted delivery of a stimulus, has emerged as a potential option in tinnitus treatment. this review provides a brief overview of the current neuromodulation techniques as tinnitus treatment options. the main intention is to provide updated knowledge especially for medical professionals counselling tinnitus patients in this emerging field of medicine. non-invasive methods such as repetitive transcranial magnetic stimulation, transcranial electrical stimulation, neurofeedback, and transcutaneous vagus nerve stimulation were included, as well as invasive methods such as implanted vagus nerve stimulation and invasive brain stimulation. some of these neuromodulation techniques revealed promising results; nevertheless, further research is needed, especially regarding the pathophysiological principle as to how these neuromodulation techniques work and what neuronal change they induce. various studies suggest that individually different brain states and networks are involved in the generation and perception of tinnitus. therefore, in the future, individually tailored neuromodulation strategies could be a promising approach in tinnitus treatment for achieving a more substantial and longer lasting improvement of complaints.”
McCormick, D. A., & Nusbaum, M. P.. (2014). Editorial overview: Neuromodulation: Tuning the properties of neurons, networks and behavior. Current Opinion in Neurobiology
“Neuromodulation is a clinical tool used for treating chronic neuropathic pain by transmitting controlled physical energy to the pre-identified neural targets in the central nervous system. its drug-free, nonaddictive, and improved targeting characteristics have attracted increasing attention among neuroscience research and clinical practices. this article provides a brief overview of the neuropathic pain and pharmacological routines for treatment, summarizes both the invasive and noninvasive neuromodulation modalities for pain management, and highlights an emerging brain stimulation technology, transcranial focused ultrasound (tfus), with a focus on ultrasound transducer devices and the achieved neuromodulation effects and applications on pain management. practical considerations of spatial guidance for tfus are discussed for clinical applications. the safety of transcranial ultrasound neuromodulation and its future prospectives on pain management are also discussed.”
(2019). An overview on Neuromodulation. Case Medical Research
Waldron, N. H., Fudim, M., Mathew, J. P., & Piccini, J. P.. (2019). Neuromodulation for the Treatment of Heart Rhythm Disorders. JACC: Basic to Translational Science
“There is an increasing recognition of the importance of interactions between the heart and the autonomic nervous system in the pathophysiology of arrhythmias. these interactions play a role in both the initiation and maintenance of arrhythmias and are important in both atrial and ventricular arrhythmia. given the importance of the autonomic nervous system in the pathophysiology of arrhythmias, there has been notable effort in the field to improve existing therapies and pioneer additional interventions directed at cardiac-autonomic targets. the interventions are targeted to multiple and different anatomic targets across the neurocardiac axis. the purpose of this review is to provide an overview of the rationale for neuromodulation in the treatment of arrhythmias and to review the specific treatments under evaluation and development for the treatment of both atrial fibrillation and ventricular arrhythmias.”
Luigjes, J., Breteler, R., Vanneste, S., & de Ridder, D.. (2013). [Neuromodulation as an intervention for addiction: overview and future prospects].. Tijdschrift Voor Psychiatrie
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“BACKGROUND in recent years several neuromodulation techniques have been introduced as interventions for addiction. aim to review and discuss studies that have investigated the effects of treating addiction by means of electroencephalography (eeg) neurofeedback, real-time functional magnetic resonance imaging (rt-fmri) neurofeedback, transcranial magnetic stimulation/transcranial direct current stimulation (tms/tdcs) and deep brain stimulation (dbs). method we reviewed the literature, focusing on dutch studies in particular. results studies using eeg neurofeedback were shown to have positive effects on drug use, treatment compliance, and cue reactivity in patients with cocaine and alcohol dependence. a pilot study investigating the effects of rt-fmri neurofeedback on nicotine dependent patients showed that modulation of the anterior cingulate cortex can decrease smokers’ craving for nicotine. in several studies decreased craving was found in alcohol dependent patients after tms or tdcs stimulation of the anterior cingulate cortex or the dorsolateral prefrontal cortex. the first dbs pilot studies suggest that the nucleus accumbens is a promising target region for the treatment of alcohol and heroin dependence. conclusion neuromodulation provides us with a unique opportunity to directly apply neuroscientific knowledge to the treatment of addiction. however, more research is needed to ensure the efficacy, safety and feasibility of the various neuromodulation techniques that are now available.”
Brunoni, A. R., Teng, C. T., Correa, C., Imamura, M., Brasil-Neto, J. P., Boechat, R., … Fregni, F.. (2010). Neuromodulation approaches for the treatment of major depression: Challenges and recommendations from a working group meeting. Arquivos de Neuro-Psiquiatria
“The use of neuromodulation as a treatment for major depressive disorder (mdd) has recently attracted renewed interest due to development of other non-pharmacological therapies besides electroconvulsive therapy (ect) such as transcranial magnetic stimulation (tms), transcranial direct current stimulation (tdcs), deep brain stimulation (dbs), and vagus nerve stimulation (vns). method: we convened a working group of researchers to discuss the updates and key challenges of neuromodulation use for the treatment of mdd. results: the state-of-art of neuromodulation techniques was reviewed and discussed in four sections: [1] epidemiology and pathophysiology of mdd; [2] a comprehensive overview of the neuromodulation techniques; [3] using neuromodulation techniques in mdd associated with non-psychiatric conditions; [4] the main challenges of neuromodulation research and alternatives to overcome them. discussion: ect is the first-line treatment for severe depression. tms and tdcs are strategies with a relative benign profile of side effects; however, while tms effects are comparable to antidepressant drugs for treating mdd; further research is needed to establish the role of tdcs. dbs and vns are invasive strategies with a possible role in treatment-resistant depression. in summary, mdd is a chronic and incapacitating condition with a high prevalence; therefore clinicians should consider all the treatment options including invasive and non-invasive neuromodulation approaches.”
Antony, A. B., Mazzola, A. J., Dhaliwal, G. S., & Hunter, C. W.. (2019). Neurostimulation for the treatment of chronic head and facial pain: A literature review. Pain Physician
“Background: head and facial pain is a common and often difficult to treat disorder. routine treatments sometimes fail to provide acceptable relief, leaving the patient searching for something else, including narcotics and surgery. recently, neuromodulation has been expanding to provide another option. secondary to its potentially temporary nature and relatively manageable risk profile, several reviews have suggested trialing neuromodulation prior to starting narcotics or invasive permanent surgeries. there is evidence that neuromodulation can make a difference in those patients with intractable severe craniofacial pain. objectives: to provide a basic overview of the anatomy, epidemiology, pathophysiology and common treatments of several common head and facial disorders. furthermore, to demonstrate the suggested mechanisms of neuromodulation and the evidence currently existing for the use of neuromodulation. methods: a comprehensive review was performed regarding the available literature through targeting articles reporting on the use of neuromodulation to treat pain of the head and face. results: we compiled and discuss the current evidence available in treating head and facial pain. the strongest evidence currently for neuromodulation is for occipital nerve stimulation for migraine, transcutaneous vagal nerve stimulation for migraine and cluster headache, sphenopalatine ganglion microstimulation for cluster headache, and transcutaneous supraorbital and supratrochlear nerve stimulation for migraine. in addition, there is moderate evidence for occipital nerve stimulation in treating occipital neuralgia. limitations: neuromodulation has been trialed and is promising in several craniofacial pain disorders; however, there remains a need for large-scale, randomized, placebo-controlled clinical trials to further evaluate the efficacy and safety of most treatments. much of the current data relies on case reports without randomization or placebo controls. conclusions: with advancing techniques and technology, neuromodulation can be promising in treating intractable pain of the head and face. although more randomized controlled trials are warranted, the current literature supports the use of neuromodulation in intractable craniofacial pain.”
Schluter, R. S., Daams, J. G., Van Holst, R. J., & Goudriaan, A. E.. (2018). Effects of non-invasive neuromodulation on executive and other cognitive functions in addictive disorders: A systematic review. Frontiers in Neuroscience
“Background: in order to improve the current treatment of addictive disorders non-invasive neuromodulation over the dorsolateral prefrontal cortex (dlpfc) has gained attention. the dlpfc is crucially involved in executive functioning, functions which are related to the course of addictive disorders. non-invasive stimulation of the dlpfc may lead to changes in executive functioning. currently an overview of effects of neuromodulation on these functions is lacking. therefore, this systematic review addresses the effects of non-invasive neuromodulation on executive functioning in addictive disorders. methods: the current review is conducted and reported in accordance with the preferred reporting items for systematic reviews and meta-analyses for protocols 2015 (prisma-p 2015) guidelines and has been registered in prospero international prospective register of systematic reviews (www.crd.york.ac.uk/prospero/, registration number: crd42018084157). original articles were searched using the ovid medline, embase and psycinfo database. results: the systematic search resulted in 1,228 unique studies, of which sixteen were included in the current review. some of these studies do not address the classic definition of executive functions, but another cognitive function. however, they were included in this review since the field is small and still under development and we aim to give an inclusive overview in its broadest sense. the following executive and other cognitive functioning domains were assessed: attention, cognitive flexibility, response inhibition, memory and learning, problem solving, social cognition, risk taking, cognitive bias modification and overall executive functioning. the executive function domain most positively affected was social cognition followed by memory & learning, response inhibition, cognitive flexibility and attention. conclusions: the studies addressed in the current review used a large variability of stimulation protocols and study designs which complicates comparability of the results. nevertheless, the results of these studies are promising in light of improvement of current treatment. therefore, we recommend future studies that compare the effect of different types of stimulation, stimulation sides and number of stimulation sessions in larger clinical trials. this will significantly increase the comparability of the studies and thereby accelerate and clarify the conclusion on whether non-invasive neuromodulation is an effec…”
Hunter, C. W., Stovall, B., Chen, G., Carlson, J., & Levy, R.. (2018). Anatomy, pathophysiology and interventional therapies for chronic pelvic pain: A review. Pain Physician
“Background: chronic pelvic pain (cpp) represents a group of poorly understood disorders that are often refractory to conventional treatment. referral to pain management typically occurs later in the continuum of care; as such, many of the injections and nerve blocks commonly prescribed for such patients are potentially limited in efficacy. while neuromodulation is conventionally considered the next algorithmic step in the treatment of chronic pain after injections fail, there is a common perception that neuromodulation is largely ineffective for cpp conditions. however, there is evidence that suggests neuromodulation may in fact be a viable treatment option for this particular patient population when utilized properly. objectives: to provide a basic overview of the pathophysiology of cpp and the relevant neuroanatomy as it pertains to various available treatment options, as well as the techniques and potential targets for neuromodulation. study design: literature review. setting: private practice, academic and hospital setting. methods: a comprehensive review of the available literature was performed targeting publications focused on cpp and various techniques for utilizing neuromodulation to treat it. results: neuromodulation is an established treatment modalities, however its usefulness as it relates to treating cpp has typically been drawn into question. in this literature review, we discuss the efficacy of various techniques for treating cpp with neuromodulation. limitations: evidence to support the various treatments, while encouraging, is based on small studies and case series. large-scale randomized, placebo-controlled clinical trials are warranted to evaluate the clinical efficacy and safety of the different treatments described, particularly neuromodulation. conclusions: in addition to the percutaneous, injection-based treatments described herein, neuromodulation remains a plausible option for recalcitrant cases that fail to respond to more conventional means.”
Powell, K., Shah, K., Hao, C., Wu, Y.-C., John, A., Narayan, R. K., & Li, C.. (2019). Neuromodulation as a new avenue for resuscitation in hemorrhagic shock. Bioelectronic Medicine
“Hemorrhagic shock (hs), a major cause of early death from trauma, accounts for around 40% of mortality, with 33–56% of these deaths occurring before the patient reaches a medical facility. intravenous fluid therapy and blood transfusions are the cornerstone of treating hs. however, these options may not be available soon after the injury, resulting in death or a poorer quality of survival. therefore, new strategies are needed to manage hs patients before they can receive definitive care. recently, various forms of neuromodulation have been investigated as possible supplementary treatments for hs in the prehospital phase of care. here, we provide an overview of neuromodulation methods that show promise to treat hs, such as vagus nerve stimulation, electroacupuncture, trigeminal nerve stimulation, and phrenic nerve stimulation and outline their possible mechanisms in the treatment of hs. although all of these approaches are only validated in the preclinical models of hs and are yet to be translated to clinical settings, they clearly represent a paradigm shift in the way that this deadly condition is managed in the future.”
