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Fins JJ, Shulman KS. Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation? J Cogn Neurosci 2024; 36:1667-1674. [PMID: 38579252 DOI: 10.1162/jocn_a_02157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
In this article, we consider the intersection of cognitive motor dissociation (CMD) and artificial intelligence (AI), hence when CMD meets AI. In covert consciousness, there is a discordance between the observed behavior, the traditional bedside mode of assessment, and the response to volitional commands as depicted by neuroimaging or EEG studies. This alphabet soup of acronyms represents both the promise and peril of nascent technology in covert consciousness. On the diagnostic side, there is the complexity and uncertainty of identifying the discordance between cognitive activity and overt behavior. On the therapeutic side, when AI is used to generate speech, there is the possibility of misrepresenting the thoughts and intentions of those who are otherwise voiceless. This concordance of factors makes the application of AI to CMD worthy of deeper consideration. We offer this analysis in the spirit of anticipatory governance, a prudential process by which one plans to prevent or mitigate unintended consequences of novel technology. We first consider the normative challenges posed by CMD for clinical practice, neuroethics, and the law. We then explore the history of covert consciousness and the relationship of severe brain injury to the right-to-die movement, before introducing three biographies of brain injury that highlight the potential impact of disability bias or ableism in clinical practice, assistive technology, and translational research. Subsequently, we explore how AI might give voice to conscious individuals who are unable to communicate and the ethical challenges that this technology must overcome to promote human flourishing drawing upon what Nussbaum and Sen have described as a "capabilities approach" to promote normative reasoning.
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Sanz LR, Laureys S, Gosseries O. Towards modern post-coma care based on neuroscientific evidence. Int J Clin Health Psychol 2023; 23:100370. [PMID: 36817874 PMCID: PMC9932483 DOI: 10.1016/j.ijchp.2023.100370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
Background Understanding the mechanisms underlying human consciousness is pivotal to improve the prognostication and treatment of severely brain-injured patients. Consciousness remains an elusive concept and the identification of its neural correlates is an active subject of research, however recent neuroscientific advances have allowed scientists to better characterize disorders of consciousness. These breakthroughs question the historical nomenclature and our current management of post-comatose patients. Method This review examines the contribution of consciousness neurosciences to the current clinical management of severe brain injury. It investigates the major impact of consciousness disorders on healthcare systems, the scientific frameworks employed to identify their neural correlates and how evidence-based data from neuroimaging research have reshaped the landscape of post-coma care in recent years. Results Our increased ability to detect behavioral and neurophysiological signatures of consciousness has led to significant changes in taxonomy and clinical practice. We advocate for a multimodal framework for the management of severely brain-injured patients based on precision medicine and evidence-based decisions, integrating epidemiology, health economics and neuroethics. Conclusions Major progress in brain imaging and clinical assessment have opened the door to a new era of post-coma care based on standardized neuroscientific evidence. We highlight its implications in clinical applications and call for improved collaborations between researchers and clinicians to better translate findings to the bedside.
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Affiliation(s)
- Leandro R.D. Sanz
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
| | - Steven Laureys
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
- Joint International Research Unit on Consciousness, CERVO Brain Research Centre, CIUSS, Laval University, Québec, Canada
| | - Olivia Gosseries
- Coma Science Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Centre du Cerveau, University Hospital of Liège, Liège, Belgium
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Alimohammadi E, Arast A, Vlaisavljevic Z, Abdi A, Ramadhan H. The experiences of the caregivers caring for the patients in persistent vegetative state due to traumatic brain injury. SAGE Open Med 2023; 11:20503121231177550. [PMID: 37324120 PMCID: PMC10262620 DOI: 10.1177/20503121231177550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/07/2023] [Indexed: 06/17/2023] Open
Abstract
Objective Persistent vegetative state often occurs as a result of traumatic brain injuries; these patients are usually hospitalized for sustained periods, and the family caregivers are the main care providers in Iranian hospitals, especially for chronic and persistent vegetative state patients. The current study was conducted to investigate the family caregivers' experiences of caring for persistent vegetative state patients following traumatic brain injury. Methods This descriptive phenomenological study was carried out in 2019. Semi-structured interviews were done with 12 family caregivers caring for the patients in persistent vegetative state, hospitalized in a trauma center, after taking informed written consent and assuring about anonymity and confidentiality of their personal information. The interviews were analyzed using the Colaizzis҆ method. Results After analysis of 12 interviews, 5 themes, and 10 subthemes were extracted from 428 codes. Five themes include "uncountable struggles/challenges," "looking for peace," "therapeutic concerns," "preserving the connection," and "unheard sounds." Conclusion In this study, the family caregivers of the persistent vegetative state patients in the hospital experienced some challenges, and looked for peace by doing some work, for example, praying. They had some therapeutic concerns and unheard sounds and tried to fulfill them. We recommend, by using the results of this study and other related research, necessary care and facilities would be provided for the family caregivers of persistent vegetative state patients in hospitals.
