Ethical Proponents of Patient End-of-Life Decision Making Using Functional Magnetic Resonance Imaging Techniques

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Major medical advancements have revolutionized the field of medicine in recent years, including procedures such as the one undertaken by Dr. Adrian Owen and his research team regarding the use of functional magnetic resonance imaging (fMRI) to detect levels of consciousness in permanently vegetative state (PVS) patients. Similar to other medical interventions, this technique has led to ethical dilemmas amongst members of the medical community, regarding the ability of PVS patients and their families to make decisions regarding the withdrawal of life-sustaining interventions.  Prior to this discovery, little exchanges of information had been done with patients who have been diagnosed as being in a PVS.  Furthermore, initial findings from the research that has been undertaken may help support the notion that this technique should play a role in allowing patients and their families to make choices in regards to end of life decisions, despite their physical and mental state. Initial findings have led to two distinct arguments within the ethical realm surrounding the idea of asking these patients questions regarding end-of- life decisions and what can and should be done to improve their quality of life. The context of this paper will be supported by the ideas behind individuals right to life supporting the direction of health care moving patient autonomy. Thus, I believe that patients that have successfully undergone Dr.Owen’s technique should have the right to make their own choices regarding end of life decisions as supported by the principles of liberalism due to their conscious awareness of their surroundings.


Within the past few months, a breakthrough has been seen in regards to patients who have experienced traumatic brain injuries leaving them in vegetative states. This breakthrough method involves monitoring real-time brain activity with the use of an fMRI- by visualizing the flow of oxygenated blood through the brain as the patient answers specific questions (Mole, 2012). Patients are therefore trained and instructed to imagine doing tasks such as playing tennis to simulate the answer no, and to visualize walking through their homes as yes (Blackwell, 2013). Thus, when being asked questions the thoughts from the patient cause different regions of the brain to light up and is then captured on fMRI scans which captures brain activity over time (Blackwell, 2013).  This method is the first technique that has shown clinically vegetative patients answering questions pertaining to their condition (Mole, 2012).

Prior to the discovery of this technique, it was noted that PVS patients were seen to be unable to respond to stimuli from the outside world. Patients in permanently vegetative states (PVS) have been characterized as being “awake”; mainly due to the fact that their eyes are open (Blackwell, 2013).  However, they were thought to be incapable of responding to any form of stimuli or possessing any form of thinking capabilities (Blackwell, 2013). It has been noted that some PVS patients may emerge to higher levels of consciousness, however many others remain unchanged for years in a vegetative state (Blackwell, 2013).  Thus, Dr. Owen’s findings help to support the idea that if these patients are indeed conscious, then PVS patients in these should have authority to make their own decisions regarding the removal of life support.

            Similar to other medical interventions and techniques, these recent findings have raised several ethical questions. One question relates to Owen’s technique of testing consciousness itself. Dr. Owen’s findings have been contested on the findings that these individuals are not conscious and that the findings should have no bearing on end-of-life decisions. I will not deny that the technique does require improvement, however, I feel that it does offer some insight into initial stages of testing the levels of consciousness in PVS patients. Generally, it is agreed that this technique relays an opportunity for these patients to provide important information pertaining to things such as pain and discomfort (Cyranoski, 2012).

What has generally not been agreed upon is the idea surrounding whether these patients should be able to choose death rather than remaining in a PVS. John Stuart Mill’s principle of liberty helps to rebut the presumption that if found to be conscious, patients should be able to come to a decision that reflects their own values and beliefs. Mill’s principle also promotes the notion that “a person is sovereign over his or her own body and mind” (Glannon, 2005). If this technology proves to be effective, it would allow medical practitioners and the patient’s family to explore the individuals’ thoughts to make an informed decision. Individuals could therefore decide on treatment plans that reflect their own values, rather than decisions that solely reflect the interests of practitioners and their families. Critics have also expressed concern in regards to the premise of answering yes or no questions as reflecting the idea that a patient therefore has some level of consciousness and therefore does not completely understand their mental state or cognitive abilities (Cyranoski, 2012).  However, Owen’s has stated that the task is no easy feat, as it requires patients to focus on the task for 30 seconds and then rest for another 30 seconds (Cyranoski, 2012). The treatment has been proven to work in all patients, with only one in five responding to the technique. However, we should not limit this treatment to help in end-of-life decision making for the small proportion of PVS patients when it may lead to a better understanding of consciousness and the condition, which will benefit future PVS patients and society. Individual freedom should only be restricted if the treatment proves futile or would harm others. Other implications revolve around the idea that even if patients are able to make a full recovery (seen in some patients with serious brain injuries), many patients remain incompetent and unable to care for themselves (Blackwell, 2013).

