Emerging Consciousness at a Clinical Crossroads.
Emerging Consciousness at a Clinical Crossroads.
复制标题
DOI：
10.1080/21507740.2021.1904032
复制
发表时间：
2021-04
影响因子：
--
通讯作者：
Edlow BL
中科院分区：
文献类型：
--
作者：
Young MJ;Edlow BL
Growing awareness of shortcomings of standard behavioral approaches to the diagnosis and prognosis of patients with disorders of consciousness (DoC) has paved the way for neurotechnological discoveries permitting assessment of consciousness and prediction of its recovery in the absence of overt bedside behaviors. This remarkable scientific leap, once considered impossible by many clinical neuroscientists and philosophers wedded to the orthodoxy that “we can only infer the self-awareness of others by their appearance and their acts”(Plum and Posner 1982) or through first-personal introspective access (Kant 1781; Nagel 1974; Wittgenstein 1953), has not only widened the boundaries of DoC nosology but has revealed new avenues for impactful neurorehabilitative intervention (Young 2017; Edlow et al. 2021). These neurotechnologies, which include neuroimaging and electrophysiologic techniques to detect covert consciousness (ie, awareness undetectable by standard behavioral examination), are now endorsed by American professional society guidelines, as emphasized by Peterson et al.,(2021) and by European and other international society guidelines (Comanducci et al. 2020; Giacino et al. 2018; Kondziella et al. 2020). Weaving together recent evidence of clinical utility with epistemological and normative arguments surrounding the value of consciousness and its assessment, Peterson et al. persuasively contend that the provision of these neurotechnologies and allocation of related resources to patients with DoC are ethically justified. While the considerations advanced by the authors in support of this position are rigorous and compelling, they invite an even more pressing question that is left unaddressed: given the ethical imperative of supporting those with emerging consciousness, how can we ensure that patients who stand to benefit from these neurotechnological innovations actually receive them? Despite current professional society recommendations and growing clinical consensus supporting their use, staggering gaps exist in clinical access to these modalities in our communities and around the world (Young 2021). Only a few quaternary centers worldwide are equipped to collect and analyze advanced neuroimaging and electrophysiologic data to detect consciousness, aid in neuroprognostication and illuminate windows of opportunity for neurorecovery. These gaps in access are particularly conspicuous in light of the recent European Academy of Neurology (EAN) guideline endorsing a composite reference standard in assessing consciousness that supplements standardized clinical behavioral scales (such as the Coma Recovery Scale-Revised (CRS-R) or Full Outline of Unresponsiveness (FOUR) score) with advanced functional neuroimaging measures (such as functional magnetic resonance imaging (fMRI) or positron emission tomography (PET)), and electroencephalography (EEG)-based techniques (Kondziella et al. 2020). Evaluating patients with DoC according to the recommended composite reference standard requires that “a given patient should be diagnosed with the highest level of consciousness as revealed by any of the three approaches (clinical [behavioral], EEG, neuroimaging)”(Kondziella et al. 2020). It follows from this that if there is uncertainty
