‘Neglected Personhood’ and Neglected Questions: Remarks on the Moral Significance of Consciousness
    
    Open peer commentary on Fins. et al “Neuroimaging and disorders of consciousness: envisioning an ethical research agenda”
    
    Dominic Wilkinson1,2, Guy Kahane1, Julian Savulescu1 1. Oxford Uehiro Centre for Practical Ethics, University of Oxford 2. The Ethox Centre, University of Oxford
    
    Corresponding Address: Dr Dominic Wilkinson, Uehiro Centre for Practical Ethics, Littlegate House, St Ebbes St, Oxford, OX1 1PT, United Kingdom dominic.wilkinson@green.ox.ac.uk
    
    Word Count: 1483 words
    
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    Introduction
    
    Fins et al. (2008) outline a number of ethical issues associated with neuroimaging in conditions where consciousness is absent or impaired, and make a number of useful suggestions. However they are virtually silent on what we take to be crucial questions Here we briefly discuss two key issues. Firstly, talk about consciousness is notoriously contentious and can refer to a range of potentially distinct phenomena, not all of which might be of moral significance. Secondly, if some of these patients are indeed conscious in a morally significant sense, what would be the implications for treatment?
    
    The significance of consciousness
    
    Our existing everyday and clinical criteria for ascribing consciousness are in the main behavioural. This is reflected in current diagnostic criteria for VS, where absence of consciousness is defined in behavioural terms. However we should not confuse a phenomenon with our means of finding out about it. The great interest in neuroimaging severely brain damaged patients is precisely that it offers an entirely new means of detecting consciousness even in the absence of behavioural response. (It is of course a separate and controversial matter whether the brain activation detected by neuroimaging amounts to more than a further source of evidence for the presence of consciousness.)
    
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    Consciousness is central to the ethical issues raised by patients in VS. Controversies about withdrawing life sustaining treatment (LST) from such patients have revolved around the question of whether they have irreversibly lost the capacity for consciousness, a matter taken to have momentous moral significance. By contrast, patients in the minimally conscious state (MCS) are commonly assumed to have a measure of consciousness, although accompanied only by minimal cognitive capacities. Given that current neuroimaging studies appear to suggest that some brain-damaged patients diagnosed as in VS might in fact be in MCS, a crucial ethical question must concern the moral significance of the difference between the absence of consciousness and its minimal presence.
    
    The moral problem of consciousness
    
    Consciousness is a contentious concept. Fins, Illes et al. (2008) write that consciousness encompasses “subjectivity, sentience, self-awareness and an ability to appreciate the relationship between the self and the environment,” and recognize that it has been philosophically identified both with access to information and with phenomenality. Indeed philosophers of mind distinguish these and further senses of consciousness. As Ned Block recently remarked, “the word ‘consciousness’ connotes a number of different concepts and denotes a number of different phenomena” (Block 2002; see also Levy 2008). When Fins et al. (2008) write that consciousness is required for intentional behaviour, this may be correct only for certain senses of consciousness. The problem that this diversity raises for medical practice cannot be side stepped,
    
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    as the authors suggest, by adopting a neurobiological approach that focuses on the different neural processes that might underlie these phenomena. After all, the difficulty raised by disorders of consciousness in brain damaged patients is precisely that these different aspects of consciousness seem to come apart, and it cannot be simply assumed that all of them have equal (or any) moral significance. For example, even if Owen et al (2006) are correct to claim that their fMRI study showed their patient to be conscious in some sense (a matter still under scientific and philosophical dispute) this finding might make no moral difference if she is not conscious in a sense that is significant.
    
    Here we can only make brief remarks about the moral significance of one central notion, that of phenomenal consciousness or qualia. This notion is notoriously difficult to define: a state is phenomenally conscious if there is something ‘it is like’ to be in it. We assume that genuine VS patients lack subjectivity whereas patients in MCS possess it at least intermittently. From a philosophical standpoint, however, talk of minimal consciousness is misleading, as what MCS patients have only in minimal form are rather cognitive and motivational capacities.
    
    Arguably, the value of phenomenal consciousness is grounded in the moral significance of interests (Kahane & Savulescu 2008). The interests of persons include hedonic, desiderative and objective elements. Hedonic interests relate to states of suffering or enjoyment. Desiderative interests relate to the satisfaction of a person’s desires. Objective interests relate, more
    
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    contentiously, to having a meaningful existence by possessing goods such as relations with other people, achievement, or knowledge. It is clear enough why phenomenal consciousness is needed if one is to have hedonic interests. Pleasure and pain matter only because of what it is like to experience them. Arguably, phenomenal consciousness is also needed if one is to have desiderative and objective interests: without subjectivity there is no point of view to which such interests can be ascribed.
    
