One patient's recovery from a vegetative state sheds new light on consciousness.
friends, returning home around midnight. He made himself a snack, said goodnight to his parents, and turned in. Everything seemed normal. But at 6:30 a.m. the following morning, things were far from normal. Margaret awoke to the sound of her 19-year-old son choking to death in his bedroom, just a few yards away. She rushed into his room and found him unresponsive, lying face down in his own vomit.
John was rushed to his local emergency room. A CT scan showed extensive damage to the white matter in his brain, including the frontal and parietal lobes, regions critical for working memory, attention and other high-level cognitive functions. This kind of brain damage, widespread and diffuse with no clear borders between healthy and damaged tissue, is common when the brain has been starved of oxygen. When the oxygen dries up, the brain starts shutting down little by little, piece by piece, until there isn’t even enough functional tissue left to keep our most primitive bodily functions, like breathing, going. John wasn’t quite there, but he was close. On admission, he had a Glasgow Coma Score of three out of a possible fifteen. You can’t score lower than a three, not without being dead.
Several months later, John was declared to be in a vegetative state. Vegetative state patients open their eyes, grunt and groan, and occasionally utter isolated words, although they remain unresponsive to any form of external stimulation. Like zombies, they appear to live entirely in their own world, devoid of thoughts or feelings. The condition differs from a coma; comatose patients are also unresponsive, but their eyes remain closed and they do not exhibit any sleeping and waking cycles.
Arriving in hospital after a serious brain injury there will be some period, usually days or a few weeks, when the prognosis – the likelihood of making a reasonable recovery – is completely uncertain. Yet paradoxically, as time passes, the possibility of recovery diminishes rapidly. With a brain injury like John’s, the chances of recovering after three months are very low and patients are usually reclassified as "permanently vegetative." We tested John using every tool we had at our disposal, looking for some sign of inner life, but we found nothing. A state-of-the-art fMRI scan revealed a moribund, unresponsive brain. High-density electroencephalography (EEG) also yielded null results. Everything we tried failed to kick start John’s severely damaged brain.
Seven months later, we called Margaret to see whether John’s condition had changed. “Why don’t you ask him?” Margaret said. Against all the odds, John was now talking, brushing his teeth, eating, and walking. When I heard the news, I couldn’t believe it. I checked his medical records. The circumstances of his case were clearly described by several neurologists who had examined him over the course of his illness. Everyone agreed that John had sustained very severe brain damage that had left him in a vegetative state. And the CT scan revealed just how extensive that damage had been. Yet, now he had recovered. And we had no idea how.
I arranged to examine John again to see if he remembered anything of his time in a vegetative state. As he sat opposite me in his wheelchair, he remained quiet and detached. Perhaps it was all part of his recovery. Perhaps only some parts of John had come back – maybe, some part of his personality had been left behind. “Do you remember anything of your previous visit to my lab?” I asked him. “I remember Steve, your student. He put electrodes on my head and he had a deep voice." Steve does have a deep voice and “he put electrodes on my head” is as good a lay description of EEG as I have ever heard. But that was only the beginning. John went on to tell us everything about that first visit, down to the tiniest detail. His account was extraordinary. Despite appearing to be completely vegetative for many months, John had been entirely aware all the time, silently watching, listening, and waiting.
A little over a year later, I drove to John’s home to see how he was doing. As the front door opened, my astonishment – and curiosity – deepened. I was immediately struck by John’s personality, which now broke through in a way that had been entirely absent when I’d seen him a year earlier. I started to wonder whether he had returned from the abyss in parts, bit by bit. The last time I’d seen John, some parts of him were definitely there—his body, his memory, his physical being. But some parts were definitely missing, and it was only clear now, a year later, what they were. Now John the person had returned; John the personality. The essence of John was finally back, perhaps not completely, but enough to know that he was going to make it eventually. All of him.
John is not the first person to have made a seemingly miraculous recovery from a coma or vegetative state. Jan Grzebski, a 65-five-year-old Polish Railway worker, woke up in 2007 after 19 years in a coma, which he had entered as the result of a brain tumor. Grzebski credited his wife Gertruda with his awakening. She would not give up on him, although doctors said he would never recover and gave him only two or three years to live. She moved him every hour for 19 years to keep him from getting bedsores.
Could anyone achieve the same miraculous result with enough willpower, love, and family support? I don’t think so. Every brain is different and every brain injury is different. We have learned a tremendous amount about the brain over the past 20 years, and about the tenuous, fragile nature of consciousness, yet we still know so little about how and why some people recover from brain injury and some don’t.
What we do know is that any sort of brain injury will likely have long-lasting pervasive effects. It’s not the same for any other organ of the body. We can replace kidneys, lungs, hearts, and livers and essentially we are still ourselves—a little wobbly for a while perhaps, but the same person. Many of us manage to return to live full and complete lives—perhaps the same lives we would have lived had we not fallen ill, notwithstanding the emotional scars we inevitably carry when our lives have been threatened.
But serious brain injury is fundamentally different. It changes us, it alters our ability to move, react, interact, and respond. And recovery is far harder, if it occurs at all. Of course, we can’t transplant brains (at least not yet) but even if we could it wouldn’t help us to recover in the way that transplanting a heart or a kidney helps us to recover. Because after a brain transplant, “we” would not recover; “we” would be someone else. We might look the same, but with someone else’s brain in our heads we would be an entirely different person. Conversely, transplant your brain into another body and you would still be you—not that other person. Of course, you’d look different. It’s tantalizing to think that you might even feel different in ways both subtle and apparent. But you would be essentially the same person living in another body. The same thoughts, the same memories, the same personality. Your sense of being, the cascade of thoughts, feelings, and emotions that comprise our conscious experience of the world would be largely identical. Like a perfect disguise, the appearance is different, but underneath the person is unchanged.
There’s no escaping it: We are our brains.
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When a Vegetative-State Patient Returns to Tell the Tale