You may have read this week about the case of Rom Houben, the Belgian man who was involved in a car crash in 1983, then diagnosed and treated as comatose for over 20 years, and is now reported to be communicating intelligently with his family and hospital staff. Since the story was first reported in the German magazine Der Spiegel, it has been carried by news outlets around the world. Houben apparently claims that he has been able to "hear, see, feel and think", but not able to express those thoughts, and the experience left him "lonely" and "frustrated".
On the face of it, this is a horrifying scenario. What if a physical injury locked you into a state of seeming coma, but all the while you remained aware? What if you could understand everything that people were saying about and doing around you, but were unable to participate in any understandable way? What if you were treated as a literal non-entity? What if this state of being persisted for decades?
If that sounds like something out of a Stephen King story, it is: his "Autopsy Room Four" from the collection Everything's Eventual actually uses this as its framing device. (I won't spoil the read for you, but it has a happy ending -- pun intended.) However, there are numerous reported cases of people waking up during medical operations. In these cases, people typically have claimed to be able to bear full witness to their own surgeries but unable to tell their surgeons about it; recurrent nightmares of the experience are likely to follow.
There is much that we do not yet know about the relationship between brain, awareness, and consciousness. Misdiagnoses of persistent vegetative states certainly can occur, as do misdiagnoses in all areas of medicine. Once a person is labelled with a particular ailment, it may serve as an interpretative lens that filters out contradictory evidence. Therefore it is possible that Houben was a man trapped inside himself, freed only by recent advancements in technology and family members who believed that he never really went away. It would be an amazing thing if this were so, and a good lesson for those eager to simply write off people with serious brain injuries or motor deficits.
However, it is also possible, and perhaps more probable, that Rom Houben is not actually the person sharing his thoughts with his family and the rest of the world. If you read the stories about him carefully, you will notice that the bulk of cited evidence for his awareness comes from messages typed out on a computer keyboard. Ostensibly Houben is the author of all of these messages, but he may have a ghostwriter in the guise of his ‘facilitator'. The facilitator is a person who helps guide his right index finger around the keyboard in order to help Houben spell out his thoughts.
Facilitated communication (FC) is a technique that garnered much attention in the 1980s and 1990s as a means for people with autistic disorders -- and others who similarly lacked the capacity for fully self-directed speech or writing -- to express themselves. Indeed, it continues to be supported by some very well-known institutions, including Syracuse University in New York (http://www.inclusioninstitutes.org/fci/). However, FC is also highly controversial (Romanczyk et al., 2003).
(The excellent PBS Frontline documentary "Prisoners of Silence", originally aired in 1993, is well worth watching if you are interested in the controversy; its transcript is available here.)
Most of the video footage shown with this story has been edited (intentionally or not) to suggest that Houben is intently concentrating on the FC task - i.e., a shot of his open, apparently attentive, eyes is followed by a cut to his computer screen, and then back to his eyes.
Compare that to the video footage from an Australian network seen here: http://news.ninemsn.com.au/world/975121/belgian-coma-man-was-just... Watch closely beginning at 0:13 of this clip. Houben has his eyes completely shut while the facilitator guides his hand. (Let us be charitable and assume that he is not asleep at this moment.) How likely is it that he is accurately hitting the keys he intends to hit?
I can type approximately 70 words per minute on a QWERTY keyboard with about 95% accuracy. Let's see how I do using a hunt-and-peck one-finger approach while keeping my eyes shut:
The wuivl btpr, y[g over yje ;dci f'ty[.j sif/
Yikes! That was supposed to be "The quick brown fox jumped over the lazy sleeping dog."
Note that my performance was lousy even though the keyboard provided tactile clues to me: for example, I could make guesses based on the relative position of the shift and spacebar keys, the gaps between the number and function keys, and so on. These clues would appear to be absent from Houben's typing apparatus, which uses a flat touch-screen. Yet Houben is apparently able to produce far more intelligible statements than I can with his eyes shut.
I am also troubled by the fact that Houben is so articulate and forgiving after years of isolation. He would not have been able to practice conversation or other use of language, except in his own head, for over twenty years. Yet his messages are very eloquent. The media reports imply that he was effectively ostracised due to his diagnosis, that doctors and others treated him as a non-person for decades. We know that even very short periods of ostracism can cause hurt feelings and a desire to retaliate (Williams, 2007). Yet Houben seems entirely understanding and forgiving of those who ignored him.
Now, you might think that I am accusing Houben's family and therapy team of deliberately perpetrating a hoax. I am not. Indeed, I think it is more likely that they truly believe in the genuineness of his communications, and that these beliefs come from a place of heartfelt desire for Houben to return to the functional world. However, I also believe that the facilitator may be producing the messages herself without believing that she is doing so. If so, it would be an instance of the ideomotor effect, in which ideas bring about associated actions (Wegner, Fuller, & Sparrow, 2003). If his facilitator believes that a man in Houben's state would be frustrated but happy to see his family -- an entirely reasonable belief, I might add! -- then the messages produced by FC could reflect her beliefs rather than his experiences.
Very simple tests could reveal whether the FC technique is telling us about Houben's thoughts or those of his facilitator. For example, Houben could be shown a few words randomly chosen (at that moment) out of a book or newspaper with the facilitator waiting outside of the room. Or somebody could silently mime a particular simple action chosen randomly from a list - chopping wood, skipping rope, playing a flute, or the like. Everyone except Houben would then leave the room (to prevent the classic "Clever Hans" problem). The facilitator would then come in and help Houben type the words or actions that he saw.
Multiple trials would be needed to reduce the odds of success by mere chance, and the facilitator would need to come into the room through a separate door to prevent any deliberate or unintentional communication between the facilitator and witnesses to the original event. Such tests would take all of about 30 minutes to complete, and if Houben is the true author of his facilitated communications we should expect a very high success rate across the trials.
Now, you might contend that the other evidence cited in the stories about Houben - i.e., the "brain activity scans", or answering yes/no questions with a foot pedal - prove that he is more conscious and cogent than his doctors first thought. They might indeed; I am not expert enough in neuroscience to comment. However, it is important to realize that such evidence in no way implies that the messages yielded through the FC technique are valid. If Rom Houben really does have more awareness and cognitive abilities than previously thought, it still does not imply that the messages produced by FC are of any value in knowing the contents of his mind.
