Still in the Image of God? The Ethical Challenge of Brain Damaged Persons
James is a retired English professor who has recently suffered a left hemisphere stroke. Once extremely articulate, when James now attempts to speak the result is slow and labored, causing an apparent degree of distress readily evident in James’s facial expression. Also apparent is the depression James now exhibits concerning his current situation. However, speech therapy and neuropsychological evaluations demonstrate that James is improving, albeit slowly. James is acutely aware of the difference between how he was and how he now exists and the recovery itself is filled with stress and emotional setback at every little failure. Hundreds of thousands of Americans suffer cerebral vascular accidents each year, with a variety of effects on the individual, ranging from minor changes in behavior to profound and long-lasting disabilities.
Mary is one of about 1.5 million people who suffered a traumatic brain injury last year. Six months prior to the accident in which she sustained her injuries Mary was a college senior ready to go on to graduate school. Now Mary’s time is filled trying to relearn the names and faces of her friends as well as how to walk. The quality of her life will probably never be identical to what it once was.
The case of Christopher Reeve paints another picture of central nervous system damage. In this case, Mr. Reeve retained all of his normal cognitive functions while losing his ability to walk due to spinal cord damage sustained from a horse riding accident in 1995. Indeed, the damage to Christopher Reeve’s spine prevented his breathing from being maintained by the lower portions of the brain responsible for this function—this descending control was blocked due to the injury. Mr. Reeve remained on respiratory life support until he died of heart failure in 2004.
Brain damage comes in many shapes and sizes and its effects vary widely. This state of affairs can produce profound ethical questions about the nature of personhood. After trauma, stroke, or disease is this human being still the same person they once were? Years ago, it is likely that the basic liberal humanist position would have been “Yes, of course—this is the same human being, having the same inherent worth and dignity as they did before the injury and they should be treated accordingly.” However, many contemporary philosophers and bioethicists are now addressing this question, the question of personhood, in terms of interests, awareness and level of awareness, and the autobiographical abilities of the brain-damaged human. If one of these categories is found to be lacking to a certain degree, the designation of “person” might be stripped from the individual. This manner of thinking leads to other questions. How severe must the deficit be before the designation is taken away? What then are the legal rights of this “non-person?” The answers to such questions are as numerous as the individuals producing the philosophies that bring them about. Regardless, such discussions have entered into the modern discourse and societies are grappling with these issues.
Texts on clinical neuropsychology sometimes include a dedication of the volume to “the patients” based upon their cases providing evidence of the power of the “human spirit” to strive after triumph in the face of adversity.1 Not only do cases of brain damage and recovery show us the power of the human will and spirit, neuroanatomical research on recovery from brain damage has also revealed the remarkable resiliency of the human brain and its capacity to adapt in the face of trauma. This ability is usually referred to as “neuroplasticity.” Knowledge of this concept is important in terms of making plans for neurological rehabilitation.
For recovery to occur, the person—and the nervous system of the person—needs to be challenged. The brain must be, in a very real sense, forced by environmental challenge to rewire itself. People may have to relearn names, faces, how to speak, how to walk, or even how to communicate using ways they had probably never imagined before the trauma. Brain damage and its effects exist on a continuum. Patients who have lingered in comas for several years have emerged unexpectedly, and nurses and physicians often comment that the continued presence and attempts at communication on the part of the family may have helped. Verbal and tactile stimulation were being provided constantly, even in apparently hopeless situations. While such examples are admittedly anecdotal, such efforts may have aided in the process of recovery. It is perhaps wise to lean towards optimism in these matters (although I know some may not agree). Better to provide the patient with environmental stimulation than to assume that no recovery is possible. Many patients with profound brain damage simply are “given up on” because they are given a diagnosis that places them in a hopeless category. A British study conducted at the Royal Hospital for Neurodisability found that of the patients given a diagnosis of being in a “persistent vegetative state” (most clearly defined by an inability to engage in intentional behavior), 43% were classified incorrectly as such, perhaps because not enough time had been spent with the patient to ascertain whether the patient could communicate.2 Of course, if only a short block of time is spent with a severely brain damaged patient and the clinician is unlucky enough to not observe any attempts at communication during that period, the patient will be left without rehabilitation due to their being considered a “lost cause.” The dividing line between hope and hopelessness, between the classification of a persistent vegetative state and a state of minimal consciousness, is very slim indeed. Care should be taken before a final label is applied to the patient.
Why this lengthy segue into neuroplasticity and the importance of proper, careful diagnosis? The traditional Christian teaching concerning the nature of humanity rests in the assumption that mankind is created in the image of God, that there is inherent dignity in this creature that is valued above all other creatures. Classical western humanism embraced this view as well, even after uprooting the idea from a theistic mooring. It is still the underpinning of our society and the practice of medicine and the pursuits of biomedical research.
Often the concept of being created “in the image and likeness of God” has been unpacked in Jewish and Christian theology to mean that as God is rational, creative, personal, and loving; these characteristics are, to some degree, reflected in this creature made in His image.3 Pope John Paul II, in his philosophical writings on Christian anthropology, has argued that the most important element expressed in the nature of the human being is the ability to love and to be loved.4 Many clerics and clinicians have commented that when all else is stripped from people through damage to the brain, when rationality and creativity are cruelly taken away, one thing that comes through is their continued ability to give and respond to the love of other human beings. This isn’t a very clinical or objective element to look for, and it doesn’t fit well in philosophies that want to quantify interests or autobiographical capabilities and judge the value of human life accordingly, but it is one that speaks to a true humanism that should (I would hope) strike a chord in the hearts of all people who seek to love and to be loved as creatures carrying within them dignity and worth.
1 Jenni A. Ogden, Fractured Minds: A Case Study Approach to Clinical Neuropsychology (New York: Oxford, 1996); see also the dedication in The Handbook of Cognitive Neuropsychology, ed. Brenda Rapp (Philadelphia: Psychology Press, 2001).
2 Keith Andrews, Lesley Murphy, Ros Munday, & Clare Littlewood, “Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit,” British Medical Journal 313 (1996): 13-16.
3 See Moses Maimonides, The Guide to the Perplexed (New York: Barnes and Noble, 2004); Michael Pomazansky, Orthodox Dogmatic Theology (Platina, CA: Saint Herman Press, 1994).
4 Andrew Woznicki, A Christian Humanism: Karol Wojtyla’s Existential Personalism (New Britain, CT: Mariel, 1980).