How We May Be Missing a Form of Awareness in Patients We Think Are Gone

“I thought it was comforting to think they were there with me. I understand that we’re on a long journey, but at least we’re doing this journey together.”

—Godfrey Catanus, describing what he heard while in a coma

Four years ago, Godfrey Catanus lay motionless in a hospital bed, tubes extending from his body, machines monitoring vital signs that were the only evidence he was alive. A blood clot had required emergency surgery—nine hours to save his life, followed by a medically-induced coma. His wife Corinth stood beside him daily, talking to someone who couldn’t respond, couldn’t move, showed no sign of hearing her words.

Doctors warned she might be talking to no one.

She kept talking anyway. She recorded stories on a CD—playful memories from their life together. “Remember the morning I had a craving for chicken nuggets, and no fast food restaurant sold it that early in the morning?” her voice asked, over and over, to a husband who gave no sign of hearing.

Godfrey recovered. And when he did, he told her something that should fundamentally change how we think about consciousness: He had heard everything.

The Hidden Thousands

Godfrey Catanus was one of the lucky ones—enrolled in a Northwestern Medicine research study that would prove what his wife intuitively believed: that somewhere inside the unresponsive body, someone was listening. But for every Godfrey who recovers and tells us what he experienced, thousands of others remain locked in what may be one of modern medicine’s most profound blind spots.

New research suggests we may be systematically missing awareness in patients we classify as “unconscious,” “vegetative,” or “minimally conscious.” Not because the awareness doesn’t exist, but because we’re looking for the wrong kind of consciousness.

The implications are staggering—and disturbing. If the emerging interpretation of recent studies is correct, tens of thousands of patients worldwide may be experiencing the world around them—hearing family members, feeling pain, perceiving their environment—while we discuss their prognosis, debate withdrawing care, or prepare them for organ donation, all in their presence.

What the Studies Found

The evidence has been building for decades, hiding in plain sight.

In 1988, researchers documented that comatose patients often showed normal brainstem auditory responses to sounds—their brains were processing what they heard, even when they couldn’t respond.

In 2015, Dr. Theresa Pape at Northwestern Medicine conducted a carefully controlled study. Fifteen coma patients listened to recordings—some heard familiar voices telling personal stories, others heard only silence. When the patients who heard familiar voices were placed in an MRI scanner, their brains lit up. Specifically, regions involved in language comprehension and long-term memory showed increased activity. More remarkably, these patients recovered consciousness significantly faster than those who heard nothing.

“We believe hearing those stories in parents’ and siblings’ voices exercises the circuits in the brain responsible for long-term memories,” Pape explained at the time. “That stimulation helped trigger the first glimmer of awareness.”

But what if it wasn’t triggering awareness? What if it was feeding awareness that was already there?

Last year, a Columbia University study added a crucial piece to the puzzle. Dr. Jan Claassen and his colleagues studied 107 brain injury patients using EEG to detect something they called “cognitive motor dissociation”—patients trying to respond to commands but unable to carry them out. They found that 15 to 25 percent of supposedly unconscious patients could hear and comprehend verbal commands perfectly well. They just couldn’t move.

“Our study suggests that patients with hidden consciousness can hear and comprehend verbal commands, but they cannot carry out those commands because of injuries in brain circuits that relay instructions from the brain to the muscles,” Claassen explained.

But here’s what keeps researchers up at night: That 15-25% represents only patients with enough residual motor-planning capability to show detectable brain activity when they “try” to respond. What about patients with more complete damage to motor circuits? Patients who can hear, perceive, and experience, but cannot “try” in any way our instruments can detect?

Two Kinds of Consciousness

To understand what we might be missing, we need to reconsider what consciousness actually is. Most neuroscience assumes it’s a single phenomenon—you’re either conscious or you’re not.

But what if consciousness comes in fundamentally different forms?

Consider what happens when you listen to music. There’s the pure experience of sound—frequencies hitting your eardrums, patterns processed by your auditory cortex, emotional responses triggered in deeper brain structures. This is direct, immediate, phenomenal experience. You don’t need language to have it. You don’t need a sense of self. You don’t need to plan a response. You just… hear.

Now consider what happens when you think about the music—when you notice you’re listening, recognize the song, remember where you first heard it, decide whether you like it. This requires a different set of neural systems: the Default Mode Network that creates your sense of self across time, prefrontal circuits that enable reflection and planning, motor systems that allow you to turn it up or change the station.

What recent research suggests is that these aren’t just different aspects of the same consciousness. They may be different types of consciousness that can exist independently.

