Did I really win?

Jul 21, 2014

The letter in the mail said:
Mr. Horvitz, congratulations! You are one of our prize winners.  You have already won one of the following prizes:

1. Ford Mustang
2. Men's or women's gold-plated watch
3. Samsung Camera

Please call 800-888-xxxx to claim your prize.  Once again, congratulations!
Robert Morgan
Roland Cosmetics
When I get this kind of mail, I imagine a vulnerable person getting their hopes up, and being disappointed or ripped off. It makes me feel bad. This time I decided to do what I'd never done before.   I called.

A man answered after just a few rings: "Sweepstakes center."
"Hi, I received a letter saying I'd won a prize."
"Okay sir, what is the number in your letter?"
"My number?"
"It's in red in the upper right hand corner of the letter you received."
"It says 36BGYX243."
"Okay, and can you confirm your name?"
I told him. 
"Oh my, you are one of our grand prize winners! Can I put you on hold for a moment?"
"Sure."
In the background I heard the man say to his co-workers, loud enough for me to hear, "It's Mr. Horvitz, one of our grand prize winners!" Then I heard a jumble of voices: "It's one of our grand prize winners! It's one of the winners!" He continued "Mr. Horvitz, congratulations!"
"Thank you," I said.
"Mr. Horvitz, you have already won either the Ford Mustang, a gold-plated watch, or a camera."
"Okay, great," I said.
"Now, before we continue, there are a few questions I have to ask you. Is that Okay?"
"Okay."
"First, if you win the Ford Mustang, what color would you want? You can get the car in red, beige, blue, white, or grey."
"Red," I said. "Definitely red."
"Red. Okay. And would you want that to be a convertible?"
"Sure, a convertible would be great."
"Now, if you win the gold-plated watch, would you want the men's watch or the women's watch, perhaps as a gift?"  I told him I'd take the men's watch for myself.
"Okay. Also, Mr. Horvitz, would you agree to have your photo taken next to your prize?"
"My photo?
"Yes, we print a brochure showing our grand prize winners next to their prize."
"Sure."
"Okay, now in order to receive your prize, which you've already won, we ask that you purchase a 3-year supply of our cosmetics, which come in men's and women's varieties."
"Cosmetics?"
"Yes."
"Like what?"
"Well, for men that would include top-of-the-line skin care products like facial cleanser, shaving cream, after shave balm, skin toner, deep exfoliation scrub, energizing mask - "
"The thing is, I don't use much of that type of thing. How much would it cost?"
"Only $199.  And don't forget, Mr. Horvitz, you've already won one of the three gifts. And even the camera, which is the least valuable, is worth over $250."
"I see," I said. "Let's see. My gift is worth at least $250?"
"Yes!"
"And the cosmetics only cost about $200?"
"Right."
"Can you just send me a check for $50?"
"Oh, I don't think we can do that Mr. Horvitz. It would be out of the question." I took him through the logic of it again, so he put the supervisor on the line.

The supervisor was unmoved by my logic.  They can't send me a check. It would be out of the question.  If I don't have any other questions, he'll put the prize coordinator back on the line.

"Hello Mr. Horvitz, shall we arrange for your cosmetics subscription so that we can get you your prize as soon as possible?"

I told him that I didn't think I could do that.  It would be out of the question.

Boston Sucks

Jul 14, 2014

Moving to Boston was like entering an arranged marriage. My position at Columbia University was temporary and ending, and Boston College wanted to hire someone studying the neuroscience of learning. They offered me a tenured position, and I signed the contract. "What's Boston like?" I would ask people. "It's very clean and pretty," they'd say. When entering into an arranged marriage, "she's very clean and pretty", is better than "dirty and ugly". But is there something you're not telling me about? For me, there was something strange about Boston's personality. When I'd visit to scout out housing, I'd get a bad feeling. But I couldn't quite put my finger on what it was.

