{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T01:41:27Z","timestamp":1773279687793,"version":"3.50.1"},"reference-count":68,"publisher":"MIT Press","issue":"8","funder":[{"name":"Post-trial Access, Clinical Care, Psychosocial Support, and Scientific Progress in Experimental Deep Brain Stimulation Research","award":["RO1MH133657"],"award-info":[{"award-number":["RO1MH133657"]}]},{"name":"\u201cCognitive Restoration: Neuroethics and Disability Rights\u201d","award":["1RF1MH12378-01"],"award-info":[{"award-number":["1RF1MH12378-01"]}]}],"content-domain":{"domain":["direct.mit.edu"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,7,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>In this article, we consider the intersection of cognitive motor dissociation (CMD) and artificial intelligence (AI), hence when CMD meets AI. In covert consciousness, there is a discordance between the observed behavior, the traditional bedside mode of assessment, and the response to volitional commands as depicted by neuroimaging or EEG studies. This alphabet soup of acronyms represents both the promise and peril of nascent technology in covert consciousness. On the diagnostic side, there is the complexity and uncertainty of identifying the discordance between cognitive activity and overt behavior. On the therapeutic side, when AI is used to generate speech, there is the possibility of misrepresenting the thoughts and intentions of those who are otherwise voiceless. This concordance of factors makes the application of AI to CMD worthy of deeper consideration. We offer this analysis in the spirit of anticipatory governance, a prudential process by which one plans to prevent or mitigate unintended consequences of novel technology. We first consider the normative challenges posed by CMD for clinical practice, neuroethics, and the law. We then explore the history of covert consciousness and the relationship of severe brain injury to the right-to-die movement, before introducing three biographies of brain injury that highlight the potential impact of disability bias or ableism in clinical practice, assistive technology, and translational research. Subsequently, we explore how AI might give voice to conscious individuals who are unable to communicate and the ethical challenges that this technology must overcome to promote human flourishing drawing upon what Nussbaum and Sen have described as a \u201ccapabilities approach\u201d to promote normative reasoning.<\/jats:p>","DOI":"10.1162\/jocn_a_02157","type":"journal-article","created":{"date-parts":[[2024,4,5]],"date-time":"2024-04-05T20:31:24Z","timestamp":1712349084000},"page":"1667-1674","update-policy":"https:\/\/doi.org\/10.1162\/mitpressjournals.corrections.policy","source":"Crossref","is-referenced-by-count":4,"title":["Neuroethics, Covert Consciousness, and Disability Rights: What Happens When Artificial Intelligence Meets Cognitive Motor Dissociation?"],"prefix":"10.1162","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7221-0053","authenticated-orcid":true,"given":"Joseph J.","family":"Fins","sequence":"first","affiliation":[{"name":"Weill Cornell Medical College, New York, NY"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0892-6185","authenticated-orcid":true,"given":"Kaiulani S.","family":"Shulman","sequence":"additional","affiliation":[{"name":"Weill Cornell Medical College, New York, NY"}]}],"member":"281","published-online":{"date-parts":[[2024,7,1]]},"reference":[{"key":"2024070315295409600_bib1","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1080\/0964704X.2016.1184074","article-title":"The historical origins of the vegetative state: Received wisdom and the utility of the text","volume":"26","author":"Adams","year":"2017","journal-title":"Journal of the History of the Neurosciences"},{"key":"2024070315295409600_bib2","volume-title":"On the soul (De anima)","author":"Aristotle","year":"1957"},{"key":"2024070315295409600_bib3","author":"Baze","year":"2023"},{"key":"2024070315295409600_bib4","article-title":"Anti-ableist medical education: Meeting the challenges","volume-title":"Hastings Center issue brief","author":"Bowen","year":"2024"},{"key":"2024070315295409600_bib5","volume-title":"About us: Essays from the disability series of the New York Times","author":"Catapano","year":"2019"},{"key":"2024070315295409600_bib161","article-title":"University of California Press","volume-title":"Nothing about us without us: Disability oppression and