Diagnosing consciousness: Neuroimaging, law, and the vegetative state

Journal of Law, Medicine and Ethics

Volumn 38, Issue 2, 2010, Pages 374-385

  Fisher, Carl E ^a   Appelbaum, Paul S ^b  

^a NEW YORK STATE PSYCHIATRIC INSTITUTE   (United States)

^b Dept of Psychiatry at the College of Physicians and Surgeons of Columbia Univ ^*  (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BRAIN DEATH; CLASSIFICATION; CONSCIOUSNESS DISORDER; CUSTODY; DECISION MAKING; DIAGNOSTIC IMAGING; ETHICS; HUMAN; LEGAL ASPECT; METHODOLOGY; NEUROLOGIC EXAMINATION; NUCLEAR MAGNETIC RESONANCE IMAGING; PATIENT CARE; PERSISTENT VEGETATIVE STATE; POSITRON EMISSION TOMOGRAPHY; UNITED STATES;

ADVANCE CARE PLANNING; BRAIN DEATH; CONSCIOUSNESS DISORDERS; DECISION MAKING; DIAGNOSTIC IMAGING; DIAGNOSTIC TECHNIQUES, NEUROLOGICAL; HUMANS; MAGNETIC RESONANCE IMAGING; PERSISTENT VEGETATIVE STATE; POSITRON-EMISSION TOMOGRAPHY; PROXY; UNITED STATES;

EID: 77954895573     PISSN: 10731105     EISSN: 1748720X     Source Type: Journal    
DOI: 10.1111/j.1748-720X.2010.00496.x     Document Type: Article

References (99)

