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Into the Grey Zone: can one really be conscious while in a coma?

Neuropsychologist Adrian Owen's work raises many more questions than it answers.

The physical basis of consciousness is perhaps the greatest mystery and problem in modern science. There can be little doubt that consciousness is a physical phenomenon but we cannot even begin to explain how it arises in brains. The simple – and doubtless simplistic – medical model of consciousness is that the cerebral hemispheres, where thinking and feeling goes on, are like millions of light bulbs. Consciousness is the brightness with which they shine. If you progressively damage the cerebral hemispheres, consciousness dims. Small areas of damage to the hemispheres have little effect on consciousness: many neuro­surgeons have seen patients who walked into hospital with a knife or a nail, for instance, stuck in their brains, and yet who are fully conscious.

The hemispheres are powered, in ways we do not understand, by the brainstem, the part of the brain between the hemispheres and the spinal cord. In the medical model, the brainstem is equivalent to an electric cable supplying the millions of light bulbs. Small injuries to the brainstem can cause profound coma – all the light bulbs will be dimmed at once.

Many years ago, when I was still training to be a neurosurgeon, I admitted an elderly American man who had collapsed with a brainstem stroke while watching the Championships at Wimbledon. He was completely paralysed but able to move his eyes up and down in response to my speaking to him. It seemed fairly clear to me that he was “locked in” – fully conscious but trapped within his body. The next morning, I showed the poor man to my consultant on the ward round. “These are just reflexes,” he said of the patient’s eye movements. “Just reflexes,” he repeated fiercely, as he quickly walked away – meaning, I suppose, that he preferred to think that the man was not conscious or suffering.

I did not agree but nor, to my shame, did I return and talk to the patient and comfort him. I fear that my failure was even more egregious than my consultant’s denial of the obvious, but it is extraordinarily difficult to talk to an immobile body, knowing that you cannot get any response, and even more difficult to know what to say. It feels like talking to a corpse. It is not just that the thought of what the patient might be experiencing is too horrible to contemplate but also that it feels unnatural. It is indeed unnatural, to the extent that modern medicine can now keep people alive with profound brain damage who, in the past, would invariably have died in the first few days after the stroke or injury.

So there is now a group of people who are mute and immobile and require 24-hour nursing care. They are categorised as being in a persistent vegetative state (PVS) if they show no reactions whatsoever, and as being in a minimally conscious state (MCS) if they respond to stimulation to some extent. Some, like the patient in Wimbledon, are fully aware and “locked in” (as was Jean-Dominique Bauby, the author of The Diving-Bell and the Butterfly).

Adrian Owen is a neuropsychologist who has devoted his life to working with these patients. In Into the Grey Zone, he describes how, almost by chance, he became involved in putting PVS patients in scanners that show brain activity rather than just brain anatomy. He demonstrated that some PVS patients, despite being completely mute and immobile, show evidence of mental activity and are possibly conscious. We must say “possibly”, because consciousness is an entirely subjective phenomenon and cannot be measured or directly observed from outside. It can only be inferred.

The method Owen developed was to ask PVS patients to imagine that they were playing tennis. In some of these patients – but only a minority – the functional scans showed activity in the parts of the brain that light up in normal volunteers’ brains when they are asked to imagine playing tennis. He concluded that the PVS patients whose scans show this same activity must be conscious. Not everybody who works in this field agrees – it can be argued that awareness, which these patients certainly show, is not the same as having a conscious sense of self. There is much room for philosophical speculation and argument.

Owen was able to establish communication of a sort with some of these patients, by asking questions to which the patients could reply yes (by imagining a game of tennis) or no (by imagining walking around their home), but the communication was very limited.

There was tremendous media excitement about this groundbreaking work, as Owen recounts in some detail. But what does his discovery mean? Do PVS patients think and feel? Are they in hell, or perhaps even in heaven? Is the law right in permitting PVS patients to be allowed to die – withdrawing food and water so that they slowly starve to death? All that is clear is that some patients who have previously been diagnosed as being in PVS have some kind of inner, mental life. What this life might be like is impossible to know. It is, in many ways, a deeply disturbing thought, above all for the patients’ families.

This is a fascinating and highly readable book, written with evangelical fervour, but it needs to be read with some care. Owen has made a remarkable discovery and is right to be proud of it. He describes in gripping and moving detail – and there is no doubting his deep compassion for the patients and their families – how his work evolved, but only towards the end of the book does he start to admit how complicated the problem is.

There are many causes of PVS and MCS. Carol, his first subject, who made a remarkable (but incomplete) recovery, having been written off as being in PVS, had suffered from an inflammatory condition of the brain that was entirely different from what many of the other patients he describes suffered: head injuries with extensive structural brain damage. Patients who become clearly conscious after severe head injuries often have terrible personality changes and disabilities, and the same would probably apply to many of the PVS and MCS patients if they are conscious, albeit mute and immobile. As it is, many of the PVS patients Owen studied showed no brain activation when asked to imagine playing tennis. Finally, consciousness is a complex grey-scale phenomenon, not simply a matter of on or off. In places, Owen comes close to making it sound as though all PVS patients were potentially wide awake but locked in.

We cannot know what these patients are experiencing but what we do know is that the suffering of their families is terrible, as I have seen in my life as a neurosurgeon. Any­body who has read Cathy Rentzenbrink’s beautiful book The Last Act of Love will know this, too. Owen’s work raises many more questions than it answers. The complicated problems of how to look after PVS patients and how their families should see them have become a lot more difficult.