empowerment","author":"Charlton","year":"1998"},{"key":"2024070315295409600_bib6","doi-asserted-by":"publisher","first-page":"2497","DOI":"10.1056\/NEJMoa1812757","article-title":"Detection of brain activation in unresponsive patients with acute brain injury","volume":"380","author":"Claassen","year":"2019","journal-title":"New England Journal of Medicine"},{"key":"2024070315295409600_bib7","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1007\/s12028-023-01769-3","article-title":"Cognitive motor dissociation: Gap analysis and future directions","volume":"40","author":"Claassen","year":"2024","journal-title":"Neurocritical Care"},{"key":"2024070315295409600_bib303","article-title":"Cruzan v. Director, Missouri Department of Health","author":"Cruzan","year":"1990"},{"key":"2024070315295409600_bib8","first-page":"3","article-title":"Common sense and science","volume":"2","author":"Dewey","year":"2005","journal-title":"Knowledge: Critical Concepts"},{"key":"2024070315295409600_bib9","doi-asserted-by":"publisher","first-page":"2399","DOI":"10.1093\/brain\/awx176","article-title":"Early detection of consciousness in patients with acute severe traumatic brain injury","volume":"140","author":"Edlow","year":"2017","journal-title":"Brain"},{"key":"2024070315295409600_bib10","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1097\/HTR.0000000000000448","article-title":"Assessment of covert consciousness in the intensive care unit: Clinical and ethical considerations","volume":"33","author":"Edlow","year":"2018","journal-title":"Journal of Head Trauma Rehabilitation"},{"key":"2024070315295409600_bib11","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1038\/nrn1079","article-title":"Constructing an ethical stereotaxy for severe brain injury: Balancing risks, benefits and access","volume":"4","author":"Fins","year":"2003","journal-title":"Nature Reviews Neuroscience"},{"key":"2024070315295409600_bib12","first-page":"22","article-title":"Rethinking disorders of consciousness: New research and its implications","volume":"35","author":"Fins","year":"2005","journal-title":"Hastings Center Report"},{"key":"2024070315295409600_bib13","doi-asserted-by":"publisher","first-page":"169","DOI":"10.1017\/S1478951506060238","article-title":"Affirming the right to care, preserving the right to die: Disorders of consciousness and neuroethics after Schiavo","volume":"4","author":"Fins","year":"2006","journal-title":"Palliative & Supportive Care"},{"key":"2024070315295409600_bib14","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1080\/15265160601064231","article-title":"Border zones of consciousness: Another immigration debate?","volume":"7","author":"Fins","year":"2007","journal-title":"American Journal of Bioethics"},{"key":"2024070315295409600_bib15","first-page":"234","article-title":"Neuroethics and disorders of consciousness: A pragmatic approach to neuropalliative care","volume-title":"The neurology of consciousness, cognitive neuroscience and neuropathology","author":"Fins","year":"2008"},{"key":"2024070315295409600_bib16","doi-asserted-by":"publisher","first-page":"895","DOI":"10.1093\/oxfordhb\/9780199570706.013.0195","article-title":"Neuroethics and the lure of technology","volume-title":"The Oxford handbook of neuroethics","author":"Fins","year":"2011"},{"key":"2024070315295409600_bib17","doi-asserted-by":"publisher","DOI":"10.1017\/CBO9781139051279","volume-title":"Rights come to mind: Brain injury ethics and the struggle for consciousness","author":"Fins","year":"2015"},{"key":"2024070315295409600_bib18","doi-asserted-by":"publisher","first-page":"583","DOI":"10.1017\/S0963180116000323","article-title":"Giving voice to consciousness: Neuroethics, human rights, and the indispensability of neuroscience","volume":"25","author":"Fins","year":"2016","journal-title":"Cambridge Quarterly of Healthcare Ethics"},{"key":"2024070315295409600_bib19","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1007\/978-3-319-54651-3_4","article-title":"Toward a pragmatic neuroethics in theory and practice","volume-title":"The debate about neuroethics: Perspectives on its development, focus, and future","author":"Fins","year":"2017"},{"key":"2024070315295409600_bib20","doi-asserted-by":"publisher","first-page":"449","DOI":"10.1093\/med\/9780190208875.003.0011","article-title":"Disorders of consciousness in clinical practice: Ethical, legal and policy considerations","volume-title":"Plum and Posner's diagnosis of stupor and coma","author":"Fins","year":"2019","edition":"5th ed."