Special article
Ethical challenges of the finding of covert awareness with neuroimaging in vegetative states
Retos éticos del hallazgo de consciencia encubierta con neuroimagen en estados vegetativos
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After a period of coma which can last up to 3 or 4 weeks, some patients recover while others open their eyes and begin to breathe spontaneously, but show no voluntary response (“Vegetative State” or “Unresponsive Wakefulness Syndrome”) or are able to demonstrate a voluntary response, but this is not sustained (“Minimally Conscious State”). In both cases, a clinical evaluation is difficult. Vegetative state diagnosis is based on detecting the absence of voluntary response signs to stimuli using validated clinical scales. Various published series report that these methods’ sensitivity and specificity can be clearly improved.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The diagnosis of permanent vegetative state can activate limited therapeutic plans driven by an irreversible outcome assumption. Since 1994, following a consensus of several scientific societies, the previously mentioned diagnosis is considered when there are no signs of voluntary response one year after a traumatic brain injury or 6 months after non-traumatic brain injury.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent neuroscientific findings<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> show that brain-computer interfaces based on functional magnetic resonance imaging (fMRI), electroencephalography (EEG) and/or event-related potentials can be a viable strategy for detecting ‘covert’ conscious activity in patients who are in a sustained altered state of consciousness when leaving a period of coma secondary to brain damage. Brain functions have been found intact in some of these patients (verbal comprehension, recent and autobiographical memory, orientation, etc.). These have been interpreted as conscious activity which goes unnoticed in validated clinical scales. There have even been cases of patients that were able to communicate assisted by fMRI and/or EEG.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Current situation</span><p id="par0015" class="elsevierStylePara elsevierViewall">This debate was opened in 2006 when a fMRI study detected conscious activation to a verbal order in a 23-year-old female patient who met the clinical criteria for post-traumatic vegetative state.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Despite not showing responses suggestive of voluntary behaviour in repeated clinical examinations, the authors interpreted that the patient could intentionally modulate her brain activity in response to verbal proposals. While inside a fMRI scan, it was asked verbally to imagine two activities: playing tennis or going from one room to another inside her home. Following the request, changes were observed in the transport of oxygen in blood, detectable by fMRI, in specific brain regions respectively involved in motor programming and spatial orientation, with a pattern comparable to healthy controls.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In 2012,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> another patient diagnosed with vegetative state during more than 12 years of progression could sustain a ‘coherent’ conversation with investigators by using the fMRI activation paradigms described above to establish a “yes”/“no” binary code. Among other things, the patient knew the current year and the name of his caregiver, unknown to him before the accident. Therefore, this demonstrated that the patient had (according to currently up to date clinical criteria, the condition was irreversible and deprived of any complex cognitive function) at least: verbal comprehension; ability to activate and voluntarily stop brain activation patterns using it to establish yes–no response codes; use old memories and store new ones, as well as time and space orientation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">fMRI paradigms have encouraged similar experiments based on EEG or evoked potential records. These cases and some more series published in the last decade have led to consider these advances as a possible solution to clinical diagnostic inaccuracy, even suggesting some prognostic correlation. Some authors argue that the detection of preserved covert cognition would predict a greater likelihood of functional recovery, although specific data on the latter are scarce, inconsistent and offer little information about the extent of long-term expected recovery.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">6,7</span></a> In fact, there is scientific consensus that, today, neither diagnosis nor prognosis can be based solely on ancillary tests.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In short, the new findings show that the clinical diagnosis of “vegetative state” in a patient that demonstrates conscious activity by other methods should be considered incorrect. How should we then call these patients who, clinically, do not express conscious responses but these are detected with imaging and/or neurophysiological technologies? The following term has been suggested: “<span class="elsevierStyleItalic">Non-behavioural minimally conscious state</span>”,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> but it may not be the most fitting because it seems clear that at least some of the patients reported show conscious activities that far exceed those observed externally in “states of minimal consciousness”: sustained attention, orientation, use and storage of memories and language comprehension.