title: Ethics of neuroimaging after serious brain injury.
abstract: BACKGROUND
  Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to "yes" or "no" answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients.
  
  
  METHODS
  Our research program encompasses four projects and uses a mixed methods approach. Project 1 asks whether decision making capacity can be assessed in behaviorally nonresponsive patients. We will specify cognitive functions required for capacity and detail their assessment. Further, we will develop and pilot a series of scenarios and questions suitable for assessing capacity. Project 2 examines the ethics of welfare as a guide for neuroimaging. It grounds an obligation to explore patients' interests, and we explore conceptual issues in the development of a quality of life instrument adapted for neuroimaging. Project 3 will use grounded theory interviews to document families' understanding of the patient's condition, expectations of neuroimaging, and the impact of the results of neuroimaging. Project 4 will provide an ethical analysis of neuroimaging to investigate residual cognitive function in comatose patients within days of serious brain injury.
authors.affiliation: Rotman Institute of Philosophy, Western University, London, ON, N6A 5B8, Canada. cweijer@uwo.ca.
authors.forename: Charles
authors.initials: C
authors.lastname: Weijer
authors.forename: Andrew
authors.initials: A
authors.lastname: Peterson
authors.forename: Fiona
authors.initials: F
authors.lastname: Webster
authors.forename: Mackenzie
authors.initials: M
authors.lastname: Graham
authors.forename: Damian
authors.initials: D
authors.lastname: Cruse
authors.forename: Davinia
authors.initials: D
authors.lastname: Fernández-Espejo
authors.forename: Teneille
authors.initials: T
authors.lastname: Gofton
authors.forename: Laura E
authors.initials: LE
authors.lastname: Gonzalez-Lara
authors.forename: Andrea
authors.initials: A
authors.lastname: Lazosky
authors.forename: Lorina
authors.initials: L
authors.lastname: Naci
authors.forename: Loretta
authors.initials: L
authors.lastname: Norton
authors.forename: Kathy
authors.initials: K
authors.lastname: Speechley
authors.forename: Bryan
authors.initials: B
authors.lastname: Young
authors.forename: Adrian M
authors.initials: AM
authors.lastname: Owen
mesh_terms: D001930:Brain Injuries / Q000503:physiopathology*; D003071:Cognition; D003128:Coma / Q000503:physiopathology*; D003657:Decision Making / Q000941:ethics; D004569:Electroencephalography / Q000941:ethics; D005071:Evoked Potentials; D005190:Family; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000941:ethics; D008297:Male; D059906:Neuroimaging / Q000941:ethics*; D018458:Persistent Vegetative State / Q000503:physiopathology*; D011379:Prognosis; D011788:Quality of Life; D020127:Recovery of Function; D012720:Severity of Illness Index