Monthly Archives: September 2014

Man in Vegetative State Shows Brain Activity to Movie: What Does It Mean?

In a recent study, Naci et al. investigated how the brain responds to an 8 minute Alfred Hitchcock movie. In healthy subjects they found that frontal and parietal areas indicative of executive functioning were active during the most suspenseful parts of the movie. Then they showed the same movie to two patients diagnosed as being in a vegetative state, one of which who had been in VS for 16 years. In one of the patients they found that “activity in a network of frontal and parietal regions that are known to support executive processing significantly synchronized to that of healthy participants”. In other words, the vegetative man’s brain “tracked” the suspense-points of the movie in the same way that healthy controls did. They reasoned that the patient was therefore consciously aware of the video, despite being behaviorally unresponsive:

The patient’s brain activity in frontal and parietal regions was tightly synchronized with the healthy participants’ over time, and, crucially, it reflected the executive demands of specific events in the movie, as measured both qualitatively and quantitatively in healthy individuals. This suggested that the patient had a conscious cognitive experience highly similar to that of each and every healthy participant, while watching the same movie.

But what’s the connection between executive functioning and conscious experience? The authors write:

The “executive” function of the brain refers to those processes that coordinate and schedule a host of other more basic cognitive operations, such as monitoring and analyzing information from the environment and integrating it with internally generated goals, as well as planning and adapting new behavioral schemas to take account of this information. As such, executive function is integral to our conscious experience of the world as prior knowledge is integrated into the current “state of play” to make predictions about likely future events.

Does this mean that executive functioning is always conscious? Is the unconscious brain incapable of “monitoring and analyzing information from the environment” and “integrating” that information with goals? Color me skeptical but I believe in the power of the unconscious mind to perform these functions without the input of conscious awareness.

Several examples come to mind. In the “long-distance truck driver” phenomenon people can drive automobiles for minutes if not hours without the input of conscious awareness. Surely driving requires “monitoring and analyzing information from the environment” in addition to integrating with goals and adapting new behaviors to deal with novel road conditions.

Another example is automatic writing, where people can write whole intelligent paragraphs without the input of conscious attention and the “voice” of the writing is distinct from that of the person’s normal personality, channeling the personalities of deceased persons or famous literary people. People would hold conversations with their automatic writing indicating that the unconscious writer was responding to the environment and surely “monitoring and analyzing information”. Im not aware of any brain imaging studies of automatic writing but I would not be surprised if frontal and parietal regions were active given the complexity of handwriting as a cognitive task. Same with long-distance truck driving.

My point is simply to raise the question: Can executive function happen unconsciously? Naci et al. say that executive function is “integral” to conscious experience. That might be true. But is conscious experience integral to executive functioning? Maybe not. There is a litany of complex behaviors that can be performed unconsciously, all of which likely recruit frontal and parietal networks of the brain. We can’t simply assume that just because information integration occurred that conscious awareness was involved. To make that inference would require us to think that the unconscious mind is “dumb” and incapable of integrating information. But there is plenty of reason to think that what Timothy Wilson calls the “adaptive unconscious” is highly intelligent and capable of many “higher-order” cognitive functions including monitoring, integrating, planning, reasoning, etc.


Filed under Consciousness, Psychology

The Vegetative State as an Interactive Kind

Note: This is the introduction to the draft of my dissertation prospectus.

Doctors diagnosing the vegetative state have always found themselves embroiled in scientific and ethical controversy. Over the last several decades, the diagnosis of the vegetative state has stirred the public imagination and the writings of bioethicists in a way that few other diagnoses has. Take the example of Terri Schiavo, who suffered from a heart attack in 1990 and subsequently lapsed into a coma from lack of oxygen to her brain. After months of no recovery she was formally diagnosed with the vegetative state, a condition doctors describe as a state of “wakeful unawareness”. In this state Schiavo opened her eyes and appeared to be awake but showed no clear-cut intelligent, contingent behavior in response to any stimulation or human interaction. Contingent behaviors are behaviors that occur as appropriate responses to the behavior of other people or objects e.g. if someone sticks out their hand, the appropriate behavior (in some contexts) is to shake it. However, though Schiavo didn’t show any contingent behavior she would show reflexive behaviors such as laughing or crying or randomly moving her eyes or limbs. After years of no recovery from VS her husband Michael asked the state for permission to remove her artificial feeding and hydration.

However, when videos of Terri’s wakeful behaviors were released to the public widespread outrage was provoked in response to what many people considered to be the immoral murder of a living human being. Towards the end of her life during the 2000s, the Schiavo family was convinced that she was in fact in a state called the “minimally conscious state” (MCS) because they thought she showed intermittent signs of conscious awareness, such as laughing appropriately when a joke was told or responding to a family member with an appropriate emotional display. Because the operational standards of diagnosing MCS allow for the possibility of only showing signs of conscious awareness intermittently there is a genuine epistemic question of whether Schiavo was diagnosed properly with most experts retrospectively believing she could not have been in a MCS based on her autopsy reports, which revealed extensive cortical lesioning. But the public imagination was rarely if ever aware of these nuances distinguishing VS and MCS but instead took her wakeful behavior and physical health to be a clear sign that it would be wrong to kill Schiavo by removing her artificial life support.

