Neuroimaging and Disorders of Consciousness: Envisioning an Ethical Research Agenda

The application of neuroimaging technology to the study of the injured brain has transformed how neuroscientists understand disorders of consciousness, such as the vegetative and minimally conscious states, and deepened our understanding of mechanisms of recovery. This scientific progress, and its potential clinical translation, provides an opportunity for ethical reflection. It was against this scientific backdrop that we convened a conference of leading investigators in neuroimaging, disorders of consciousness and neuroethics. Our goal was to develop an ethical frame to move these investigative techniques into mature clinical tools. This paper presents the recommendations and analysis of a Working Meeting on Ethics, Neuroimaging and Limited States of Consciousness held at Stanford University during June 2007. It represents an interdisciplinary approach to the challenges posed by the emerging use of neuroimaging technologies to describe and characterize disorders of consciousness.

[1]  Gustave Moonen,et al.  Cortical Processing of Noxious Somatosensory Stimuli in the Persistent Vegetative State , 2002, NeuroImage.

[2]  Joseph,et al.  Protecting human subjects in brain research: a pragmatic perspective , 2005 .

[3]  B. Jennett,et al.  Assessment of coma and impaired consciousness. A practical scale. , 1974, Lancet.

[4]  B. Vogt Pain and emotion interactions in subregions of the cingulate gyrus , 2005, Nature Reviews Neuroscience.

[5]  J. Illes,et al.  Interacting and paradoxical forces in neuroscience and society , 2007, Nature Reviews Neuroscience.

[6]  D. Dennett Are we explaining consciousness yet? , 2001, Cognition.

[7]  F. Miller,et al.  Protecting vulnerable research subjects without unduly constraining neuropsychiatric research. , 1999, Archives of general psychiatry.

[8]  F. Miller,et al.  Enrolling Decisionally Incapacitated Subjects in Neuropsychiatric Research , 2000, CNS Spectrums.

[9]  AH Chowdhury,et al.  Assessment of coma and impaired consciousness : A critical review , 2009 .

[10]  Robert W. Matthews,et al.  Uniform requirements for manuscripts submitted to biomedical journals: Writing and editing for biomedical publication , 2010, Journal of pharmacology & pharmacotherapeutics.

[11]  Steven Laureys,et al.  Brain function in coma, vegetative state, and related disorders , 2004, The Lancet Neurology.

[12]  C. Akinsanya Cancer pain relief and palliative care , 1992 .

[13]  J. Giacino,et al.  The minimally conscious state: a diagnosis in search of an epidemiology. , 2007, Archives of neurology.

[14]  David Bates,et al.  The vegetative state: guidance on diagnosis and management. , 2003, Clinical medicine.

[15]  J. Beaumont,et al.  Incidence and prevalence of the vegetative and minimally conscious states , 2005, Neuropsychological rehabilitation.

[16]  Carla H. Lagorio,et al.  Psychology , 1929, Nature.

[17]  L. A. Goldblatt,et al.  The birth of bioethics , 1999, Pediatrics.

[18]  C. Machado Cerebral processing in the minimally conscious state , 2005, Neurology.

[19]  E. Charlton Ethical guidelines for pain research in humans. Committee on Ethical Issues of the International Association for the Study of Pain. , 1995, Pain.

[20]  M. Kronbichler,et al.  Selective brain activity in response to one’s own name in the persistent vegetative state , 2006, Journal of Neurology, Neurosurgery & Psychiatry.

[21]  Steven Laureys,et al.  What is it like to be vegetative or minimally conscious? , 2007, Current opinion in neurology.

[22]  J. Fins Clinical pragmatism and the care of brain damaged patients: toward a palliative neuroethics for disorders of consciousness. , 2005, Progress in brain research.

[23]  J. Fins,et al.  A proposed ethical framework for interventional cognitive neuroscience: A consideration of deep brain stimulation impaired consciousness , 2000, Neurological research.

[24]  Steven Laureys,et al.  Cerebral response to patient's own name in the vegetative and minimally conscious states , 2007, Neurology.

[25]  Jan Kassubek,et al.  Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O–H2O PET study , 2003, Journal of the Neurological Sciences.

[26]  M. Lotze,et al.  MRI brain lesion patterns in patients in anoxia-induced vegetative state , 2007, Journal of the Neurological Sciences.

[27]  Matthew H. Davis,et al.  Using functional magnetic resonance imaging to detect covert awareness in the vegetative state. , 2007, Archives of neurology.

[28]  M. Raichle,et al.  The neural correlates of consciousness: an analysis of cognitive skill learning. , 1998, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[29]  Michael I. Posner,et al.  Analyzing and shaping human attentional networks , 2006, Neural Networks.

[30]  C. Levine The loneliness of the long-term care giver. , 2020, Caring : National Association for Home Care magazine.

[31]  Ermenegyldo Munhoz Junior Requisitos uniformes para manuscritos submetidos a periódicos biomédicos: escrevendo e editando para publicações biomédicas , 2006 .

[32]  J. Bernat Chronic disorders of consciousness , 2006, The Lancet.

[33]  Jaak Panksepp,et al.  Philosophy, Ethics, and Humanities in Medicine Does Any Aspect of Mind Survive Brain Damage That Typically Leads to a Persistent Vegetative State? Ethical Considerations , 2007 .

