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Never Say Never: Limitations of Neuroimaging for Communicating Decisions After Brain Injury

Patients with brain injury have benefitted tremendously from advances in neuroimaging that have improved clinical diagnosis (Hirschberg and Giacino 2011) and the ability to distinguish between disordered states of consciousness (Cruse et al. 2012; Fins and Illes 2008; Monti et al. 2010). An accurate diagnosis is tantamount to improving patient prognosis. In the target article “Communicating With the Minimally Conscious,” published in this issue of AJOB Neuroscience, Bendtsen (2013) addresses the unalienable need to respect autonomy with minimally conscious patients in whom responsive cognition—sometimes interpreted as deliberate communication—may be detected with functional magnetic resonance imaging (fMRI) or electrophysiology (EEG). For these cases, Bendtsen argues in favor of assent for guiding patient involvement in health care decisions. The author asserts that the understanding of the patient’s response can only be inferred and not interpreted directly, however, much like a child’s response when involved in decisions regarding medical treatment (Bendtsen 2013). New capabilities may indeed offer the potential to give otherwise noncommunicative patients a voice, whether it is ultimately for consent or assent. However, we argue that there is a limit to the use of these capacities, given the complexity and heterogeneity of neurotechnological systems and the range of possible interpretations of functional signals. Neuroscience has yet to reveal the still uncertain meaning of blood oxygenation level-dependent (BOLD) response or electrical signals in the nonlaboratory real-world context unconstrained by paradigms and highly controlled stimuli. These limitations extend further to consideration of possible fluctuations in prefrontally mediated executive function, such as decision making that even healthy, unaffected people regularly experience, and to consciousness itself. Therefore, while neurotechnology may powerfully enable discrete expressions of preferences about room temperature, food choice, or even levels of pain, we draw the line at its application for matters of life and values. Here we think specifically about matters such as succession, that is, legal matters such as codicils, and end-of-life decision making.