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Wexler A, Sullivan LS. Translational Neuroethics: A Vision for a More Integrated, Inclusive, and Impactful Field. AJOB Neurosci 2023; 14:388-399. [PMID: 34851808 PMCID: PMC9187971 DOI: 10.1080/21507740.2021.2001078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As early-career neuroethicists, we come to the field of neuroethics at a unique moment: we are well-situated to consider nearly two decades of neuroethics scholarship and identify challenges that have persisted across time. But we are also looking squarely ahead, embarking on the next generation of exciting and productive neuroethics scholarship. In this article, we both reflect backwards and turn our gaze forward. First, we highlight criticisms of neuroethics, both from scholars within the field and outside it, that have focused on speculation and lack of skepticism; the dearth of consideration of broader social issues such as justice and equality, both with regard to who speaks for neuroethics as a field and who benefits from its recommendations and findings; and the insufficient focus on the practical impact of our ethical work. Second, we embrace the concept of "translational neuroethics" to outline a vision for neuroethics that is integrated, inclusive, and impactful. Integration can help us identify more pertinent, real-world issues, and move away from speculation; inclusivity can help ensure that the questions we attend to are not merely relevant to a single subgroup but aim toward just distribution of benefits; and impact can help us think beyond guidelines and recommendations to focus on implementation. Our goal is for this call to action to help shape neuroethics into a discipline that develops rigorous research agendas through relationships with interdisciplinary partners, that is broadly inclusive and attends to issues beyond novel neurotechnologies, and that is devoted to the translation of scholarship into practice.
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Reconsidering the Many Disorders of Consciousness. Camb Q Healthc Ethics 2023:1-5. [PMID: 36927665 DOI: 10.1017/s0963180123000117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Peterson A, Young MJ, Fins JJ. Ethics and the 2018 Practice Guideline on Disorders of Consciousness: A Framework for Responsible Implementation. Neurology 2022; 98:712-718. [PMID: 35277446 PMCID: PMC9071367 DOI: 10.1212/wnl.0000000000200301] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/16/2022] [Indexed: 11/15/2022] Open
Abstract
The 2018 practice guideline on disorders of consciousness marks an important turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.
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Affiliation(s)
- Andrew Peterson
- From the Institute for Philosophy and Public Policy (A.P.), George Mason University, Fairfax, VA; Penn Program on Precision Medicine for the Brain (A.P.), University of Pennsylvania, PA; Department of Neurology and Edmond J. Safra Center for Ethics (M.J.Y.), Harvard University, Boston, MA; Division of Medical Ethics (J.J.F.), Weill Cornell Medical College, Cornell University, New York, NY; and Solomon Center for Health Law & Policy (J.J.F.), Yale Law School, New Haven, CT
| | - Michael J Young
- From the Institute for Philosophy and Public Policy (A.P.), George Mason University, Fairfax, VA; Penn Program on Precision Medicine for the Brain (A.P.), University of Pennsylvania, PA; Department of Neurology and Edmond J. Safra Center for Ethics (M.J.Y.), Harvard University, Boston, MA; Division of Medical Ethics (J.J.F.), Weill Cornell Medical College, Cornell University, New York, NY; and Solomon Center for Health Law & Policy (J.J.F.), Yale Law School, New Haven, CT
| | - Joseph J Fins
- From the Institute for Philosophy and Public Policy (A.P.), George Mason University, Fairfax, VA; Penn Program on Precision Medicine for the Brain (A.P.), University of Pennsylvania, PA; Department of Neurology and Edmond J. Safra Center for Ethics (M.J.Y.), Harvard University, Boston, MA; Division of Medical Ethics (J.J.F.), Weill Cornell Medical College, Cornell University, New York, NY; and Solomon Center for Health Law & Policy (J.J.F.), Yale Law School, New Haven, CT
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Farisco M, Pennartz C, Annen J, Cecconi B, Evers K. Indicators and criteria of consciousness: ethical implications for the care of behaviourally unresponsive patients. BMC Med Ethics 2022; 23:30. [PMID: 35313885 PMCID: PMC8935680 DOI: 10.1186/s12910-022-00770-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/13/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Assessing consciousness in other subjects, particularly in non-verbal and behaviourally disabled subjects (e.g., patients with disorders of consciousness), is notoriously challenging but increasingly urgent. The high rate of misdiagnosis among disorders of consciousness raises the need for new perspectives in order to inspire new technical and clinical approaches. MAIN BODY We take as a starting point a recently introduced list of operational indicators of consciousness that facilitates its recognition in challenging cases like non-human animals and Artificial Intelligence to explore their relevance to disorders of consciousness and their potential ethical impact on the diagnosis and healthcare of relevant patients. Indicators of consciousness mean particular capacities that can be deduced from observing the behaviour or cognitive performance of the subject in question (or from neural correlates of such performance) and that do not define a hard threshold in deciding about the presence of consciousness, but can be used to infer a graded measure based on the consistency amongst the different indicators. The indicators of consciousness under consideration offer a potential useful strategy for identifying and assessing residual consciousness in patients with disorders of consciousness, setting the theoretical stage for an operationalization and quantification of relevant brain activity. CONCLUSIONS Our heuristic analysis supports the conclusion that the application of the identified indicators of consciousness to its disorders will likely inspire new strategies for assessing three very urgent issues: the misdiagnosis of disorders of consciousness; the need for a gold standard in detecting consciousness and diagnosing its disorders; and the need for a refined taxonomy of disorders of consciousness.
