Operationalizing Neuroimaging for Disorders of Consciousness: The Canadian Context.

Severe brain injury affects tens of thousands of Canadians each year, leaving a small but significant proportion who survive the acute phase in a vegetative state (VS) or minimally conscious state (MCS). Patients in both VS and MCS have diurnal patterns of sleep-wake cycles, but have no behavioral response (VS) or only an inconsistent response (MCS) to stimuli. New technological capabilities offer a window into these disorders—not only changing our understanding of the levels of consciousness, but also enabling the potential for better diagnosis. For example, studies using functional magnetic resonance imaging, now extending over a decade and involving many participants, have revealed that a small minority of patients with severe disorders of consciousness (DoC) can modulate their neural states and thereby demonstrate a limited degree of awareness and even reasoning comparable to unaffected persons. The governments of Canada, its provinces, and territories have recognized and enshrined in legislation and the Constitution moral obligations to persons with disabilities based on the fundamental human rights of autonomy and equality, among others. The right to equality and nondiscrimination is reflected in the Canadian Charter of Rights and Freedoms (section 15), the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), and provincial human rights legislation requiring reasonable accommodation for persons with disabilities. Canada’s 2010 ratification of the UNCRPD marks a fundamental change in the way Canadian society views persons with disabilities in that they are “no longer considered to be recipients of charity or objects of others’ decisions, but holders of rights.” This rightscentric view would apply equally to MCS and VS patients as to any other group with disabilities. Given Canada’s moral and legal commitment to persons with disabilities, the evidence of awareness in some patients with disorders of consciousness, and the results of prior phases of research that suggest broad conceptual support from physicians, researchers, and legal experts, we believe that Canada, as a society, is obliged to explore whether and how neuroimaging technology could be made available to patients with DoC. To this end, we prioritize the following steps for action, that both newly complement and build upon recommendations advanced by other scholars.