The Schiavo case rests at the intersection of epistemology, medical diagnosis, ethics, the law, and the norms of society at large. These issues are intertwined. The goal of this dissertation will be to systematically argue that in diagnosing the vegetative state and other disorders of consciousness (DOC) these normative issues are essentially intertwined. In other words, the epistemic certainty attached to any diagnosis of the vegetative state cannot occur outside the broader context of ethics, law, and society. I call this the Thesis of Diagnostic Interaction. The thesis says that diagnosing disorders of consciousness is not a purely objective affair in the same way it is for physicists to determine the number of protons in a gold atom. In other words, a diagnostic label such as “the vegetative state” is not a natural kind because it does not cut nature at its joints in the way the kind GOLD does. The upshot of my thesis is that the question of whether Schiavo was truly in a vegetative state cannot be answered by merely examining her brain or behavior in isolation from the cultural time and place she was diagnosed. We must look at the broader culture of diagnostic practice which itself is essentially shaped by complex ethical and legal norms and steeped in the social milieu of the day.

Interactive Kinds

Instead of VS being understood as a natural kind like GOLD, INFLUENZA, or H2O, the vegetative state can be better understood as what Ian Hacking calls an interactive kind. An interactive kind is a concept that applies to classificatory schemes, ones that influence the thing being classified in what Hacking calls “looping effects”. Hacking’s examples of interactive kinds includes childhood, “transient” mental illnesses such as 19th-century hysteria, child abuse, feeblemindedness, anorexia, criminality, and homosexuality. Interactive classifications change how the people classified behave because they are either directly aware of the classification or the classification functions in a broader socio-cultural matrix whereby individuals and institutions use the classification to influence the individuals being classified. For Hacking, interactive kinds are

“Especially concerned with classifications that, when known by people or by those around them, and put to work in institutions, change the ways in which individuals experiences themselves–and may even lead people to evolve their feelings and behavior in part because they are so classified.” (Social Construction of What, p. 104).

Hacking’s proposal that some kinds of people are interactive kinds boils down to two features. First, scientific classifications of people can literally bring into being a new kind of person that did not exist before. Call this the “new people” effect. Second, such classifications are prone to “looping effects” because the classification interacts with people when they know about the classification or when the classification functions in a larger institutional settings which then influence the individual being classified. For example, consider the diagnosis of “dissociative identity disorder” (DID) otherwise known as “multiple personality disorder”. According Hacking, DID did not come into fruition until scientists and psychiatrists began to look for it i.e. until it became an accepted diagnostic category by a group of therapists and institutions. Moreover, once the classification of DID was popularized in novels and movies, the rates of diagnosis increased dramatically suggesting that the disease had a social-cultural origin not a purely biological origin like the Ebola virus, which is an example of what Hacking calls an “indifferent kind” because the virus does not know about human classification schemes. DID is an example of a looping kind because the spreading awareness of the diagnostic classification led people to conform to the diagnostic criteria.

Making Up Diagnostic Labels

I contend that the vegetative state can also be considered an interactive kind in a similar way that Hacking claims mental illness is. There are several, interrelated reasons why this is the case.

  1. Clinical diagnosis of DOC is essentially a process or an activity carried out by finite human beings. Diagnosis does not happen at discrete time points but is an unfolding activity of humans making fallible judgments that have an ineliminable human element of subjectivity.
  2. The classification of DOC is under continual revision and varies from time and place, doctor to doctor, institution to institution. A diagnosis about the vegetative state made in 2014 simply would not have made sense in 1990 because the classificatory schemes were different, giving rise to new kinds of patients with DOC. Some doctors are more skilled at making a diagnosis than others and different institutions utilize different classificatory procedures that are mutually exclusive yet equally justified given the pragmatic constraints of neurological diagnosis.
  3. The diagnosis of DOC is prone to “looping effects” due to the emergence of new technologies which affect diagnostic practice which in turn shape the development of newer technologies. Decisions to utilize different technology will affect the diagnostic outcomes of whether someone is in a vegetative state or not. For example, whether you use behavioral bedside methods, resting-state PET, or active probe fMRI methods will give different diagnostic outcomes.
  4. The diagnosis of DOC is prone to the “new people” effect because new diagnostic categories literally create new kinds of people that did not exist prior to the creation of the diagnostic category. And since the process of diagnosis is an on-going activity, clinical neurology is continually in the process of making up new kinds of people that did not exist before. Moreover, the individuals classified are susceptible to looping effects because once classified they are changed by the classification.
  5. The creation of diagnostic categories of DOC cannot be disentangled from broader issues in ethics, the law, and society. Consciousness plays a central role in many moral theories because of its central role in defining the interests of animals and people. We do not consider entities without the capacity for consciousness to have any interests, and therefore they do not deserve our moral consideration. Thus, facts about consciousness determine our ethical obligations in the clinic. A person diagnosed with the vegetative state by definition lacks consciousness. But the criteria for this diagnosis are continually changing in ways that do not reflect pure advances in scientific understanding.



Filed under Consciousness, Neuroethics, Philosophy of science