Open Access Highly Accessed Study protocol

Ethics of neuroimaging after serious brain injury

Charles Weijer1234*, Andrew Peterson12, Fiona Webster5, Mackenzie Graham1, Damian Cruse2, Davinia Fernández-Espejo2, Teneille Gofton6, Laura E Gonzalez-Lara2, Andrea Lazosky7, Lorina Naci2, Loretta Norton2, Kathy Speechley48, Bryan Young6 and Adrian M Owen12

Author Affiliations

1 Rotman Institute of Philosophy, Western University, London, ON, N6A 5B8, Canada

2 Brain and Mind Institute, Western University, London, ON, N6A 5B7, Canada

3 Department of Medicine, London Health Sciences Centre–University Hospital, London, ON, N6A 5A5, Canada

4 Department of Epidemiology and Biostatistics, Western University, London, ON, N6A 5C1, Canada

5 Department of Family and Community Medicine, University of Toronto, Toronto, ON, M5G 1V7, Canada

6 Department of Clinical Neurological Sciences, London Health Sciences Centre–University Hospital, London, ON, N6A 5A5, Canada

7 Department of Psychiatry, London Health Sciences Centre–Victoria Hospital, London, ON, N6A 5W9, Canada

8 Department of Pediatrics, Children’s Hospital of Western Ontario, London, ON, N6C 2V5, Canada

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BMC Medical Ethics 2014, 15:41  doi:10.1186/1472-6939-15-41

Published: 20 May 2014



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.


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.

Ethics; Brain injury; Vegetative state; Unresponsive wakefulness syndrome; Minimally conscious state; Functional magnetic resonance imaging; Electroencephalography; Decision making capacity; Informed consent; Quality of life; End of life care