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Affiliation(s)
- Michele Farisco
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden.
- Science and Society Unit, Biogem, Biology and Molecular Genetics Research Institute, Ariano Irpino, AV, Italy.
| | - Cyriel Pennartz
- Department of Cognitive and Systems Neuroscience, Swammerdam Institute for Life Sciences, University of Amsterdam, Amsterdam, The Netherlands
- Research Priority Area, Brain and Cognition, University of Amsterdam, Amsterdam, The Netherlands
| | - Jitka Annen
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Benedetta Cecconi
- Coma Science Group, GIGA-Consciousness, University of Liege, Liege, Belgium
- Centre du Cerveau, University Hospital of Liege, Liege, Belgium
| | - Kathinka Evers
- Centre for Research Ethics and Bioethics, Uppsala University, Uppsala, Sweden
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Peterson A, Mintz K, Owen AM. Unlocking the Voices of Patients with Severe Brain Injury. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09492-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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Dieudonné Rahm N, Morawska G, Pautex S, Elia N. Monitoring nociception and awareness during palliative sedation: A systematic review. Palliat Med 2021; 35:1407-1420. [PMID: 34109873 DOI: 10.1177/02692163211022943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Providing unawareness and pain relief are core elements of palliative sedation. In addition to clinical scales, nociception and electroencephalogram-based depth of sedation monitoring are used to assess the level of consciousness and analgesia during sedation in intensive care units and during procedures. AIM To determine whether reported devices impact the outcomes of palliative sedation. DESIGN Systematic review and narrative synthesis of research published between January 2000 and December 2020. DATA SOURCES Embase, Google Scholar, PubMed, CENTRAL, and the Cochrane Library. All reports describing the use of any monitoring device to assess the level of consciousness or analgesia during palliative sedation were screened for inclusion. Data concerning safety and efficacy were extracted. Patient comfort was the primary outcome of interest. Articles reporting sedation but that did not meet guidelines of the European Association for Palliative Care were excluded. RESULTS Six reports of five studies were identified. Four of these were case series and two were case reports. Together, these six reports involved a total of 67 sedated adults. Methodological quality was assessed fair to good. Medication regimens were adjusted to bispectral index monitoring values in two studies, which found poor correlation between monitoring values and observational scores. In another study, high nociception index values, representing absence of pain, were used to detect opioid overdosing. Relatives and caregivers found the procedures feasible and acceptable.
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Affiliation(s)
- Nathalie Dieudonné Rahm
- Division of Palliative Medicine, Department of Geriatrics and Rehabilitation, Geneva University Hospitals, Hôpital de Bellerive, Collonge-Bellerive, Geneva, Switzerland
| | - Ghizlaine Morawska
- Division of Palliative Medicine, Department of Geriatrics and Rehabilitation, Geneva University Hospitals, Hôpital de Bellerive, Collonge-Bellerive, Geneva, Switzerland
| | - Sophie Pautex
- Division of Palliative Medicine, Department of Geriatrics and Rehabilitation, Geneva University Hospitals, Hôpital de Bellerive, Collonge-Bellerive, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
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Scolding N, Owen AM, Keown J. Prolonged disorders of consciousness: a critical evaluation of the new UK guidelines. Brain 2021; 144:1655-1660. [PMID: 33778883 PMCID: PMC8320298 DOI: 10.1093/brain/awab063] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/06/2020] [Accepted: 12/11/2020] [Indexed: 11/14/2022] Open
Abstract
In March 2020, the Royal College of Physicians in the UK published national guidelines on the management of patients with prolonged disorders of consciousness, updating their 2013 guidance 'particularly in relation to recent developments in assessment and management and … changes in the law governing … the withdrawal of clinically assisted nutrition and hydration'. The report's primary focus is on patients who could live for many years with treatment and care. This update, by a neurologist, an imaging neuroscientist, and a lawyer-ethicist, questions the document's rejection of any significant role for neuroimaging techniques including functional MRI and/or bedside EEG to detect covert consciousness in such patients. We find the reasons for this rejection unconvincing, given (i) the significant advances made in the use of this technology in recent years; and (ii) the wider scope for its use envisaged by the earlier (2018) guidelines issued by the American Academy of Neurology. We suggest that, since around one in five patients diagnosed with prolonged disorders of consciousness are in fact conscious enough to follow commands in a neuroimaging context (i.e. those who are 'covertly conscious' or those with 'cognitive motor dissociation'), and given the clinical, ethical and legal importance of determining whether patients with prolonged disorders of consciousness are legally competent or at least able to express their views and feelings, the guidance from the Royal College of Physicians requires urgent review.