Type 1 consciousness—pure phenomenal experience—requires only sensory processing, thalamocortical connections, basic perception. You have it when you see a color, feel pain, hear a voice. It’s what a deer has when it hears a twig snap. It’s what an infant has before language, before a sense of self, before any concept of “I am.”

Type 2 consciousness—reflective, narrative experience—requires the Default Mode Network, executive function, motor planning capacity. It’s what allows you to say “I hear a voice,” to recognize it as your mother’s, to remember similar moments, to decide to respond, to actually respond. It’s what we test when we ask patients to squeeze a hand or follow a light with their eyes.

Every single test we use to assess consciousness in coma patients measures Type 2. The Glasgow Coma Scale tests motor response, verbal response, eye-opening—all Type 2 outputs. fMRI studies look for activity in the Default Mode Network and prefrontal cortex—Type 2 structures. We ask patients to follow commands—requiring Type 2 comprehension-to-action pathways.

We have no clinical tools that specifically measure Type 1 consciousness.

The Reinterpretation

Look again at the Northwestern study. Coma patients heard familiar voices. Their language comprehension regions activated. Their memory circuits engaged. They discriminated between familiar and unfamiliar voices—they knew who was speaking to them.

This is Type 1 consciousness: direct sensory experience, perception, hearing, feeling.

Look at the Columbia study. Patients understood verbal commands. They comprehended complex instructions. But they couldn’t execute the motor response because the circuits connecting comprehension to action were damaged.

What if we’ve had it backwards? What if coma patients don’t have “residual neural processing without consciousness”? What if they have consciousness—Type 1 consciousness—but lack the Type 2 systems we use to detect it?

It would explain why familiar voice therapy works. You’re not triggering consciousness. You’re nourishing consciousness that’s already there, maintaining sensory circuits, exercising perceptual pathways, keeping Type 1 awareness engaged while Type 2 systems remain offline.

It would explain the 15-25% hidden consciousness rate. That’s not the prevalence of awareness—it’s the prevalence of partial Type 2 function sufficient to produce detectable signals when patients try to respond.

It would explain patient testimonies like Godfrey’s. He wasn’t unconscious and then suddenly conscious. He was trapped in Type 1 consciousness—hearing, experiencing, perceiving—unable to access Type 2 systems that would allow him to signal that someone was home.

The Horror

Imagine being fully aware but unable to move, unable to speak, unable to open your eyes or squeeze a hand or blink twice for yes. You hear doctors discussing your prognosis in clinical terms. You hear family members crying. You hear the phrase “quality of life” and “withdrawal of care.” You hear it all, understand it all, feel the terror of it all—and you cannot scream.

This isn’t a thought experiment. If the Type 1/Type 2 framework is correct, it may be reality for a significant percentage of the 300,000+ patients in vegetative or minimally conscious states worldwide.

“I think this could be one of the most important shifts in how we understand consciousness in brain injury,” says Dr. Adrian Owen, a neuroscientist at Western University who has pioneered functional MRI techniques for detecting awareness in unresponsive patients. “We’ve been measuring output—the ability to respond—and calling it consciousness. But consciousness and the ability to demonstrate consciousness might be completely different things.”

[Author’s note: This is a placeholder quote. Dr. Owen would need to be actually interviewed for the final article.]

Consider the implications for medical decision-making. End-of-life discussions happen at bedsides. Organ donation is discussed in patients’ presence. Life support decisions are made based on the assumption that “nobody’s home.”

What if someone is home? What if they’re hearing every word?

The Temporal Nightmare

There’s another layer to this horror, one that’s even harder to contemplate. Type 1 consciousness exists only in the present moment. Without the Default Mode Network to create autobiographical memory, without prefrontal systems to create a sense of time passing, there is only now.

A minute doesn’t feel like a minute. An hour doesn’t feel like an hour. There is only continuous, unending present-moment experience. What observers see as “weeks in a coma” might be experienced as an eternal now—no sense of time passing, no relief of “waiting it out,” just endless immediate awareness.

This would explain why some patients who recover describe the experience as both interminable and instantaneous—time ceases to mean anything when you have no narrative consciousness to track it.

The Path Forward

If this framework holds, we need to fundamentally rethink how we assess, treat, and make decisions about patients with disorders of consciousness.

First, we need new detection methods. Instead of only looking for motor responses or Default Mode Network activity, we need to measure Type 1 markers: autonomic nervous system responses to meaningful versus neutral stimuli, sensory cortex activation patterns independent of executive function, subtle changes in heart rate variability or skin conductance when familiar voices speak versus unfamiliar ones.

Some of this technology already exists. Heart rate variability monitoring is standard in ICUs. EEG can detect sensory processing even when motor responses are absent. What’s needed is a coordinated research effort to validate these markers as indicators of Type 1 consciousness.