1. " Book-Writing Man in Coma Fails Communication Test,": National Public Radio. February 17, 2010, http://www.npr.org/blogs/health/2010/02/bookwriting_man_in_coma_flunks.html, last visited May 11, 2010
2. Monti M M, Vanhaudenhuyse A, Coleman M R, Boly M, Pickard J D, Tshibanda L, Owen A M, Laureys S. " Willful Modulation of Brain Activity in Disorders of Consciousness," New England Journal of Medicine 2010, 362(no. 7):579-589.
3. Skene L, Wilkinson D, Kahane G, Savulescu J. " Neuroimaging and the Withdrawal of Life-Sustaining Treatment from Patients in Vegetative State," Medical Law Review 2009, 17(no. 2):245-261.
4. Though for discussion of withdrawal of life saving therapy in light of these developments, see D. J. Wilkinson, G. Kahane, M. Horne, and J. Savulescu, " Functional Neuroimaging and Withdrawal of Life-Sustaining Treatment from Vegetative Patients," 35, no. 8 (2009): 508-511.
5. Meisel A, Cerminara K L. The Right to Die: The Law of End-of-Life Decisionmaking 2004, New York, Aspen Publishers, at 6-128.1
6. Plum F, Posner J B. The Diagnosis of Stupor and Coma 1980, Philadelphia, F. A. Davis Co.
7. Laureys S, Owen A M, Schiff N D. " Brain Function in Coma, Vegetative State, and Related Disorders," Lancet Neurology 2004, 3(no. 9):537-546.
8. The Multi-Society Task Force on PVS, " Medical Aspects of the Persistent Vegetative State (1)," 330, no. 21 (1994): 1499-1508.
9. Giacino J T, Ashwal S, Childs N, Cranford R, Jennett B, Katz D I, Kelly J P, Rosenberg J H, Whyte J, Zafonte R D, Zasler N D. " The Minimally Conscious State: Definition and Diagnostic Criteria," Neurology 2002, 58(no. 3):349-53.
10. Fins J J, Schiff N D, Foley K M. " Late Recovery from the Minimally Conscious State: Ethical and Policy Implications," Neurology 2007, 68(no. 4):304-307.
11. Schnakers C, Vanhaudenhuyse A, Giacino J, Ventura M, Boly M, Majerus S, Moonen G, Laureys S. " Diagnostic Accuracy of the Vegetative and Minimally Conscious State: Clinical Consensus Versus Standardized Neurobehavioral Assessment," BMC Neurology 2009, 9:35.
12. Laureys S, Perrin F, Bredart S. " Self-Consciousness in Non-Communicative Patients," Consciousness and Cognition 2007, 16(no. 3):722-741.
13. Owen A M, Coleman M R. " Functional Neuroimaging of the Vegetative State," Nature Reviews Neuroscience 2008, 9(no. 3):235-243.
14. Koch C. The Quest for Consciousness: A Neurobiological Approach 2004, Denver, Roberts and Co.
15. Dehaene S, Changeux J P, Naccache L, Sackur J, Sergent C. " Conscious, Preconscious, and Subliminal Processing: A Testable Taxonomy," Trends in Cognitive Science 2006, 10(no. 5):204-211.
16. Block N J, Flanagan O J, Güzeldere G. The Nature of Consciousness: Philosophical Debates 1997, Cambridge, MIT Press
17. Block N J. " Concepts of Consciousness," Philosophy of Mind: Classical and Contemporary Readings 2002, Chalmers D J. New York, Oxford University Press, at 206
18. Güzeldere G. " The Many Faces of Consciousness: A Field Guide," The Nature of Consciousness: Philosophical Debates 1997, 1-68. Block N JFlanagan O JGüzeldere G. Cambridge, MIT Press
19. See Block, note 18, at 206.
20. Zola E. Thérèse Raquin 1867, Paris, E. Fasquelle
21. Laureys S, Lemaire C, Maquet P, Phillips C, Franck G. " Cerebral Metabolism During Vegetative State and After Recovery to Consciousness," Journal of Neurology, Neurosurgery, and Psychiatry 1999, 67(no. 1):121-122.
22. de Jong B M, Willemsen A T, Paans A M. " Regional Cerebral Blood Flow Changes Related to Affective Speech Presentation in Persistent Vegetative State," Clinical Neurology and Neurosurgery 1997, 99(no. 3):213-216.
23. Menon D K, Owen A M, Williams E J, Minhas P S, Allen C M, Boniface S J, Pickard J D. " Cortical Processing in Persistent Vegetative State," The Lancet 1998, 352(no. 9123):200.