I lived in Boston for 5 years, and I'll tell you my feelings about it.   I don't pretend that this account is objective.  Maybe it's a libel, a slander. But it's how I saw it.

Early on, I met a woman there who, when she heard I was coming from NYC, told me that she felt like she could breathe for the first time when she took a trip from Boston down to NYC's Greenwich Village. Over the next few years, as I'd travel from Boston to NYC to visit friends, or to Philadelphia to visit family, I was struck by how much more relaxing it was to be in these other cities compared to Boston. I would have thought just the opposite, that the small city of Boston would be the more relaxed one. But about the only area of Boston with a relaxed vibe and an artistic feel was the gay neighborhood, the South End (not to be confused with South Boston), which resembled parts of lower Manhattan with its unique-looking cafe's, small restaurants hidden in narrow streets, boutique stores.  To my mind, most of the rest of Boston was filled with loud sports bars and big chain restaurants. It was slick and impersonal.

There are nice areas surrounding Boston, like Cape Cod, with its natural rustic beauty, Somerville, and the town the Bostonians refer to as "The People's Republic of Cambridge". As U.S. troops were pouring into Iraq to look for Sadam's WMDs after 9/11, many Boston stores had signs showing the red, white and blue of the American flag and the caption "These colors don't run". You were less likely to see this kind of silliness in Cambridge. Commie bastards! The red-blooded chest-thumping Americans were in Boston.

In Boston, nearly every bar is a sports bar, and nearly every restaurant is basically a sports bar. Feel like a quiet dinner at a Japanese restaurant tonight? As soon as you sit down, you notice that there are two big screen TVs -- one showing a football game and the other showing a basketball game -- and lots of hooting when there's a touchdown or a basket. Even in Japanese restaurants!  One night, I was in a bar in Boston with some friends I'd made there -- Boston's Red Sox looked poised to win the World Series, and their football team (New England Patriots) were on their way to win the Super Bowl. The guy sitting next to me said "If we win both of these championships, this town's going to have more sports swagger than it's had in a long time." I thought the last thing the people in this town need is more swagger. The truth is, the sports fanaticism might have been fun with the right attitude. I tried briefly, but couldn't sustain it.

There's something else about Boston's restaurants besides the big screen sports on TV. They have a slick, phony Applebee's or TGIFridays type of feel. Even the places that were individually owned rather than franchises still seemed artificial and overproduced. The slick, corporate look seems to be part of the Boston aesthetic. I always felt like I was walking around in Disney World without the rides. And there was no exit until you got out of town. In NYC, there's some of that feeling around Times Square. But that's about 2% of Manhattan. In Boston, the phoniness just permeated the place. As Rosa would say of Boston, "you feel like you can't touch it."

In Boston, there's a very clear idea of what a successful life looks like. It's a stereotypical American life - not black or Hispanic, not artistic, and definitely not European. It was a big difference from Philadelphia, founded by the Quakers, with its live and let live attitude; or from NYC, founded by the Dutch, with its mix of so many cultures that 'fitting in' seems like a non-issue. Boston, founded by the Puritans, is parochial. There is a strong vibe of what is normal and what is 'weihd'. You might think that a wind of openness would blow into Boston with its universities. But mostly the wind was from fraternity kids whose idea of a good time was to make a loud noise.  To me, Boston felt like a room with its windows closed, hammered shut.

To be fair, I had friends who went out of their way to include me in things when I was new to the neighborhood. One friend down the block would meet me for coffee with just 5 minutes notice anytime. I had wonderful colleagues at Boston College. On an individual level, of course people are people, and there are nice people everywhere.

Rosa joined me in my last year in Boston, and with her, the city felt less brash and overbearing, a little gentler. But the place was like clothes that never fit. After five years, I was glad to leave.

