Ethical issues in the treatment of severe brain injury: the impact of new technologies

Technological developments in functional neuroimaging have important ethical implications for the care of brain-injured patients. Patterns of fMRI and PET responses to stimuli may help clarify if a patient is utterly unaware, and thereby enhance a physician's confidence in reaching an accurate diagnosis of vegetative state or minimally conscious state. The analysis of similar responses may enhance a physician's confidence in pronouncing an accurate prognosis for functional recovery and help avoid committing the fallacy of the self-fulfilling prophesy. Surrogate decision making is necessary to secure consent for treatment decision in brain-injured patients and should attempt to reproduce the treatment decision the patient would have made. Physicians should manage irreducible clinical uncertainty by sharing their level of certainty of diagnosis and prognosis with the surrogate decision-maker. Shared decision making between the physician and surrogate is the current formulation of the doctrine of informed consent. Advance care planning can help inform surrogate decision making, but is available less commonly among young, previously healthy brain-injured patients. Functional neuroimaging technologies also impact on ethical issues of treatment, rehabilitation, and palliation. Families of brain-injured patients should be compassionately counseled that, despite provocative and highly publicized case reports, these technologies, while promising, are currently investigational and have not been sufficiently validated yet to be available for routine clinical use.