Fletcher, N.. (2020). An overview of sacral neuromodulation: A treatment for patients with symptoms of lower urinary tract dysfunction. British Journal of Nursing
“This article provides an introduction to patient selection for, and the processes involved in, sacral neuromodulation (snm) device implantation as a treatment for urinary symptoms. snm has been an option to treat lower urinary tract dysfunction for more than 20 years and is a treatment for both overactive bladder syndrome (oab) and female non obstructed chronic urinary retention (fcur). it is recognised by the national institute for health and care excellence as a therapeutic option for oab and fcur. snm has its place in the pathway for the treatment of both conditions and, in the correctly assessed patient, can be the last option before considering major surgical intervention.”
Shin, S. S., & Pelled, G.. (2017). Novel neuromodulation techniques to assess interhemispheric communication in neural injury and neurodegenerative diseases. Frontiers in Neural Circuits
“Interhemispheric interaction has a major role in various neurobehavioral functions. its disruption is a major contributor to the pathological changes in the setting of brain injury such as traumatic brain injury, peripheral nerve injury, and stroke, as well as neurodegenerative diseases. because interhemispheric interaction has a crucial role in functional consequence in these neuropathological states, a review of noninvasive and state-of-the-art molecular based neuromodulation methods that focus on or have the potential to elucidate interhemispheric interaction have been performed. this yielded approximately 170 relevant articles on human subjects or animal models. there has been a recent surge of reports on noninvasive methods such as transcranial magnetic stimulation and transcranial direct current stimulation. since these are noninvasive techniques with little to no side effects, their widespread use in clinical studies can be easily justified. the overview of novel neuromodulation methods and how they can be applied to study the role of interhemispheric communication in neural injury and neurodegenerative disease is provided. additionally, the potential of each method in therapeutic use as well as investigating the pathophysiology of interhemispheric interaction in neurodegenerative diseases and brain injury is discussed. new technologies such as transcranial magnetic stimulation or transcranial direct current stimulation could have a great impact in understanding interhemispheric pathophysiology associated with acquired injury and neurodegenerative diseases, as well as designing improved rehabilitation therapies. also, advances in molecular based neuromodulation techniques such as optogenetics and other chemical, thermal, and magnetic based methods provide new capabilities to stimulate or inhibit a specific brain location and a specific neuronal population.”
Abboud, H., Hill, E., Siddiqui, J., Serra, A., & Walter, B.. (2017). Neuromodulation in multiple sclerosis. Multiple Sclerosis
“Neuromodulation, or the utilization of advanced technology for targeted electrical or chemical neuronal stimulation or inhibition, has been expanding in several neurological subspecialties. in the past decades, immune-modulating therapy has been the main focus of multiple sclerosis (ms) research with little attention to neuromodulation. however, with the recent advances in disease-modifying therapies, it is time to shift the focus of ms research to neuromodulation and restoration of function as with other neurological subspecialties. preliminary research supports the value of intrathecal baclofen pump and functional electrical stimulation in improving spasticity and motor function in ms patients. deep brain stimulation can improve ms-related tremor and trigeminal neuralgia. spinal cord stimulation has been shown to be effective against ms-related pain and bladder dysfunction. bladder overactivity also responds to sacral neuromodulation and posterior tibial nerve stimulation. despite limited data in ms, transcranial magnetic stimulation and brain–computer interface are promising neuromodulatory techniques for symptom mitigation and neurorehabilitation of ms patients. in this review, we provide an overview of the available neuromodulatory techniques and the evidence for their use in ms.”
Tohyama, S., Walker, M. R., Sammartino, F., Krishna, V., & Hodaie, M.. (2020). The Utility of Diffusion Tensor Imaging in Neuromodulation: Moving Beyond Conventional Magnetic Resonance Imaging. Neuromodulation
“Objectives: conventional targeting methods for neuromodulation therapies are insufficient for visualizing targets along white matter pathways and localizing targets in patient-specific space. diffusion tensor imaging (dti) holds promise for enhancing neuromodulation targeting by allowing detailed visualization of white matter tracts and their connections on an individual level. material and methods: we review the literature on dti and neuromodulation, focusing on clinical studies that have utilized dti tractography for surgical neuromodulation planning. this primarily includes the growing number of studies on tractography-guided targeting in deep brain stimulation as well as magnetic resonance-guided focused ultrasound. results: in this review, we discuss three main topics: 1) an overview of the basic principles of dti, its metrics, and tractography, 2) the evolution and utility of dti to better guide neuromodulation targets, and 3) the ability of dti to investigate structural connectivity and brain networks, and how such a network perspective may be an integral part of identifying new or optimal neuromodulation targets. conclusion: there is increasing evidence that dti is superior to conventional targeting methods with respect to improving brain stimulation therapies. dti has the ability to better define anatomical targets by allowing detailed visualization of white matter tracts and localizing targets based on individual anatomy. network analyses can lead to the identification of new or optimal stimulation targets based on understanding how target regions are connected. the integration of dti as part of routine mri and surgical planning offers a more personalized approach to therapy and may be an important path for the future of neuromodulation.”
Lakatos, P., Gross, J., & Thut, G.. (2019). A New Unifying Account of the Roles of Neuronal Entrainment. Current Biology
“Rhythms are a fundamental and defining feature of neuronal activity in animals including humans. this rhythmic brain activity interacts in complex ways with rhythms in the internal and external environment through the phenomenon of ‘neuronal entrainment’, which is attracting increasing attention due to its suggested role in a multitude of sensory and cognitive processes. some senses, such as touch and vision, sample the environment rhythmically, while others, like audition, are faced with mostly rhythmic inputs. entrainment couples rhythmic brain activity to external and internal rhythmic events, serving fine-grained routing and modulation of external and internal signals across multiple spatial and temporal hierarchies. this interaction between a brain and its environment can be experimentally investigated and even modified by rhythmic sensory stimuli or invasive and non-invasive neuromodulation techniques. we provide a comprehensive overview of the topic and propose a theoretical framework of how neuronal entrainment dynamically structures information from incoming neuronal, bodily and environmental sources. we discuss the different types of neuronal entrainment, the conceptual advances in the field, and converging evidence for general principles. lakatos, gross, and thut review the evidence for neuronal entrainment by environmental, self-produced, and neuromodulatory rhythms, which leads them to propose a new, unifying account of the role of neuronal entrainment in the selection and structuring of information – taking into account the brain in a wider context.”
Vlaicu, A., & Bustuchina Vlaicu, M.. (2020). New neuromodulation techniques for treatment resistant depression. International Journal of Psychiatry in Clinical Practice
“In the treatment of depression, when pharmacotherapy, psychotherapy and the oldest brain stimulation techniques are deadlocked, the emergence of new therapies is a necessary development. the field of neuromodulation is very broad and controversial. this article provides an overview of current progress in the technological advances in neuromodulation and neurostimulation treatments for treatment-resistant depression: magnetic seizure therapy; focal electrically administered seizure therapy; low field magnetic stimulation; transcranial pulsed electromagnetic fields; transcranial direct current stimulation; epidural cortical stimulation; trigeminal nerve stimulation; transcutaneous vagus nerve stimulation; transcranial focussed ultrasound; near infra-red transcranial radiation; closed loop stimulation. the role of new interventions is expanding, probably with more efficacy. nowadays, still under experimentation, neuromodulation will probably revolutionise the field of neuroscience. at present, major efforts are still necessary before that these therapies are likely to become widespread.key points there is a critical need for new therapies for treatment resistant depression. newer therapies are expanding. in the future, these therapies, as an evidence-based adjunctive treatments, could offer a good therapeutic choice for the patients with a trd. the current trend in the new neuromodulation therapies is to apply a personalised treatment. these news therapies can be complementary. that treatment approaches can provide clinically significant benefits.”
Yang, X., McGlynn, E., Das, R., Paşca, S. P., Cui, B., & Heidari, H.. (2021). Nanotechnology Enables Novel Modalities for Neuromodulation. Advanced Materials
“Neuromodulation is of great importance both as a fundamental neuroscience research tool for analyzing and understanding the brain function, and as a therapeutic avenue for treating brain disorders. here, an overview of conceptual and technical progress in developing neuromodulation strategies is provided, and it is suggested that recent advances in nanotechnology are enabling novel neuromodulation modalities with less invasiveness, improved biointerfaces, deeper penetration, and higher spatiotemporal precision. the use of nanotechnology and the employment of versatile nanomaterials and nanoscale devices with tailored physical properties have led to considerable research progress. to conclude, an outlook discussing current challenges and future directions for next-generation neuromodulation modalities is presented.”
Ramirez-Zamora, A., Giordano, J. J., Gunduz, A., Brown, P., Sanchez, J. C., Foote, K. D., … Okun, M. S.. (2018). Evolving applications, technological challenges and future opportunities in neuromodulation: Proceedings of the fifth annual deep brain stimulation think tank. Frontiers in Neuroscience
“The annual deep brain stimulation (dbs) think tank provides a focal opportunity for a multidisciplinary ensemble of experts in the field of neuromodulation to discuss advancements and forthcoming opportunities and challenges in the field. the proceedings of the fifth think tank summarize progress in neuromodulation neurotechnology and techniques for the treatment of a range of neuropsychiatric conditions including parkinson’s disease, dystonia, essential tremor, tourette syndrome, obsessive compulsive disorder, epilepsy and cognitive, and motor disorders. each section of this overview of the meeting provides insight to the critical elements of discussion, current challenges, and identified future directions of scientific and technological development and application. the report addresses key issues in developing, and emphasizes major innovations that have occurred during the past year. specifically, this year’s meeting focused on technical developments in dbs, design considerations for dbs electrodes, improved sensors, neuronal signal processing, advancements in development and uses of responsive dbs (closed-loop systems), updates on national institutes of health and darpa dbs programs of the brain initiative, and neuroethical and policy issues arising in and from dbs research and applications in practice.”
Goudriaan, A. E., & Schluter, R. S.. (2019). Non-invasive Neuromodulation in Problem Gambling: What Are the Odds?. Current Addiction Reports
“Purpose of review: non-invasive neuromodulation as a potential therapeutic target in addiction treatment is a fast-growing, but nascent research field. with gambling disorder as the first behavioral addiction, the goal of this review is to provide an overview of the current state-of-the-art of neuromodulation in substance use disorders and gambling disorder. recent findings: only a few neuromodulation studies in gambling disorder are present, most of these are single-session studies. effects of rtms on craving have been described, but large placebo effects are also present, indicating a need for larger, blinded, multiple-session neuromodulation trials. summary: the field of neuromodulation in gambling is in its infancy, given the limited number of studies, with small sample sizes. the effects that neuromodulation can have on diminishing craving and improving cognitive functions in substance use disorders are promising. as these factors also play a role in relapse in gambling disorder, these findings in suds indicate that investment in larger studies in gambling disorder, focusing on both clinically relevant outcome measures and on intermediate working mechanisms like craving and cognitive functions, is warranted.”
Elias, G. J. B., Boutet, A., Parmar, R., Wong, E. H. Y., Germann, J., Loh, A., … Bhat, V.. (2021). Neuromodulatory treatments for psychiatric disease: A comprehensive survey of the clinical trial landscape. Brain Stimulation
“Background: numerous neuromodulatory therapies are currently under investigation or in clinical use for the treatment of psychiatric conditions. objective/hypothesis: we sought to catalogue past and present human research studies on psychiatric neuromodulation and identify relevant trends in this field. methods: clinicaltrials.gov (www.clinicaltrials.gov/) and the international clinical trials registry platform (www.who.int/ictrp/en/) were queried in march 2020 for trials assessing the outcome of neuromodulation for psychiatric disorders. relevant trials were categorized by variables such as neuromodulation modality, country, brain target, publication status, design, and funding source. results: from 72,086 initial search results, 1252 unique trials were identified. the number of trials registered annually has consistently increased. half of all trials were active and a quarter have translated to publications. the largest proportion of trials involved depression (45%), schizophrenia (18%), and substance use disorders (14%). trials spanned 37 countries; china, the second largest contributor (13%) after the united states (28%), has increased its output substantially in recent years. over 75% of trials involved non-convulsive non-invasive modalities (e.g., transcranial magnetic stimulation), while convulsive (e.g., electroconvulsive therapy) and invasive modalities (e.g., deep brain stimulation) were less represented. 72% of trials featured approved or cleared interventions. characteristic inter-modality differences were observed with respect to enrollment size, trial design/phase, and funding. dorsolateral prefrontal cortex accounted for over half of focal neuromodulation trial targets. the proportion of trials examining biological correlates of neuromodulation has increased. conclusion(s): these results provide a comprehensive overview of the state of psychiatric neuromodulation research, revealing the growing scope and internationalism of this field.”
