A psychological prison

How would you feel if you lost all your physical powers but remained aware of the world around you? We now know that some people, believed to be in a persistent vegetative state, have demonstrated this awareness.

For me, the frustration would boggle my addled mind. I imagine it would feel like a psychological prison…

News has emerged of a brain scanning technique in which simple decisions can be discerned from the evidence of brain activity. It’s been tested by volunteers, including the BBC’s Medical Correspondent, Fergus Walsh.

It works like this: patients are asked a question and told that to answer “yes” they should imagine playing tennis; to answer “no” they should imagine walking through their home. The tennis engages the pre-motor cortex and a brain scan shows this. However walking through one’s home is is a spatial activity and a different area of the brain is engaged.

Researchers have tried this technique with patients believed to be in a persistent vegetative state (PVS). Out of 23 tested, four showed a response. One of them, a Belgian man injured in a traffic accident seven years ago, was asked six simple questions and got five right. Was his father’s name Alexander, for example? Yes. Perhaps, after seven years, he’d forgotten the answer to the sixth question.

Four in 23 is just 17%. Of course, this is just an indicator. 23 is a small sample and 17% is low. However it is a significant proportion and the revelation is astonishing.

We need to review how PVS is diagnosed. Too often, assumptions have been made and now it’s possible there may be many comatose patients with more awareness than previously thought.

Often relatives talk to their comatose loved ones. Now we know it’s probably – in many cases – a highly valuable thing to do. Even if they can’t respond they might still be able to hear, comprehend and take encouragement from the voice of their husband, wife, children, etc.

There are ethical challenges to consider. The technique might be used to help some families decide whether to switch the off their loved one’s life support. This is not euthanasia. Withdrawing life support is different to actively helping someone to die.

However, what about those patients who do respond? Could they choose whether to live or die? I posit that I may prefer the latter than to remain comatose but aware for years. But under British law, having found signs of response, my family would be unable to switch me off, even if that was what I wanted. No doubt my wife would feel compelled to spend more time with me, and she’d find me well-disposed to listening to her!

I wonder whether the technique could be tried with the former Israeli Prime Minister, Ariel Sharon? He’s been in a coma, following a stroke, for more than four years. If doctors knew, in January 2006, what they know now, could Mr Sharon have been making binary executive decisions by playing tennis or walking around the Knesset in his head? Could he have appointed his successor, for example, or formally tendered his resignation? Or called a strike on Iran?

Somehow I doubt we’re ready for that kind of government, but perhaps Mr Sharon could still be tested.

In the meantime, this discovery will get many heads thinking.These brain scans and what they reveal are not a matter just for purists, they will have a real practical impact. Today, I cannot begin to imagine what that will be, but we always wonder whether some comatose patients are really there. Now we know some of them are.


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