    Treatment decisions and consciousness
    
    One of the most ethically contentious decisions concerning patients with severe disorders of consciousness is the withdrawal of LST. Ethical and legal justification for withdrawal of LST in such patients is based upon patients’ prior wishes as well as upon considerations of futility or the patient’s best interests. Some of the scientists involved in fMRI research in VS patients have suggested that neuroimaging evidence for consciousness in such patients would have profound implications for decision-making about withdrawal of LST, (Owen 2008) and something of this nature appears to be implied by Fins et al. (2008) concern about “neglected personhood”. There have already been calls for the use of fMRI in this setting in a legal case in the UK.(Lewis 2007) There appears to be a prevailing assumption that such evidence for consciousness would provide a strong reason not to withdraw LST from a patient. However this common assumption is highly problematic, and there are grounds for thinking that the opposite might in fact be the case. Life with minimal consciousness may be worse than the VS.(Wilkinson et al 2008)
    
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    Neuroimaging findings might be relevant to such decisions in several ways. They may be relevant to the patient’s previously-expressed wishes and their desiderative interests; this will depend upon how their desires were expressed. For example a patient may have expressed a desire for their life not to continue if they were permanently unconscious or they may have explicitly referred to the possibility of minimal consciousness. Fins et al. (2008) discuss the potential incorporation of our changing understanding of VS/MCS into advanced directives.
    
    Neuroimaging may be relevant for the prognosis of patients with disorders of consciousness, and thus to considerations concerning futility. Patterns of preserved higher cortical function may place patients into a subgroup of vegetative patients with a better prognosis, or may portend partial recovery as reported for a small number of cases,(Owen et al 2006, Di et al 2007). Further evidence is needed before such claims could be drawn with confidence. And on the basis of the patients reported to date, the extent of the recovery appears to be limited. The three patients who recovered were reported as reaching the MCS,(Owen et al 2006, Di et al 2007) and one has apparently subsequently relapsed.(Owen, personal communication) Whether such findings portend meaningful recovery is another question. Indeed minor degrees of recovery may be worse than none at all.
    
    If some patients diagnosed on behavioural grounds as being in VS are actually in a state closer to the MCS, this may be worse for them in one
    
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    important way. If patients in MCS possess phenomenal consciousness then, unlike patients in VS, they are able to feel pain, although they are largely unable to communicate their distress and discomfort.(Nelson et al 1999) We may do them significant harm by keeping them alive: it is doubtful that a life that contains suffering while containing little or no desiderative or objective goods is a meaningful life. Judicial and ethical argument in VS has sometimes relied upon an inversion of the best interests standard, to suggest that since such patients are completely unaware, they do not have interests; consequently continuing LST cannot be in their interests.(Fenwick 1998) However if such patients are partly aware and suffering we may have a stronger reason to let them die – it may be against their interests to continue LST. Beyond considerations of pain and suffering, the compromise of their objective and desiderative interests may make their lives worse than nonexistence.
    
    Conclusion
    
    Fins et al. (2008) make a number of recommendations for a framework for ethical research in this field. They have however remained silent on some of the most important questions about the clinical translation of neuroimaging findings. Difficult philosophical questions about consciousness and its moral significance need to be addressed before the scientific and medical community can adequately interpret the results of research into consciousness in brain damaged patients. Most importantly, the question of what makes life worth living will need to be addressed if we are to decide
    
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    whether we are benefiting or harming this group of patients by keeping them alive. Greater clarity on these issues is needed to avoid fostering false hope in families of affected patients.
    
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    Block, Ned, Some Concepts of Consciousness, in Philosophy of Mind: Classical and Contemporary Readings, David Chalmers (ed.) Oxford University Press, 2002. Di, H.B., Yu, S.M., Weng, X.C., Laureys, S., Yu, D., Li, J.Q., Qin, P.M., Zhu, Y.H., Zhang, S.Z., and Chen, Y.Z. Cerebral response to patient’s own name in the vegetative and minimally conscious states, Neurology 2007; 68; 895-899. Fenwick A. J. Applying best interests to persistent vegetative state--a principled distortion? J Med Ethics 1998;24(2):86-92. Fins J and Illes J, Bernat J, Hirsch J, Laureys S, Murphy E. Neuroimaging and disorders of consciousness: envisioning an ethical research agenda. American Journal of Bioethics 2008. Kahane, G. and J. Savulescu. Brain-damaged Patients and the Moral Significance of Consciousness. Under review. 2008 Lewis P. Withdrawal of treatment from a patient in a permanent vegetative state: judicial involvement and innovative 'treatment': an NHS Trust v. J. Medical law review 2007;15(3):392-9. Levy N. Going beyond the Evidence. American Journal of Bioethics 2008 Nelson L. J., Cranford R. E.. Michael Martin and Robert Wendland: beyond the vegetative state. The Journal of contemporary health law and policy 1999;15(2):427-53. Owen, Adrian M., Coleman, Martin R., Boly, Melanie, Davis, Matthew H., Laureys, Steven, Pickard, John D. Detecting Awareness in the Vegetative State, Science, 313, 8 September 2006. Owen, Adrian M. and Coleman, Martin R. Functional neuroimaging of the vegetative state. Nature Reviews: Neuroscience. 9, 2008. 235-243.
    
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    Wilkinson, D., G. Kahane and J. Savulescu. Letting Vegetative Patients Die: What are the Implications of Functional Neuroimaging? Under review. 2008
    
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