Doshi, P. P., Russo, M., & Doshi, P. K.. (2021). Practice Trends of Neuromodulation Therapies for Pain and Spasticity in India. Neuromodulation
“Background: neuromodulation has been successfully used globally to address severe refractory chronic pain for over five decades. compared to the wide acceptance that it enjoys in united states and europe, it is fairly underutilized in asia, including india. objectives: we conducted the first systematic nationwide survey to provide an overview of neuromodulation in the past 20 years to investigate the practice trends for severe refractory chronic pain and barriers for the uptake of neuromodulation therapies for pain in india. design: a 20-point detailed questionnaire survey was sent out for online completion in august 2020 to practitioners in india involved in interventions for pain. the survey was completed by 112 practitioners (10% return rate). the response data collected were analyzed, tabulated, and presented as percentages. results: the average duration of pain practice in india for the majority of respondents was less than a decade. about 70% of practitioners expressed that they manage severe refractory pain without neuromodulation. this survey confirms that neuromodulation is grossly underutilized for pain, comprising only 10% of total neuromodulation implants performed per annum in india. the most common indications were neuropathic pain (45%) and failed back surgery syndrome (42%). the respondents expressed the main barriers to be related to the cost (85%); lack of awareness (68%) and lack of good training (59%). more than 50% of respondents also expressed difficulty of access to neuromodulation therapies for pain and acceptance by patients. conclusion: the younger generation of pain practitioners in india is becoming more aware and convinced about the role of neuromodulation to alleviate severe pain and suffering. an all-round approach combining improved training, awareness at various levels, more flexible options of newer technology and reimbursement approval can positively influence its use. this can be achieved with the collective efforts of physicians, insurers, industry, and focused academic activities of clinical societies.”
Ward, M., Doran, J., Paskhover, B., & Mammis, A.. (2018). The 50 Most Cited Articles in Invasive Neuromodulation. World Neurosurgery
“Objective: bibliometric analysis is a commonly used analytic tool for objective determination of the most influential and peer-recognized articles within a given field. this study is the first bibliometric analysis of the literature in the field of invasive neuromodulation, excluding deep brain stimulation. the objectives of this study are to identify the 50 most cited articles in invasive neuromodulation, provide an overview of the literature to assist in clinical education, and evaluate the effect of impact factor on manuscript recognition. methods: bibliometric analysis was performed using the science citation index from the institute for scientific information, accessed through the web of science. search terms relevant to the field of invasive neuromodulation were used to identify the 50 most cited journal articles between 1900 and 2016. results: the median number of citations was 236 (range, 173–578). the most common topics among the articles were vagus nerve stimulation (n = 24), spinal cord stimulation (n = 9), and motor cortex stimulation (n = 6). median journal impact factor was 5.57. most of these articles (n = 19) contained level i, ii, or iii evidence. conclusions: this analysis provides a brief look into the most cited articles within the field, many of which evaluated innovated procedures and therapies that helped to drive surgical neuromodulation forward. these landmark articles contain vital clinical and educational information that remains relevant to clinicians and students within the field and provide insight into areas of expanding research. journal impact factor may play a significant role in determining the literary relevance and general awareness of invasive neuromodulation studies.”
Starling, A.. (2018). Noninvasive neuromodulation in migraine and cluster headache. Current Opinion in Neurology
“Purpose of review the purpose of this narrative review is to provide an overview of the currently available noninvasive neuromodulation devices for the treatment of migraine and cluster headache. recent findings over the last decade, several noninvasive devices have undergone development and clinical trials to evaluate efficacy and safety. based on this body of work, single-pulse transcranial magnetic stimulation, transcutaneous supraorbital neurostimulation, and noninvasive vagal nerve stimulation devices have been cleared by the united states food and drug administration and are available for clinical use for the treatment of primary headache disorders. summary overall, these novel noninvasive devices appear to be safe, well tolerated, and have demonstrated promising results in clinical trials in both migraine and cluster headache. this narrative review will provide a summary and update of the proposed mechanisms of action, evidence, safety, and future directions of various currently available modalities of noninvasive neuromodulation for the treatment of migraine and cluster headache.”
Senova, S., Fomenko, A., Gondard, E., & Lozano, A. M.. (2020). Anatomy and function of the fornix in the context of its potential as a therapeutic target. Journal of Neurology, Neurosurgery and Psychiatry
“The fornix is a white matter bundle located in the mesial aspect of the cerebral hemispheres, which connects various nodes of a limbic circuitry and is believed to play a key role in cognition and episodic memory recall. as the most prevalent cause of dementia, alzheimer’s disease (ad) dramatically impairs the quality of life of patients and imposes a significant societal burden on the healthcare system. as an established treatment for movement disorders, deep brain stimulation (dbs) is currently being investigated in preclinical and clinical studies for treatment of memory impairment in ad by modulating fornix activity. optimal target and stimulation parameters to potentially rescue memory deficits have yet to be determined. the aim of this review is to consolidate the structural and functional aspects of the fornix in the context of neuromodulation for memory deficits. we first present an anatomical and functional overview of the fibres and structures interconnected by the fornix. recent evidence from preclinical models suggests that the fornix is subdivided into two distinct functional axes: a septohippocampal pathway and a subiculothalamic pathway. each pathway’s target and origin structures are presented, followed by a discussion of their oscillatory dynamics and functional connectivity. overall, neuromodulation of each pathway of the fornix is discussed in the context of evidence-based forniceal dbs strategies. it is not yet known whether driving fornix activity can enhance cognition-optimal target and stimulation parameters to rescue memory deficits have yet to be determined.”
Doesborg, P., & Haan, J.. (2018). Cluster headache: New targets and options for treatment. F1000Research
“Cluster headache is a severe headache disorder with considerable impact on quality of life. the pathophysiology of the disease remains poorly understood. with few specific targets for treatment, current guidelines mainly include off-label treatment with medication. however, new targets for possible treatment options are emerging. calcitonin gene-related peptide (cgrp)-targeted medication could become the first (cluster) headache-specific treatment option. other exciting new treatment options include invasive and non-invasive neuromodulation techniques. here, we provide a short overview of new targets and treatment options that are being investigated for cluster headache.”
Gardner, J.. (2017). Securing a future for responsible neuromodulation in children: The importance of maintaining a broad clinical gaze. European Journal of Paediatric Neurology
“Aim this perspective paper provides an overview of several key tensions and challenges within the social context of neuromodulation, and it suggests a means of securing the future of paediatric neuromodulation in light of these. results tensions and challenges relate to: the considerable clinical and economic need for new therapies to manage neurological diseases; significant commercial involvement in the field; funding pressures; public perceptions (particularly unrealistic expectations); and the emerging responsible research and innovation initiative. this paper argues that managing these challenges and tensions requires that clinicians working within the field adopt what could be called a broad clinical gaze. this paper will define the broad clinical gaze, and it will propose several ways in which a broad clinical gaze can be – and indeed is being – operationalised in recent advances in neuromodulation in children. these include the use of multidisciplinary and interdisciplinary clinical team structures, the adoption of clinical assessment tools that capture day-to-day functionality, and the use of patient registries. conclusion by adopting a broad clinical gaze, clinicians and investigators can ensure that the field as a whole can responsibly and ethically deliver on its significant clinical potential.”
Crockett, M. J., & Fehr, E.. (2014). Social brains on drugs: Tools for neuromodulation in social neuroscience. Social Cognitive and Affective Neuroscience
Edwards, C. A., Kouzani, A., Lee, K. H., & Ross, E. K.. (2017). Neurostimulation Devices for the Treatment of Neurologic Disorders. Mayo Clinic Proceedings
“Rapid advancements in neurostimulation technologies are providing relief to an unprecedented number of patients affected by debilitating neurologic and psychiatric disorders. neurostimulation therapies include invasive and noninvasive approaches that involve the application of electrical stimulation to drive neural function within a circuit. this review focuses on established invasive electrical stimulation systems used clinically to induce therapeutic neuromodulation of dysfunctional neural circuitry. these implantable neurostimulation systems target specific deep subcortical, cortical, spinal, cranial, and peripheral nerve structures to modulate neuronal activity, providing therapeutic effects for a myriad of neuropsychiatric disorders. recent advances in neurotechnologies and neuroimaging, along with an increased understanding of neurocircuitry, are factors contributing to the rapid rise in the use of neurostimulation therapies to treat an increasingly wide range of neurologic and psychiatric disorders. electrical stimulation technologies are evolving after remaining fairly stagnant for the past 30 years, moving toward potential closed-loop therapeutic control systems with the ability to deliver stimulation with higher spatial resolution to provide continuous customized neuromodulation for optimal clinical outcomes. even so, there is still much to be learned about disease pathogenesis of these neurodegenerative and psychiatric disorders and the latent mechanisms of neurostimulation that provide therapeutic relief. this review provides an overview of the increasingly common stimulation systems, their clinical indications, and enabling technologies.”
Rimmele, F., & Jürgens, T. P.. (2020). Neuromodulation in primary headaches: current evidence and integration into clinical practice. Current Opinion in Neurology
“PURPOSE of review: neuromodulatory approaches add to our armamentarium of therapeutic tools for the treatment of primary headaches. this review provides a comprehensive overview of current controlled studies on the different neuromodulation techniques and recommendations for clinical practice. recent findings: evidence for efficacy of transcutaneous vagal nerve stimulation (tvns) is limited to acute use in migraine with ambiguous results and episodic cluster headache as well as chronic cluster headache if applied in addition to conventional treatment. transcutaneous stimulation of the supraorbital and supratrochlear nerve was effective in both acute and preventive stimulation (the latter with ambiguous results) in episodic migraines. thus, invasive procedures should be reserved for severe and refractory cases only. occipital nerve stimulation for chronic refractory cluster headache is the only available invasive approach with a conformité européenne mark. summary: neuromodulation can complement conventional therapy, with noninvasive procedures being used preferably. given the limited number of studies for each modality and the lack of head-to-head studies, it is difficult to place neuromodulation techniques in a conventional treatment algorithm.”
La Rosa, V. L., Platania, A., Ciebiera, M., Garzon, S., Jȩdra, R., Ponta, M., & Buttice, S.. (2019). A comparison of sacral neuromodulation vs. transvaginal electrical stimulation for the treatment of refractory overactive bladder: The impact on quality of life, body image, sexual function, and emotional well-being. Przeglad Menopauzalny
“Overactive bladder syndrome (oab) is defined by the presence of urinary urgency, with or without urge incontinence, usually accompanied by an increase in urinary frequency and nocturia in the absence of urinary tract infections (uti) or other diseases. the overall prevalence of oab symptoms in the female population is reported to be 16.6% and increases with advancing age and menopause. the aetiology of oab is not fully understood and is likely to affect a heterogeneous population of patients due to changes to their central and peripheral nervous systems. although oab is frequently associated with female sexual dysfunction (fsd), its real impact on sexual function in women has been evaluated only in a few studies. the first line of treatment for oab includes behavioural modification and physical therapy, either as monotherapies or in combination. many patients who have not had success in managing their symptoms with more conservative therapies may decide to resort to third-line treatments for refractory oab. these treatments include neuromodulation therapies, particularly transvaginal electrical stimulation (tes) and sacral neuromodulation (sn). the aim of this short commentary is to provide an overview of the effectiveness of these treatments and of their impact on quality of life, body image, sexual function, and emotional well-being.”
Pericolini, M., Miget, G., Hentzen, C., Finazzi Agrò, E., Chesnel, C., Lagnau, P., … Amarenco, G.. (2021). Cortical, Spinal, Sacral, and Peripheral Neuromodulations as Therapeutic Approaches for the Treatment of Lower Urinary Tract Symptoms in Multiple Sclerosis Patients: A Review. Neuromodulation
“Introduction: multiple sclerosis (ms) is often associated with urological disorders, mainly urinary incontinence and retention, the management of which being necessary to improve patient’s quality of life (qol) and to reduce potential urological complications. besides the classical treatments based mainly on anticholinergics and/or self-catheterization, several neuromodulation techniques have been tried in recent years to improve these urinary disorders. by this review, we aim at providing an overview of neuromodulation and electrostimulation approaches to manage urinary symptoms in ms patients. materials and methods: a literature search using medline was performed. only papers in english, and describing the effects of neuromodulation in ms patients, were considered. results: a total of 18 studies met inclusion criteria and were reviewed. of them, four related to sacral neuromodulation (snm), seven to percutaneous tibial nerve stimulation (ptns), six to spinal cord stimulation (scs), and one to transcranial magnetic stimulation (tms). discussion: ptns and snm seem to be effective and safe therapeutic options for treating lower urinary tract symptoms in ms patients principally in case of overactive bladder (oab) symptoms. similarly, also scs and tms have been shown to be effective, despite the very limited number of patients and the small number of studies found in the literature. interestingly, these techniques are effective even in patients who do not respond well to conservative therapies, such as anticholinergics. furthermore, given their safety and efficacy, stimulations such as ptns could be considered as a first-line treatment for oab in ms patients, also considering that they are often preferred by patients to other commonly used treatments.”