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">A deep ethical approach to the questions raised by these findings is not available to date, but it is unavoidable before any clinical practice implementation. It is from this perspective that we will consider the most significant issues.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Scientific soundness</span><p id="par0040" class="elsevierStylePara elsevierViewall">There is no point in addressing a bioethical deliberation; that is, it is not worth discussing values unless we start from a solid foundation of scientifically proven facts. Today we are still far from a clinical applicability in healthcare practice of the neurophysiological tests and/or functional neuroimaging.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> The systematic clinical evaluation of behaviour and responses remains the “gold standard” despite its deficiencies. The main scientific objections proposed are:</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Epidemiology</span><p id="par0045" class="elsevierStylePara elsevierViewall">Some authors claim that 17–19% of patients who meet the clinical criteria for vegetative state maintain conscious activity undetectable by clinical observation, but these claims are based on small series, being the total number of patients who have reported these activations still very small (probably less than 20, if we consider only the vegetative state and neuroimaging). In addition, these findings have occurred, almost exclusively, in a very specific subgroup within these patients (those of traumatic aetiology with prevalence of axonal injury versus neuronal bodies). Therefore, it is unwise for the time being, to extend the diagnostic concern to all patients in a vegetative state, let alone the prognostic concern.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Validity, sensitivity and specificity of the experimental model</span><p id="par0050" class="elsevierStylePara elsevierViewall">It is relevant to know if we find what we want to detect (validity), if we do it in all cases (sensitivity) and if whatever we observe with these methods always reflects conscious activity (specificity). Despite impressive initial results, the scientific community reacted with scepticism at first, quickly objecting.</p><p id="par0055" class="elsevierStylePara elsevierViewall">After the first case reported in 2006,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> critics argued that verbal stimuli can produce spontaneous neuronal activation, not necessarily “conscious”. Therefore, the changes found could simply amount to unconscious reflex activity or “conditional”, for example, to the last word in the order.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Supporters of the use of neuroimaging counterargue that the activity is not observed in areas related with auditory processing but with the requested task and remains for prolonged periods, until the patient is asked to “relax”.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Isolated models that have allowed easy communication with patients, providing these up-to-date and/or autobiographical data, could not be easily explained just by unconscious processing.</p><p id="par0060" class="elsevierStylePara elsevierViewall">These studies require a control group consisting of conscious healthy subjects. However, no research group, whether using fMRI or EEG, has managed cortical activation on verbal order in 100% of controls studied.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11–13</span></a> For example, up to 25% of subjects were unable to perform and/or understand exactly the meaning of the task on mental images using EEG. This opens the door to both, false positives as well as false negatives, with the consequent secondary limitations for clinical applicability.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The technique itself has inherent limitations. Many of these patients have involuntary movements that prevent capturing signals and producing images or records. In some protocols, up to 41% of the subjects could not be properly evaluated for this reason.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Applied statistical methods and established significance thresholds, essential in the interpretation of results in such small samples, are very heterogeneous, becoming an active focus of discussion in scientific literature.</p><p id="par0075" class="elsevierStylePara elsevierViewall">All these considerations make it advisable to exercise caution regarding making the results and conclusions public, and highlight the need for standardization and coordinated effort among different research teams.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Media coverage</span><p id="par0080" class="elsevierStylePara elsevierViewall">These results have been actively publicized in different mass media and have had a striking social impact (mainstream press, internet, television, social networks, etc.).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> Perhaps, too often, the visual impact of fMRI colour images has gone ahead of reflection, scientific rigour and prudence. False and/or premature expectations generated can contaminate the debate and the practical decisions derived from it.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Moral status</span><p id="par0085" class="elsevierStylePara elsevierViewall">What moral considerations, rights and obligations do we owe to people who cannot express conscious capabilities, who, on the other hand, remain active as shown by neuroscientific findings? If confirmed, and from a philosophical point of view, we would be talking about a new state, affecting very important qualities for conceptualizing what the philosophical tradition means by “person” and “autonomy”.