Letters Response

Panorama responds to editorial on fMRI for vegetative and minimally conscious states

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8702 (Published 08 January 2013) Cite this as: BMJ 2013;346:e8702
  1. Fergus Walsh, medical correspondent1,
  2. Frank Simmonds, deputy editor, Panorama1,
  3. G Bryan Young, professor, Department of Clinical Neurological Sciences2,
  4. Adrian M Owen, Canada excellence research chair in cognitive neuroscience and imaging2
  1. 1BBC, Broadcasting House, London W1A 1AA, UK
  2. 2University of Western Ontario, London, ON, Canada
  1. fergus.walsh{at}bbc.co.uk

Turner-Stokes and colleagues’ editorial suggests that the Panorama special, The Mind Reader: Unlocking My Voice, did not “clearly distinguish” between patients who live in a vegetative state and those in a minimally conscious state.1 However, the script contained several explanations of these conditions; for example, when referring to one patient undergoing assessment: “Staff here will try to assess whether he is minimally conscious with fragments of understanding or vegetative—with no awareness at all.”

Just by viewing this one hour documentary the authors felt able to discern that both the Canadian patients “said to be in a vegetative state” are “probably” minimally conscious.

One of these patients, Scott, has had the same neurologist for more than a decade. Professor Young, who appeared in the film, made it clear that Scott had appeared vegetative in every assessment, including those done after his functional magnetic resonance imaging (fMRI) scan. The fact that these authors took Scott’s fleeting movement, shown in the programme, to indicate a purposeful (“minimally conscious”) response shows why it is so important that the diagnosis is made in person, by an experienced neurologist, using internationally agreed criteria. In the programme, Professor Young stated that it was only Scott’s cognitive responses in the fMRI scanner that had revealed covert awareness.

Indeed, Scott was able to respond in the scanner that he was not in any pain, information that his parents felt was extremely valuable. This was the first time that a patient in a vegetative state had been able to answer a question of clinical relevance while undergoing fMRI.

The programme did not say that the other Canadian patient, Steven, was vegetative. His parents explained on camera that he had a variety of means of physically responding, but that these were inconsistent. This fragmented ability to respond is indicative of the minimally conscious state.

Nevertheless, Steven was also able to respond in the scanner and to show that he is aware that he has a niece, born three years after his brain injury. Irrespective of Steven’s formal diagnosis (minimally conscious or vegetative), his physical condition had precluded any such questions being asked, or answered, until he entered the scanner—a moment that was captured for the first time in the film. This was vital information for his parents, who wanted to know whether he could lay down new memories and retain information. The documentary made it clear that the level of the patients’ cognitive abilities was unclear.

The authors also say that Professor Owen’s assertion that nearly 20% of vegetative patients who he had scanned showed awareness is not supported by the published evidence. Yet the available peer reviewed evidence, including four of 23 (17%) vegetative patients in a study published in the New England Journal of Medicine in 2010,2 bears this out. In a later study of another group of patients, a related technology not featured in the programme (electroencephalography) placed this figure at an even higher 19%.3 4

Notes

Cite this as: BMJ 2013;346:e8702

Footnotes

  • Competing interests: None declared.

References