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Neuroimaging, impaired states of consciousness, and public outreach

Nature Clinical Practice Neurology volume 4, pages 542–543 (2008)Cite this article

One of the greatest challenges in science and medicine is negotiating public responses to the dissemination of research results that have potential clinical implications. This challenge has been particularly acute for clinical researchers who are involved in the development of novel applications of functional brain imaging for the assessment of patients with disorders of consciousness.1,2,3,4,5,6 In our experience, scientific publication of experimental findings in this area is often followed closely by media inquiries regarding the clinical and societal relevance of the results reported and, shortly thereafter, by inquiries from patient caregivers and family members. While many areas of research are susceptible to similar public curiosity, neuroimaging procedures and disorders of consciousness have especially captured the imagination of the media and public alike.7,8 Subsequent to publication of newspaper and magazine articles—What if There is Something Going on in There; Twighlight Zone; Mental Activity Seen in a Brain Gravely Injured; For the First Time, Doctors Communicate with Patient in Persistent Vegetative State; and Silent Minds9,10,11,12,13—we received numerous inquiries at JFK Medical Center and Stanford University both from family members of patients in our institutions and from individuals in geographically remote regions. Some requests were made simply in order to acquire additional information, while others were pleas to obtain a brain scan that might enable a patient's level of consciousness to finally be discerned. Some requests followed accurate and well-balanced media reports; others followed reports with sensationalized findings and unrealistic appraisals of the diagnostic and prognostic capabilities of functional brain imaging.

Expressions of belief and hope that functional neuroimaging may provide signals about a patient's state of consciousness, offer prospects for recovery and assist with health-care decision-making are as profound as the accompanying ethical issues. Indeed, the complex problem of 'consciousness' after brain injury is unlikely to be resolved by neuroimaging studies alone. Human consciousness encompasses unique capacities such as perception, subjectivity, sentience and self-awareness that exist within a distributed neural network of circuits including the posterior and anterior attentional brain networks,14 the ascending reticular formation15 and frontoparietal associative cortical systems.16 Detection of conscious awareness via functional neuroimaging is further complicated by procedural challenges. Functional activation studies with healthy control individuals that are designed to engage cognitive processes assume adequate comprehension of instructions, attentional focus and maintenance of mental set across tasks. In the population of people with brain injury, however, these prerequisite functions represent core deficits that interfere with task demands, changing both the manner in which tasks are performed and the neural structures activated during the task. The type of information that can be expected to be gleaned from functional neuroimaging studies, and the strength of the evidence acquired are, therefore, also contingent upon the paradigmatic features of study, such as choice of stimuli, modality of stimuli (e.g. aural, visual or haptic)17 and timing. The latest generation of studies provides more-convincing data than ever before on the temporal contiguity between task instructions, the onset of specific cognitive activities, and the activation of corresponding neural structures that are believed to mediate these activities, but the sources of variance attributable to patients and paradigms remain poorly understood.

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Acknowledgements

This Viewpoint is derived in part from the workshop “Ethics, Neuroimaging, and Limited States of Consciousness”, held at Stanford University in June 2007. The workshop was hosted by the Center for Biomedical Ethics, Stanford University, and supported by The Greenwall Foundation and NIH/NINDS RO1 #NS 045831. Development of the FAQ was supported by The Greenwall Foundation. Writing of this Viewpoint was supported by The Greenwall Foundation, the Vancouver Coastal Health Research Institute, CIHR/INMHA #CNE 85117, and the Michael Smith Health Research Foundation.

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Authors and Affiliations

  1. J Illes is Professor of Neurology and Canada Research Chair in Neuroethics and PW Lau is the Clinical Neuroethics Coordinator at the National Core for Neuroethics, both at the University of British Columbia in Vancouver, BC, Canada.,

    Judy Illes & Patricia W Lau

  2. JT Giacino is the Associate Director of Neuropsychology at JFK Johnson Rehabilitation Institute and the New Jersey Neuroscience Institute at JFK Medical Center in Edison, NJ, USA,

    Joseph T Giacino

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Correspondence to Judy Illes.

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Illes, J., Lau, P. & Giacino, J. Neuroimaging, impaired states of consciousness, and public outreach. Nat Rev Neurol 4, 542–543 (2008). https://doi.org/10.1038/ncpneuro0888

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