Slate's Bizbox
human nature: Science, technology, and life.

The UnspeakableBuried alive in your own skull.

By William Saletan
Posted Tuesday, Sept. 12, 2006, at 5:46 PM ET

Listen to the MP3 audio version of this story here, or sign up for Slate's free daily podcast on iTunes.

The wheels lock, the car skids, you see the 18-wheeler heading for your windshield. You have just enough time to open your mouth. Then the bite of glass and metal, and merciful blackness.

Somebody's talking. You try to open your eyes, but nothing happens. You can't move or feel anything. In the murmurs around you, you make out a few words: prognosis, unresponsive, permanent. They keep talking about somebody who's here, somebody who never speaks and is never spoken to.

A child cries. You've heard that cry before. Out of the blackness, the thought comes at you, engulfing you: The unspeaking person is you. You're dead. And then a more horrible idea: Maybe you're not.

You try to call out, to scream. No one knows you're here, awake inside your skull. No one will ever know.

That nightmare is no longer science fiction. Five days ago, Science published a report on a young woman devastated by a car crash in England. For five months after the accident, tests showed no signs of awareness. Doctors declared her vegetative. Then, scientists put her in a Functional Magnetic Resonance Imaging scanner, which tracks blood flow to different parts of the brain. They asked her to imagine playing tennis and walking through her home. The scan lit up with telltale patterns of language, movement, and navigation indistinguishable from the brains of healthy people.

Something was awake inside that woman's skull. Without the scanner, no one but her would have known.

How rarely does this happen? Until a decade ago, FMRI didn't even exist. According to the authors, 60 other vegetative patients have been tested on it and have flunked. The English patient had several factors in her favor: Her injury was traumatic, her brain was largely intact, and she had been vegetative for only a few months. At the other end of the spectrum are people such as Terri Schiavo. Their injuries are caused by oxygen starvation, their brains are liquefied, and they've been vegetative for years. By various estimates, 25,000 to 35,000 Americans have been diagnosed as vegetative. How many of them have received FMRI scans? How many would light up? How many are awake in there?

The scientists who studied the English patient report that in the five months after her injury, "No elaborated motor behaviors, which are regarded as 'voluntary' or 'willed' responses, were observed from the upper or lower limbs. There was no evidence of orientation, fixation greater than 5 seconds or tracking to visual or auditory stimuli. No overt motor responses to command were observed." In short, she was "unresponsive." She met the standard for a vegetative diagnosis, displaying "no reproducible evidence of purposeful behavior." In an analysis that accompanies the study, a French neuroscientist notes that she repeatedly failed to "manifest" such behavior.

Then they put her in the machine and gave her the imagination test. Result: "Significant activity was observed" in key brain areas. She managed "to respond to [commands] through her brain activity, rather than through speech or movement. Moreover, her decision to cooperate with the authors by imagining particular tasks when asked to do so represents a clear act of intention." According to the attached analysis, her "patterns of brain activation" suggest "an active mental performance."

Nothing about the patient changed. What changed was the test—and with it, our definitions of evidence and activity. Before the scan, "behavior," "response," "action," and "performance" were things done by your visible body. To be "manifest," "observed," or counted as "evidence," they had to be external. By making the brain's blood flow observable, the scan expanded our understanding of physical reality and human agency. Thought is activity. Imagination is performance. Intention, which used to be defined as separate from action, is now an "act of intention."

Try stretching your mind to comprehend that reality: a technology that stretches reality to comprehend your mind. Outside the scanner, your thoughts are invisible, immeasurable, meaningless. Inside it, they're visible, measurable, real. One minute, you aren't there. The next, you are.

Now scientists are debating what goes on in the English patient's head. Some call her performance a "decision"; others dismiss it as a mere "response." They ask why her body doesn't move, since her motor pathways appear to be preserved. The analysis in Science concludes that she has a "rich mental life" but may not be "conscious." What in God's name does that mean? Would you pull the plug on a 24-year-old relative with a rich and responsive but unconscious mental life? Go ahead, raise your hand. Or just think about raising it, and we'll record your vote by brain scan.