24. Schiff N D, Ribary U, Moreno D R, Beattie B, Kronberg E, Blasberg R, Giacino J, McCagg C, Fins J J, Llinas R, Plum F. " Residual Cerebral Activity and Behavioural Fragments Can Remain in the Persistently Vegetative Brain," Brain 2002, 125(no. 6):1210-1234.
25. Schiff N D, Rodriguez-Moreno D, Kamal A, Kim K H, Giacino J T, Plum F, Hirsch J. " fMRI reveals Large-Scale Network Activation in Minimally Conscious Patients," Neurology 2005, 64(no. 3):514-523.
26. Hildebrandt H, Happe S, Deutschmann A, Basar-Eroglu C, Eling P, Brunhober J. " Brain Perfusion and VEP Reactivity in Occipital and Parietal Areas are Associated to Recovery from Hypoxic Vegetative State," Journal of the Neurological Sciences 2007, 260(no. 1-2):150-158.
27. Kassubek J, Juengling F D, Els T, Spreer J, Herpers M, Krause T, Moser E, Lucking C H. " Activation of a Residual Cortical Network During Painful Stimulation in Long-Term Postanoxic Vegetative State: A 15O-H2O PET Study," Journal of the Neurological Sciences 2003, 212(no. 1-2):85-91.
28. Laureys S, Faymonville M E, Peigneux P, Damas P, Lambermont B, Del Fiore G, Degueldre C, Aerts J, Luxen A, Franck G, Lamy M, Moonen G, Maquet P. " Cortical Processing of Noxious Somatosensory Stimuli in the Persistent Vegetative State," Neuroimage 2002, 17(no. 2):732-741.
29. Di H B, Yu S M, Weng X C, Laureys S, Yu D, Li J Q, Qin P M, Zhu Y H, Zhang S Z, Chen Y Z. " Cerebral Response to Patient's Own Name in the Vegetative and Minimally Conscious States," Neurology 2007, 68(no. 12):895-899.
30. See Owen and Coleman, note 14.
31. Staffen W, Kronbichler M, Aichhorn M, Mair A, Ladurner G. " Selective Brain Activity in Response to One's Own Name in the Persistent Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry 2006, 77(no. 12):1383-1384.
32. Perrin F, Schnakers C, Schabus M, Degueldre C, Goldman S, Bredart S, Faymonville M E, Lamy M, Moonen G, Luxen A, Maquet P, Laureys S. " Brain Response to One's Own Name in Vegetative State, Minimally Conscious State, and Locked-In Syndrome," Archives of Neurology 2006, 63(no. 4):562-569.
33. Owen A M, Coleman M R, Menon D K, Berry E L, Johnsrude I S, Rodd J M, Davis M H, Pickard J D. " Using a Hierarchical Approach to Investigate Residual Auditory Cognition in Persistent Vegetative State," Progress in Brain Research 2005, 150:457-471.
34. Coleman M R, Rodd J M, Davis M H, Johnsrude I S, Menon D K, Pickard J D, Owen A M. " Do Vegetative Patients Retain Aspects of Language Comprehension? Evidence from fMRI," Brain 2007, 130(no. 10):2494-2507.
35. Davis M H, Coleman M R, Absalom A R, Rodd J M, Johnsrude I S, Matta B F, Owen A M, Menon D K. " Dissociating Speech Perception and Comprehension at Reduced Levels of Awareness," Proceedings of the National Academy of Sciences of the United States of America 2007, 104(no. 41):16032-16037.
36. Schnakers C, Perrin F, Schabus M, Majerus S, Ledoux D, Damas P, Boly M, Vanhaudenhuyse A, Bruno M A, Moonen G, Laureys S. " Voluntary Brain Processing in Disorders of Consciousness," Neurology 2008, 71(no. 20):1614-1620.
37. Schnakers C, Perrin F, Schabus M, Hustinx R, Majerus S, Moonen G, Boly M, Vanhaudenhuyse A, Bruno M A, Laureys S. " Detecting Consciousness in a Total Locked-In Syndrome: An Active Event-Related Paradigm,": Neurocase. 2009, 1-7.
38. Laureys S, Pellas F, Van Eeckhout P, Ghorbel S, Schnakers C, Perrin F, Berre J, Faymonville M E, Pantke K H, Damas F, Lamy M, Moonen G, Goldman S. " The Locked-In Syndrome: What Is It Like to Be Conscious but Paralyzed and Voiceless?" Progress in Brain Research 2005, 150:495-511.
39. Owen A M, Coleman M R, Boly M, Davis M H, Laureys S, Pickard J D. " Detecting Awareness in the Vegetative State," Science 2006, 313(no. 5792):1402.
40. Owen A, Coleman M R, Boly M, Davis M H, Laureys S, Jolles D, Pickard J D. " Response to Comments on " Detecting Awareness in the Vegetative State," Science 2007, 315(no. 5816):1221.
