Wednesday, August 5, 2009

The PVS, fMRI, Radiolab, & 'Murder'

Journal of Medical Ethics has a discussion on the implications of functional MRI imaging on the withdrawal of life-prolonging treatments in vegetative patients (free full-text here; Pallimed posts on similar topics here, here, here, here for further context).

The authors make 2 main arguments, and make them specifically in the context of whether fMRI findings - which suggest some form of consciousness/awareness in some patients diagnosed as being vegetative - make it therefore unacceptable to withdraw life-sustaining medical treatments in those patients.

First, they note, as have others, that the state of the science is such that we don't really know what these fMRI findings mean, and certainly don't know that they mean patients have consciousness (capacity for thought, self-awareness, etc.) . Except for the most reductionist and overconfident neuroscientists, I think everyone agrees with that. It could of course, and completely 'negative' fMRIs would I think be taken as decent evidence these patients' cerebral cortices don't work, but we just don't know.

Second, and more saliently, they argue that even if these patients were actually in a minimally conscious state or in fact fully cognitively intact but also fully/completely locked-in, that doesn't necessarily lead to a conclusion that it is inappropriate to stop life-prolonging medical treatments and allowing them to die. And, in fact, the possibility that these patients can suffer/experience pain and have no way of asking for help etc. actually strengthens an argument to allow them to die.

Even ignoring that point, the question of consciousness or not is not what is fundamentally important about medical decision-making in these settings. The question is whether given what is happening, and their prognosis, whether they'd want their life prolonged medically; the exact same question that patients/surrogates face all the time in the setting of poor prognosis and available medical technology to prolong life but not improve quality of life. This is a point that I (see here) and others have made, and it's good to see it prominently in a journal.

The question of consciousness is important: it might have some prognostic implications, it might aid loving families in making decisions about what to do for a gravely brain-injured person (but not predictably one way or the other), but it doesn't fundamentally alter a surrogate's right to advocate for the cessation of unwanted medical treatment that is maintaining a patient in a way that would be unacceptable to that patient.

Coincidentally, Radiolab, a science-themed public radio show which I love (and still do), recently broadcast a new episode on 'the afterlife' (can be streamed/downloaded here). In it they talk about this very phenomenon, and one of the hosts says something like 'this means we are in danger of inadvertently murdering people' (ie - if someone is 'truly' vegetative withdrawal of life-prolonging medical treatments is not murder; if someone has some consciousness then doing the same thing would be murder). The scientist with whom he was discussing this, noted that 'it's complicated' but didn't challenge the host's characterization of this as 'murder.'

I can appreciate that people might be uncomfortable with this and that some families would find it impossible to agree to stopping life-prolonging treatments if there was a suggestion of consciousness, despite the possibility as well of unmitigated suffering (of course some families choose not to stop such treatments even with good evidence of permanent unconsciousness). But murder? *Sigh.*

I challenged the use of 'murder' on the Radiolab website's comments section (same link as above), and concluded with these comments:

Where fMRI may eventually help is to stratify patients into those who have virtually zero chance of ever recovering and those who have a small (but real) chance of actually recovering (most never will under any circumstances at least with current technology).

This may *help* of course, but it will do so by presenting families with some variation of this choice: your loved one cannot indicate any signs of consciousness, awareness, pain, or suffering. This scan suggests they may be aware of their surroundings in some way. They might be in agony and we'd never know it. There is a 10% chance that in a year they will have improved somewhat - not sure how much - but it's possible they'd regain the ability to communicate. Would the patient want to be kept alive with artificial medical support given those odds?

Yikes.

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