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Today's News & Views
October 22, 2007
Not so Silent Minds
"Most scans show what is wrong with your brain,
which doctors need to know. But Adrian Owen's
scans show what is working. I say they found
parts of my brain were working. It really scares
me to think what might have happened to me if I
had not had the scans. They show people it was
worth carrying on even though my body was
unresponsive."
Kate Bainbridge, quoted in "Silent Minds: What
scanning techniques are revealing about
vegetative patients," which appeared in the
October 15, 2007, edition of
the New Yorker.
Dr. Jerome Groopman,
a physician at Harvard Medical School,
will never be accused of being a card-carrying
member of the Pro-Life Movement. But clearly you
can learn a lot from reading him.
In April I referenced a thoughtful review of
Groopman's latest book, How Doctors Think,
that ran in the Washington Post. [www.nrlc.org/News_and_Views/April07/nv041307part1.html]
One of the observations made by Dr. David Brown
directly applies to what Groopman talks about in
his latest New Yorker piece.
"Groopman catalogues the many
species of clinical errors, a whole taxonomy of
misperceptions and wrong conclusions illustrated
with real examples offered as representative
types. All are fascinating, a few are chilling."
In his New Yorker essay, Groopman
examines a lot of recent work on the interior
mental activity of patients supposedly in either
a "persistent vegetative state" (PVS) or a
"minimally conscious state" to investigate the
larger topic of consciousness. While the latter
is way beyond what I can intelligently discuss,
there are some issues raised about the former
with which we all need to be conversant with.
A very important consideration is that today's
conventional wisdom is tomorrow's "how did we
ever believe THAT?" Another was illustrated by
an impassioned back and forth sparked by an
article in the September 2006, edition of
Science.
Adrian Owen at the Medical Research Council
Cognition and Brain Sciences Unit in Cambridge,
England, and Martin Coleman,
a neuroscientist at Addenbrooke Hospital, at the
University of Cambridge,
wrote about two patients diagnosed to be in a
PVS. Their findings (which began a decade before
with
Kate Bainbridge) "stunned" Owen.
Referring to a 23-year-old woman, they found
that her
brain activity almost exactly paralleled the
responses researchers found in the brains of 12
healthy volunteers. As the Washington Post's
Rob Stein put it at the time, she "showed clear
signs of conscious awareness on brain imaging
tests."
Neurologists wrote to Science. They
challenged Owen and Coleman's results, insisting
that the woman must have been misdiagnosed.
But Owen told Groopman, "She fulfilled all of
the internationally agreed-upon criteria, and
there wasn't anything that she did that would
lead anybody to say she wasn't vegetative."
Owen added, "Now, naturally, in hindsight she
wasn't vegetative; she was actually conscious."
But what is most significant is Owen's next
statement to Groopman: "It's a very interesting
issue, because it means that she was in fact
misdiagnosed, but not misdiagnosed in the sense
that somebody made an error. Clearly, she is
consciously aware of things around her. So
something is missing in the diagnostic
criteria."
All of these diagnostic labels are increasingly
up for grabs. Not just because they pretend a
level of precision that they lack, but also
because people with impaired brain function
appear to retain more capacity than anyone has
suspected.
Doctors often miss signs of consciousness in
patients with severe brain injuries, Groopman
observes. The lethal loop is complete when
insurers refuse to continue therapy on the
grounds that these patients are unlikely to
improve.
"These people with brain trauma are out of our
view," Joseph Fins, an internist and medical
ethicist at Weill Cornell Medical College, in
Manhattan, told Groopman. "We ignore them, and
we sequester them in places where we can't see
them, usually in nursing homes."
Virtually every few months, scientists are
learning more about the brain's remarkable
ability to repair itself, to find alternative
ways to make up for capacities that injury or
diseases have taken way. Groopman brings in
Terry Wallis,
a forty-three-year-old man who spent 19 years in
a nursing home, supposedly in a "minimally
conscience state," who began to speak in 2003.
After all the fanfare that accompanied his
recovery, Wallis received only 12 weeks of
physical therapy.
Fortunately, "[Dr.Nicholas]
Schiff and Fins contacted Wallis's family and
offered to help him obtain medical care during
his recovery, and to use brain scans to document
his progress," Groopman writes." Later,
"The
scans suggested that the axons in Wallis's brain
were growing and forming new connections--a
finding that contradicts the long-standing
assumption that a damaged brain is incapable of
healing after such a lengthy period."
Take time, if you can, to read Groopman's piece.
It has its flaws, including a very dismissive
attitude toward Terri Schindler Schiavo's
abilities, but is still very much worth
pondering at length.
www.newyorker.com/reporting/2007/10/15/071015fa_fact_groopman.
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