How is new technology helping us gain a better understanding of consciousness in patients with severe brain damage? If a patient is unable to communicate or even blink, does that mean he or she is completely unaware? At what point should the intentions stated in a living will be determined by the patient’s family or surrogate?
These questions were among the issues discussed at Harvard Medical School’s most recent neuroethics seminar, titled “Seeing Consciousness: The Promise and Perils of Brain Imaging in Disorders of Consciousness.” The school’s Center for Bioethics invited Joseph Giacino, Ph.D., director of Rehabilitation Neuropsychology at Spaulding Rehabilitation Hospital; Joseph Fins, M.D., chief of the Division of Medical Ethics at Weill Cornell Medical College; and James Bernat, M.D., Louis and Ruth Frank Professor of Neuroscience at The Dartmouth Institute to share the stage and give a brief talk for its Neuroethics Seminar Series.
Giacino began the discussion by describing a study that introduced three states of disordered consciousness that all three speakers further explored. Following severe traumatic brain injury—a disability that affects 3.5 million Americans—patients can go into a vegetative state (VS), minimally conscious state (MCS), or post traumatic confusional state (PTCS). Giacino’s study looked at patients in these conditions, along with ten healthy controls, to research neuroimaging methodologies and certain techniques used to determine the patients’ level of response.
Some of these techniques involved scanning the patient’s brain to monitor responses, or lack thereof, when given various forms of visual stimuli, such as specific words and images of landscapes. Giacino noted that there are distinct sections of the brain that respond to various stimuli. By using a scanner to monitor a patient’s responses, his or her level of command-following communication can be determined.
To place Giacino’s discourse “into a bioethical context,” Fins opened with a quote from American psychologist John Dewey. He wanted to remind the audience “how far we’ve come in such a short amount of time” in the way of technology and ethics. The ethical issue emerges when patients are so impaired that they have lost the capacity for decision-making, Fins said, and it’s important to acknowledge the dichotomy between research and clinical work. He also stressed the importance of timing: When a patient moves from coma to vegetative state to minimally conscious state, labeling them “early on can become stigmatizing…It’s a label they can carry forever, even if [their state] evolves over time.”
According to Fins, who recently published a book on this topic called Rights Come to Mind, “there is nothing more important than knowing the patient may be conscious, especially when there’s a paucity of motor output,” and a possibility that the imaging data suggests an individual thought to be vegetative might actually be aware.
In 2005, Fins and Bernat, both of whom are Dana Alliance members, were featured in a New York Times article that came out a day after the new brain-imaging study was published. The paper revealed that seemingly unaware, brain-damaged patients could potentially be aware of their surroundings but unable to respond.
Bernat’s presentation focused on the impact of fMRI and FDG-PET imaging and how it “may become useful clinically for diagnosis and prognosis.” In terms of future directions for neuroimaging and the ethics of consciousness, he believes that more detailed studies with a greater number of patients, as well as more reliable funding, will lead to refined mapping of the anatomy and physiology of human consciousness. Bernat trusts that within the next ten years, the diagnostic criteria of patients in a vegetative or minimally conscious state will be revised to incorporate new brain imaging data. To read more about disorders of consciousness, check out our Report on Progress article from earlier this year.
The next seminar, which is free and open to the public, will take place on October 21 at Harvard Medical School. If you’re in the Boston area, you can register here or watch it live on your computer. In partnership with Harvard Medical School, the International Neuroethics Society makes it possible to live stream the seminars in this series. To view any past sessions, click here.
– Seimi Rurup