Most hospitals don't have equipment that can find trapped souls like the English patient. Does the reality of your mental life depend on which hospital you're taken to? Does it depend on which tests your insurance covers or your family can afford? The Bible says it's harder for a rich man to get into heaven. Is it harder for a poor man to get out of hell?

In the forest, the old question goes: If a tree falls, and nobody hears it, does it make a sound? Does a vegetable not matter if no animal perceives it? In the city, the puzzle is different. What falls when a car jumps a curb is a person, not a tree. If nobody sees her thinking, is she a vegetable? Or should the rest of us animals look harder?

Print This ArticlePRINTDiscuss this in The FrayDISCUSSEmail to a FriendE-MAIL
Share on FacebookPost to MySpace!Share with MixxDigg ThisShare with RedditShare with del.icio.usShare with FurlShare with Ma.gnolia.comShare with SphereShare with Stumble Upon
William Saletan is Slate's national correspondent and author of Bearing Right: How Conservatives Won the Abortion War.
Photograph of brain scans on Slate's home page by Lawrence Berkeley National Library/Photodisc Green.
Join the Fray: our reader discussion forum
What did you think of this article?
POST A MESSAGE | READ MESSAGES

Remarks from the Fray:

It seems to me that doctor's make "best guesses" on a regular basis as to what's ailing their patients. In the English patient's case—and this is the key question—it appears her doctor's believe she is aware. Speaking for myself, if total powerlessness is the hell I imagine it to be, I'd be begging my doctor's not to ask me to imagine playing tennis, but to ask me if I wanted to be kept alive.

I suppose the trick is in both explaining to me my condition, and in finding a ways to ask me that result in brain activity that can be interpreted as a definitive "yes" or "no". Perhaps they already know the brain patterns indicative of distress, anger, joy or pleasure. [...]

I see, however, why their doctor's responsibility to be trying to determine their patient's wishes isn't all that obvious to you. It's the day and age we live in. The first thing you and most people think about when they read the story is how it might impact the euthanasia debate. If I didn't know better, I'd say you were so caught up in bringing this story to the podium, that you forgot the English patient is more than just a science experiment

--Ender

(To read more, click here.)

There are people who will find endless agony over the results of this test, become fixated on legal rights and be morose for long periods of time contemplating this mysterious and unsettling existence.

But what about those billions who are alive, functioning, feeling, talking, walking and actually living in this world? Life is for the living, not the dead, near dead or dying. The problem with this and much of medicine is it has no clue what to do with the results of this test or many others. It just advances "science" in some academic way but leaves human beings, and their world of reality, far behind. [...]

This woman, and her "inner life", may be happier, more fulfilled and content than those of us who are conscious. So just wish her "good day", allow her to die in time like we all do and keep her in an occasional prayer. She most likely would prefer that to some machine beside her bed.

--Luchese

(To reply, click here.)

Yes, the doctors have found these brain patterns in this particular patient; the big BUT is how then can they help this woman articulate? Will she ever be able to posit her wishes? Will she live beyond brain patterns on a computer print out?

What to do, what to do... I felt for both sides in the Schiavo matter as I deeply love my family and could not imagine giving up hope while any still breathed, however, the reality is that maintaining bodily function without brain activity is without merit and sadly, in our costly medical society, unreachable for most families in the long-term.

--seascape

(To reply, click here.)

I'm not sure that this really changes anything. I'm sure the doctors were doing all they could to help this woman before they did this experiment. I don't think there is anything more they can do now. I assume vegetative patients are kept alive on the chance that they will spontaneously recover or some new technology will come along. This patient has mental activity that we could measure, none of the others do (so far). Maybe, with sufficiently sensitive tests, all vegetative patients will show some signs of mental activity.

There is no indication that the prognosis for this patient is any different than any other vegetative patient. The only difference is that we might be able to ask this patient if they want to wait around hoping for a cure. I don't think we could ever trust our interpretation if the patient attempted to communicate that she wants to die; so we can only treat her like every vegetative patient. I just hope they are providing some sort of entertainment for her, like playing books on tape.

--jimsum

(To reply, click here.)

(9/16)

Washington Post
The Washington Post
OPINIONS
Let the Oil Deals Flow
Raad Alkadiri | Congress should not interfere in the oil industry's contract negotiations with the Iraqi government.