41. Boly M, Coleman M R, Davis M H, Hampshire A, Bor D, Moonen G, Maquet P A, Pickard J D, Laureys S, Owen A M. " When Thoughts Become Action: An fMRI Paradigm to Study Volitional Brain Activity in Non-Communicative Brain Injured Patients," Neuroimage 2007, 36(no. 3):979-992.
42. See Monti et al., note 2.
43. Eisenberg J B. " Schiavo on the Cutting Edge: Functional Brain Imaging and its Impact on Surrogate End-of-Life Decision-Making," Neuroethics 2008, 1:75-83.
44. See Meisel and Cerminara, note 5, at 6-125.
45. Henceforth, we use the term " unconscious state" or " unconsciousness" to refer to the formal state-law definition of consciousness, though it bears noting that states vary in these overall labels; i.e., some incorrectly use the term " persistent VS" instead of " permanent VS" or " permanent unconsciousness." In these cases, the accompanying state-law definition might bear little resemblance to the clinical definition of VS.
46. See Meisel and Cerminara, note 5, at 6-128.1.
47. A note on methods: our aim was to identify explicit state-laws definitions of consciousness, which are found most frequently in advance directive or surrogate decisionmaking statues. To generate this list we took as our starting point the thorough review of Meisel et al, note 5, which we supplemented with our own review of primary sources. Many end-of-life statutes do not provide such a definition (e.g., Alaska Stat. § 13.52, which does not explicitly define a vegetative state or other conditions having to do with consciousness). While we attempted to be as exhaustive as possible in this review, it is difficult to determine with certainty the absence of a law about a particular topic.
48. Missouri Department of Health. 261 U.S.344 (1990)
49. Me. Rev. Stat. Ann. tit. 18-A § 5-801(s) (West 2009).
50. S.C. Code Ann. § 44-77-20(7) (1976).
51. Idaho Code Ann. § 39-4502(10) (2009).
52. See Skene et al., note 3.
53. Ala. Code § 22-8A-3(10) (1975); 755 Ill. Comp. Stat. Ann. 40/10 (West 2009).
54. Wis. Stat. Ann. § 154.01(5m).
55. See Meisel and Cerminara, note 5, at 7-83.
56. Fla. Stat § 765.101(12) (West 2006).
57. Ala. Code § 22-8A-3(10) (1975).
58. S.D. Codified Laws § 34-12D-1(7).
59. Fla. Stat § 765.101(12) (West 2006).
60. Ga. Code Ann. § 31-32-2(13) (West 2009); Va. Code Ann. § 54.1-2982 (West 2009).
61. Ga. Code Ann. § 31-32-2(13) (West 2009).
62. 755 Ill. Comp. Stat. Ann. 40/10 (West 2009).
63. Conn. Gen. Stat. Ann. § 19a-570(10) (West 2009); Ga. Code Ann. § 31-32-2.
64. See Jong et al., note 23.
65. See Menon et al., note 24; see Schiff et al., note 26.
66. Ohio Rev. Code Ann. § 1337.11(V) (West 2009).
67. Ala. Code § 22-8A-3(10) (1975); 755 Ill. Comp. Stat. Ann. 40/10 (West 2009); Ark. Code. Ann. § 20-17-201(6) (West 2009).
68. See Laureys et al., note 29.
69. See Coleman et al., note 35.
70. See Davis et al., note 36.
71. Fla. Stat § 765.101(12) (West 2006); Ala. Code § 22-8A-3(10) (1975); Conn. Gen. Stat. Ann. § 19a-570(10) (West 2009); Ga. Code Ann. § 31-32-2(13) (West 2009); 755 Ill. Comp. Stat. Ann. 40/10 (West 2009).
72. Ala. Code § 22-8A-4 (1975).
73. Ala. Code § 22-8A-3(10) (1975).
74. Carey B. " Trace of Thought Is Found in 'Vegetative' Patient,": The New York Times. February 4, 2010, A1. See, at, J. Groopman, " Silent Minds," , October 15, 2007, at 38-43; and note 1
75. See Schnakers et al., note 35.
76. Wegner D M. White Bears and Other Unwanted Thoughts: Suppression, Obsession, and the Psychology of Mental Control 1989, New York, Viking
77. Logothetis N K. " What We Can Do and What We Cannot Do with fMRI," Nature 2008, 453(no. 7197):869-878.
