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April 29, 2014 | Posted By Marleen Eijkholt, PhD

Earlier this month, the New York Times (NYT) reported on individuals in a minimally conscious state (MCS). Although the article headed: ‘PET Scans offer clues on Vegetative States’, its contents addressed the technologies around MCS: a ‘newly’ diagnosed state of consciousness. The paper commented that PET scans would be more beneficial than functional Magnetic Resonance Imaging (functional M.R.I.) in diagnosing this state. Around the same time, the NYT published a paper that headed: ‘Cost of treatment may influence doctors’. This paper quoted a doc saying: “There should be forces in society who should be concerned about the budget, about how many M.R.I.s we do, but they shouldn’t be functioning simultaneously as doctors,”

In this blog post I want to focus on the cost and price of consciousness. I do not only want to focus on the economic costs, but also on costs in a more holistic sense, including the psychological and emotional costs. In the end, I want to ask you: how much is consciousness worth to you?

The meaning of ‘consciousness’ is controversial in both the scientific and philosophical world. For clarity, I will adopt a definition where consciousness stands for ‘awareness of the self and environment’. This must be distinguished from wakefulness, as you will see in the diagram below.  

Minimally conscious individuals are a ‘newly’ diagnosed patient-category, constituting individuals who suffer from a disorder of consciousness. Original research allowed distinguishing these patients from individuals in a persistent vegetative state (PVS) and individuals in a coma. The original study asked individuals to imagine playing tennis or walking through their house, which would result in different parts of their brain to light up. These activities were equated to Yes and No answers, in responses to several questions and showed brain activity in certain parts of the brain (read: I am not saying awareness just yet). These signs are different from PVS or comatose individuals who have no such activities, and allows distinguishing MCS patients. MCS patients have also been distinguished from individuals who are in a locked-in-state, who have substantial brain activity and awareness that is hardly affected. Locked-in patients are overall affected in their ability to move and communicate, but their self-awareness is not necessarily affected.  In diagram it looks as follows:

The NYT article, and the article on which it is based, report on the prevalence of the MCS diagnosis and the potential misdiagnoses. They suggest that diagnosis of MCS is necessary for an adequate prediction of recovery, and proposes that PET scans are the better technology to determine brain function. Finally it notes the limited availability of PETs at bedside and warns against false hope based on signs of awareness. It qualifies the predictors, as some scans may show brain function without good chances of recovery.

But what this article tells us is  1. PET scans are not yet available everywhere and are a costly technology, one of the reasons it has not yet been used in the clinic and 2. PET scans have allowed us to move away from false negatives, compared to MRI and clinical diagnosis: from instances where individuals were assessed to lack brain function (while they did have such functions = false negatives) to a situation of false positives: where individuals are now diagnosed as having brain function but this function does not mean anything for recovery. PET scans have allowed for even more nuanced signals to be identified.

Application of these technologies raises many questions. For example, these technologies detect brain function, but it is still controversial if brain function really stands for awareness, and moreover, if this awareness equates self-awareness and consciousness. The responses of these individuals are difficult to obtain, the responses are difficult to interpret, and the responses are fraught with methodological difficulties.

For the sake of argument, let’s say that this brain function really stands for some awareness and consciousness in some sense, I would now ask about the price of consciousness. 

  1. Do you think that detecting consciousness goes beyond any economic costs or price? So no matter what the actual economic costs are of applying this technology, should we use this technology to distinguish individuals as being in an MCS, even if it would cost 1 million dollar a person, and even if we detect awareness but this says nothing about recovery? 
  2. What is the price of this technology and detection for my surroundings, particularly in psychological costs? Imagine I am in a MCS and technology detects brain activity, what would a decision to turn off life support be like, especially for my family who would be decision makers. I suspect a decision to turn off LIFE SUPPORT would perhaps even be harder if you imagine I have brain function conscious than where I am not. 
  3. What is the price of this technology for the MCS individual self? Aside from questions about whether/not this individual needs to be treated differently from those in a PVS, for example, through pain medications, there may be another price to pay: Imagine I am the person in the MCS: If the technology is available only in limited circumstances, and someone starts to communicate with me, how would I feel once the communication is over, unable to communicate; Unable to communicate about my consciousness. Would I rather have been left alone in the first place? Or even if this technology is available at the bedside, and my answers would be reduced to a yes/no communication. I would be unable to nuance the question or nuance my answer. Personally I wonder if I would find this price too high. I think I would have preferred that they’d leave me alone rather than being reduced to a being in a yes-no world. I think I would prefer to be left alone or even to step out of existence. The NYT article suggests however that we will now find even more people, and more people will be reduced to a yes/no entity. The more nuanced answers we find, the higher the price
  4. What is the price for patients in PVS or for those who lack consciousness? Does this mean more support to switch off ventilators or withdraw Artificial Nutrition and Hydration? 

In my opinion the price of consciousness increases under these technologies, and it’s not a price I’d be necessarily willing to pay. How much is consciousness worth to you?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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