},{"key":"2024070315295409600_bib21","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1086\/JCE2019301027","article-title":"Once and future clinical neuroethics: A history of what was and what might be","volume":"30","author":"Fins","year":"2019","journal-title":"Journal of Clinical Ethics"},{"key":"2024070315295409600_bib22","first-page":"235","article-title":"The Jeremiah Metzger Lecture: Disorders of consciousness and the normative uncertainty of an emerging nosology","volume":"131","author":"Fins","year":"2020","journal-title":"Transactions of the American Clinical and Climatological Association"},{"key":"2024070315295409600_bib23","first-page":"91","article-title":"Cruzan and the other evidentiary standard: A reconsideration of a landmark case given advances in the classification of disorders of consciousness and the evolution of disability law","volume-title":"73 Southern Methodist University law review","author":"Fins","year":"2020"},{"key":"2024070315295409600_bib24","first-page":"41","article-title":"The complicated legacy of Terry Wallis and his brain injury","volume":"29","author":"Fins","year":"2023","journal-title":"Issues in Science and Technology"},{"key":"2024070315295409600_bib25","article-title":"Lewis Thomas, Michel de Montaigne, and Johann Sebastian Bach: Next day thoughts on artificial intelligence and the Sasha seminar","volume-title":"Artificial intelligence or consciousness: Shasha seminar for human concerns","author":"Fins","year":"2023"},{"key":"2024070315295409600_bib162","doi-asserted-by":"publisher","first-page":"471","DOI":"10.1212\/WNL.0000000000005927","article-title":"Ethical, palliative, and policy considerations in disorders of consciousness","volume":"91","author":"Fins","year":"2018","journal-title":"Neurology"},{"key":"2024070315295409600_bib26","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1353\/hcr.2006.0094","article-title":"Shades of gray: New insights into the vegetative state","volume":"36","author":"Fins","year":"2006","journal-title":"Hastings Center Report"},{"key":"2024070315295409600_bib27","doi-asserted-by":"publisher","first-page":"141","DOI":"10.3233\/NRE-230118","article-title":"Brain injury, medical progress, and the disability paradox: Towards an Americans with Abilities Act","volume":"54","author":"Fins","year":"2024","journal-title":"NeuroRehabilitation"},{"key":"2024070315295409600_bib28","doi-asserted-by":"publisher","first-page":"1732","DOI":"10.1016\/j.mayocp.2020.02.008","article-title":"Disorders of consciousness and disability law","volume":"95","author":"Fins","year":"2020","journal-title":"Mayo Clinic Proceedings"},{"key":"2024070315295409600_bib29","volume-title":"The disability rights movement: From charity to confrontation","author":"Fleischer","year":"2011"},{"key":"2024070315295409600_bib30","doi-asserted-by":"publisher","first-page":"522","DOI":"10.1632\/S0030812900167835","article-title":"Disability and representation","volume":"120","author":"Garland-Thomson","year":"2005","journal-title":"Publications of the Modern Language Association of America"},{"key":"2024070315295409600_bib31","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1212\/WNL.58.3.349","article-title":"The minimally conscious state: Definition and diagnostic criteria","volume":"58","author":"Giacino","year":"2002","journal-title":"Neurology"},{"key":"2024070315295409600_bib32","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1212\/WNL.0000000000005926","article-title":"Practice guideline update recommendations summary: Disorders of consciousness: Report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research","volume":"91","author":"Giacino","year":"2018","journal-title":"Neurology"},{"key":"2024070315295409600_bib33","doi-asserted-by":"publisher","first-page":"461","DOI":"10.1212\/WNL.0000000000005928","article-title":"Comprehensive systematic review update summary: Disorders of consciousness: Report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research","volume":"91","author":"Giacino","year":"2018","journal-title":"Neurology"},{"key":"2024070315295409600_bib34","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1007\/s11673-011-9292-4","article-title":"Minimally conscious states, deep brain stimulation, and what is worse than futility","volume":"8","author":"Gillett","year":"2011","journal-title":"Journal of Bioethical Inquiry"},{"key":"2024070315295409600_bib35","doi-asserted-by":"publisher","first-page":"AIp2400036","DOI":"10.1056\/AIp2400036","article-title":"To do no harm\u2014and the most good\u2014with AI in health care","volume":"1","author":"Goldberg","year":"2024","journal-title":"NEJM AI"},{"key":"2024070315295409600_bib36","doi-asserted-by":"publisher","first-page":"218","DOI":"10.1177\/0306312713508669","article-title":"Understanding \u2018anticipatory governance.