Critical Discussion:

Liberalism is an ethical theory that focuses on “the rights, interests, and reasoning of individual moral agents” (Glannon, 2005). The theory states that individuals should have the right to a good life, provided it does not have any interference on other individuals to do the same (Glannon, 2005). In the case of Dr. Owens’ fMRI technique, I believe that this would not impact the ability of others to have a good life, considering these individuals may be fully conscious. The first distinction liberalism states is that there should not be one conception of an overarching moral value that all individuals should live and abide by (Glannon, 2005). The second distinction points to the idea that “the interests of individuals should not be sacrificed for the interests of the larger society” (Glannon, 2005).

Taking patients off life support would impede on the individuals ability to enjoy life. One interpretation of the neuroimaging evidence surrounds the idea that “patients who are able to obey instructions and demonstrate patterns of activation of functional imaging may be completely aware of their surroundings” (Wilkinson, Kahane, Horne, & Savulescu, 2009). This procedure has led to reconsideration of the patient’s prognosis, since doctors have a clearer understanding of the patient’s needs and mental functioning. Consciousness may also become an important factor in the treatment of patients who show signs of consciousness. This consciousness may indicate that the patients in PVS are aware of their surroundings including family and friends, and therefore might be able to take pleasure from those things (Wilkinson, Kahane, Horne, & Savulescu, 2009).  This idea helps to reinforce the second distinction of liberalism that was previously mentioned. If these patients are conscious and aware of their surroundings, it helps support the idea that they can still experience pleasure. Morally, it would be wrong to assume that since an individual is not awake and moving around that their life is not as “good” as others. I agree with the argument Glannon (2005) sets out in stating that it is wrong to set out a conception of what constitutes a good life for everyone to adopt. All individuals have the right to embrace their own values and beliefs and if the advancement technology supports the notion that the patients are indeed conscious, then they are entitled to make their own decisions.

The removal of life-sustaining interventions has been noted to go as far as violating the ethical principle patient autonomy. This deontological principle is concerned with things such as “a patient’s rights, dignity, and values, as well as the doctor’s corresponding duty to respect them” (Glannon, 2005). A counter argument to this ethical principle may include the notion of informed consent and how patients are not entitled to all treatments they request. Informed consent has been noted to be a practical application of respect for personal autonomy (Glannon, 2005). Glannon (2005) points out that in most cases doctors are required to provide treatment, and patients have the right to access it if it entails therapeutic benefit. Some may say that keeping patients on life support has no therapeutic benefits since the PVS patient will most likely not return to normal functioning. Families of PVS patients may argue that the issue here is more about the quality of life, and that keeping him on life support may undermine his dignity. However, I believe that the real issue here is the sanctity of life. Prior to this technique it was thought these patients were unaware of their surroundings, the fact that Owen’s findings support the signs of consciousness indicates that the person “still exists”. Since these patients were taught to answer questions, it could be said that future technological advancements may help them to lead a more meaningful life with the ability to communicate their thoughts to the outside world and allow them to further expand on their wishes and beliefs in regards to their future treatment. Glannon (2005) points out that physicians should not coerce patients or family into withdrawing treatment. If found conscious, patients should be allowed to understand their own condition, the benefits and costs of continued interventions in order to formulate their own opinions reflecting their own values and beliefs.
PVS patients should have the right to access those treatments if they choose to do so since it does involve their interests and well-being. Many people have thought for years that these patients had no sense of consciousness or awareness, with this recent advancement it offers some indication that the medical community can work to improve the lives of these patients (Panksepp, Fuchs, Garcia, & Lisiak,, 2007). Future technological advancements seek to understand and allow patients to communicate their thoughts, which may allow them to lead meaningful lives. Other findings have also found that some patients are able to retain consciousness after their brain injuries, noting that patients studied earlier, who showed a higher level of associative cortices, were more likely to improve clinically (Wilkinson, Kahane, Horne, & Savulescu, 2009).  If the preliminary findings are true, it would be immoral for doctors and the patient’s families to remove patients from life support, since neuroimaging might be able to detect patients who are more likely to experience full recoveries. Removing life support of a PVS patient is inhumane in the sense that because they are seen as being physically responsive to outside stimuli they are not leading a “good life”.
It is important to note that we do not want autonomy to be the sole focus of medical treatment; we want physicians to be compassionate in helping to make decisions. PVS patients should have the opportunity to be able to communicate to the outside world and be able to decide whether they want to continue treatment or end it. However, sometimes physicians are stuck in an ethical dilemma revolving issues surrounding justification of allocating scarce medical resources in allowing patients to access this technique. One objection to the idea of liberal ideals includes the burden that these patients place on the health care system in terms of both access to treatment and the cost of life support. Based on the idea PVS patients are not making contributions to society, society may see these patients as being a burden to support. However, just because they are not “contributing members” that does not mean PVS patients should not have the opportunity to choose their own “fate”. If they have some form of conscious awareness then they should be entitled to the same rights as everyone else. It is not justifiable to remove a patients feeding tube if they are found to be aware of their surroundings, just because they are not responsive to outside stimuli.