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Examining their quality of life</span><p id="par0090" class="elsevierStylePara elsevierViewall">Beyond ontological debates, the real challenge would be to know what the patient thinks about his/her situation. In other words, it is important to know the perception of quality of life and/or suffering of people who, outside the experimental setting, cannot express behavioural patterns towards the external environment or use conventional language. It is already a challenge to measure such a subjective concept in the rest of the people, let alone these cases, where the difficulties grow considerably, as the only expression link the person has is the brain–computer interface conveyed by imaging or neurophysiological techniques. In fact, applying quality of life assessment methods to patients with no behavioural response is only a project, as currently there are not any validated instruments available.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ability to participate in decisions and competence assessment</span><p id="par0095" class="elsevierStylePara elsevierViewall">A question arises in relation with the moral and autonomy status: who should make decisions affecting this patient and how, especially those related to his/her health, biological survival, emotional and/or personal domain? In other words, could the patient decide through this kind of techno-mediated telepathy? Surely, professionals would want to know if the patient wants to be resuscitated in the event of cardiac arrest; or if the patient is in pain, is itching, bored or afraid, etc.; or simply whether the kind of existence under these conditions is acceptable to him or her.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Given the hypothesis that perhaps a small proportion of these patients could now communicate using neuroimaging and/or EEG, it may seem appropriate to ask whether they can participate in decisions about their own health care. But, before considering this about decisions that are often difficult, their competence should be established. Can a simple conversation via “brain–computer” interface allow for this assessment? Given that the techniques available to date only allow for ‘yes’ or ‘no’ answers, and that patients cannot formulate their own questions or answers, some have argued that it is not possible to assess the ability of decision-making and, therefore, new technologies would not contribute anything to the issue of patient autonomy, which is the main challenge in treatment decisions in these cases. However, others defend the possibility of further developing competence assessment methods based on the decomposition of its standard elements (understanding, appreciation and reasoning) into its constituent cognitive functions, and exploring these by neuropsychological instruments adapted to functional neuroimaging. Although, again, it should be noted that the threshold of competence to decide must be calibrated depending on the complexity of the decisions to be made. Even when a measure of success is achieved in this area, the capacity assessment through neuroimaging may only apply to low or medium complexity decisions, finding that it is not enough to determine that the patient has the needed degree of competence in order to make difficult decisions, such as those related with the end of life or, for example, with a potential rejection of treatment.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Another very important challenge relates to the fact that the competence assessment does not only involve having a number of neuropsychological skills. It is very important to have the patient's feedback to assess whether the information provided has been really understood and has been applied to him/herself. With no fluent exchange of messages of some complexity, determining decision competence is not easy, especially if the decision to make is not a simple one.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Impact on families and social environment</span><p id="par0110" class="elsevierStylePara elsevierViewall">The visual spectacle of these findings and their quick media circulation has generated a huge impact on families that, for long periods of time, have had to deal with despair and uncertainty. Perhaps, these hopes were not justified if we consider that:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">The validation of these techniques is still under scientific debate</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">The sensitivity and specificity demonstrated to date are limited</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">The actual prognosis impact has not yet been properly proven</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0130" class="elsevierStylePara elsevierViewall">They are limited for now to a very specialized realm, mostly experimental</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0135" class="elsevierStylePara elsevierViewall">These findings have only been described in a small subgroup out of all patients with altered states of consciousness</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0140" class="elsevierStylePara elsevierViewall">The ethical deliberation about its real impact is limited.</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">All of this has resulted in a strong demand for the application of these tests. In some countries, this pressure has even reached the courts, where functional neuroimaging tests have been requested in a lawsuit in the context of decision making in these patients.