[34]  Thomas Krause,et al.  Separating functional and structural damage in persistent vegetative state using combined voxel-based analysis of 3-D MRI and FDG-PET , 2005, Journal of the Neurological Sciences.

[35]  Lionel Naccache,et al.  Is She Conscious? , 2006, Science.

[36]  F. Plum,et al.  Residual cerebral activity and behavioural fragments can remain in the persistently vegetative brain. , 2002, Brain : a journal of neurology.

[37]  J. Giacino,et al.  The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. , 2004, Archives of physical medicine and rehabilitation.

[38]  M. Boly,et al.  Auditory processing in severely brain injured patients: differences between the minimally conscious state and the persistent vegetative state. , 2004, Archives of neurology.

[39]  S. Ashwal,et al.  Medical aspects of the persistent vegetative state--a correction. The Multi-Society Task Force on PVS. , 1995, The New England journal of medicine.

[40]  Nicholas D Schiff,et al.  Late recovery from the minimally conscious state , 2007, Neurology.

[41]  Steven Laureys The neural correlate of (un)awareness: lessons from the vegetative state , 2005, Trends in Cognitive Sciences.

[42]  Matthew H. Davis,et al.  Do vegetative patients retain aspects of language comprehension? Evidence from fMRI. , 2007, Brain : a journal of neurology.

[43]  F. Plum,et al.  Words without Mind , 1999, Journal of Cognitive Neuroscience.

[44]  S. Eckstein The Belmont Report: ethical principles and guidelines for the protection of human subjects of research , 2003 .

[45]  Steven Laureys,et al.  Advances in Experimental Medicine and Biology, 550 (2004) 229-38 BRAIN FUNCTION IN THE VEGETATIVE STATE , 2022 .

[46]  B. Jennett The vegetative state , 2002, Journal of neurology, neurosurgery, and psychiatry.

[47]  J. Fins,et al.  Constructing an ethical stereotaxy for severe brain injury: balancing risks, benefits and access , 2003, Nature Reviews Neuroscience.

[48]  J. Illes,et al.  Trust and Reciprocity: Foundational Principles for Human Subjects Imaging Research , 2007, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques.

[49]  S Laureys,et al.  Measuring the effect of amantadine in chronic anoxic minimally conscious state , 2008, Journal of Neurology, Neurosurgery, and Psychiatry.

[50]  M S Gazzaniga,et al.  Brain and Conscious Experience , 1965, Springer Berlin Heidelberg.

[51]  A. Owen,et al.  Functional neuroimaging of the vegetative state , 2008, Nature Reviews Neuroscience.

[52]  N. Schiff,et al.  Shades of Gray: New Insights into the Vegetative State , 2006, The Hastings Center report.

[53]  I. de Melo-Martín,et al.  Viewpoint: Developing a Research Ethics Consultation Service to Foster Responsive and Responsible Clinical Research , 2007, Academic medicine : journal of the Association of American Medical Colleges.

[54]  J. Giacino,et al.  The minimally conscious state: Definition and diagnostic criteria , 2002, Neurology.

[55]  J Gabbay,et al.  Companion Encyclopedia of the History of Medicine , 1994 .

[56]  Paul S. Appelbaum,et al.  Research involving persons with mental disorders that may affect decisionmaking capacity. , 2002, Journal international de bioethique = International journal of bioethics.

[57]  Active Supportive Care Cancer pain relief and palliative care. Report of a WHO Expert Committee. , 1990, World Health Organization technical report series.

[58]  Bruce D. McCandliss,et al.  Possible axonal regrowth in late recovery from the minimally conscious state. , 2006, The Journal of clinical investigation.

[59]  Caroline Schnakers,et al.  Pain assessment and management in disorders of consciousness , 2007, Current opinion in neurology.

[60]  David A Rottenberg,et al.  Conscious awareness in PVS and MCS , 2007, Neurology.

[61]  P. Appelbaum,et al.  Therapeutic misconception in clinical research: frequency and risk factors. , 2004, IRB.

[62]  F. Plum,et al.  Behavioural improvements with thalamic stimulation after severe traumatic brain injury , 2008, Nature.

[63]  P. Eling,et al.  Brain perfusion and VEP reactivity in occipital and parietal areas are associated to recovery from hypoxic vegetative state , 2007, Journal of the Neurological Sciences.

[64]  Lionel Naccache,et al.  Psychology. Is she conscious? , 2006, Science.

[65]  R. Michels,et al.  Are research ethics bad for our mental health? , 1999, The New England journal of medicine.

[66]  J. Armony,et al.  Acute head drop after cervical hyperflexion injury , 2004, Journal of Neurology, Neurosurgery & Psychiatry.

[67]  P. Zhong,et al.  [Functional magnetic imaging of brain cortical activities in minimally conscious patients stimulated by visual presentation]. , 2007, Zhonghua yi xue za zhi.

[68]  Multi-Society Task Force on Pvs Medical aspects of the persistent vegetative state (1). , 1994, The New England journal of medicine.

[69]  J. Fins In an Instant: A Family’s Journey of Love and Healing , 2007 .

[70]  Matthew H. Davis,et al.  Detecting awareness in the vegetative state. , 2006, Science.

[71]  M. Farah Neuroethics and the Problem of Other Minds: Implications of Neuroscience for the Moral Status of Brain-Damaged Patients and Nonhuman Animals , 2008 .

[72]  Judy Illes,et al.  Brain Imaging , 2006, Science communication.