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Affiliation(s)
- Neil Scolding
- Institute of Clinical Neurosciences, University of Bristol, Bristol, UK
| | | | - John Keown
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
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Peterson A, Webster F, Gonzalez-Lara LE, Munce S, Owen AM, Weijer C. Caregiver reactions to neuroimaging evidence of covert consciousness in patients with severe brain injury: a qualitative interview study. BMC Med Ethics 2021; 22:105. [PMID: 34320966 PMCID: PMC8320067 DOI: 10.1186/s12910-021-00674-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Severe brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope. Methods To examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who were enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study. Results Twelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results. Conclusion This study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00674-8.
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Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University, Fairfax, USA.
| | - Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Canada
| | | | - Sarah Munce
- Toronto Rehabilitation Institute-University Health Network, Toronoto, Canada
| | - Adrian M Owen
- Brain and Mind Institute, Western University, London, Canada
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Canada
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Peterson A, Aas S, Wasserman D. What Justifies the Allocation of Health Care Resources to Patients with Disorders of Consciousness? AJOB Neurosci 2021; 12:127-139. [PMID: 33787458 DOI: 10.1080/21507740.2021.1896594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper critically engages ethical issues in the allocation of novel, and potentially costly, health care resources to patients with disorders of consciousness. First, we review potential benefits of novel health care resources for patients and their families and outline preliminary considerations to address concerns about cost. We then address two problems regarding the allocation of health care resources to patients with disorders of consciousness: (1) the problem of uncertain moral status; and (2) the problem of accurately measuring the welfare burdens these resources would relieve. We conclude by suggesting that opportunity-based frameworks might complement standard approaches for justifying resources allocation to patients with disorders of consciousness.
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Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University
| | - Sean Aas
- Kennedy Institute of Ethics, Georgetown University
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Peterson A, Owen AM, Karlawish J. Translating the Discovery of Covert Consciousness Into Clinical Practice. JAMA Neurol 2021; 77:541-542. [PMID: 32176251 DOI: 10.1001/jamaneurol.2020.0232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University, Fairfax, Virginia
| | - Adrian M Owen
- The Brain and Mind Institute, University of Western Ontario, London, Ontario, Canada
| | - Jason Karlawish
- Penn Memory Center, University of Pennsylvania, Philadelphia.,Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Confronting the grey zone after severe brain injury. Emerg Top Life Sci 2020; 3:707-711. [PMID: 32915226 DOI: 10.1042/etls20190115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 11/17/2022]
Abstract
In recent years, rapid technological developments in the field of neuroimaging have provided several new methods for revealing thoughts, actions and intentions based solely on the pattern of activity that is observed in the brain. In specialized centres, these methods are now being employed routinely to assess residual cognition, detect consciousness and even communicate with some behaviorally non-responsive patients who clinically appear to be comatose or in a vegetative state. In this article, we consider some of the ethical issues raised by these developments and the profound implications they have for clinical care, diagnosis, prognosis and medical-legal decision-making after severe brain injury.
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Peterson A, Owen AM, Karlawish J. Alive inside. BIOETHICS 2020; 34:295-305. [PMID: 31577856 PMCID: PMC7065158 DOI: 10.1111/bioe.12678] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/08/2019] [Accepted: 08/02/2019] [Indexed: 06/10/2023]
Abstract
This article provides an ethical analysis of the U.S. practice guideline update on disorders of consciousness. Our analysis focuses on the guideline's recommendations regarding the use of investigational neuroimaging methods to assess brain-injured patients. Complex and multifaceted ethical issues have emerged because these methods alter the clinical understanding of consciousness. We address issues of false hope, patient suffering, and cost. We argue that, in spite of these concerns, there is significant benefit to using neuroimaging to assess brain-injured patients in most cases.
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Affiliation(s)
- Andrew Peterson
- Department of Philosophy, Institute for Philosophy and Public PolicyGeorge Mason UniversityFairfaxVirginia
| | - Adrian M. Owen
- Departments of Psychology and Neuroscience, Brain and Mind InstituteUniversity of Western OntarioLondonCanada
| | - Jason Karlawish
- Departments of Medicine, Medical Ethics and Health Policy, and Neurology, Penn Memory Center and Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
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Peterson A. How Will Families React to Evidence of Covert Consciousness in Brain-Injured Patients? NEUROETHICS-NETH 2020. [DOI: 10.1007/s12152-019-09428-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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