Pauwels, N., Willemse, C., Hellemans, S., Komen, N., Van den Broeck, S., Roenen, J., … De Schepper, H.. (2021). The role of neuromodulation in chronic functional constipation: A systematic review. Acta Gastro-Enterologica Belgica
“Background: chronic functional constipation is a highly prevalent disorder in which, when conservative measures fail to relieve symptoms, surgical interventions are sometimes indicated. in recent years, neuromodulation for the treatment of functional constipation has gained interest but its role and effectiveness are still unclear. the purpose of this review is to provide a systematic overview on the current literature on the different modalities of neurostimulation and their effect on chronic functional constipation in adults as reported in the literature. methods: a search in the literature for articles concerning the effect of different types of neuromodulation on constipation was performed in pubmed using extensive search terms for the different modalities of neuromodulation. studies and trials were checked for eligibility. for all types of neuromodulation together, 27 articles were included. results: 17 studies were included on snm (sacral nerve modulation). although multiple studies show positive results on the effect of snm in constipation, double-blind crossover rct’s (randomised controlled trials) showed no significant effect. 3 studies were included for tsns (transcutaneous sacral nerve stimulation), 2 for ptns (percutaneous tibial nerve stimulation) and 2 for ttns (transcutaneous tibial nerve stimulation). studies and trials on these modalities of neuromodulation reported ambiguous results on statistical significance of the effect. for transcutaneous ifc (interferential current therapy) 2 studies were included, which both reported a statistically significant effect on all outcomes. conclusion: the beneficial effect of neuromodulation in chronic functional constipation remains questionable. however, neuro-modulation might be worth considering in patients refractory to treatment before turning to more invasive measures. future research should shed more light on the effects of neuromodulation in constipation. (acta gastroenterol. belg., 2021, 84, 467-476).”
Azad, T. D., Veeravagu, A., & Steinberg, G. K.. (2016). Neurorestoration after stroke. Neurosurgical Focus
“Recent advancements in stem cell biology and neuromodulation have ushered in a battery of new neurorestorative therapies for ischemic stroke. while the understanding of stroke pathophysiology has matured, the ability to restore patients’ quality of life remains inadequate. new therapeutic approaches, including cell transplantation and neurostimulation, focus on reestablishing the circuits disrupted by ischemia through multidimensional mechanisms to improve neuroplasticity and remodeling. the authors provide a broad overview of stroke pathophysiology and existing therapies to highlight the scientific and clinical implications of neurorestorative therapies for stroke.”
de Wall, L. L., & Heesakkers, J. P. F. A.. (2017). Effectiveness of percutaneous tibial nerve stimulation in the treatment of overactive bladder syndrome. Research and Reports in Urology
“Overactive bladder syndrome (oab) is a common condition affecting adults and children worldwide, resulting in a substantial economic and psychological burden. percutaneous tibial nerve stimulation (ptns) is derived from acupuncture used in chinese traditional medicine and was first described in the early 1980s. it is a neuromodulation technique used to modulate bladder function and facilitate storage. being a minimally invasive, easily applicable, but time-consuming treatment, future developments with implantable devices might be the solution for the logistical problems and economic burden associated with ptns on the long term. this nonsystematic review provides a current overview on ptns and its effectiveness in the treatment of oab for both adults and children.”
Ramirez-Zamora, A., Giordano, J., Boyden, E. S., Gradinaru, V., Gunduz, A., Starr, P. A., … Okun, M. S.. (2019). Proceedings of the Sixth Deep Brain Stimulation Think Tank Modulation of Brain Networks and Application of Advanced Neuroimaging, Neurophysiology, and Optogenetics. In Frontiers in Neuroscience
“The annual deep brain stimulation (dbs) think tank aims to create an opportunity for a multidisciplinary discussion in the field of neuromodulation to examine developments, opportunities and challenges in the field. the proceedings of the sixth annual think tank recapitulate progress in applications of neurotechnology, neurophysiology, and emerging techniques for the treatment of a range of psychiatric and neurological conditions including parkinson’s disease, essential tremor, tourette syndrome, epilepsy, cognitive disorders, and addiction. each section of this overview provides insight about the understanding of neuromodulation for specific disease and discusses current challenges and future directions. this year’s report addresses key issues in implementing advanced neurophysiological techniques, evolving use of novel modulation techniques to deliver dbs, ans improved neuroimaging techniques. the proceedings also offer insights into the new era of brain network neuromodulation and connectomic dbs to define and target dysfunctional brain networks. the proceedings also focused on innovations in applications and understanding of adaptive dbs (closed-loop systems), the use and applications of optogenetics in the field of neurostimulation and the need to develop databases for dbs indications. finally, updates on neuroethical, legal, social, and policy issues relevant to dbs research are discussed.”
Klooster, D. C. W., de Louw, A. J. A., Aldenkamp, A. P., Besseling, R. M. H., Mestrom, R. M. C., Carrette, S., … Boon, P.. (2016). Technical aspects of neurostimulation: Focus on equipment, electric field modeling, and stimulation protocols. Neuroscience and Biobehavioral Reviews
“Neuromodulation is a field of science, medicine, and bioengineering that encompasses implantable and non-implantable technologies for the purpose of improving quality of life and functioning of humans. brain neuromodulation involves different neurostimulation techniques: transcranial magnetic stimulation (tms), transcranial direct current stimulation (tdcs), vagus nerve stimulation (vns), and deep brain stimulation (dbs), which are being used both to study their effects on cognitive brain functions and to treat neuropsychiatric disorders. the mechanisms of action of neurostimulation remain incompletely understood. insight into the technical basis of neurostimulation might be a first step towards a more profound understanding of these mechanisms, which might lead to improved clinical outcome and therapeutic potential. this review provides an overview of the technical basis of neurostimulation focusing on the equipment, the present understanding of induced electric fields, and the stimulation protocols. the review is written from a technical perspective aimed at supporting the use of neurostimulation in clinical practice.”
De Ridder, D., Manning, P., Cape, G., Vanneste, S., Langguth, B., & Glue, P.. (2016). Pathophysiology-Based Neuromodulation for Addictions: An Overview. In Neuropathology of Drug Addictions and Substance Misuse
“Treatments for addiction are of limited effectivity and characterized by high relapse rates, requiring the development of novel pathophysiology-based treatment approaches. one such option is to use neuromodulation. neuromodulation can be defined as the use of techniques to focally induce directed neuroplasticity. both nonsurgical and surgical neuromodulation have been experimentally used for the suppression of craving. noninvasive techniques used include transcranial magnetic stimulation, transcranial electrical stimulation, and neurofeedback. surgical neuromodulation techniques involve lesioning and electrical stimulation via implanted electrodes. most studies using noninvasive stimulation have investigated the dorsolateral prefrontal cortex as the target. the two brain areas most commonly used as targets for lesioning are the anterior cingulate and nucleus accumbens. for implanted electrodes the nucleus accumbens and subthalamic nucleus have been investigated. the targets used can be linked to brain circuits involved in craving or withdrawal. for noninvasive neuromodulation no long-term studies have been performed and for implanted electrodes only small case series have been reported. thus even if results seem to be promising, they still have to be considered preliminary.”
Lo, P. A., Huang, K., Zhou, Q., Humayun, M. S., & Yue, L.. (2020). Ultrasonic retinal neuromodulation and acoustic retinal prosthesis. Micromachines
“Ultrasound is an emerging method for non-invasive neuromodulation. studies in the past have demonstrated that ultrasound can reversibly activate and inhibit neural activities in the brain. recent research shows the possibility of using ultrasound ranging from 0.5 to 43 mhz in acoustic frequency to activate the retinal neurons without causing detectable damages to the cells. this review recapitulates pilot studies that explored retinal responses to the ultrasound exposure, discusses the advantages and limitations of the ultrasonic stimulation, and offers an overview of engineering perspectives in developing an acoustic retinal prosthesis. for comparison, this article also presents studies in the ultrasonic stimulation of the visual cortex. despite that, the summarized research is still in an early stage; ultrasonic retinal stimulation appears to be a viable technology that exhibits enormous therapeutic potential for non-invasive vision restoration.”
Krauss, J. K., Lipsman, N., Aziz, T., Boutet, A., Brown, P., Chang, J. W., … Lozano, A. M.. (2021). Technology of deep brain stimulation: current status and future directions. Nature Reviews Neurology
“Deep brain stimulation (dbs) is a neurosurgical procedure that allows targeted circuit-based neuromodulation. dbs is a standard of care in parkinson disease, essential tremor and dystonia, and is also under active investigation for other conditions linked to pathological circuitry, including major depressive disorder and alzheimer disease. modern dbs systems, borrowed from the cardiac field, consist of an intracranial electrode, an extension wire and a pulse generator, and have evolved slowly over the past two decades. advances in engineering and imaging along with an improved understanding of brain disorders are poised to reshape how dbs is viewed and delivered to patients. breakthroughs in electrode and battery designs, stimulation paradigms, closed-loop and on-demand stimulation, and sensing technologies are expected to enhance the efficacy and tolerability of dbs. in this review, we provide a comprehensive overview of the technical development of dbs, from its origins to its future. understanding the evolution of dbs technology helps put the currently available systems in perspective and allows us to predict the next major technological advances and hurdles in the field.”
S., V., & D., D. R.. (2012). Noninvasive and invasive neuromodulation for the treatment of tinnitus: An overview. Neuromodulation
Show/hide publication abstract
“Objective: nonpulsatile tinnitus is an auditory phantom percept characterized as a tone, or a noise-like sound such as a hissing or buzzing sound or polyphonic, in the absence of any objective physical sound source. although advances have been made in symptomatic pharmacologic and nonpharmacologic treatments, these treatments are unable to eliminate the tinnitus sensation in most patients. a novel approach using noninvasive and invasive neuromodulation has emerged as an interesting and promising modality for tinnitus relief. methodology: we review noninvasive neuromodulation techniques including transcranial magnetic stimulation, transcranial direct current stimulation, transcutaneous electrical nerve stimulation, and cortical neurofeedback, as well as invasive neuromodulation techniques including auditory cortex stimulation, dorsolateral prefrontal cortex stimulation, subcutaneous occipital nerve stimulation, and deep brain stimulation, as potential treatments of tinnitus. conclusion: although the different techniques introduced revealed promising results, further research is needed to better understand how these techniques work and how the brain responds to neuromodulation. more sophisticated stimulation regimens and parameters should be developed to dynamically stimulate various regions at different frequencies and intensities, physiologically tailored to the patient’s brain state in an attempt to maximize efficacy. (copyright) 2012 international neuromodulation society.”
Kaczmarek, K. A.. (2017). The Portable Neuromodulation Stimulator (PoNS) for neurorehabilitation. Scientia Iranica
“The portable neuromodulation stimulator (pons) is a compact, self-contained device that delivers a fixed sequence of dc-balanced voltage pulses to the anterior-dorsal tongue through a matrix of 143 gold-plated electrodes. this form of stimulation is being investigated as a possible aid to rehabilitation of motor, cognitive, and emotional symptoms resulting from a range of neurological disorders of traumatic, degenerative, or developmental origin. this article provides a technical overview of the pons device as well as a summary of applications research to date.”
Somani, A., & Kar, S. K.. (2019). Efficacy of repetitive transcranial magnetic stimulation in treatment-resistant depression: The evidence thus far. General Psychiatry
“Depression is a common mental disorder, which attributes to significant morbidity, disability and burden of care. a significant number of patients with depression still remain symptomatic after adequate trials of antidepressant treatment as well as psychotherapy, which is often referred to as treatment-resistant depression. neuromodulation techniques-like electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation (tms) and transcranial direct current stimulation, may be useful augmenting techniques in depression, mostly recommended for treatment-resistant cases. robust evidence exists regarding the efficacy of electroconvulsive therapy in the management of treatment-resistant depression; however, other techniques are understudied. tms has been increasingly studied in various psychiatric disorders including depression. it has been approved by the us food and drug administration for use in major depressive disorder. over the past two decades, tms has been studied in diverse groups of the population with depression using several research designs. this article gives an overview of the efficacy of repetitive tms in treatment-resistant depression with the recent evidence.”