\u2019","volume":"44","author":"Guston","year":"2014","journal-title":"Social Studies of Science"},{"key":"2024070315295409600_bib37","doi-asserted-by":"publisher","first-page":"297","DOI":"10.1377\/hlthaff.2020.01452","article-title":"Physicians\u2019 perceptions of people with disability and their health care","volume":"40","author":"Iezzoni","year":"2021","journal-title":"Health Affairs"},{"key":"2024070315295409600_bib313","article-title":"In re Quinlan. (N.J. 1976)"},{"key":"2024070315295409600_bib38","doi-asserted-by":"publisher","first-page":"734","DOI":"10.1016\/s0140-6736(72)90242-5","article-title":"Persistent vegetative state after brain damage. A syndrome in search of a name","volume":"1","author":"Jennett","year":"1972","journal-title":"Lancet"},{"key":"2024070315295409600_bib39","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1136\/jme.2010.038877","article-title":"The right to die in the minimally conscious state","volume":"37","author":"Johnson","year":"2011","journal-title":"Journal of Medical Ethics"},{"key":"2024070315295409600_bib40","doi-asserted-by":"publisher","first-page":"1469","DOI":"10.1056\/NEJM199405263302101","article-title":"Neuropathological findings in the brain of Karen Ann Quinlan. The role of the thalamus in the persistent vegetative state","volume":"330","author":"Kinney","year":"1994","journal-title":"New England Journal of Medicine"},{"key":"2024070315295409600_bib41","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1186\/1741-7015-8-68","article-title":"Unresponsive wakefulness syndrome: A new name for the vegetative state or apallic syndrome","volume":"8","author":"Laureys","year":"2010","journal-title":"BMC Medicine"},{"key":"2024070315295409600_bib42","first-page":"168","article-title":"Brain\u2013computer interfaces and the right to be heard: Calibrating legal and clinical norms in pursuit of the patient\u2019s voice","volume":"33","author":"Lawrence","year":"2019","journal-title":"Harvard Journal of Law & Technology"},{"key":"2024070315295409600_bib43","doi-asserted-by":"publisher","first-page":"579","DOI":"10.1056\/NEJMoa0905370","article-title":"Willful modulation of brain activity in disorders of consciousness","volume":"362","author":"Monti","year":"2010","journal-title":"New England Journal of Medicine"},{"key":"2024070315295409600_bib166","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1145\/3356727","article-title":"AI and accessibility","volume":"63","author":"Morris","year":"2020","journal-title":"Communications of the ACM"},{"key":"2024070315295409600_bib44","doi-asserted-by":"publisher","first-page":"1499","DOI":"10.1056\/NEJM199405263302107","article-title":"Medical aspects of the persistent vegetative state (1)","volume":"330","author":"Multi-Society Task Force on PVS","year":"1994","journal-title":"New England Journal of Medicine"},{"key":"2024070315295409600_bib45","doi-asserted-by":"publisher","first-page":"1572","DOI":"10.1056\/NEJM199406023302206","article-title":"Medical aspects of the persistent vegetative state (2)","volume":"330","author":"Multi-Society Task Force on PVS","year":"1994","journal-title":"New England Journal of Medicine"},{"key":"2024070315295409600_bib46","doi-asserted-by":"publisher","DOI":"10.4159\/harvard.9780674061200","volume-title":"Creating capabilities: The human development approach","author":"Nussbaum","year":"2011"},{"key":"2024070315295409600_bib47","doi-asserted-by":"publisher","DOI":"10.1126\/science.1130197","article-title":"Detecting awareness in the vegetative state","volume":"313","author":"Owen","year":"2006","journal-title":"Science"},{"key":"2024070315295409600_bib48","doi-asserted-by":"publisher","first-page":"1409","DOI":"10.1001\/archneurol.2010.282","article-title":"Fred Plum, MD (1924\u20132010)","volume":"67","author":"Posner","year":"2010","journal-title":"Archives of Neurology"},{"key":"2024070315295409600_bib49","doi-asserted-by":"publisher","first-page":"1413","DOI":"10.1001\/jamaneurol.2015.2899","article-title":"Cognitive motor dissociation following severe brain injuries","volume":"72","author":"Schiff","year":"2015","journal-title":"JAMA Neurology"},{"key":"2024070315295409600_bib50","first-page":"7","article-title":"Hope for \u201ccomatose\u201d