By Dave Andrusko
Editor’s note. While my family and I are on vacation, we are running some of our favorite NRL News Today stories from the last four months, entries from our “Roe at 40″ series, and an occasional update. This editorial appeared in the October 2003 edition of National Right to Life News
“Their evidence suggests that even after an injury that leaves a brain badly damaged, even after months or years with little sign of consciousness, people may still be capable of complex mental activity.” — New York Times Magazine, September 28, 2003
Professor William Brennan is a pro-life scholar whose academic life’s work it’s been to illuminate the dark power of destructive language. “Dehumanizing the Vulnerable: When Word Games Take Lives” helps us understand how a witch’s brew of derogatory words mingled with degrading labels and stirred with a demeaning stamp of disapproval works to poison our attitude toward the medically vulnerable.
We see this at work in the case of Terri Schindler-Schiavo. Her husband wishes to have the feeding tube through which his brain-injured wife is fed removed, according to the Associated Press (AP). Various “experts” called by the husband insist Terri is in “persistent vegetative state (PVS),” even though her parents and more than a dozen experts brought in by her parents insist she is not.
This is no mere quibble over words. It’s crucial. Under Florida law, if she is said to be in a PVS, there need not be “clear and convincing evidence” Terri would want her feeding tube removed. Terri is, in fact, severely brain-damaged, but that is NOT the same as being in a PVS. (To be clear, pro-lifers would adamantly oppose robbing her of nourishment by removing the tube even if she were in a PVS.)
But the PVS label is not the only diagnostic label that opens the door to taking food and fluids away from severely brain-injured patients. Of more recent coinage is the “minimally conscious state.” But this is “an inaccurate name for an invalid concept,” according to Dr. Alan D. Shewmon, chief of pediatric neurology at the Olive View-UCLA Medical Center in Los Angeles.
As reported in the September 28 edition of the New York Times Magazine, Shewmon told Carl Zimmer that “there is no scientific way to draw a line between full consciousness and minimal consciousness, and says he worries that the definition is so broad that it easily encompasses people who are conscious but suffer from other neurological disorders that impair their ability to communicate.”
In practice “PVS” and “minimally conscious” are code words for “lives not worth living.” It’s only a few syllables from there to the ultimate dehumanizing label: “vegetables.” And who could be expected to care for “vegetables”?
So the trap we must not fall into is to accept these vaguely defined labels as accurately describing anything. Alas, many physicians, “bioethicists,” and ordinary people do give them credence. How to get out of this box? One route is by showing that there is far more reason for hope than they ever imagined for patients so labeled. And that is what Zimmer’s New York Times Magazine article – – “What If There Is Something Going On in There?” – – is all about.
Early on Zimmer alludes to an article that appeared last year in the journal “Neurology,” titled, “The Minimally Conscious State: Definition and Diagnostic Criteria.” Written by neuropsychologist Joseph T. Giacino and 10 co-authors, it fashioned this “new category of consciousness.” It is as dangerous to the vulnerable as it is slippery.
But, fortunately, ongoing work is revealing that “a vast number of people who might once have been considered vegetative actually have hidden reserves of mental activity.” This is also true for people diagnosed in a minimally conscious state as well, Zimmer writes. (Sometimes “impaired consciousness” is used as an all-purpose designation, which is even more open to abuse.)
Thanks to highly sophisticated MRI machines the brains of these injured patients are scanned and then mapped for changes in activity. Let me quote from what researchers found after 24-year-old Daniel Rios (thought to lack “any meaningful mental life”) listened to a 40-second loop of his sister’s voice telling Daniel that “she was there with him, that she loved him.”
“Several hours afterward, two researchers, Nicholas D. Schiff and Joy Hirsch, took a look at the images from the scan. They hadn’t been sure what to expect – – Rios was among the first people in his condition to have his brain activity measured in this way – – but they certainly weren’t expecting what they saw. ’We just stared at these images,’ recalls Schiff, an expert in consciousness disorders at Weill Medical College of Cornell University.’ There didn’t seem to be anything missing.'”
As Zimmer eloquently describes it, “Even the visual centers of Rios’s brain had come alive, despite the fact that his eyes were covered. It was as if his sister’s words awakened his mind’s eye.” Zimmer likens these scans to “eavesdropping” on the patients’ inner worlds. “’It’s free speech for people who have no speech,’ Hirsch says.”
Theories to explain these “enigmatic hints of awareness” are too complex and too lengthy to go into in any depth. Suffice it to say that higher-level thought (such as language and memory) is believed to occur in networks of neurons located at the surface of the brain in the cortex. According to Zimmer, these neurons “form loops which dip deep within the brain where they converge and then return to the surface.”
One theory is that the activity of the loops is “synchronized” by a special set of neurons deep in the brain. When the synchronizers are damaged, “harmony” is disrupted and the brain “slips into a vegetative state.” But even after extensive brain damage, Schiff and his colleagues believe, “some of the loops may still function, though in isolation – – like fragments of mind.”
According to Zimmer, in looking for more subjects for his study,
“Schiff discovered the Center for Head Injuries in Edison, where Rios is treated. Neuropsychologists there have specialized in tracking how patients recover from brain injuries, moving from comas toward consciousness. Joseph Giacino, the lead author of the Neurology paper that defined the minimally conscious state, is the center’s associate director of neuropsychology. He is one of the few doctors who focus on both the study and the long-term treatment of patients with impaired consciousness. ‘You come in in a coma, and you can get your treatment all the way to when you’re back at work and you still need some follow-up.'”
Given what is at stake, it is almost eerie what one skilled man can do. In some cases, just by working his fingers deep into muscles and stimulating nerve endings, Giacino “can actually coax patients into consciousness.” Some diagnosed as being in a minimally conscious state can speak. “Some tell him their names, others tell him to leave them alone. As soon as he removes his hands, they slip away again,” Zimmer writes.
The potential implications are staggering. Typically, without outward signs of recovery (often times the wait is no more than a few weeks), such patients are dumped off in ill-suited nursing homes “and they rarely see a neurologist again.”
Joseph Fins, who has been exploring the ethical dimension of Schiff’s new research, provides Zimmer with one of the great understatements: “It certainly raises the question that there’s more `there’ there than we’ve been giving them credit for,” he says, adding, `It’s very suggestive that there’s consciousness.”’
Near the very end of the story, we learn that, based on his responses to questioning, Rios is said to have “officially emerged from the minimally conscious state.” But then there’s Fins’ very sobering closing observation: “If he ended up in a nursing home and started doing things like this, no one would have noticed.”
When it comes to the debate over those who are brain-injured, we can hope that the work of Schiff, Hirsch, and others is changing the evidentiary ledger.
Where before, only the debit side had entries, now there is an important entry on the credit side. How ironic that it should come from the New York Times!