Meng, Y., Hynynen, K., & Lipsman, N.. (2021). Applications of focused ultrasound in the brain: from thermoablation to drug delivery. Nature Reviews Neurology
“Focused ultrasound (fus) is a disruptive medical technology, and its implementation in the clinic represents the culmination of decades of research. lying at the convergence of physics, engineering, imaging, biology and neuroscience, fus offers the ability to non-invasively and precisely intervene in key circuits that drive common and challenging brain conditions. the actions of fus in the brain take many forms, ranging from transient blood–brain barrier opening and neuromodulation to permanent thermoablation. over the past 5 years, we have seen a dramatic expansion of indications for and experience with fus in humans, with a resultant exponential increase in academic and public interest in the technology. applications now span the clinical spectrum in neurological and psychiatric diseases, with insights still emerging from preclinical models and human trials. in this review, we provide a comprehensive overview of therapeutic ultrasound and its current and emerging indications in the brain. we examine the potential impact of fus on the landscape of brain therapies as well as the challenges facing further advancement and broader adoption of this promising minimally invasive therapeutic alternative.”
Coman, A., Skårderud, F., Reas, D. L., & Hofmann, B. M.. (2014). The ethics of neuromodulation for anorexia nervosa: A focus on rTMS. Journal of Eating Disorders
“Objective: recently there has been emerging clinical and research interest in the application of deep brain stimulation (dbs) and repetitive transcranial magnetic stimulation (rtms) to the treatment of anorexia nervosa (an). to our knowledge, few studies have discussed ethical aspects associated with the increased use of neuromodulation in an, some of which are quite specific to an, despite the rapid development and dissemination of these new technologies.method: we provide a brief overview of three published rtms studies for an and discuss ethical issues involved in the use of neuromodulation for an.results: in contrast to neurosurgery or dbs, rtms is a less invasive technique, with less associated risk, and thus has greater potential to become a more widespread augmentation or add-on therapy for an. new therapeutic procedures are promising, yet they raise ethical questions regarding informed consent and patient selection. illness-specific issues surrounding authenticity and autonomy are important to consider, ensuring an ethical approach to treatment for patients with an.discussion: we argue that ethical investigations for neuromodulation techniques are timely and important, and discussions should go beyond the immediate goals of patient safety, consent, and risk and benefit, to consider broader ethical concepts such as authenticity and autonomy.”
Herremans, S. C., & Baeken, C.. (2017). Clinical effects of non-invasive neuromodulation techniques in substance use disorder: An overview. Tijdschrift Voor Psychiatrie
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“BACKGROUND substance dependence is a chronic disorder that is difficult to treat. non-invasive stimulation techniques may have beneficial effects on the course of the illness. aim to provide an overview of studies that evaluate the clinical effects that transcranial magnetic stimulation (tms) and transcranial direct current stimulation (tdcs) have on patients with substance use disorders. method we performed an extensive search of the literature, using pubmed. results most studies showed that both tms and tdcshavea beneficial effect on clinical outcomes. however, the effects seemed to wear off over time, even if tms and tdcs had been administered to patients over several sessions. conclusion in terms of efficacy, we award a level b qualification to both tms and tdcs, which means that we regard both techniques as’very probably efficient’.”
Tyler, W. J.. (2011). Noninvasive neuromodulation with ultrasound? A continuum mechanics hypothesis. Neuroscientist
Yamamoto, K., Elias, G. J. B., Beyn, M. E., Zemmar, A., Loh, A., Sarica, C., … Lozano, A. M.. (2021). Neuromodulation for Pain: A Comprehensive Survey and Systematic Review of Clinical Trials and Connectomic Analysis of Brain Targets. Stereotactic and Functional Neurosurgery
“Background: chronic pain is a debilitating condition that imposes a tremendous burden on health-care systems around the world. while frontline treatments for chronic pain involve pharmacological and psychological approaches, neuromodulation can be considered for treatment-resistant cases. neuromodulatory approaches for pain are diverse in both modality and target and their mechanism of action is incompletely understood. objectives: the objectives of this study were to (i) understand the current landscape of pain neuromodulation research through a comprehensive survey of past and current registered clinical trials (ii) investigate the network underpinnings of these neuromodulatory treatments by performing a connectomic mapping analysis of cortical and subcortical brain targets that have been stimulated for pain relief. methods: a search for clinical trials involving pain neuromodulation was conducted using 2 major trial databases (clinicaltrials.gov and the international clinical trials registry platform). trials were categorized by variables and analyzed to gain an overview of the contemporary research landscape. additionally, a connectomic mapping analysis was performed to investigate the network connectivity patterns of analgesic brain stimulation targets using a normative connectome based on a functional magnetic resonance imaging dataset. results: in total, 487 relevant clinical trials were identified. noninvasive cortical stimulation and spinal cord stimulation trials represented 49.3 and 43.7% of this count, respectively, while deep brain stimulation trials accounted for <3%. the mapping analysis revealed that superficial target connectomics overlapped with deep target connectomics, suggesting a common pain network across the targets. conclusions: research for pain neuromodulation is a rapidly growing field. our connectomic network analysis reinforced existing knowledge of the pain matrix, identifying both well-described hubs and more obscure structures. further studies are needed to decode the circuits underlying pain relief and determine the most effective targets for neuromodulatory treatment.”
Hennessey, D. B., Hoag, N., & Gani, J.. (2017). Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence-a review. Translational Andrology and Urology
“Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (rp). it can be the sole cause of post prostatectomy incontinence (ppi) or may be found in association with stress urinary incontinence (sui). the aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post rp bladder dysfunction. a comprehensive literature review using medical search engines was performed. the search included a combination of the following terms, ppi, detrusor overactivity (do), detrusor underactivity (du), impaired compliance, anticholinergic, onabotulinumtoxina (botox®) and sacral neuromodulation (snm). definitions, general overview and management options were extracted from the relevant medical literature. do, du and impaired compliance are common and may occur alone or in combination with sui. in some patients the conditions exist pre rp, in others they arise due to denervation and surgical changes. do can be treated with anticholinergics, botox® and snm. do may need to be treated before sui surgery. du may be a contraindication to male sling surgery as some patients may go into urinary retention. severely impaired bladder compliance may be a contraindication to sui surgery as the upper tracts may be at risk. each individual dysfunction may affect the outcome of ppi treatments and clinicians should be alert to managing bladder dysfunction in ppi patients.”
Urits, I., Schwartz, R., Smoots, D., Koop, L., Veeravelli, S., Orhurhu, V., … Viswanath, O.. (2020). Peripheral neuromodulation for the management of headache. Anesthesiology and Pain Medicine
“Context: neuromodulation is an expanding field of study for headache treatment to reduce pain by targeting structures within the nervous system that are commonly involved in headache pathophysiology, such as the vagus nerve (vns), occipital nerves, or sphenopalatine ganglion (spg) for stimulation. pharmaceutical medical therapies for abortive and prophylactic treatment, such as triptans, nsaids, beta-blockers, tcas, and antiepileptics, are effective for some individuals, but the role that technology plays in investigating other therapeutic modalities is essential. peripheral neuromodulation has gained popularity and fda approval for use in treating certain headaches and migraine headache conditions, particularly in those who are refractory to treatment. early trials found fda approved neurostimulatory implant devices, including cephaly and springtms, improved patient-oriented outcomes with reductions in headaches per month (frequency) and severity. evidence acquisition: this was a narrative review. the sources for this review are as follows: searching on pubmed, google scholar, medline, and sciencedirect from 1990 – 2019 using keywords: peripheral neuromodulation, headache, vagus nerve, occipital nerves, sphenopalatine ganglion. results: the first noninvasive neurostimulator device approved for migraine treatment was the cefaly device, an external trigeminal nerve stimulation device (e-tns) that transcutaneously excites the supratrochlear and supraorbital branches of the ophthalmic nerve. the second noninvasive neurostimulation device receiving fda approval was the single-pulse transcranial magnetic stimulator, springtms, positioned at the occiput to treat migraine with aura. gammacore is a handheld transcutaneous vagal nerve stimulator applied directly to the neck at home by the patient for treatment of cluster headache (ch) and migraine. several other devices are in development for the treatment of headaches and target headache evolution at different levels and inputs. the scion device is a caloric vestibular stimulator (cvs) which interfaces with the user through a set of small cones resting in the ear canal on either side and held in place by modified over-ear headphones. the pulsante spg microstimulator is a patient-controlled device implanted in the patient’s upper jaw via an hour-long oral procedure to target the sphenopalatine ganglion. the occipital nerve stimulator (ons) is an invasive neuromodulation device for headache treatment that consist…”
Robbins, M. S., & Burch, R.. (2021). Preventive Migraine Treatment. CONTINUUM Lifelong Learning in Neurology
“PURPOSE of review this article provides an overview of preventive interventions for migraine, including when to start and how to choose a treatment, pharmacologic options (both older oral treatments and new monoclonal antibodies to calcitonin gene-related peptide [cgrp] or its receptor), nonpharmacologic treatment such as neuromodulation, and preventive treatment of refractory migraine. recent findings the migraine preventive treatment landscape has been transformed by the development of monoclonal antibodies targeting cgrp or its receptor. these treatments, which are given subcutaneously or intravenously monthly or quarterly, have high efficacy and were well tolerated in clinical trials. emerging real-world studies have found higher rates of adverse events than were seen in clinical trials. they are currently recommended for use if two traditional preventive therapies have proven inadequate. since the commonly cited 2012 american headache society/american academy of neurology migraine prevention guidelines were released, clinical trials supporting the preventive use of lisinopril, candesartan, and memantine have been published. neuromodulation devices, including external trigeminal nerve stimulation and single-pulse transcranial magnetic stimulation devices, have modest evidence to support preventive use. the american headache society/american academy of neurology guidelines for the preventive treatment of migraine are currently being updated. a new class of oral cgrp receptor antagonists (gepants) is being tested for migraine prevention. summary successful preventive treatment of migraine reduces disease burden and improves quality of life. many pharmacologic and nonpharmacologic treatment options are available for the prevention of migraine, including newer therapies aimed at the cgrp pathway as well as older treatments with good evidence for efficacy. multiple treatment trials may be required to find the best preventive for an individual patient.”
Ahmed, A. I., & Lucas, J. D.. (2020). Spinal cord injury: pathophysiology and strategies for regeneration. Orthopaedics and Trauma
“Spinal cord injury (sci) is regarded as a devastating irreversible process leading to high morbidity and dependence. the pathophysiology is complex resulting in changes in the spinal cord in the acute phase, followed by sub-acute and chronic changes. this leads to cell death, glial scar formation and the inability to regenerate. nevertheless, many strategies for regeneration are being actively pursued, including cell therapy, drug delivery and neuromodulation. several of these strategies are in current clinical trials. this review aims to give an overview of the current understanding of the injury process and the potential treatment strategies for sci.”
Argiolas, A., & Melis, M. R.. (1995). Neuromodulation of penile erection: an overview of the role of neurotransmitters and neuropeptides. Progress in Neurobiology
Mohammad, S. S., Paget, S. P., & Dale, R. C.. (2019). Current therapies and therapeutic decision making for childhood-onset movement disorders. Movement Disorders
Rajan, R., Skorvanek, M., Magocova, V., Siddiqui, J., Alsinaidi, O., Shinawi, H., … Bajwa, J.. (2020). Neuromodulation Options and Patient Selection for Parkinson’s Disease. In Neurology India
“Neuromodulation therapies, including deep brain stimulation (dbs) and pump therapies, are currently the standard of care for pd patients with advanced disease and motor complications that are difficult to control with medical management alone. the quest for alternate lesser invasive approaches led to the development of several novel therapies like intrajejunal levodopa infusions (ijli), continuous subcutaneous apomorphine infusions (csai) and magnetic resonance guided focused ultrasound (mrgfus) in recent years. to achieve good outcomes with any of these therapeutic modalities, careful patient selection, multidisciplinary evaluation and technical expertise are equally important. in this review, we will provide an overview of the neuromodulation strategies currently available for pd, emphasizing on patient selection and choosing among the various strategies.”
Dean, O. M., Gliddon, E., Van Rheenen, T. E., Giorlando, F., Davidson, S. K., Kaur, M., … Williams, L. J.. (2018). An update on adjunctive treatment options for bipolar disorder. Bipolar Disorders
“Objectives: bipolar disorder is a complex illness often requiring combinations of therapies to successfully treat symptoms. in recent years, there have been significant advancements in a number of therapies for bipolar disorder. it is therefore timely to provide an overview of current adjunctive therapeutic options to help treating clinicians to inform their patients and work towards optimal outcomes. methods: publications were identified from pubmed searches on bipolar disorder and pharmacotherapy, nutraceuticals, hormone therapy, psychoeducation, interpersonal and social rhythm therapy, cognitive remediation, mindfulness, e-health and brain stimulation techniques. relevant articles in these areas were selected for further review. this paper provides a narrative review of adjunctive treatment options and is not a systematic review of the literature. results: a number of pharmacotherapeutic, psychological and neuromodulation treatment options are available. these have varying efficacy but all have shown benefit to people with bipolar disorder. due to the complex nature of treating the disorder, combination treatments are often required. adjunctive treatments to traditional pharmacological and psychological therapies are proving useful in closing the gap between initial symptom remission and full functional recovery. conclusions: given that response to monotherapy is often inadequate, combination regimens for bipolar disorder are typical. correspondingly, psychiatric research is working towards a better understanding of the disorder’s underlying biology. therefore, treatment options are changing and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes. towards this end, this paper provides an overview of novel treatments that may improve clinical outcomes for people with bipolar disorder.”