Owen is now working in Canada, trying to use electroencephalography to detect awareness and possible consciousness in comatose patients – a less complex method than using brain scanners. It is not yet clear whether this will work. “Emerging technologies will undoubtedly one day allow us to read the minds of others,” he states . I am not so sure, but time will tell.

Henry Marsh is a consultant neurosurgeon and the author of “Admissions: A Life in Brain Surgery” (Weidenfeld & Nicolson)

Into the Grey Zone
Adrian Owen
Guardian Faber, 320pp, £16.99

This article first appeared in the 24 August 2017 issue of the New Statesman, Sunni vs Shia

Credit: The Bureau/Film4 Productions/British Film Council
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Lean on Pete builds on the proud history of horses in film

Cinema’s equine love affair is in no danger of dimming.

The mane attraction in cinemas next week is Andrew Haigh’s film adaptation of Willy Vlautin’s novel Lean On Pete, the story of a teenage boy and the horse he rescues.

If there’s any justice, audiences will gallop rather than trot to see it. Anyone who hasn’t read the book could be forgiven for expecting an inspirational, uplifting tale. Maybe, like the kid in Carroll Ballard’s beautiful, dialogue-light 1979 film The Black Stallion, the hero of Lean On Pete will train his four-legged companion to be a champion racehorse. But that isn’t how things turn out. Not even close. Haigh’s picture has more in common with Au hasard Balthazar, Bresson’s plaintive 1966 study of the sad life of a donkey, or Ken Loach’s Kes. Boy and horse help alleviate the other’s loneliness and suffering, at least in the short term, but they reflect it too.

That’s also the role of the horse that 15-year-old Mia (Katie Jarvis) finds tied up in Fish Tank, and attempts to liberate. As its title suggests, Andrea Arnold’s 2009 drama is not short on nature metaphors; there’s also a dog called Tennents, and a carp that meets a sticky end. To be honest, the horse is probably pushing things a bit. Don’t you see? It’s really Mia and she wants to set it free because she herself yearns to be emancipated! Yeah, yeah, we get it. But such objections count for little next to the sheer physical might of a horse on screen. There’s no getting around it. Did you ever see a horse that didn’t exude awesomeness, magnificence and film-star charisma? They’ve got what it takes.

Trigger was first out the gate. Though when Olivia de Havilland rode him in The Adventures of Robin Hood, he was still going by the name Golden Cloud, which sounds uncomfortably like an obscure sexual practice. Roy Rogers coughed up $2,500 to buy him, then changed the animal’s name when his co-star Smiley Burnette remarked that the beast was “quick on the trigger.” It stuck. Trigger and Rogers first appeared together in 1938 in Under Western Stars. Down the years, other horses sometimes stood in for him, so estimates vary as to how many appearances the horse-formerly-known-as-Golden-Cloud actually made. You’d need a photo finish, though, to tell the difference.

A horse plays a vital part in Valeska Grisebach’s recent Western, a tense and mysterious study of German labourers working in Bulgaria. The title demands at least one horse, I suppose, as well as the various macho stand-offs that occur in the course of the film, but its presence introduces an air of nobility and calm amidst the general lawlessness. “Horses make everything alright,” says a character in Willy Vlautin’s most recent novel, Don’t Skip Out On Me, and you’d have to agree. When the horse in Western is imperilled, you know trouble is a-coming. Look what happened in The Godfather.

Horse sense tells you these creatures have got to be respected. In the sort-of Bond movie Never Say Never Again (essentially a second adaptation of Thunderball, made possible due to complicated copyright reasons pertaining to the original novel), there’s a nasty stunt in which a horse leaps from a great height into the ocean, hitting the water upside down. There was a furore about it at the time of release in 1983 and it tends to be excised on those rare occasions when the film is screened today. Quite right, too. The filmmakers’ cavalier attitude toward animal safety really takes the Seabiscuit.

Equine enthusiasts aren’t short of cinematic opportunities to indulge their passion—everything from National Velvet and International Velvet to War Horse, Phar Lap and The Horse Whisperer. Among the various incarnations of Black Beauty, allow me to flag up the 1994 version, adapted and directed by Caroline Thompson, the pen behind Edward Scissorhands. Sadly it has no trace of the stirring theme music from the 1970s television series (surely a contender for greatest TV theme ever) but there is ample compensation in Alan Cummings’s gentle Scottish lilt, which gives Beauty’s internal monologue the ebbing rhythm of a bedtime story. Human roles are shaved bare but David Thewlis gets the sweetest moment, when Beauty steals his doorstep sandwich, gambols about with it victoriously, then showers him in a confetti of crumbs.

Jockeying for position with all these movie horses, though, are some that don’t exist anywhere except in the imagination. I’m referring, of course, to the invisible ones on which King Arthur rides through medieval England in Monty Python and the Holy Grail while his servant follows nearby, clapping together two halves of a coconut shell. This was the ultimate case of necessity being the mother of comic invention, since the budget wouldn’t stretch to actual horses. It’s just a shame that when Arthur later encounters three fabled knights, their catchphrase turns out to be “Nii!” rather than “neigh.”

Lean On Pete opens 4 May. Western is on release.

Ryan Gilbey is the New Statesman's film critic. He is also the author of It Don't Worry Me (Faber), about 1970s US cinema, and a study of Groundhog Day in the "Modern Classics" series (BFI Publishing). He was named reviewer of the year in the 2007 Press Gazette awards and is Film Critic in Residence at Falmouth University.