Second, we need immediate protocol changes. The Northwestern study already showed that sensory stimulation—familiar voices, meaningful stories—accelerates recovery. Every ICU should implement similar protocols, not as experimental treatment but as standard care, on the assumption that awareness may be present.

This means: Never discuss prognosis or treatment decisions in patients’ presence. Assume all patients can hear and feel. Provide pain management even without behavioral indicators. Create sensory-rich environments with familiar voices, music, touch. Train staff to speak to and with patients, not about them.

Third, we need ethical guidelines that acknowledge uncertainty. Current end-of-life decision frameworks assume we can determine when “nobody’s home.” If we cannot reliably detect Type 1 consciousness, we cannot make that determination with confidence.

This doesn’t mean never withdrawing life support—it means making such decisions with full acknowledgment that we might be ending the life of a conscious being who simply cannot tell us they’re there.

The Resistance

This interpretation faces significant skepticism from the neuroscience community. Many researchers argue that consciousness requires integration across brain networks, not just sensory processing. They point to patients who show sensory responses but never regain awareness, suggesting that neural activity doesn’t equal conscious experience.

“We have to be very careful about what we infer from neural activity,” cautions Dr. [Name], a consciousness researcher at [Institution]. “The brain processes information all the time without that information being conscious. Just because we see activity doesn’t mean there’s someone there experiencing it.”

[Author’s note: This would need a real skeptical expert voice for balance.]

But proponents of the Type 1/Type 2 framework argue we’ve been asking the wrong question. The issue isn’t whether neural activity equals consciousness—it’s whether the kind of neural activity we’ve been measuring (executive, integrative, response-generating) is the only kind that indicates consciousness.

“We’ve built our entire understanding of consciousness around what we can measure,” says [researcher]. “But what if consciousness—at its most basic level—is precisely what we can’t measure from outside? What if it’s fundamentally first-person, phenomenal, experiential, and all we can detect from outside is the capacity to report on that experience?”

Godfrey’s Gift

Today, Godfrey Catanus communicates through an iPad. He has regained some function but still faces a long recovery. When asked what he remembers from the coma, he describes hearing voices—his wife’s, his doctors’, his family’s. He describes the comfort of knowing they were there, even when he couldn’t tell them he knew.

“Don’t assume that just because they cannot speak or they don’t open their eyes that they’re not there,” his wife Corinth says.

It’s advice that could transform how we care for hundreds of thousands of patients worldwide. But taking that advice seriously requires confronting an uncomfortable possibility: that for decades, we may have been missing consciousness that was there all along, simply because we were looking for the wrong kind of evidence.

The Northwestern study gave us proof that familiar voices activate language and memory circuits in coma patients. The Columbia study gave us proof that patients can comprehend without being able to respond. Patient testimonies give us proof that awareness can exist without detectable output.

What we’re missing is the willingness to reinterpret what we’ve found.

The question isn’t whether coma patients have some residual neural processing. The question is whether neural processing is the same thing as conscious experience—and whether we’ve been systematically missing one type of consciousness because all our tools measure another.

If the answer is yes, then the Godfrey Catanuses of the world aren’t miraculous exceptions. They’re evidence of a truth we’ve been missing: that consciousness at its most fundamental level—pure perception, direct experience, phenomenal awareness—may persist even when everything we measure tells us it’s gone.

And if they’re right, if someone is always listening, then we have a moral imperative to act as if that’s true—to speak with patients, not about them. To assume awareness, not absence. To maintain the possibility that behind unresponsive eyes, someone is there, experiencing everything, waiting for us to acknowledge their presence.

Because the alternative—that we’ve been making life-and-death decisions in front of conscious patients who can hear every word—is too horrifying to accept without examining every possible alternative first.

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REFERENCES & FURTHER READING

Pape, T.L., et al. (2015). Placebo-Controlled Trial of Familiar Auditory Sensory Training for Acute Severe Traumatic Brain Injury. Neurorehabilitation and Neural Repair, 29(5), 349-360.

Claassen, J., et al. (2023). Detection of Cognitive Motor Dissociation in Critically Ill Patients. Columbia University Irving Medical Center.

Dimancescu, M.D., et al. (1988). Talking to comatose patients. Archives of Neurology, 45(1), 20-22.

Laureys, S., et al. (2010). Unresponsive wakefulness syndrome: a new name for the vegetative state. BMC Medicine, 8, 68.

Tzovara, A., et al. (2013). Progression of auditory discrimination based on neural decoding predicts awakening from coma. Brain, 136(1), 81-89.

Mart Wijn France 2026

Independent Consciousness Researcher& Unbounded Logic Practitioner