Moisset, X., Lanteri-Minet, M., & Fontaine, D.. (2020). Neurostimulation methods in the treatment of chronic pain. Journal of Neural Transmission
“The goal of this narrative review was to give an up-to-date overview of the peripheral and central neurostimulation methods that can be used to treat chronic pain. special focus has been given to three pain conditions: neuropathic pain, nociplastic pain and primary headaches. both non-invasive and invasive techniques are briefly presented together with their pain relief potentials. for non-invasive stimulation techniques, data concerning transcutaneous electrical nerve stimulation (tens), transcranial direct current stimulation (tdcs), repetitive transcranial magnetic stimulation (rtms), remote electrical neuromodulation (ren) and vagus nerve stimulation (vns) are provided. concerning invasive stimulation techniques, occipital nerve stimulation (ons), vagus nerve stimulation (vns), epidural motor cortex stimulation (emcs), spinal cord stimulation (scs) and deep brain stimulation (dbs) are presented. the action mode of all these techniques is only partly understood but can be very different from one technique to the other. patients’ selection is still a challenge. recent consensus-based guidelines for clinical practice are presented when available. the development of closed-loop devices could be of interest in the future, although the clinical benefit over open loop is not proven yet.”
Erőss, L., Entz, L., & Fabó, D.. (2015). Invasive neuromodulation in the treatment of drug-resistant epilepsies. Orvosi Hetilap
“Neuromodulation is one of the most developing new disciplines of medical science, which examines how electrical, chemical and mechanical interventions can modulate or change the functioning of the central and peripheral nervous system. neuromodulation is a reversible form of therapy which uses electrical or mechanical stimulation or centrallydelivered drugs to modulate the abnormal function of the central nervous system in pain, spasticity, epilepsy, movement and psychiatric disorders, and certain cardiac, incontinency, visual and auditory diseases. neuromodulation therapy has two major branches. non-invasive neuromodulation includes transcranial magnetic simulation, direct current stimulation and transcutaneous electric nerve stimulation. invasive neuromodulation includes deep brain stimulation, cortical stimulation, spinal cord stimulation, peripheral nerve stimulation, sacral nerve simulation, and subcutan stimulation. in this article the authors overview the apparently available neural interface technologies in epilepsy surgery.”
Ashina, M., Buse, D. C., Ashina, H., Pozo-Rosich, P., Peres, M. F. P., Lee, M. J., … Dodick, D. W.. (2021). Migraine: integrated approaches to clinical management and emerging treatments. The Lancet
“Migraine is a highly disabling neurological disorder that directly affects more than 1 billion individuals worldwide. available treatment options differ between countries and include acute, preventive, and non-pharmacological therapies. because of major progress in the understanding of migraine pathogenesis, novel mechanism-based medications have emerged and expanded the armamentarium of treatments. we provide a comprehensive overview of the current standard of care that will enable informed clinical management. first, we discuss the efficacy, tolerability, and safety profile of various pharmacological therapies for acute and preventive treatment of migraine. second, we review the current knowledge on non-pharmacological therapies, such as neuromodulation and biobehavioural approaches, which can be used for a multidisciplinary approach to clinical management. third, we emphasise that any effective treatment strategy starts with building a therapeutic plan tailored to individual clinical characteristics, preferences, and needs. finally, we explore the outlook of emerging mechanism-based treatments that could address unmet challenges in clinical management of migraine.”
All, A. H., Zeng, X., Teh, D. B. L., Yi, Z., Prasad, A., Ishizuka, T., … Liu, X.. (2019). Expanding the Toolbox of Upconversion Nanoparticles for In Vivo Optogenetics and Neuromodulation. Advanced Materials
“Optogenetics is an optical technique that exploits visible light for selective neuromodulation with spatio-temporal precision. despite enormous effort, the effective stimulation of targeted neurons, which are located in deeper structures of the nervous system, by visible light, remains a technical challenge. compared to visible light, near-infrared illumination offers a higher depth of tissue penetration owing to a lower degree of light attenuation. herein, an overview of advances in developing new modalities for neural circuitry modulation utilizing upconversion-nanoparticle-mediated optogenetics is presented. these developments have led to minimally invasive optical stimulation and inhibition of neurons with substantially improved selectivity, sensitivity, and spatial resolution. the focus is to provide a comprehensive review of the mechanistic basis for evaluating upconversion parameters, which will be useful in designing, executing, and reporting optogenetic experiments.”
Fandel, T., & Tanagho, E. A.. (2005). Neuromodulation in voiding dysfunction: A historical overview of neurostimulation and its application. Urologic Clinics of North America
“This article presents a historical overview of neurostimulation and its application in voiding dysfunction.”
Zbar, A. P.. (2014). Sacral neuromodulation and peripheral nerve stimulation in patients with anal incontinence: An overview of techniques, complications and troubleshooting. Gastroenterology Report
“4 sacral neuromodulation (snm) therapy has revolutionized the management of many forms of anal incontinence, with an expanded use and a medium-term efficacy of 75% overall. this review discusses the technique of snm therapy, along with its complications and troubleshooting and a discussion of the early data pertaining to peripheral posterior tibial nerve stimulation in incontinent patients. future work needs to define the predictive factors for neurostimulatory success, along with the likely mechanisms of action of their therapeutic action.”
Karri, J., Singh, M., Orhurhu, V., Joshi, M., & Abd-Elsayed, A.. (2020). Pain Syndromes Secondary to Cluneal Nerve Entrapment. Current Pain and Headache Reports
“Purpose of review: the purpose of this review is to provide an overview of the cluneal nerves, present a summary of pain syndromes secondary to clunealgia, and evaluate current literature for diagnostic and treatment modalities. recent findings: multiple trials and studies have reported success with numerous modalities ranging from nerve blocks, neuroablation, and even peripheral neuromodulation with varying degrees of clinical benefit. summary: cluneal nerve entrapment or chronic impingement can cause buttock pain or referred pain to nearby areas including the lower back, pelvic area, or even the lower extremities. clunealgias and associated pain syndromes can often be challenging to diagnose and differentiate. an appreciation of the pathophysiology of clunealgias can assist with patient selection for interventional pain strategies targeted towards the cluneal nerves, including nerve blocks, neuroablation, and peripheral neuromodulation. more research is needed to better delineate the efficacy of these procedures for clunealgias.”
“Infrared neuromodulation (inm) is a branch of photobiomodulation that offers direct or indirect control of cellular activity through elevation of temperature in a spatially confined region of the target tissue. research on inm started about 15 ago and is gradually attracting the attention of the neuroscience community, as numerous experimental studies have provided firm evidence on the safe and reproducible excitation and inhibition of neuronal firing in both in vitro and in vivo conditions. however, its biophysical mechanism is not fully understood and several engineered interfaces have been created to investigate infrared stimulation in both the peripheral and central nervous system. in this review, recent applications and present knowledge on the effects of inm on cellular activity are summarized, and an overview of the technical approaches to deliver infrared light to cells and to interrogate the optically evoked response is provided. the micro- and nanoengineered interfaces used to investigate the influence of inm are described in detail.”
Zhu, A., Qureshi, A. A., Kozin, E. D., & Lee, D. J.. (2020). Concepts in Neural Stimulation: Electrical and Optical Modulation of the Auditory Pathways. Otolaryngologic Clinics of North America
“Understanding the mechanisms of neural stimulation is necessary to improve the management of sensory disorders. neurons can be artificially stimulated using electrical current, or with newer stimulation modalities, including optogenetics. electrical stimulation forms the basis for all neuroprosthetic devices that are used clinically. off-target stimulation and poor implant performance remain concerns for patients with electrically based neuroprosthetic devices. optogenetic techniques may improve cranial nerve stimulation strategies used by various neuroprostheses and result in better patient outcomes. this article reviews the fundamentals of neural stimulation and provides an overview of recent major advancements in light-based neuromodulation.””
LeBeau, F. E. N., El Manira, A., & Griller, S.. (2005). Tuning the network: Modulation of neuronal microcircuits in the spinal cord and hippocampus. Trends in Neurosciences
“Purpose: the purpose of this article is to provide an overview of the current status of neural signal processing techniques for closed-loop neuromodulation. methods: first we described overall structure of closed-loop neuromodulation systems. then, the techniques for the stimulus artifact removal were explained, and the methods for neural state monitoring and biomarker extraction were described. finally, the current status of neuromodulation based on neural signal processing was provided in detail. results: closed-loop neuromodulation system automatically adjusts stimulation parameters based on the brain response in real time. adequate tools for signal sensing and signal processing can be used to obtain meaningful biomarkers reflecting the state of neural systems. especially, an appropriate neural signal processing technique can optimize the details of stimulation for effective treatment of target disease. conclusions: neural signal-based biomarkers reflecting the pathophysiological statuses of patients are essential for closedloop neuromodulation, and they should be developed from an understanding of the relationship between clinical states and neural signals.”
Hoffmann, J., & May, A.. (2019). Neuromodulation for the treatment of primary headache syndromes. Expert Review of Neurotherapeutics
“Introduction: neuromodulation techniques play an increasing role in the treatment of primary headaches. while initially reserved for refractory cases they are now increasingly taken into consideration in earlier treatment phases and in non-refractory situations. one of the main reasons for this paradigm shift is that most neuromodulation techniques are better tolerated as compared to the majority of pharmacological approaches. however, these techniques have their limitations that should be considered. areas covered: the review provides an overview of the available techniques and their therapeutic rationale as well as on the evidence for their efficacy and their limitations. the review covers these aspects for non-invasive vagal nerve stimulation, sphenopalatine ganglion stimulation, external trigeminal nerve stimulation, occipital nerve stimulation as well as single-pulse and repetitive-pulse transcranial magnetic stimulation. expert commentary: most of the evidence is based on open-label studies. sham devices used in controlled studies remain problematic as they either do not produce the paresthesias perceived during stimulation or induce some degree of stimulation. invasive techniques require a surgical intervention with all the potential complications that may arise. in summary, some of the techniques provide an effective expansion of available treatment options but their indication should be thoroughly evaluated before treatment is considered.”
Martens, F. M. J., & Sievert, K. D.. (2020). Neurostimulation in neurogenic patients. Current Opinion in Urology
“Purpose of reviewto provide an overview of available electrical stimulation devices in neurogenic patients with lower urinary tract disease.recent findingsit is advocated to do more studies in neurogenic patients as results seem promising and useful but most studies did not include neurogenic patients or neurogenic patients were not analyzed or reported separately. most studies included a small heterogenous neurogenic group with multiple pathophysiologic origin focusing on effect of a treatment instead of results of a treatment in a specific neurogenic group. neuromodulation or stimulation has the advantage that it acts on different organs, like bladder and bowel, so can treat neurogenic patients, who mostly suffer from multiple organ failure.summarybrindley procedure, sacral neuromodulation (snm) and posterior tibial nerve stimulation (ptns) are available for a while already. the brindley procedure (including sacral anterior root stimulation in combination with a rhizotomy of posterior sacral roots) is developed for selected spinal cord injury patient with a complete spinal injury, and has shown results for many years in neurogenic patients. an alternative to the rhizotomy is not established yet. snm and ptns are other modalities that are used in nonneurogenic patients, but are not yet indicated and much studied in neurogenic patients.”
Harmsen, I. E., Elias, G. J. B., Beyn, M. E., Boutet, A., Pancholi, A., Germann, J., … Lozano, A. M.. (2020). Clinical trials for deep brain stimulation: Current state of affairs. Brain Stimulation
“Background: deep brain stimulation (dbs) is a surgical neuromodulation procedure with a historically wide range of possible therapeutic indications, including movement disorders, neuropsychiatric conditions, and cognitive disorders. ongoing research in this field is critical to gain further insights into the mechanisms of dbs, to discover novel brain targets for new and existing indications, and to refine targeting and post-operative programming techniques for the optimization of therapeutic outcomes. objective: to update on the state of dbs-related clinical human research by cataloging and summarizing clinical trials that have been completed or are currently ongoing in this field worldwide. methods: a search was conducted for clinical trials pertaining to dbs, currently listed on the clinicaltrials.gov database. trials were analyzed to generate a detailed overview of ongoing dbs-related research. specifically, trials were categorized by trial start date, study completion status, clinical phase, projected subject enrollment, disorder, brain target, country of origin, device manufacturer, funding source, and study topic. results: in total, 384 relevant clinical trials were identified. the trials spanned 28 different disorders across 26 distinct brain targets, with almost 40% of trials being for conditions other than movement disorders. the majority of dbs trials have been us-based (41.9% of studies) but many countries are becoming increasingly active. the ratio of investigator-sponsored to industry-sponsored trials was 3:1. emphasizing the need to better understand the mechanism of action of dbs, one-third of the studies predominantly focus on imaging or electrophysiological changes associated with dbs. conclusions: this overview of current dbs-related clinical trials provides insight into the status of dbs research and what we can anticipate in the future concerning new brain targets, indications, techniques, and developing a better understanding of the mechanisms of action of dbs.”
