Is the "Minimally Conscious State" Patient Minimally Self-Aware?

Constantinos Picolas

doi:10.3389/fpsyg.2020.539665

Abstract

Patients in a Minimally Conscious State (MCS) constitute a subgroup of awareness impaired patients who show minimal signs of awareness as opposed to patients in a Vegetative State who do not exhibit any such signs. While the empirical literature is rich in studies investigating either overt or covert signs of awareness in such patients the question of self-awareness has only scarcely been addressed. Even in the occasion where self-awareness is concerned, it is only higher-order or reflective self-awareness that is the target of such investigations. In the first part of this paper, I briefly review the relevant clinical neuroscience literature to demonstrate that the conception of self-awareness at play in such studies is indeed that of reflective self-awareness. In the second part, I present the philosophical notion of pre-reflective (or minimal) self-awareness. This is shown to primarily refer to the implicit awareness of our embodied subjectivity which essentially permeates all our experiences. As discussed, this minimal self-awareness is not specifically addressed when clinically or experimentally assessing patients in MCS. My suggestion is that neuroimaging studies targeting minimal self-awareness as in First-Person Perspective-taking paradigms could be used with MCS patients to shed light on the question of whether those individuals are minimally self-aware even in the case where they lack self-reflective abilities. Empirical evidence of this kind could have important theoretical implications for the discussion about the notion of self-awareness but also potential medical and social/legal implications for awareness impaired patients’ management.

Highlights

According to a recent discussion in the area of Philosophy of Mind and Phenomenological Philosophy, our psychological states are characterized by an inherent self-awareness considered to be a constitutive part of our experiences
I intend to query about the following: Should we trace the difference between patients in Minimally Conscious State (MCS) – who are minimally capable of awareness – and patients in Vegetative State (VS) – who are considered utterly unaware – back to the former’s exclusively possessing pre-reflective self-awareness1 (PRSA)? My interest is to try to make sense of what is it that clinicians and neuroscientists mean when describing a patient in MCS as being minimally conscious and on the other hand to examine whether the neuroscientific literature on the topic can shed any light on the philosophical debate about self-awareness
Information about the presence of minimal self-awareness in reflectively incapacitated patients will have at least some effect on these patients’ medical management and potentially ethical/legal implications about end-of-life decision making9. With these matters in mind we turn to the last section of the paper. It is composed of two subsections: A penultimate part where we take up our original title question to discuss the potential importance, the presence of PRSA in patients in MCS might have as empirical evidence, to experiential minimalism and a final part where we propose a way to test PRSA in such patients

Summary

INTRODUCTION

According to a recent discussion in the area of Philosophy of Mind and Phenomenological Philosophy, our psychological states are characterized by an inherent self-awareness considered to be a constitutive part of our experiences. In the subsections I will briefly focus on neuroimaging and neurophysiological studies explicitly designed to present covert awareness According to this clinical scale, a patient with impaired consciousness is considered to be minimally conscious when consistently exhibiting appropriate behavioral responses to verbal commands, when demonstrating practical understanding of seen objects (affordances), when appearing to experience bodily pain (by reacting with an avoidance response), when he tries to communicate and when he shows recognition of his ownface in the mirror. As we presented the case in the previous sections (pages 3– 6) a patient in MCS in considered minimally aware because he shows minimal signs of overt or covert voluntary responses to verbal commands or other sensory stimuli as evidenced in CRSR and neuroimaging studies. Information about the presence of minimal self-awareness in reflectively incapacitated patients will have at least some effect on these patients’ medical management and potentially ethical/legal implications about end-of-life decision making

DISCUSSION

CONCLUSION