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">It has also been argued that the clinical application of neuroimaging can have a negative impact on the welfare of these families. Given potential false positives and false negatives, communicating the results of these tests to relatives is a complex task, and may not contribute in the least to help families out of uncertainty, or can anchor them in the same from a prior state of resignation.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Therapeutic limitation decisions</span><p id="par0155" class="elsevierStylePara elsevierViewall">According to recent studies, most deaths secondary to severe brain damage (up to 70%) occur after decisions related to withdrawal of life support measures, many of them within the first 72<span class="elsevierStyleHsp" style=""></span>h. In this sense, the authors suggest that, perhaps, these decisions are taken at a time when it is still difficult to provide a good “neuro-prognosis”.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> In fact, considerable variability in mortality rates between different centres have been observed. This can relate to the different opinions of doctors regarding long-term prognosis of these patients.</p><p id="par0160" class="elsevierStylePara elsevierViewall">It has been proposed<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18,19</span></a> that patients who activate these fMRI patterns have better prognosis than those who do not, but data are scarce, inconsistent and offer little useful information about long-term recovery rates. It seems clear that we need more research about these issues. Enabling an earlier and more accurate prognosis, which is properly communicated to the families (and to the patient him/herself if technology would allow it), could greatly improve care and treatment decisions. If an assessable functional recovery is not expected (or rather, acceptable to the person), discovering that these patients are conscious could confront us, relatively speaking, to the ethical dilemmas already raised by other ailments without cortical compromise, cases where nobody doubts about the patient's full competence, such as motor neuron disease or brain stem disease with “locked-in syndrome”.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The moral permissibility associated with the withdrawal of life support measures, including artificial nutrition and hydration, to patients in a vegetative state is widely accepted, based on the irreversibility and absence of “inner life” that is assumed in these patients. Two currents of opinion exist when cases of covert awareness are detected:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">That which considers that the detection of covert awareness invalidates any therapeutic limitation option. In fact, in several highly publicized legal cases it has been suggested that vegetative patients should undergo neuroimaging techniques.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">That which considers that covert awareness finding does not give us, by itself, a clear reason to keep the patient alive. Of course, this conscious life deserves respect, but respect, well understood, can lead and indeed leads in many other diseases suffered by fully conscious people to suitable therapeutic decisions. The patient's situation may be even more unbearable if a remnant of self-consciousness and/or capacity for suffering is still present. It is argued that, if these patients suffer, continuing with life support measures can be more of a detriment than a benefit, and this would provide even stronger reasons for the limitation in terms of nonmaleficence and honouring the true interests of the patient. Therefore, from this perspective, it is argued that the new findings would not change clinical practice in connection with these patient's therapeutic adaptation, unless a clearly favourable prognosis and intense functional reversibility is shown in patients that demonstrate these signs in fMRI, or the development of these techniques allow patients a level of reliable communication regarding their preferences and/or experience of the situation. If their state, together with technological advancement, would allow it in the future, a hypothetical shared decision making scenario with patients in an “apparent vegetative state” could be raised, but we already explained that this is far from possible at present.</p></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">Another crucial obstacle when trusting treatment-limiting decisions to technology lies, again, in the false positives and false negatives, extensively described in all models used, which is a cause for concern in scientific literature today. If the previously discussed issues are not clear, the only wise course is one of caution before implementing their use in clinical practice, let alone incorporating them as key players in treatment-limiting or non-limiting decisions.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Accessibility and sustainability</span><p id="par0185" class="elsevierStylePara elsevierViewall">Even if the validity and reliability of these techniques were scientifically demonstrated, unless accessible “bedside” tests become available, its practical application would be impossible or unfair (if finally, they are only available in “certain specialized centres” and in a “quasi” or totally experimental environment). But, as noted before, the debate has already in progress. In the USA, there are already lawsuits for this reason against sites caring for these patients when these new techniques are not “offered”. Curiously, humans, in many occasions, make their way to the courts first, even before dedicating time to a reflective pause.