Chen, Y., Tang, T., & Erdek, M. A.. (2019). Advanced Image-Guided Procedures for Painful Spine. Neuroimaging Clinics of North America
“In addition to basic image-guided injections, there are many advanced procedures to address the challenges of spine pain. patients with debilitating symptoms are offered relief, a shorter recovery period, and fewer potential complications. pain arises from numerous sites along the spine, presenting as spine pain or radiculopathy. this article is an overview of advanced techniques in this rapidly progressing field, including neuromodulation, radiofrequency thermocoagulation, discography, intradiscal thermocoagulation, and percutaneous image-guided lumbar decompression; and it highlights etiologic factors and their relationship to therapeutic technique and clinical evidence.”
Mishra, S., Kumar, A., Padmanabhan, P., & Gulyás, B.. (2021). Neurophysiological correlates of cognition as revealed by virtual reality: Delving the brain with a synergistic approach. Brain Sciences
“The synergy of perceptual psychology, technology, and neuroscience can be used to comprehend how virtual reality affects cognition of human brain. numerous studies have used neuroimaging modalities to assess the cognitive state and response of the brain with various external stimulations. the virtual reality-based devices are well known to incur visual, auditory, and haptic induced perceptions. neurophysiological recordings together with virtual stimulations can assist in correlating humans’ physiological perception with response in the environment designed virtually. the effective combination of these two has been utilized to study human behavior, spatial navigation performance, and spatial presence, to name a few. moreover, virtual reality-based devices can be evaluated for the neurophysiological correlates of cognition through neurophysiological recordings. challenges exist in the integration of real-time neuronal signals with virtual reality-based devices, and enhancing the experience together with real-time feedback and control through neuronal sig-nals. this article provides an overview of neurophysiological correlates of cognition as revealed by virtual reality experience, together with a description of perception and virtual reality-based neuromodulation, various applications, and existing challenges in this field of research.”
Christen, M., & Müller, S.. (2017). Editorial: The Clinical and Ethical Practice of Neuromodulation – Deep Brain Stimulation and Beyond. Frontiers in Integrative Neuroscience
“Neuromodulation is among the fastest-growing areas of medicine, involving many diverse specialties and affecting hundreds of thousands of patients with numerous disorders worldwide. it can briefly be described as the science of how electrical, chemical, and mechanical interventions can modulate the nervous system function. a prominent example of neuromodulation is deep brain stimulation (dbs), an intervention that reflects a fundamental shift in the understanding of neurological and psychiatric diseases: namely as resulting from a dysfunctional activity pattern in a defined neuronal network that can be normalized by targeted stimulation. the application of dbs has grown remarkably and more than 130,000 patients worldwide have obtained a dbs intervention in the past 30 years—most of them for treating movement disorders. these numbers will grow further for several reasons. first, dbs is investigated for various novel neurological and psychiatric indications. second, current research suggests that stimulation may be more beneficial if it is applied earlier in the course of the disease, especially for parkinsonian patients. third, the number of countries, centers, and companies that get involved in this field is steadily increasing. this frontiers research topics provides an overview on the current discussion beyond basic research in dbs and other brain stimulation technologies. researchers from clinical disciplines (e.g., neurology, neurosurgery, and psychiatry), neuroethics, social science, law, and economics who are working on broader clinical and social issues related to dbs and related neuromodulation technologies have contributed to this research topic. in the following, we provide a brief overview on the content of the e-book on ” the clinical and ethical practice of neuromodulation – deep brain stimulation and beyond. ” the paper from ineichen and christen exemplifies the impressive publication activity in the field. they analyzed more than 7,000 papers published between 1991 and 2014 on dbs using quantitative methods. the study confirms known trends within the field such as the emergence of psychiatric indications with a particular focus on depression and the increasing discussion of complex side-effects such as personality changes. other findings are more surprising, e.g., that hardware-related issues are far more robustly connected to ethical issues compared to impulsivity, concrete side-effects or death/suicide. this indicates that the bioethica…”
Stakenborg, N., & Boeckxstaens, G. E.. (2021). Bioelectronics in the brain-gut axis: Focus on inflammatory bowel disease (IBD). International Immunology
“Accumulating evidence shows that intestinal homeostasis is mediated by cross-talk between the nervous system, enteric neurons and immune cells, together forming specialized neuroimmune units at distinct anatomical locations within the gut. in this review, we will particularly discuss how the intrinsic and extrinsic neuronal circuitry regulates macrophage function and phenotype in the gut during homeostasis and aberrant inflammation, such as observed in inflammatory bowel disease (ibd). furthermore, we will provide an overview of basic and translational ibd research using these neuronal circuits as a novel therapeutic tool. finally, we will highlight the different challenges ahead to make bioelectronic neuromodulation a standard treatment for intestinal immune-mediated diseases.”
Serrano-Munoz, D., Taylor, J., Megia-Garcia, A., & Gomez-Soriano, J.. (2019). Neuromodulation for neurorehabilitation of motor disorders for stroke and spinal cord injury: An overview. Neuromodulation
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“The international neuromodulation society has defined therapeutic neuromodulation as ‘the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body’ (1). therapeutic neuromodulation can improve functional recovery and relieve neurological symptoms associated with stroke and spinal cord injury (sci), which has been highlighted by a tenfold increase in the number of studies cited in this field (institute for scientific information, january 2019). however, the overall quality of these studies needs to be assessed to facilitate better evidence-based choices about health interventions, especially as recent advances in this field has attracted intense online media attention (altmetric. bodleian oxford library, january 2019). in this workshop leading international researchers in the field of therapeutic neuromodulation for sci and stroke will present their latest results for improving motor system neurorehabilitation using both invasive and non-invasive neuromodulation techniques, ranging from repetitive magnetic motor cortex, transcutaneous spinal and deep brain cerebellum stimulation. each speaker will highlight the clinical impact of their research line and the priority areas that need to be addressed for further technical development. results from a systematic review of non-invasive transcutaneous spinal cord stimulation for sci motor neurorehabilitation will be presented, with a special emphasis on stimulation parameters, clinical trial design and outcome measures. finally, two ongoing research projects at the hospital nacional de paraplejicos and the universidad castilla-la mancha will be introduced to the audience. the neurotrain project will apply lumbosacral transcutaneous electrical spinal stimulation in combination with intensive cycling, with the aim of potentiating gait function and controlling spasticity for patients with incomplete sci. in parallel the recode project will assess how non-invasive transcutaneous spinal and transcortical direct current stimulation, synchronized with robotic exoskeletons, can potentiate gait rehabilitation after sci.”
Civelli, O.. (2012). Orphan GPCRs and Neuromodulation. Neuron
“Most g protein-coupled receptors (gpcrs) started as orphan gpcrs. matching them to known neuromodulators led to the elucidation of the broad diversity of the neuroreceptor families. moreover, orphan gpcrs have also been used as targets to discover novel neuromodulators. these discoveries have had profound impact on our understanding of brain function. here, i present an overview of how some of the novel neuropeptides have enlarged our comprehension of responses that direct sleep/wakefulness, the onset of obesity and the feeding response. i also discuss other advances gained from orphan gpcr studies such as the concept of specificity in neuromodulation or of receptors acting as sensors instead of synaptic transmitters. finally, i suggest that the recently discovered neuromodulators may hold the keys to our understanding of higher brain functions and psychiatric disorders.”
Wagner, T., Valero-Cabre, A., & Pascual-Leone, A.. (2007). Noninvasive human brain stimulation. Annual Review of Biomedical Engineering
“Modulation of the peripheral nervous system (pns) has a great potential for therapeutic intervention as well as restore bodily functions. recent interest has focused on autonomic nerves, as they regulate extensive functions implicated in organ physiology, chronic disease state and appear tractable to targeted modulation of discrete nerve units. therapeutic interventions based on specific bioelectronic neuromodulation depend on reliable neural interface to stimulate and record autonomic nerves. furthermore, the function of stimulation and recording requires energy which should be delivered to the interface. due to the physiological and anatomical challenges of autonomic nerves, various forms of this active neural interface need to be developed to achieve next generation of neural interface for bioelectronic medicine. in this article, we present an overview of the state-of-the-art for peripheral neural interface technology in relation to autonomic nerves. also, we reveal the current status of wireless neural interface for peripheral nerve applications. recent studies of a novel concept of self-sustainable neural interface without battery and electronic components are presented. finally, the recent results of non-invasive stimulation such as ultrasound and magnetic stimulation are covered and the perspective of the future research direction is provided.”
Linster, C.. (2014). Neuromodulation: Overview. In Encyclopedia of Computational Neuroscience
Lakatos, P., Gross, J., & Thut, G.. (2019). Review A New Unifying Account of the Roles of Neuronal. Current Biology
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“Rhythms are a fundamental and defining feature of neuronal activity in animals including humans. this rhyth- mic brain activity interacts in complex ways with rhythms in the internal and external environment through the phenomenon of ‘neuronal entrainment’, which is attracting increasing attention due to its suggested role in a multitude of sensory and cognitive processes. some senses, such as touch and vision, sample the environ- ment rhythmically, while others, like audition, are faced with mostly rhythmic inputs. entrainment couples rhythmic brain activity to external and internal rhythmic events, serving fine-grained routing and modulation of external and internal signals across multiple spatial and temporal hierarchies. this interaction between a brain and its environment can be experimentally investigated and even modified by rhythmic sensory stimuli or invasive and non-invasive neuromodulation techniques. we provide a comprehensive overview of the topic and propose a theoretical framework of how neuronal entrainment dynamically structures information from incoming neuronal, bodily and environmental sources. we discuss the different types of neuronal entrainment, the conceptual advances in the field, and converging evidence for general principles.”
Bartoli, F., Burnstock, G., Crocamo, C., & Carrà, G.. (2020). Purinergic signaling and related biomarkers in depression. Brain Sciences
“It is established that purinergic signaling can shape a wide range of physiological functions, including neurotransmission and neuromodulation. the purinergic system may play a role in the pathophysiology of mood disorders, influencing neurotransmitter systems and hormonal pathways of the hypothalamic-pituitary-adrenal axis. treatment with mood stabilizers and antidepressants can lead to changes in purinergic signaling. in this overview, we describe the biological background on the possible link between the purinergic system and depression, possibly involving changes in adenosine-and atp-mediated signaling at p1 and p2 receptors, respectively. furthermore, evidence on the possible antidepressive effects of non-selective adenosine antagonist caffeine and other purinergic modulators is reviewed. in particular, a2a and p2x7 receptors have been identified as potential targets for depression treatment. preclinical studies highlight that both selective a2a and p2x7 antagonists may have antidepressant effects and potentiate responses to antidepressant treatments. consistently, recent studies feature the possible role of the purinergic system peripheral metabolites as possible biomarkers of depression. in particular, variations of serum uric acid, as the end product of purinergic metabolism, have been found in depression. although several open questions remain, the purinergic system represents a promising research area for insights into the molecular basis of depression.”
Fellous, J. M., & Linster, C.. (1998). Computational Models of Neuromodulation. Neural Computation
“Computational modeling of neural substrates provides an excellent theoretical framework for the understanding of the computational roles of neuromodulation. in this review, we illustrate, with a large number of modeling studies, the specific computations performed by neuromodulation in the context of various neural models of invertebrate and vertebrate preparations. we base our characterization of neuromodulations on their computational and functional roles rather than on anatomical or chemical criteria. we review the main framework in which neuromodulation has been studied theoretically (central pattern generation and oscillations, sensory processing, memory and information integration). finally, we present a detailed mathematical overview of how neuromodulation has been implemented at the single cell and network levels in modeling studies. overall, neuromodulation is found to increase and control computational complexity.”
