The terrifying possibility that an unresponsive patient is 'still in there'

After brain injury, some patients are no longer able to respond to the world around them. But research on covert consciousness suggests the reality is more complex.

- Daniela Lamas

The fourth floor of the long-term care hospital where I sometimes work houses patients with severe brain injuries. When I am called there to consult, I always hesitate before entering the room. Of all the ways that our bodies can fail, brain injuries are some of the most devastating to witness. Some patients moan involuntarily. Others lie still, their eyes open but unresponsive.

As I place my stethoscope on the patient's chest, often without a word, I reassure myself that at least the patient is unaware. Her personhood is gone. She is "not in there" any longer.

But an increasing body of research indicates that patients who have suffered catastrophic brain injuries experience a far more complicated reality. A provocative study published in 2024 in The New England Journal of Medicine suggests that at least one in four people who appears unresponsive actually is conscious enough to understand language. As a doctor who sometimes sees patients like this, these findings are, in a word, terrifying.

Studies like this raise the possibility that there are tens of thousands of men and women locked inside their own minds, isolated to a degree I cannot even imagine. They are voiceless and largely invisible, with some of them being cared for in nursing facilities.

There are a handful of researchers in a few institutions working to identify these patients and develop tools they can use to communicate. A lack of resources is one major barrier. A larger one is philosophical. The way many doctors think about these patients reflects the medical system's inability to deal with uncertainty, and even what kind of life we believe to be worth living.