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In conclusion, the prognosis of patients with severe brain damage is very variable. After a period of days or weeks in a coma, some of them recover while others progress to altered states of consciousness (minimally conscious states or vegetative state). It is very difficult to predict who and why will experience an assessable recovery using clinical methods. This situation forces families and health professionals to make complex decisions under states of uncertainty.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Recent advances in neuroimaging and neurophysiology detect intact brain functions that go unnoticed to the clinical scales, especially in cases of traumatic aetiology. Therefore, these techniques point to the possibility of improving the diagnosis and perhaps better prognosis predictions in these processes. But, in many respects, these findings are still under deliberation and exchange of knowledge within the scientific community, so any translation into clinical practice or into society should be, for the moment, prudent. One cannot ignore the ethical issues raised by these findings, which must be addressed before its widespread use in healthcare, if that is really possible and sustainable in clinical practice.</p><p id="par0200" class="elsevierStylePara elsevierViewall">However, it is important to stress that all these concerns are being raised regarding a very specific subgroup of patients with altered states of consciousness after brain damage, those with a trauma-related origin and in which the predominant lesion is diffuse axonal injury. In other words, there is nothing in the reviewed studies on new evaluation techniques of altered states of consciousness to indicate that the prognosis beyond a year for a person who meets the vegetative state clinical criteria should be encouraging, or that their ‘acceptable’ reversibility rates for their status should be any more than anecdotal. These only suggest to increase caution in the case of traumatic patients and those who meet the “minimally conscious state” criteria. And this, we already knew in 1994.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">This does not mean that the criteria for clinical diagnosis and prognostic evaluation of these patients should not be reviewed, especially in view of the new knowledge available, although it would be vital to have studies with larger samples, multicentre, standardized and long term, also considering studying earlier stages of the process, for example, the first few days or weeks in coma.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Currently, several authors advocate an early and multimodal approach that integrates the contributions of all available methods (clinical and ancillary tests) to obtain more accurate and useful diagnoses and prognoses.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20–23</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">In short, it would be wrong to generate an unweighted snowball of enthusiasm or to ignore the neuroscientific findings, which, at least, involve a conceptual, healthcare and bioethical challenge.</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Current situation" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Discussion" "secciones" => array:9 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Scientific soundness" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Epidemiology" ] ] ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Validity, sensitivity and specificity of the experimental model" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Media coverage" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Moral status" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Examining their quality of life" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Ability to participate in decisions and competence assessment" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Impact on families and social environment" ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Therapeutic limitation decisions" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Accessibility and sustainability" ] ] ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-14" "fechaAceptado" => "2015-07-22" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Robles del Olmo B, García Collado D. Retos éticos del hallazgo de consciencia encubierta con neuroimagen en estados vegetativos. Med Clin (Barc). 2016;146:218–222.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accuracy of diagnosis of persistent vegetative state" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.L. Childs" 1 => "W.N. Mercer" 2 => "H.W. Childs" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Neurology" "fecha" => "1993" "volumen" => "43" "paginaInicial" => "1465" "paginaFinal" => "1467" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8350997" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0125" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medical aspects of the persistent vegetative state" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "The Multi-Society Task Force on PVS" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199405263302107" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1994" "volumen" => "330" "paginaInicial" => "1499" "paginaFinal" => "1508" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7818633" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0130" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Using functional magnetic resonance imaging to detect covert awareness in the vegetative state" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.M. Owen" 1 => "M.R. Coleman" 2 => "M. Boly" 3 => "M.H. Davis" 4 => "S. Laureys" 5 => "J.D. Pickard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archneur.64.8.1098" "Revista" => array:6 [ "tituloSerie" => "Arch Neurol" "fecha" => "2007" "volumen" => "64" "paginaInicial" => "1098" "paginaFinal" => "1102" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17698699" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0135" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detecting awareness in the vegetative state" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.M. Owen" 1 => "M.R. Coleman" 2 => "M. Boly" 3 => "M.H. Davis" 4 => "S. Laureys" 5 => "J.D. Pickard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1126/science.1130197" "Revista" => array:5 [ "tituloSerie" => "Science" "fecha" => "2006" "volumen" => "313" "paginaInicial" => "1402" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16959998" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0140" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Detecting awareness after severe brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Fernández-Espejo" 1 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/nrn3608" "Revista" => array:7 [ "tituloSerie" => "Nat Rev Neurosci" "fecha" => "2013" "volumen" => "14" "paginaInicial" => "801" "paginaFinal" => "809" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24088810" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1556086415327404" "estado" => "S300" "issn" => "15560864" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0145" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Towards the routine use of brain imaging to aid the clinical diagnosis of disorders of consciousness" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.R. Coleman" 1 => "M.H. Davis" 2 => "J.M. Rodd" 3 => "T. Robson" 4 => "A. Ali" 5 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/brain/awp183" "Revista" => array:6 [ "tituloSerie" => "Brain" "fecha" => "2009" "volumen" => "132" "paginaInicial" => "2541" "paginaFinal" => "2552" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19710182" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0150" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk, diagnostic error, and the clinical science of consciousness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Peterson" 1 => "D. Cruse" 2 => "L. Naci" 3 => "C. Weijer" 4 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nicl.2015.02.008" "Revista" => array:6 [ "tituloSerie" => "Neuroimage Clin" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "588" "paginaFinal" => "597" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25844313" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0155" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unresponsive, but aware: the Non-Behavioral Minimally Conscious State" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Stender" 1 => "R. Kupers" 2 => "M. Maurice Ptito" 3 => "A. Gjedde" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Brain Disord Ther" "fecha" => "2014" "volumen" => "3" "paginaInicial" => "e115" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0160" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The source of consciousness" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K.A. Paller" 1 => "S. Suzuki" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trends Cogn Sci" "fecha" => "2014" "volumen" => "18" "paginaInicial" => "387" "paginaFinal" => "389" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25023451" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0165" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comment on detecting awareness in the vegetative state" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.L. Greenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1126/science.1135284" "Revista" => array:5 [ "tituloSerie" => "Science" "fecha" => "2007" "volumen" => "315" "paginaInicial" => "1221" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17332395" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0170" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Substitute or complement? Defining the relative place of EEG and fMRI in the detection of voluntary brain reactions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Gabriel" 1 => "J. Henriques" 2 => "A. Comte" 3 => "L. Grigoryeva" 4 => "J.P. Ortega" 5 => "E. Cretin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.neuroscience.2015.01.053" "Revista" => array:6 [ "tituloSerie" => "Neuroscience" "fecha" => "2015" "volumen" => "290" "paginaInicial" => "435" "paginaFinal" => "444" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25644421" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0175" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The clinical utility of fMRI for identifying covert awareness in the vegetative state: a comparison of sensitivity between 3<span class="elsevierStyleHsp" style=""></span>T and 1.5<span class="elsevierStyleHsp" style=""></span>T" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Fernández-Espejo" 1 => "L. Norton" 2 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0095082" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "e95082" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24733575" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0180" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bedside detection of awareness in the vegetative state: a cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Cruse" 1 => "S. Chennu" 2 => "C. Chatelle" 3 => "T.A. Bekinschtein" 4 => "D. Fernández-Espejo" 5 => "J.D. Pickard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(11)61224-5" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2011" "volumen" => "378" "paginaInicial" => "2088" "paginaFinal" => "2094" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22078855" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0185" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic