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Dissenting on the Matter of Assent

involve complex health-related concepts, which are often unfamiliar to patients, they may require extensive decomposition into several simpler questions that would allow the patient to fully understand the issue at hand. The result of this requirement could yield an unfeasibly long scanning session that would tax even the attention span of a healthy participant. While these technical limitations may be resolved with future improvements in noninvasive imaging technologies, integrating the mental imagery method into medical practice by way of assessing decision-making capacity remains conceptually problematic. As any healthy individual’s ability to provide informed consent is contingent upon the presumption of capacity, a central epistemological question is how we can ever know that a given DOC patient does, in fact, have some residual dimension of decisionmaking capacity intact. Though Bendtsen suggests medical decision making on behalf of children may serve as a possible solution to this question, it is not clear that this would adequately address the issue of capacity assessment in DOC patients. For one, DOC patients exhibit no behavioral markers of residual cognitive function. Unlike the case of children, where modest levels of cognitive function can be inferred, DOC patients reveal no such information. Thus, starting from the initial point of successful responses to the mental imagery tasks, investigators must build a model of the patient’s residual cognitive profile from the ground up. Moreover, as Bendtsen notes, identifying capacity in DOC patients with our imaging method is complicated by several other obstacles: Patients are unable to initiate their own questions, and psychiatric problems secondary to neurological conditions are difficult to rule out. One solution to this broadly epistemological problem may be to more precisely define what decision-making capacity amounts to in these cases, and determine how it might be operationalized in ways that are detectable through fMRI and EEG. The first step may be to take the complex set of faculties we refer to as “capacity” and describe them in terms of decomposed cognitive functions. These might include, for example, whether the patient can localize himor herself in space and time, has any memory or knowledge of basic facts about the world, has any reasoning skills, or has retained the ability to form new memories based on experiences that occurred after the initial injury. We would then need to consider how this information could be synthesized to provide a reliable and ethically responsible overall assessment of the more complex dimensions of decision-making capacity in this patient group. If these components can be operationalized for binary assessment successfully, the mental imagery method may, indeed, be a satisfactory tool for this specific application. While concrete resolutions to these practical and philosophical problems have yet to be worked out, we remain optimistic that solutions to these issues will emerge in the near future. Notwithstanding these obstacles, Bendtsen’s article successfully raises a number of important questions related to our work, including how we assess capacity in DOC patients and whether they can be included in the clinical decision-making process aided by neuroimaging BCIs. We are hopeful that, with further technical developments, these methods will yield effective and economically sustainable results, thereby mitigating many of the technical limitations discussed here. More importantly, we anticipate that in the near future a conceptual framework will be developed to accommodate the epistemological and ethical challenges that our work has generated in this area.