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Affiliation(s)
- Ehsan Alimohammadi
- Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Atefeh Arast
- Student Research Committee, Kermanshah University of Medical Sciences, Imam Reza hospital, Kermanshah, Iran
| | - Zeljko Vlaisavljevic
- Department of Nursing, High School of Medical Professional Studies Medika, Clinical Center of Serbia, Belgrade, Serbia
| | - Alireza Abdi
- Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Fred Plum (1924-2010). J Neurol 2023; 270:1811-1812. [PMID: 36216890 DOI: 10.1007/s00415-022-11420-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 10/17/2022]
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant, and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically-responsible care in this domain are especially timely given recent surges in critically ill patients with unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness, and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and up until the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery, and ethical issues that arise within the context of caring for persons with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI 02906, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, Department of Veterans Affairs Medical Center, Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA
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Abstract
Abstract:This paper, presented as the 2019 Cambridge Quarterly Neuroethics Network Charcot Lecture, traces the nosology of disorders of consciousness in light of 2018 practice guidelines promulgated by the American Academy of Neurology, the American College of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research. By exploring the ancient origins of Jennett and Plum’s persistent vegetative state and subsequent refinements in the classification of disorders of consciousness—epitomized by the minimally conscious state, cognitive motor dissociation, and the recently described chronic vegetative state—the author argues that there is a counter-narrative to the one linking these conditions to the right to die. Instead, there is a more nuanced schema distinguishing futility from utility, informed by technical advances now able to identify covert consciousness contemplated by Jennett and Plum. Their prescience foreshadows recent developments in the disorders of consciousness literature yielding a layered legacy with implications for society’s normative and legal obligations to these patients.
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Fins JJ, Bernat JL. Ethical, Palliative, and Policy Considerations in Disorders of Consciousness. Arch Phys Med Rehabil 2018; 99:1927-1931. [PMID: 30098790 DOI: 10.1016/j.apmr.2018.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of "permanent" vegetative state to "chronic" vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor "unaware wakefulness syndrome" is no clearer than "vegetative state" in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline's high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics and Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy, Yale Law School, New Haven, CT
| | - James L Bernat
- Departments of Neurology and Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
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Fins JJ, Bernat JL. Ethical, palliative, and policy considerations in disorders of consciousness. Neurology 2018; 91:471-475. [PMID: 30089621 DOI: 10.1212/wnl.0000000000005927] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/07/2018] [Indexed: 11/15/2022] Open
Abstract
This essay complements the scientific and practice scope of the American Academy of Neurology Guideline on Disorders of Consciousness by providing a discussion of the ethical, palliative, and policy aspects of the management of this group of patients. We endorse the renaming of "permanent" vegetative state to "chronic" vegetative state given the increased frequency of reports of late improvements but suggest that further refinement of this class of patients is necessary to distinguish late recoveries from patients who were misdiagnosed or in cognitive-motor dissociation. Additional nosologic clarity and prognostic refinement is necessary to preclude overestimation of low probability events. We argue that the new descriptor "unaware wakefulness syndrome" is no clearer than "vegetative state" in expressing the mismatch between apparent behavioral unawareness when patients have covert consciousness or cognitive motor dissociation. We advocate routine universal pain precautions as an important element of neuropalliative care for these patients given the risk of covert consciousness. In medical decision-making, we endorse the use of advance directives and the importance of clear and understandable communication with surrogates. We show the value of incorporating a learning health care system so as to promote therapeutic innovation. We support the Guideline's high standard for rehabilitation for these patients but note that those systems of care are neither widely available nor affordable. Finally, we applaud the Guideline authors for this outstanding exemplar of engaged scholarship in the service of a frequently neglected group of brain-injured patients.
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Affiliation(s)
- Joseph J Fins
- From the Division of Medical Ethics and Consortium for the Advanced Study of Brain Injury (J.J.F.), Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy (J.J.F.),Yale Law School, New Haven, CT; and Departments of Neurology and Medicine (J.L.B.), Geisel School of Medicine at Dartmouth, Hanover, NH
| | - James L Bernat
- From the Division of Medical Ethics and Consortium for the Advanced Study of Brain Injury (J.J.F.), Weill Cornell Medical College, New York, NY; Solomon Center for Health Law & Policy (J.J.F.),Yale Law School, New Haven, CT; and Departments of Neurology and Medicine (J.L.B.), Geisel School of Medicine at Dartmouth, Hanover, NH.
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Adams ZM, Fins JJ. Penfield's ceiling: Seeing brain injury through Galen's eyes. Neurology 2017; 89:854-858. [PMID: 28827458 DOI: 10.1212/wnl.0000000000004267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 05/18/2017] [Indexed: 11/15/2022] Open
Abstract
The cathedral ceiling located in the entrance hall of the Montreal Neurological Institute, planned by its founder Wilder Penfield, has intrigued visitors since it was erected in 1934. Central to its charm is a cryptic comment by the ancient physician Galen of Pergamum, which refutes a dire Hippocratic aphorism about prognosis in brain injury. Galen's optimism, shared by Penfield, is curious from a fellow ancient. In this article, we use primary sources in Ancient Greek as well as secondary sources to not only examine the origins of Galen's epistemology but also, using a methodology in classics scholarship known as reception studies, illustrate how an awareness of this ancient debate can illuminate contemporary clinical contexts. While Galen based his prognostications on direct clinical observations like the Hippocratics, he also engaged in experimental and anatomic work in both animals and humans, which informed his views on neurologic states and outcomes. Penfield's memorialization of Galen is representative of the evolution of the neurosciences and the ongoing importance of evidence-based prognostication in severe brain injury.
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Affiliation(s)
- Zoe M Adams
- From the Consortium for the Advanced Study of Brain Injury (CASBI) (Z.M.A., J.J.F.), Department of Neurology and Brain and Mind Research Institute (Z.M.A.), and Division of Medical Ethics (J.J.F.), Weill Cornell Medical College; and The Rockefeller University (J.J.F.), New York, NY.
| | - Joseph J Fins
- From the Consortium for the Advanced Study of Brain Injury (CASBI) (Z.M.A., J.J.F.), Department of Neurology and Brain and Mind Research Institute (Z.M.A.), and Division of Medical Ethics (J.J.F.), Weill Cornell Medical College; and The Rockefeller University (J.J.F.), New York, NY
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