Monday, June 19, 2017

Medical life-and-death decisions just got even harder

British-Canadian neuroscientist Dr. Adrian Owen has added yet more confusion to an already murky and fraught area of medical ethics, with his new book Into the Gray Zone: A Neuroscientist Explores the Border Between Life and Death.
Dr. Owen's contention is that up to 20% of seriously brain-damaged patients who are in a minimally-conscious, vegetative or non-responsive state are actually more aware than they may seem. He has spent the last 20 years using brain-scanning technology like fMRI to try and communicate with such patients in a kind of "20 questions" type of yes-no query approach.  He maintains that these patients can see, hear and understand what is going on in the world around them, but are unable to communicate their understanding and their wishes.
Other scientists are more skeptical about Owen's methods, results and interpretations, claiming that some of his studies are not scientifically valid, and that there is no way of telling which responses are mere automatic responses, and Owen himself accepts these criticisms as part of the scientific process. He is the first to admit that he and his fellow researchers still have a long way to go in understanding and fine-tuning his findings and their ramifications.
Dr. Owen says it is "extremely naive" to assume that all such patients are unhappy, but the questions remain as to what assumptions are in fact justifiable, and just what it is that makes a life worth living. If a patient in a persistent vegetative state is deemed to have no chance of recovery, is it doing more harm to keep him or her alive or to terminate their pain, ignorant as we are of their own feelings and wishes? Some relatives in high profile cases claim that only some imaginary friend called God is able to make such life-and-death decisions, but should we give any credence at all to such views? In Ontario, a medical ethics body called the Consent and Capacity Board (CCB) are tasked with this unenviable determination in each individual case, and other similar bodies exist in other provinces and countries.
As medical ethicist Prof. Arthur Shafer asks, what is the point in keeping a person alive when they cannot possibly benefit from "aggressive life-prolonging medical care"? Prof. Shafer argues that, if there is no chance of recovery, such care is at best futile and at worst positively harmful, keeping people alive while in pain or distress, or in a condition they themselves might find undignified or repugnant. What's more, intensive care beds are scarce and expensive, and others may benefit from them more.
Dr. Owen's research is still not available for regular use at local hospitals, and it is not clear whether it will ever amount to a reliable or definitive technique, despite all the media attention his work has been attracting. But many experts in the field question how much value it might have anyway. If It turns out that some, even a relatively small proportion, of these kinds of patients are actually cognitively intact, how then should that affect clinical practice? As one intensive care physician puts it, "that scares the bejeezus out of me".

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