Coma, vegetative states, and the brain

Jun 25, 2014

Brain activity gives rise to consciousness -- thoughts and memories, awareness of the sights and sounds that surround us. But not all of the neurons in the human brain are dedicated to conscious awareness. Some of our 100 billion or so neurons carry out more menial tasks, like regulating our breathing, speeding up or slowing down our heart rate, releasing hormones into the blood stream, positioning our fingers properly to grasp a cup without our awareness. Which parts of the brain play a role in conscious awareness?

We may get a hint about what makes the "light" of consciousness shine by asking what turns it off. When a person enters a coma or a 'vegetative state', the brain is apparently without conscious awareness.  In fact, a lack of awareness of one's self and environment is a defining feature of both of these states. I became interested in comas and vegetative states because I wondered what the state of the brain is like when it lacks consciousness.

But as I looked into the research literature on these states, I was confronted with another question with more personal, human, implications. Can we really know what is going on inside the mind of someone in a coma or vegetative state? Do some people who seem unaware have conscious experiences but no way to show it? Can brain imaging help us to know what's going on inside the mind of a non-communicative person? In the paragraphs below, I refer to a fictional character 'Tom' to illustrate what we know about these conditions of the brain, and some recent advances that seem like science fiction.

Tom had severe head injury from a car accident, and ended up in a coma. His vital signs are okay, but he doesn't open his eyes. You ask "Can you hear me?" but he doesn't respond. You shake him. No response. You squeeze his finger, then squeeze harder, hard enough to hurt, but nothing. The activity of his brain resembles that of someone in deep sleep or under anesthesia. Activity levels are about 50% of what they would be during a normal waking state.

Over the next few weeks, Tom might enter a vegetative state. If so, his eyes will open and he will appear to be awake during the day, and at night he'll sleep. His sleep-wake cycles are now normal because the brainstem circuits that control them have recovered. These areas at the base of the brain also allow him to briefly move his eyes to track a moving object. But otherwise he never fixes his eyes on any object in the room, and seems to make only reflexive responses to sounds or touch. Areas of his brain associated with thinking, memory, and attention show very little activity. The images below show brain scans for a normal brain (top left) compared to a brain in a vegetative state (top right). 

Brain activity in a person who is conscious compared to a person in a vegetative state (top). In the locked-in syndrome (bottom left) an individual has normal mental function, but cannot move. In the minimally conscious state (bottom right), the person shows only occasional signs of limited awareness (Laureys et al, The Lancet-Neurology, 2004.) 
The diagnosis of 'vegetative' state does not mean that Tom's a 'vegetable', or even that his current state is permanent. The prognosis depends upon the kind of injury. In Tom's case, the trauma from his car accident would have caused swelling or bleeding in his brain. The excess fluid would have pushed up against his skull, and pressed his brain down upon itself, causing severe brain damage. Still, he has about a 50% likelihood of recovering at least some degree of consciousness. In cases where the vegetative state results from loss of oxygen to the brain, for instance after a stroke, the chance of recovery is much lower.

Recovery from a vegetative state is often only partial. But occasionally, dramatic recovery of mental and behavioral function occurs. How? One possibility is that new neurons are born and re-establish necessary connections between brain areas. Another possibility is that new connections sprout from existing neurons that were not damaged. If researchers can better understand how the brain sometimes recovers on its own from the vegetative state, they may be able to provide neurologists with the drugs and other tools that will make recovery more common.

In the meantime we ask what Tom is experiencing as he lies in a vegetative state. The fact that Tom is diagnosed as being in a 'vegetative state' means that the neurologist believes Tom to be unaware of himself or his environment. If he had shown signs of even transient awareness, he'd have received a different diagnosis: "minimally-conscious state". But what if Tom has been misdiagnosed? It happens. What if his inability to move is preventing him from communicating or acting in a way that would allow doctors to accurately assess his mental state?