patients","volume":"5","author":"Schiff","year":"2003","journal-title":"Cerebrum"},{"key":"2024070315295409600_bib51","doi-asserted-by":"publisher","first-page":"600","DOI":"10.1038\/nature06041","article-title":"Behavioural improvements with thalamic stimulation after severe traumatic brain injury","volume":"448","author":"Schiff","year":"2007","journal-title":"Nature"},{"key":"2024070315295409600_bib167","doi-asserted-by":"publisher","first-page":"971315","DOI":"10.3389\/fnhum.2022.971315","article-title":"What names for covert awareness? A systematic review","volume":"16","author":"Schnakers","year":"2022","journal-title":"Frontiers in Human Neuroscience"},{"key":"2024070315295409600_bib52","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1186\/1471-2377-9-35","article-title":"Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized neurobehavioral assessment","volume":"9","author":"Schnakers","year":"2009","journal-title":"BMC Neurology"},{"key":"2024070315295409600_bib53","volume-title":"From good will to civil rights: Transforming federal disability policy","author":"Scotch","year":"2001"},{"key":"2024070315295409600_bib54","volume-title":"Commodities and capabilities","author":"Sen","year":"1985"},{"key":"2024070315295409600_bib55","first-page":"1729","article-title":"Designing an Americans With Abilities Act: Consciousness, capabilities, and civil rights","volume":"63","author":"Shapiro","year":"2022","journal-title":"Boston College Law Review"},{"key":"2024070315295409600_bib164","article-title":"University of North Carolina Press","author":"Shepherd","year":"2009","journal-title":"If that ever happens to me: Making life and death decisions after Terri Schiavo"},{"key":"2024070315295409600_bib56","doi-asserted-by":"publisher","first-page":"368re5","DOI":"10.1126\/scitranslmed.aaf6113","article-title":"Local changes in network structure contribute to late communication recovery after severe brain injury","volume":"8","author":"Thengone","year":"2016","journal-title":"Science Translational Medicine"},{"key":"2024070315295409600_bib57","doi-asserted-by":"publisher","first-page":"1581","DOI":"10.1503\/cmaj.101786","article-title":"Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: A Canadian multicentre cohort study","volume":"183","author":"Turgeon","year":"2011","journal-title":"CMAJ: Canadian Medical Association Journal"},{"key":"2024070315295409600_bib58","doi-asserted-by":"publisher","first-page":"2005","DOI":"10.1172\/JCI27021","article-title":"Possible axonal regrowth in late recovery from the minimally conscious state","volume":"116","author":"Voss","year":"2006","journal-title":"Journal of Clinical Investigation"},{"key":"2024070315295409600_bib59","article-title":"Disability, bias, and AI","volume":"8","author":"Whittaker","year":"2019","journal-title":"AI Now Institute"},{"key":"2024070315295409600_bib60","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.1212\/01.wnl.0000259401.36220.1a","article-title":"The family conference: End-of-life guidelines at work for comatose patients","volume-title":"Neurology","author":"Wijdicks","year":"2007"},{"key":"2024070315295409600_bib61","first-page":"233","article-title":"Rehabilitation, education, and the integration of individuals with severe brain injury into civil society: Towards an expanded rights agenda in response to new insights from translational neuroethics and neuroscience","volume":"16","author":"Wright","year":"2016","journal-title":"Yale Journal of Health Policy, Law, and Ethics"}],"container-title":["Journal of Cognitive Neuroscience"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/direct.mit.edu\/jocn\/article-pdf\/36\/8\/1667\/2456626\/jocn_a_02157.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/direct.mit.edu\/jocn\/article-pdf\/36\/8\/1667\/2456626\/jocn_a_02157.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,3]],"date-time":"2024-07-03T15:30:30Z","timestamp":1720020630000},"score":1,"resource":{"primary":{"URL":"https:\/\/direct.mit.edu\/jocn\/article\/36\/8\/1667\/120488\/Neuroethics-Covert-Consciousness-and-Disability"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024]]},"references-count":68,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2024,7,1]]},"published-print":{"date-parts":[[2024,7,1]]}},"URL":"https:\/\/doi.org\/10.1162\/jocn_a_02157","relation":{},"ISSN":["0898-929X","1530-8898"],"issn-type":[{"value":"0898-929X","type":"print"},{"value":"1530-8898","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2024]]},"published":{"date-parts":[[2024]]}}}