There is no solid definition of what constitutes as a life, some argue that it involves being able to sustain your own biological functions, others see it as having the ability to reason and understand things such as questions. To support my argument, I look to the Charter of Rights and Freedoms, which helps to formalize basic ethical and moral principles that are practiced in Canadian society. Section 7 helps to encompass principle such as autonomy, and states “everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice” (Canadian Charter of Rights and Freedoms, 1982). Since it is so broadly worded I feel that this supports and protects the ability for the patient to make his or her own decision regarding their right to life. In this context, liberty would particularly support the notion that patients should have the right to make their own decisions in regards to sustaining life support. By using this as a protection measure we as a society allow people to realize their full potential. The Charter helps to support this notion of allowing people to uniquely define their own definitions of what is good and formulate their own context of autonomous choice, including the ability to define happiness and values. Society’s role is to embrace the diversity of the individual, regardless of things such as origin or their physical or mental status. One cannot deny the issue here is that this right occurs in exchange with the individual acknowledging responsibility for their own fortunes and that of the community (Glannon, 2005). Positivist liberals may argue that having an absolute right to do something is useless if the individual does not have the capacity to do so. However, I think that prior to the discovery of Owen’s technique, this would have been a valid argument but,I would now argue that the initial findings suggest that some PVS patients’ do have some form of mental consciousness to support their ability to at least contribute on some level their own decision.

The fMRI technique is not effective for all PVS patients; current research has shown that roughly only one in five patients have been able to communicate with the outside world (CBC, 2013). It is important to note that the technique itself uses limited resources, one being the fMRI machine itself. However, all patients and their families should at least have the opportunity to access this limited technology to help them in the decision making process, particularly due to their vulnerable state. This begs the question of where do we draw the line of allocating these resources for families and patients to communicate with the outside world. It is justifiable as seen in cases from Alberta that life support should be terminated if this technique unanimously proves that the patient is without any form of awareness or hope of being able to recover and other treatments have been proved futile (Blais, 2012). I would argue that PVS patients’ that have undergone the fMRI scan unsuccessfully could morally be taken off life support, since future treatment is futile and not beneficial. However, in the case of successful patients, they should have the right to express their own individual decision, since they do have the opportunity to have their values and beliefs reflected in their choice.

         Overall, initial findings support the notion that PVS patients are indeed somewhat conscious and aware of their surroundings on some level. Dr. Owen’s findings should therefore have an impact on end-of-life decisions made by both the family and the patient themselves. Following the principles of liberalism “the good life is necessarily a freely chosen one in which a person develops unique capacities as part of a plan of life” (Stanford, 2010.). Living in a society where individual autonomy is promoted, we should take effort to protect vulnerable populations such as those in PVS in upholding the basic principles of justice such as the right to life and liberty. Although initial findings have been supportive of the idea of PVS patients being somewhat conscious, more conclusive research and technology is needed, particularly in regards to decoding the patients’ thoughts and needs before this technology can fully be integrated into the context of end of life decision-making processes. Solely based on the current information and research that is provided, my position stands in saying that this treatment should play a pivotal role in allowing PVS patients and their families to make end-of-life decisions.



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