A while back, this group had a discussion on "facilitated communication", which is a way to make an unconscious person act as a human ouija board, but with a more legit sounding name.


The question is, how do you know if someone, who is in a 100% noncommunicative state, is conscious but unable to communicate?  I thought of this discussion on reading an article this week in NEJM.  Basically the authors used functional MRI (MRI that looks for presence of oxygen or glucose metabolism in specific areas of the brain) to see if there was brain activity when the patients were asked to visualize certain tasks.  They showed that a small number of patients (about 10% in this small sample), who were thought to be fully vegetative, were actually capable of conscious communication via MRI.


"54 patients with severe brain injury, including 23 in a vegetative state and 31 in a minimally conscious state, underwent functional MRI as a means of evaluating their performance on motor and spatial imagery tasks. "...


"Before each of these imaging sessions, participants were asked a yes-or-no question (e.g., "Do you have any brothers?") and instructed to respond during the imaging session by using one type of mental imagery (either motor imagery or spatial imagery) for "yes" and the other for "no." The nature of the questions ensured that the investigators would not know the correct answers before judging the functional MRI data. Participants were asked to respond by thinking of whichever imagery corresponded to the answer that they wanted to convey. "...


"Of the 54 patients, 5 with traumatic brain injuries were able to modulate their brain activity by generating voluntary, reliable, and repeatable blood-oxygenation-level–dependent responses in predefined neuroanatomical regions when prompted to perform imagery tasks. No such responses were observed in any of the patients with nontraumatic brain injuries [in other words, oxygen deprivation or chemicals that cause diffuse damage to brain tissue, instead of localized mechanical injuries] ....Thus, in a minority of cases, patients who meet the behavioral criteria for a vegetative state have residual cognitive function and even conscious awareness."


In other words, they were able to ask the patients to think of an image or activity, depending on their answer to a question, then see in an MRI scan the brain activity that corresponded to the answer. 


So much better than a "human ouija board". 


This does bring up some ethical issues - like, if a person is shown to be conscious, and communciates via the functional MRI that they want their life support turned off, would that be allowed?  Will they be asked that question?  Is it ethical not to ask that question? 


Will every person who is in a pesistant vegetative state now have to get a functional MRI? 


If, shown by functional MRI to be unable to generate responses, is it ethical to continue to divert resources to these probably permanently comatose, nonsentient people, when those resources might better serve a far larger number of communicative, sentient people?  If so, who pays?






Tags: coma, ethics, facilitated communication

Views: 39

Replies to This Discussion

Hmm. Just because they're conscious enough to answer yes or no questions via fMRI, that may not mean they are "of sound mind" enough to make the call about whether they should be unplugged. That probably needs work.

On the other hand, the vegetative folks should be unplugged unless Mr. Burns from the Simpsons wants to pay the bill to keep them running until he needs to harvest an organ or two.
Yeah...I think I'd rather be an unconscious rutabaga than a conscious one.
My idea of hell, to be sure. Oprah & sitcoms, unable to say "turn that shit off! Please!"
It seems unlikely that the person would have the ability to comprehend their current state or surroundings. Recalling memories is one thing but evaluating their immediate situation is probably quite different.

I think that if you could be sure that the person was aware of their current state and could make coherent "modulations" regarding it then, yeah, let 'em make that decision. Unfortunately the rate of successful communication is too low to allow any of them to make this change in policy, nor would it be warranted.

Still, a very interesting area to ponder.
i don't think you could really distinguish between the yes or no answers. in the article, the evaluators didn't know if the answer to a question was yes or no when evaluating the fMRI's. i'm not sure you even could distinguish between the two. you can tell if someone is using different portions of their brains, but i'm pretty sure you can't "read their mind" to tell if they are thinking a yes or no, or to tell if they really understand the question to be able to answer yes and no. it may just be a response to stimuli.

i think this study is interesting in that it could be used to determine whether or not there is any point in keeping someone "plugged in," but i don't see it telling us much more than that.
it's a bit more than that. the researchers first 'trained' the subjects to activate different areas of the brain: one part by telling them to imagine they're swinging their arm in a tennis court (motor imagery), and another part by telling them to imagine they're navigating their way through the streets or their own home (spatial imagery). this will 'light up' different areas under fMRI.

so it seems 5 out of 54 vegetative patients were able to cooperate with this training - a marvellous achievement already!

then they did something else: they linked the activation of the brain areas to yes/no answer. a bit like 'lift up your left arm for YES and your right arm for NO' (but not quite). after that they test whether the subject understood the concept via asking personal life questions, e.g. "is your father's name Alexander?" and check their YES/NO response. out of a series of 6 questions, the subject was able to answer 5 correctly.

the researcher reading the fMRI response was blinded to the correct answer so as to reduce bias - so he's got to read the fMRI response as a YES or NO first before knowing what the correct response is supposed to be.

if a person is able to consistently answer YES/NO questions correctly in this manner, it is possible to determine whether they are of sound mind or not.
The one thing this study does seem to warrant is further investigation. It may even be able to determine better ways to communicate if enough progress was made and, perhaps more importantly, determine if independent communication abilities can be restored.
It is hard to make a call about this on a level of higher numbers and general policy because, as our other commenters have stated, it is too soon.
So this is a small amount of vegetative cases. If they do have conscious mental activity but are otherwise completely helpless, if they want to have the plug pulled that should be honored. Asking them if they want it is the same issue as asking people if they want assisted suicide...it's basically saying "hey, you might want to consider dying", which is insulting if the person doesn't want to. Even so, the cost of keeping them alive is an issue (as is overpopulation). Putting an infinite value on human life is overly sentimental. To me, people get totalled, just like cars, where the cost of keeping them alive is so high and/or their quality of life is so diminished that it isn't worth it.
I can see your point but has a car ever cured a disease (and I don't mean by killing the afflicted, hehe)? Of course, if we didn't have to worry about money/capitalism that wouldn't even matter.
I don't think a human vegetable has cured a disease, either.
I'm not sure I get the reason it's insulting to give a choice. I can imagine lying in a room with no choices, no dignity, no privacy, no hope for improvement. In pain and unable to tell anyone - possibly excrutiating pain. I would want to be given the tiny piece of autonomy that someone might let me have a choice. Maybe I didn't understand the comment.
Well maybe not worth... in $ value, but if I was in pain or unable to communicate while in a "vegetative" state, and I was told by the physicians that there was no foreseeable improvement, I would want the real deal, death.

I still believe, no matter what the technology, that it's the patient which must decide, or if not of "sound mind" then the next of kin. This rule should be able to hold up to the various challenges posed by technology.

A living will is something we should all be committing to writing down NOW. It would certainly save a lot of arguing.


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