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Neuroimaging and Disorders of Consciousness University of California, Hastings College of the Law UC Hastings Scholarship Repository Faculty Scholarship 2008 Neuroimaging and Disorders of Consciousness: Envisioning an Ethical Research Agenda Emily Murphy University of California Hastings College of Law, [email protected] Joseph J. Fins Judy Iles James L. Bernat Joy Hirsch See next page for additional authors Follow this and additional works at: https://repository.uchastings.edu/faculty_scholarship Recommended Citation Emily Murphy, Joseph J. Fins, Judy Iles, James L. Bernat, Joy Hirsch, and Steven Laureys, Neuroimaging and Disorders of Consciousness: Envisioning an Ethical Research Agenda, 8 Amer. J. Bioethics 3 (2008). Available at: https://repository.uchastings.edu/faculty_scholarship/1513 This Article is brought to you for free and open access by UC Hastings Scholarship Repository. It has been accepted for inclusion in Faculty Scholarship by an authorized administrator of UC Hastings Scholarship Repository. Authors Emily Murphy, Joseph J. Fins, Judy Iles, James L. Bernat, Joy Hirsch, and Steven Laureys This article is available at UC Hastings Scholarship Repository: https://repository.uchastings.edu/faculty_scholarship/1513 The American Journal of Bioethics, 8(9): 3–12, 2008 Copyright c Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265160802318113 Target Article Neuroimaging and Disorders of Consciousness: Envisioning an Ethical Research Agenda Joseph J. Fins, Weill Medical College of Cornell University∗ Judy Illes, University of British Columbia∗ James L. Bernat, Dartmouth Medical School∗∗ Joy Hirsch, Columbia University∗∗ Steven Laureys, University of Liege∗∗ Emily Murphy, Stanford Law School∗∗ 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. Human consciousness encompasses subjectivity, sentience, and conscious awareness of attended objects to an anterior self-awareness, and an ability to appreciate the relationship attentional network. Raichle (1998) attributes arousal con- between the self and the environment. From a philosophi- sciousness to the ascending reticular formation and con- cal perspective, we appreciate the features of consciousness tent consciousness to the engagement of cortical systems. that enable the processing of information, access to informa- Within these cortical networks, the fronto-parietal associa- tion, content and phenomenal experience, qualia and aware- tive global workspace play a key role in the emergence of ness. From a cognitive neuroscience approach, we can deter- awareness (Laureys 2005). mine different neural correlates relevant to these features of Consciousness, however, is neither a momentary con- consciousness. Posner and colleagues (2006), for example, dition nor purely dispositional (Dennett 2001) but rather have attributed the mediation and orientation of attention a phenomenon of variables that change over time. Con- (much like access) to a posterior attentional brain network sciousness is required for cognitive tasks involving working ∗Co-lead authors. ∗∗Equal authors in alphabetical order. Acknowledgment: The authors acknowledge the support of the Greenwall Foundation for sponsorship of the conference on which this paper is based. Dr. Fins is a recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research and also gratefully acknowledges support from the Charles A. Dana and Buster Foundations. Dr. Illes acknowledges the additional support of NIH/NINDS RO1 NS#045831. The meeting was hosted by the Stanford Center for Biomedical Ethics and Program in Neuroethics, Stanford University. Many thanks to Vivian Chin, Stanford University; Stephen Jones, Stanford University; Eugenie Marek, Stanford University; Navah Statman, National Alliance for Mental Illness, for attending; and Patricia Lau at the National Core for Neuroethics, University of British Columbia, for editorial assistance. Cosigning Workshop Participants Martha J. Farah, University of Pennsylvania; Joseph T. Giacino, JFK Medical Center; Oleg Jardetsky, Stanford University; Albert R. Jonsen, California Pacific Medical Center; Maarten Lansberg, Stanford University; Sofia Lombera, Stanford University; David Magnus, Stanford University; Jennifer McCormick, Stanford University; Stephen J. Morse, University of Pennsylvania; Adrian M. Owen, Medical Research Council, UK; Eric Racine, Institut de Recherches Cliniques de Montr´eal, Montreal, Canada; Christine Wijman, Stanford University; Nicholas D. Schiff, Weill Cornell Medical College; William Winslade, University of Texas, Galveston. Address correspondence to Judy Illes, University of British Columbia, National Core for Neuroethics, 2211 Wesbrook Mall, Koerner, S124, Vancouver, BC V6T 2B5 Canada. E-mail: [email protected] ajob-neuroscience 3 The American Journal of Bioethics-Neuroscience memory—the durable maintenance of information, novel If we hope to address such values choices head on, we first combinations of operations, and intentional behavior. The need to articulate the ethical rationale for a sound diagnos- interactions are dynamic and exist within a distributed tic nosology and then describe how to achieve it using these neural network of circuits with unique capacities. Split- new technological modalities in tandem with the clinical brain studies suggest that the dominant (usually left) hemi- examination. sphere may serve as the interpreter of the wide distribution Drawing upon our work at a conference called “Ethics, of circuitry-associated events across the entire brain. Even Neuroimaging, and Limited States of Consciousness” at when disconnected, this hemisphere seems to keep a run- Stanford University during the summer of 2007, we pro- ning narrative of actions emotions, thoughts, and experi- vide here an ethical framework through which investiga- ences (Gazzaniga 1998). tive neuroimaging techniques could mature into useful Much of our knowledge of the conscious brain is clinical tools for the diagnosis and treatment of those due to neuroimaging technologies. These include positron with disorders of consciousness. The framework has three emission tomography (PET), which measures the brain’s elements: clinical translation, research challenges, and metabolic activity, oxygen extraction, or neurotransmitter consent. activity; magnetoencephalography (MEG), which measures the magnetic fields generated by electrical activity within ETHICS CHALLENGES IN CLINICAL TRANSLATION— the brain; advanced magnetic resonance imaging (MRI) THE UNCERTAIN SCOPE AND GOALS methods such as voxel-based volumetry or morphome- OF THE PROBLEM try, which objectively quantify changes in brain struc- Although neuroimaging technology increasingly has been ture; MR spectroscopy, which measures biomarker of applied to the study of vegetative and minimally conscious neuronal integrity, cell membrane turnover, or energetic patients, the scientific community still awaits precise fig- function; MR diffusion tensor imaging, which assesses ures on the epidemiology of these conditions. This data gap the density, integrity, and directionality of white matter is reflective of one measure of the general neglect of this tracts (Laureys, Antoine et al. 2002); and functional MR population (Fins 2003), though the scope of the problem is imaging (fMRI), which quantifies blood-oxygenation-level- extensive. Estimates of the vegetative state in the United dependent (BOLD) changes. States range from 40 to 168 per million people (Beaumont Despite the availability of these many techniques and and Kenealy 2005). A recent model of MCS prevalence in more than 30 years of work using one or more combina- the United States was between 45,000 and 250,000 assum- tions of them to study the neural basis of consciousness, ing a 10-year life expectancy (Fins, Master et al. 2007). These no single architecture has emerged as a unifying feature estimates may constitute a serious public health challenge, of conscious reflective performance in either healthy or but it would be a mistake to see these conditions solely as a states of disordered consciousness. Nevertheless, fMRI of population-based concern. Disorders of consciousness inal- the human injured brain has begun to transform how neu- terably affect individual families who grapple with care de- roscientists understand disorders of consciousness, such cisions, haunted by whether their loved ones are conscious as the vegetative and minimally conscious states, and and if they will recover understanding, speech, and a former to deepen knowledge of mechanisms of recovery (Farah self (Fins 2005, 2007b). Neuroimaging research
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