Beyond awareness: the need for a more comprehensive ethics of disorders of consciousness

Michele FariscoDisorders of consciousness like coma, unresponsive wakefulness syndrome, and what is known as minimally conscious state, are among the most challenging issues in current ethical debates. Ethical analyses of these states usually focus on the ‘residual’ awareness that these patients might still have. Such awareness is taken to have bearing on other factors that are usually considered ethically central, like the patients’ well-being.

Yet, when we take a look at recent scientific investigations of mental activity it appears that things are much more complicated than usually thought. Cognitive science provides empirical evidence that the unconscious brain is able to perform almost all the activities that we (wrongly) think are exclusive of consciousness, including enjoying positive emotions and disregarding negative ones. To illustrate, people that are subliminally exposed to drawings of happy or sad faces are emotionally conditioned in their evaluation of unknown objects, like Chinese characters for people who don’t know Chinese. If preceded by subliminal happy faces, these characters are more likely to elicit positive feelings when consciously perceived. This means that unconscious emotions exist, and these emotions are (plausibly) positive or negative. This in turn suggests that consciousness is not required to have emotions.

Accordingly, people with disorders of consciousness could also have unconscious emotions. Even though they are not capable of external behavior from which we could infer the presence of positive or negative emotional life, we cannot rule out the possibility that these patients’ residual brain activity is related to a residual unaware emotional life, which can be either positive or negative.

We should try to avoid becoming biased by the sort of “consciousness-centrism” that impedes us from seeing the total landscape: there is a lot going on behind (and beyond) the eyes of our awareness.

What does this imply for the ethics of caring for and interacting with people affected by severe disorders of consciousness? Well, as previously said, the ethical discourse surrounding the care for and the relationship with these people has usually focused on their residual awareness, scrutinizing whether and to what extent these people could consciously experience good and bad feelings. Yet if it is possible to have these experiences at the unaware level, shouldn’t this be a relevant consideration when engaging in an ethical analysis of patients with disorders of consciousness? In other words, shouldn’t we take care of their residual unconsciousness in addition to their residual consciousness?

I believe we need to enlarge the scope of our ethical analyses of patients with disorders of consciousness, or at least acknowledge that focusing on residual consciousness is not all we should do, even if it is all we presently can do.

Michele Farisco

Winkielman P., Berridge K.C. Unconscious emotion. Current Directions in Psychological Science. 2004;13(3):120-3

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3 Responses to Beyond awareness: the need for a more comprehensive ethics of disorders of consciousness

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  2. As Michelo Farisco eloquently suggested it is indeed the case that emotions can be unconscious (something already suggested by Freud). I would like to contribute with a perspective from my own research about anxiety. A brief description of anxiety in relation to fear was provided by Kurt Goldstein “In the state of fear, we have an object in front of us that we can “meet,” that we can attempt to remove, or from which we can flee. We are conscious of ourselves as well as of the object… On the other hand, anxiety attacks us from the rear, so to speak. The only thing we can do is to attempt to flee from it without knowing where to go, because we experience it as coming from no particular place”. In the laboratory, it is possible to reproduce some equivalent behaviors associated with anxiety when mice are exposed to the smell of cat hair. Rodents respond to cat hair even if they have never been exposed to a cat because of the coevolution of smell receptors in relation to the predator. Using optogenetics to activate a special subset of inhibitory interneurons and brain recordings in the ventral hippocampus we discovered that when elicited, a special form of oscillatory activity (theta 2 activity) produced an anxiolytic effect (Mikulovic and Restrepo 2017 in revision). It is also interesting that some anxiolytic drugs are known to affect this form of brain activity in the same frequency range that we were able to control. While much needs to be done in humans, the prospects are interesting since “the mapping between structure and function is both pluripotent and degenerate…indicating that …there are not “necessary and sufficient” brain regions“ (Pessoa and Engelman 2010). In other words, brain process is shared among different brain regions and a matrix of different cell types. Therefore, patients with traumatic brain injury making use of remaining brain areas (supported with adequate stimulus) can potentialize the reorganization of brain process and circuits. Even if residual forms of consciousness could never be regained, one could speculate that unconscious states could shift to a positive although unconscious emotional state, something that could be facilitated by treatments. Of course, the empirical problem is how we could access such changes? Apart of the classical panoply of physiological tests (stress hormones, heart rhythm, breathing patterns etc) assessment of brain activity could be used as an indicator of negative and positive emotions during potential treatments. For instance type 2 theta activity changes could be an indicator of anxiety related states. Hence antidepressants, anxiolytics and why not recreational drugs and another panoply of cognitive-physiotherapies could potentially be used. Here, of course, other ethical dilemmas arise, in relation to the treatment and the social aptitudes to recognize beyond mysticism emotional unconscious states.

    Ernesto R.

  3. MicFar says:

    Thank you very much Ernesto for your most interesting comment. I think we are quite sympathetic in stressing the reality as well as the need to recognize unconscious emotions. Your empirical research is very relevant in this sense: I will go through it. I think we need more effort in the conceptual and ethical research as well. Thanks a lot!

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