78. For an extensive review of other technologies that might be used for this purpose, see the recent theme issue of on " Coma Science: Clinical and Ethical Implications," especially L. Tshibanda, A. Vanhaudenhuyse, D. Galanaud, M. Boly, S. Laureys, and L. Puybasset, " Magnetic Resonance Spectroscopy and Diffusion Tensor Imaging in Coma Survivors: Promises and Pitfalls," 177 (2009): 215-229.
79. Poldrack R A. " Can Cognitive Processes be Inferred from Neuroimaging Data?" Trends in Cognitive Science 2006, 10(no. 2):59-63.
80. Tshibanda. supra note 79. See
81. Pettit M. " FMRI and BF meet FRE: Brain Imaging and the Federal Rules of Evidence," American Journal of Law & Medicine 2007, 33(no. 2-3):319-40.
82. Feigenson N, Park J. " Emotions and Attributions of Legal Responsibility and Blame: A Research Review," Law and Human Behavior 2006, 30(no. 2):143-161.
83. 293 F. 1013 (1923)
84. 509 U.S. 579 (1993)
85. Khoshbin L S, Khoshbin S. " Imaging the Mind, Minding the Image: An Historical Introduction to Brain Imaging and the Law," American Journal of Law & Medicine 2007, 33(nos. 2-3):171-192.
86. McCabe D P, Castel A D. " Seeing is Believing: The Effect of Brain Images on Judgments of Scientific Reasoning," Cognition 2008, 107(no. 1):343-52.
87. Bennett M R, Dennett D, Hacker P, Searle J. Neuroscience and Philosophy: Brain, Mind, and Language 2007, New York, Columbia University Press, P. M. Churchland, " Eliminative Materialism and the Propositional Attitudes," 78, no. 2 (1981): 67-90
88. Neb. Rev. Stat. § 20-403(6) (West 2009); Me. Rev. Stat. Ann. tit. 18-A § 5-801(s) (West 2009).
89. Kahane G, Savulescu J. " Brain Damage and the Moral Significance of Consciousness," The Journal of Medicine and Philosophy 2009, 34(no. 1):6-26.
90. See Meisel and Cerminara, note 3, at 4-74.
91. Levy N, Savulescu J. " Moral Significance of Phenomenal Consciousness," Progress in Brain Research 2009, 177:361-370.
92. at 367
93. at 368. Note that this conception of access consciousness (originally defined as the state of having mental information available for reasoning, the control of action, and reporting, see Block, note 15) also invokes the issues of chronicity and prognosis, which, while beyond the scope of this paper, may have significant ethical and legal relevance. For example, the futility of the vegetative state is one of the foundational justifications of right-to-die movement in the United States, as reviewed in J. J. Fins, " The Ethics of Measuring and Modulating Consciousness: The Imperative of Minding Time," 177 (2009): 371-82
94. See Wilkinson et al., note 4.
95. See Skene et al., note 3.
96. See Laureys et al., note 39.
97. Lulé D, Zickler C, Häcker S, Bruno M A, Demertzi A, Pellas F, Laureys S, Kübler A. " Life Can Be Worth Living in Locked-In Syndrome," Progress in Brain Research 2009, 177:339-351.
98. Dennett DC. Consciousness Explained 1991, Boston, Little, Brown and Co.
99. AL: Ala. Code § 22-8A-3(10) (1975); AR: Ark. Code. Ann. § 20-17-201(6) (West 2009); CT: Conn. Gen. Stat. Ann. § 19a-570(10) (West 2009); DE: Del. Code Ann. Tit. 16, § 2501 (r) (1) (West 2009); FL: Fla. Stat § 765.101(12) (West 2009); GA: Ga. Code Ann. § 31-32-2(13) (West 2009); ID: Idaho Code Ann. § 39-4502(10) (2009); IL: 755 Ill. Comp. Stat. Ann. 40/10 (West 2009); MD: Md. Code Ann., [Health-Gen.] §5-601(q) (West 2009); ME: Me. Rev. Stat. Ann. tit. 18-A § 5-801(s) (West 2009); NE: Neb. Rev. Stat. § 20-403(6) (West 2009); NH: N.H. Rev. Stat. Ann. § 137-J:2(XVII) (2009); NJ: N.J. Stat. Ann. § 26:2H-55 (West 2009); OH: Ohio Rev. Code Ann. § 1337.11(V) (West 2009); OR: Or. Rev. Stat § 127.505(19) (West 2009); PA: 20 Pa. Cons. Stat. Ann. § 5422 (West 2009); SC: S.C. Code Ann. § 44-77-20(7) (1976); SD: S.D. Codified Laws § 34-12D-1(7) (2009); VA: Va. Code Ann. § 54.1-2982 (West 2009); WI: Wis. Stat. Ann. § 154.01(5m) (West 2009); WV: W.Va. Code § 16-30-3(s) (West 2009).