precision of PET imaging and functional MRI in disorders of consciousness: a clinical validation study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Stender" 1 => "O. Gosseries" 2 => "M.A. Bruno" 3 => "V. Charland-Verville" 4 => "A. Vanhaudenhuyse" 5 => "A. Demertzi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(14)60042-8" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "384" "paginaInicial" => "514" "paginaFinal" => "522" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24746174" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0190" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vegetative patient Scott Routley says ‘I’m not in pain’" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "BBC" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2012" "editorial" => "BBC" "editorialLocalizacion" => "Reino Unido" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0195" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Communicating with vegetative state patients: the role of neuroimaging in American Disability Law" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Stanf Law Rev" "fecha" => "2014" "volumen" => "66" "paginaInicial" => "1451" "paginaFinal" => "1485" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0200" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.F. Turgeon" 1 => "F. Lauzier" 2 => "J.F. Simard" 3 => "D.C. Scales" 4 => "K.E. Burns" 5 => "L. Moore" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1503/cmaj.101786" "Revista" => array:6 [ "tituloSerie" => "CMAJ" "fecha" => "2011" "volumen" => "183" "paginaInicial" => "1581" "paginaFinal" => "1588" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21876014" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0205" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can mental imagery functional magnetic resonance imaging predict recovery in patients with disorders of consciousness?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Vogel" 1 => "A. Markl" 2 => "T. Yu" 3 => "B. Kotchoubey" 4 => "S. Lang" 5 => "F. Müller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.apmr.2012.11.053" "Revista" => array:6 [ "tituloSerie" => "Arch Phys Med Rehabil" "fecha" => "2013" "volumen" => "94" "paginaInicial" => "1891" "paginaFinal" => "1898" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23735520" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0210" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The holy grail of predicting recovery after acute brain insults: a step closer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.B. Young" 1 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Clin Neurophysiol" "fecha" => "2014" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0215" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lies, damned lies and diagnoses: estimating the clinical utility of assessments of covert awareness in the vegetative state" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Cruse" 1 => "I. Gantner" 2 => "A. Soddu" 3 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/02699052.2014.920517" "Revista" => array:7 [ "tituloSerie" => "Brain Inj" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "1197" "paginaFinal" => "1201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24911058" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0169500212000190" "estado" => "S300" "issn" => "01695002" ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0220" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preservation of electroencephalographic organization in patients with impaired consciousness and imaging-based evidence of command-following" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.B. Forgacs" 1 => "M.M. Conte" 2 => "E.A. Fridman" 3 => "H.U. Voss" 4 => "J.D. Victor" 5 => "N.D. Schiff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ana.24283" "Revista" => array:6 [ "tituloSerie" => "Ann Neurol" "fecha" => "2014" "volumen" => "76" "paginaInicial" => "869" "paginaFinal" => "879" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25270034" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0225" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disorders of consciousness after acquired brain injury: the state of the science" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.T. Giacino" 1 => "J.J. Fins" 2 => "S. Laureys" 3 => "N.D. Schiff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/nrneurol.2013.279" "Revista" => array:6 [ "tituloSerie" => "Nat Rev Neurol" "fecha" => "2014" "volumen" => "10" "paginaInicial" => "99" "paginaFinal" => "114" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24468878" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0230" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple tasks and neuroimaging modalities increase the likelihood of detecting covert awareness in patients with disorders of consciousness" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.M. Gibson" 1 => "D. Fernández-Espejo" 2 => "L.E. Gonzalez-Lara" 3 => "B.Y. Kwan" 4 => "D.H. Lee" 5 => "A.M. Owen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3389/fnhum.2014.00950" "Revista" => array:5 [ "tituloSerie" => "Front Hum Neurosci" "fecha" => "2014" "volumen" => "8" "paginaInicial" => "950" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25505400" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014600000005/v1_201606230528/S238702061630225X/v1_201606230528/en/main.assets" "Apartado" => array:4 [ "identificador" => "44145" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014600000005/v1_201606230528/S238702061630225X/v1_201606230528/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702061630225X?idApp=UINPBA00004N" ]