Might brain imaging help to tell whether he is consciously aware or not? It might. After all, fMRI scans of a normal brain can tell whether the person is looking at something or hearing something (images to the right). fMRI should be able to tell us something about the conscious experience of a person who is believed to be in a vegetative or minimally-conscious state, even if they have no way to communicate directly.

Tom's brain shows some reaction to touch, sounds, and sights. This might mean that he has at least some awareness of these stimuli. But these sensory stimuli usually evoke only low levels of activity in the brain of patients in a vegetative state. The activity doesn't spread to other regions as it would in the brain of a normally conscious person. It's as if a stone were thrown into a lake and produced ripples that spread only a few inches instead of spreading across a long distance.

In a number of cases, patients in vegetative or minimally-conscious states had their brains scanned while they heard their mother reading them a story, heard their own name spoken, or saw pictures of familiar faces. In some of these patients, the brain responded to these meaningful stimuli more than to meaningless visual or auditory stimuli. But brain imaging devices aren't consciousness meters. There's no way to know the extent to which they were aware of what they were seeing or hearing.

But something big happened in 2006. Neuroscientists conducted brain scans of a 23-year-old woman diagnosed as being in a vegetative state after a car accident that left her unresponsive for five months. They asked her to imagine playing tennis. Normally, this produces brain activity in a region of the frontal cortex called the supplementary motor area (SMA in the brain images below). The same area became active in her brain when she was asked to imagine playing tennis. Then they asked her to picture herself walking through her house. This should activate a region called the parahippocampal place area (PPA) and posterior parietal cortex (PPC). These areas became active when she was asked to imagine walking through a house.

From Laureys et al 2012, Neuroimage, 2012
A few years later, researchers decided to try to ask 'yes' or 'no' questions to patients with a diagnosis of vegetative state, and to decipher their answers using brain imaging. Can you tell from examining someone's brain activity whether they're thinking 'yes' or 'no'? No, you cannot. But you don't need to be able to do this. You just need to be able to tell the difference between any two things the person's thinking about. Remember, different parts of the brain are activated when someone imagines playing tennis versus navigating a house. So, the neuroscientists told patients that if they want to say 'yes' they should imagine playing tennis, if they want to say 'no' they should picture themselves walking through their house.

The test session begins: "Is your father's name Bob?" The patient's father's name is Alex. Looking at his brain activity you could tell he was imagining navigating through a house. That means 'no'. So far, so good. "Is your father's name Alex?" Yes was the correct answer, and sure enough the brain scanner showed that the man was imagining playing tennis. "Do you have any brothers?" The answer was yes, and the playing-tennis areas of the brain lit up again. "Any sisters?" No, he correctly answered by imagining navigating through the house and activating the parahippocampal area. This communication system has worked for about 20% of the patients tested so far. Take a look.



Over the past decade there have been big advances using brain imaging to identify patients who might be misdiagnosed as in a vegetative or minimally-conscious state, and in giving them the ability to communicate.   Other lines of research are focused on ways for conscious, paralyzed patients to move robotic limbs.  A third line is devoted to promoting (at least some degree of) brain recovery through the use of drugs or electrical stimulation of the brain to promote growth of new neuronal connections.  I think that each of these avenues is a very big deal.

Posts on Coma and Boston

Jun 18, 2014

I'm working on two posts, and they're both taking longer than usual.  And so I'm delayed. One of them is about what it means to be in a coma, or a related but distinct 'vegetative state', from the point of view of the brain.  How do you know whether an individual has a mental life? Any at all?  This one's taking me a while because I want to get it right, or at least not terribly wrong.

The other is about why I so strongly dislike Boston.  One of the reasons this one's taking so long is because there is so much I disliked about the city, and I want to fit it in a post of reasonable length.  The other factor slowing me down is that I'm embarrassed to have such strong negative feelings about a city where I had great work colleagues and friends.  During my five years living there, my dislike for Boston was almost all I talked about.  

So it's taking me a while to write these posts on two very unpleasant topics: being in a coma and living in Boston.