Chaudhry, S. R., Stadlbauer, A., Buchfelder, M., & Kinfe, T. M.. (2021). Melatonin moderates the triangle of chronic pain, sleep architecture and immunometabolic traffic. Biomedicines
“Preclinical as well as human studies indicate that melatonin is essential for a physiological sleep state, promotes analgesia and is involved in immunometabolic signaling by regulating neuroin-flammatory pathways. experimental and clinical neuromodulation studies for chronic pain treatment suggest that neurostimulation therapies such as spinal cord stimulation, vagus nerve stimulation and dorsal root ganglion stimulation have an impact on circulating inflammatory mediators in blood, cerebrospinal fluid and saliva. herein, we provide an overview of current literature relevant for the shared pathways of sleep, pain and immunometabolism and elaborate the impact of melatonin on the crossroad of sleep, chronic pain and immunometabolism. furthermore, we discuss the potential of melatonin as an adjunct to neurostimulation therapies. in this narrative review, we addressed these questions using the following search terms: melatonin, sleep, immunometabolism, obesity, chronic pain, neuromodulation, neurostimulation, neuroinflammation, molecular inflammatory phenotyping. so far, the majority of the published literature is derived from experimental studies and studies specifically assessing these relationships in context to neurostimulation are sparse. thus, the adjunct potential of melatonin in clinical neurostimulation has not been evaluated under the umbrella of randomized-controlled trials and deserves increased attention as melatonin interacts and shares pathways relevant for noninvasive and invasive neurostimulation therapies.”
Konofagou, E.. (2018). Focused ultrasound for modulation of the central and peripheral nervous system. The Journal of the Acoustical Society of America
“Noninvasive neuromodulation has been the preferred option of neurological treatment but noninvasive approaches fall short when it comes to depth penetration. ultrasound modulation has been shown feasible in several species including humans both in vitro and in vivo. in this paper, an overview of our group’s ultrasound neuromodulation in both the central (cns) and the peripheral (pns) nervous systems will be provided. in cns, both motor- and sensory-related responses have been elicited in mice in vivo both in ipsilateral and contralateral limbs and pupils, respectively. the success are was highly correlated with the applied intensity and pressure in both the limb movement and ocular changes. the brain regions targeted were the somatosensory and visual cortex for the limb movement and the superior colliculus and locus coeruleus for the pupil dilation. in pns, stimulation and inhibition of the sciatic nerve with fus was elicited at different ultrasound parameters in vivo. displacement of the nerve highly cor…”
Byron, N., Semenova, A., & Sakata, S.. (2021). Mutual interactions between brain states and Alzheimer’s disease pathology: A focus on gamma and slow oscillations. Biology
“Brain state varies from moment to moment. while brain state can be defined by ongoing neuronal population activity, such as neuronal oscillations, this is tightly coupled with certain behavioural or vigilant states. in recent decades, abnormalities in brain state have been recognised as biomarkers of various brain diseases and disorders. intriguingly, accumulating evidence also demonstrates mutual interactions between brain states and disease pathologies: while abnormalities in brain state arise during disease progression, manipulations of brain state can modify disease pathology, suggesting a therapeutic potential. in this review, by focusing on alzheimer’s disease (ad), the most common form of dementia, we provide an overview of how brain states change in ad patients and mouse models, and how controlling brain states can modify ad pathology. specifically, we summarise the relationship between ad and changes in gamma and slow oscillations. as pathological changes in these oscillations correlate with ad pathology, manipulations of either gamma or slow oscillations can modify ad pathology in mouse models. we argue that neuromodulation approaches to target brain states are a promising non-pharmacological intervention for neurodegenerative diseases.”
Kohan, L., McKenna, C., & Irwin, A.. (2020). Ilioinguinal Neuropathy. Current Pain and Headache Reports
“Purpose of review: the purpose of this review is to present an overview of ilioinguinal (il) neuralgia and evaluate the current literature. recent findings: treatment of il neuralgia includes pharmacotherapies, perineural injections, radiofrequency ablation, cryoablation, neuromodulation, and neurectomy. the efficacy of these therapies varies considerably. summary: il neuralgia is a common pain disorder characterized by pain in the lower abdomen and upper thigh. while various modalities can be used in the treatment of il neuralgia, the efficacy of these modalities is at times limited. dorsal root ganglion stimulation exhibits promise in the treatment of il neuralgia. more research is needed to better address the needs of patients suffering from this disorder.”
Chen, S. P., & Ayata, C.. (2017). Novel Therapeutic Targets Against Spreading Depression. Headache
“Migraine is among the most prevalent and disabling neurological diseases in the world. cortical spreading depression (sd) is an intense wave of neuronal and glial depolarization underlying migraine aura, and a headache trigger, which has been used as an experimental platform for drug screening in migraine. here, we provide an overview of novel therapeutic targets that show promise to suppress sd, such as acid-sensing ion channels, casein kinase iδ, p2x7-pannexin 1 complex, and neuromodulation, and outline the experimental models and essential quality measures for rigorous and reproducible efficacy testing.”
Ekhtiari, H., Tavakoli, H., Addolorato, G., Baeken, C., Bonci, A., Campanella, S., … Hanlon, C. A.. (2019). Transcranial electrical and magnetic stimulation (tES and TMS) for addiction medicine: A consensus paper on the present state of the science and the road ahead. Neuroscience and Biobehavioral Reviews
“There is growing interest in non-invasive brain stimulation (nibs) as a novel treatment option for substance-use disorders (suds). recent momentum stems from a foundation of preclinical neuroscience demonstrating links between neural circuits and drug consuming behavior, as well as recent fda-approval of nibs treatments for mental health disorders that share overlapping pathology with suds. as with any emerging field, enthusiasm must be tempered by reason; lessons learned from the past should be prudently applied to future therapies. here, an international ensemble of experts provides an overview of the state of transcranial-electrical (tes) and transcranial-magnetic (tms) stimulation applied in suds. this consensus paper provides a systematic literature review on published data – emphasizing the heterogeneity of methods and outcome measures while suggesting strategies to help bridge knowledge gaps. the goal of this effort is to provide the community with guidelines for best practices in tes/tms sud research. we hope this will accelerate the speed at which the community translates basic neuroscience into advanced neuromodulation tools for clinical practice in addiction medicine.”
Fridén, J., House, J., Keith, M., Schibli, S., & van Zyl, N.. (2021). Improving hand function after spinal cord injury. Journal of Hand Surgery: European Volume
“Nerve transfer surgery has expanded reconstructive options for restoring upper extremity function following spinal cord injury. by adding new motor donors to the pool already available through tendon transfers, the effectiveness of treatment should improve. planning which procedures and in which order to perform, along with their details must be delineated. to meet these demands, refined diagnostics are needed, along with awareness of the remaining challenges to restore intrinsic muscle function and to address spasticity and its consequences. this article summaries recent advances in surgical reanimation of upper extremity motor control, together with an overview of the development of neuro-prosthetic and neuromodulation techniques to modify recovery or substitute for functional losses after spinal cord injuries.”
Anderson, N. D., & Craik, F. I. M.. (2017). 50 years of cognitive aging theory. Journals of Gerontology – Series B Psychological Sciences and Social Sciences
“Objectives: the objectives of this introduction to the journal of gerontology: psychological sciences special issue on ‘50 years of cognitive aging theory’ are to provide a brief overview of cognitive aging research prior to 1965 and to highlight significant developments in cognitive aging theory over the last 50 years. method: historical and recent theories of cognitive aging were reviewed, with a particular focus on those not directly covered by the articles included in this special issue. results: prior to 1965, cognitive aging research was predominantly descriptive, identifying what aspects of intellectual functioning are affected in older compared with younger adults. since the mid-1960s, there has been an increasing interest in how and why specific components of cognitive domains are differentially affected in aging and a growing focus on cognitive aging neuroscience. discussion: significant advances have taken place in our theoretical understanding of how and why certain components of cognitive functioning are or are not affected by aging. we also know much more now than we did 50 years ago about the underlying neural mechanisms of these changes. the next 50 years undoubtedly will bring new theories, as well as new tools (e.g., neuroimaging advances, neuromodulation, and technology), that will further our understanding of cognitive aging.”
“The Next-Generation Nonsurgical Neurotechnology (N3) program aims to develop high-performance, bi-directional brain-machine interfaces for able-bodied service members. Such interfaces would be enabling technology for diverse national security applications such as control of unmanned aerial vehicles and active cyber defense systems or teaming with computer systems to successfully multitask during complex military missions.
Whereas the most effective, state-of-the-art neural interfaces require surgery to implant electrodes into the brain, N3 technology would not require surgery and would be man-portable, thus making the technology accessible to a far wider population of potential users. Noninvasive neurotechnologies such as the electroencephalogram and transcranial direct current stimulation already exist, but do not offer the precision, signal resolution, and portability required for advanced applications by people working in real-world settings.
The envisioned N3 technology breaks through the limitations of existing technology by delivering an integrated device that does not require surgical implantation, but has the precision to read from and write to 16 independent channels within a 16mm3 volume of neural tissue within 50ms. Each channel is capable of specifically interacting with sub-millimeter regions of the brain with a spatial and temporal specificity that rivals existing invasive approaches. Individual devices can be combined to provide the ability to interface to multiple points in the brain at once.
To enable future non-invasive brain-machine interfaces, N3 researchers are working to develop solutions that address challenges such as the physics of scattering and weakening of signals as they pass through skin, skull, and brain tissue, as well as designing algorithms for decoding and encoding neural signals that are represented by other modalities such as light, acoustic, or electro-magnetic energy.”
The Intelligent Neural Interfaces (INI) program seeks to establish “Third-Wave” artificial intelligence methods to improve and expand the application space of next-generation neurotechnology. Recent progress in central and peripheral neural interface technologies has resulted in impressive capability demonstrations by utilizing artificial intelligence methods such as neural networks, evolutionary algorithms, and state space machine learning algorithms; however, a number of challenges still exist.
Martin-Sanchez, F., & Maojo, V.. (2009). Biomedical Informatics and the Convergence of Nano-Bio-Info-Cogno (NBIC) Technologies. Yearbook of Medical Informatics
“Objectives to analyze the role that biomedical informatics could play in the application of the nbic converging technologies in the medical field and raise awareness of these new areas throughout the biomedical informatics community.”
Abstract
Objectives: To analyze the role that biomedical informatics could play in the application of the NBIC Converging Technologies in the medical field and raise awareness of these new areas throughout the Biomedical Informatics community.
Methods: Review of the literature and analysis of the reference documents in this domain from the biomedical informatics perspective. Detailing existing developments showing that partial convergence of technologies have already yielded relevant results in biomedicine (such as bioinformatics or biochips). Input from current projects in which the authors are involved is also used.
Results: Information processing is a key issue in enabling the convergence of NBIC technologies. Researchers in biomedical informatics are in a privileged position to participate and actively develop this new scientific direction. The experience of biomedical informaticians in five decades of research in the medical area and their involvement in the completion of the Human and other genome projects will help them participate in a similar role for the development of applications of converging technologies -particularly in nanomedicine.
Conclusions: The proposed convergence will bring bridges between traditional disciplines. Particular attention should be placed on the ethical, legal, and social issues raised by the NBIC convergence. These technologies provide new directions for research and education in Biomedical Informatics placing a greater emphasis in multidisciplinary approaches.
Rebholz-Schuhman D, Cameron G, Clark D, van Mulligen E, Coatrieux JL, Del Hoyo Barbolla E, Martin-Sanchez F, Milanesi L, Porro I, Beltrame F, Tollis I, Van der Lei J.BMC Bioinformatics. 2007 Mar 8;8 Suppl 1(Suppl 1):S18. doi: 10.1186/1471-2105-8-S1-S18.PMID: 17430562Free PMC article.Review.
Wrye Sententia (2004, p. 227) defined cognitive liberty as concisely as
the right and freedom to control one’s own consciousness and electrochemical thought process.
SENTENTIA, W.. (2006). Neuroethical Considerations: Cognitive Liberty and Converging Technologies for Improving Human Cognition. Annals of the New York Academy of Sciences
“Developers of nbic (nano-bio-info-cogno) technologies face a multitude of obstacles, not the least of which is navigating the public ethics of their applied research. biotechnologies have received widespread media attention and spawned heated interest in their perceived social implications. now, in view of the rapidly expanding purview of neuroscience and the growing array of technologic developments capable of affecting or monitoring cognition, the emerging field of neuroethics calls for a consideration of the social and ethical implications of neuroscientific discoveries and trends. to negotiate the complex ethical issues at stake in new and emerging kinds of technologies for improving human cognition, we need to overcome political, disciplinary, and religious sectarianism. we need analytical models that protect values of personhood at the heart of a functional democracy – values that allow, as much as possible, for individual decision-making, despite transformations in our understanding and ability to manipulate cognitive processes. addressing cognitive enhancement from the legal and ethical notion of ‘cognitive liberty’ provides a powerful tool for assessing and encouraging nbic developments.”