Cochlear Implants: an Educated Choice

Nathaniel D. Herr

Senior Seminar- Thesis Paper

Professor Stanley Grove

November 10, 2007

Introduction

    1. First electric stimulation of auditory system
    2. Communities involved

Thesis: “…the medical-ethical issue of cochlear implants is best approached with both a scientific and social education of potential results, risks, and social and linguistic implications.”

Critical look

    1. Device
    2. Surgical procedure
    3. Function
    4. Rehabilitation
      1. Timeline
      2. Post vs Pre lingual implantation
    5. Cost
      1. Cost of procedure
      2. Insurance coverage
      3. International Healthcare Plans
    6. Recipients
      1. Children
      2. Adults
    7. Speech Recognition
    8. Health Risks
      1. Meningitis
      2. Loss of existing hearing capability

Social Perspectives

    1. Deaf vs deaf
    2. Deaf Community’s Perspective
    3. Child vs Parent rights

Who is to decide

    1. Adult recipients
    2. Underage recipients
    3. Team of Resources

Refined Thesis: “The right decision is one that does not disregard the social and developmental involvement of the device, keeping the well-being of the implantee at the utmost priority.”


Introduction

Alessandro Volta, developer of the conventional electric battery, heard a noise like thick boiling soup as he placed metal rods of a 50-volt circuit into his own ears. Since 1790 and the first discovery of the possibility to stimulate the auditory system with electricity, sound technology has advanced greatly through microphones, electro-magnetic transmission, hearing aids, cumulating with the recent invention of the cochlear implant (Clark, 1978) This device has lead to the intersection of multiple cultures spanning both hearing and deaf, as well as conflicting perspectives from professionals in the medical and Deaf communities. When navigating these intersections, the medical-ethical issue of cochlear implants is best approached with both a scientific and social education of potential results, risks, and social and linguistic implications.

Critical Look

A cochlear implant is a small, yet complicated electronic device surgically placed in the cochlea and under the skin of the head, behind the ear, to help provide a sense of sound to a person who is profoundly deaf or hard-of-hearing. The implant involves four main components. First, sound is received via a microphone unit that rests on the ear. Instead of amplifying the sound as a hearing aid does, a processing unit changes the sound into an electromagnetic signal. This signal is transmitted through the skin to a receiver placed permanently within the body. A magnet holds the transmitter and receiver together, making the outer portion of the implant, the microphone and processor, removable. An electric signal then travels by wire to an electrode array, which is inserted in the cochlea. The cochlea has a range of nerves to stimulate different perceived frequencies of sound. The array, upwards to 22 different electrodes, uses this differentiation to stimulate different portions of the cochlea, imitating the perception of sound (Cochlear Implant FAQ, 2007).

Speech recognition goes beyond frequency and intensity. The patterns and rhythms of speech are a crucial part and often the most challenging with cochlear implants. Variations in the emphasis, stressed rhythms, etc. change the perception greatly (Language, 2007). It is important to remember and realize that cochlear implants do not equal hearing ability, but only stimulate the auditory system giving a useful representation of sounds after much adaptation and therapy. After years of hard work, a person can function with the device to recognize warning signals, understand other sounds in the environment, and enjoy a conversation in person or by telephone (Cochlear Implants, 2007).

With reduced or minimal hearing ability, deaf individuals can learn to communicate via speech production and recognition. The use of cochlear implants in this development is extensive and by no means a quick solution. It makes a large difference if the individual was deafened post-lingual. That is to say, if they learned a hearing language before loosing their hearing ability. If one defines deafness outside the factors of hearing, a deaf person consistently relies on visual cues, speech reading, gestures, and signs in the world around them. Cochlear implants do not change or eliminate deafness by this perspective for visual ability is still a large point of cognition and communication (Cochlear Implant FAQ, 2007).

Activation of the implant typically occurs four to six weeks after the surgery to allow for swelling to decrease and healing of the incisions. It is typically done on a period of two days, activated for four hours the first day and half of that on the second. During this time an audiologist sets the levels of the electrode array to produce soft to comfortably loud perception. During the first few months, periodic appointments are set to adjust levels of the device, which is always adjustable and able to be turned off (Cochlear Implant FAQ, 2007).

The FDA and medical community has pushed for implant procedures to take place at younger and younger ages because learning to hear and utilize the signals from the implant takes much time and therapy, multiple years at the least (Cochlear Implant Program, 2007) For prelingually deaf patients, earlier implantation age yield a higher rate of improvement on auditory speech recognition tests (Miyamoto, 2003). Therapy programs differ in their methodology. Some programs, like the South Dakota School for the Deaf, keep auditory oral students separate from visual and signing students (Auditory Oral, 2007) . Signing is forbidden under the rationalization that it will decrease the auditory and speech development. Cochlear implant therapy such as this resembles the educational techniques that followed the September 1880 Milan edict in which signing was oppressed and declared sub par for education and enlightenment in schools across Europe and North America (Berke, 2006).

Post-lingual deafened adults often have marked success in using cochlear implants to again use speech recognition as a method of communication. The ability to speak is separate from hearing ability so it is a false assumption that deaf individual cannot speak. Hearing is largely involved in the development of speech skills. After the speech skills are established, hearing plays less of a role. Learning to speak without hearing ability is very difficult. Visual communication comes much easier and has no limitations in grammar, complexity, and the ability to convey both detailed and abstract ideas (Lentz, 1992). For this reason, many post-lingually deafened adults pursue hearing technology such as hearing aids and cochlear implants.

Once the decision is made to have the implant, the pressing cost of the commitment ranges from $40,000 to $60,000. This includes the cost of the device as well as the surgery to implant it and the post-op follow up by professional audiologists and speech therapists to develop the skills to utilize the device. Continuing costs of maintaining a cochlear implant, buying new or rechargeable batteries, amounts to approximately $300 per year. Most health insurance carriers cover these costs in the United States. Many national health care systems, such as Australia and Great Britain, include it as well (Cochlear Implant FAQ, 2007).

Two main groups are distinguishable when analyzing implant recipients: adults and children. While this distinction seems intuitive, there are many implications and factors making the two groups different in more ways than physical development. Deaf adults are possibly deafened after the development of a spoken language. They might have lost their hearing ability from a traumatic experience such as gunshot percussion or diseases such as meningitis that sometimes spread to the aural canal (Clinical, 2006). Many maintain close connections with the hearing community. Children, on the other hand, are often deafened pre-lingually at birth or early on in communication development. With no aural communication base, it is very difficult to learn a spoken language. For this reason, many medical professionals are pushing for younger implantation ages (Miyamoto, 2003). With the added years adjusting to the implant, a child can develop and function in the hearing world. Because cochlear implants are a medical procedure, the decision and consent for deaf individuals under the age of 18 is the responsibility of the parent or guardian. A child has no voice in the choice concerning the irreversible procedure.

Pre-lingual deafened children have difficulty learning oral communication. Sometimes they are isolated from deaf culture and signed language, lacking the foundations of communication. Over 90% of deaf children are born to hearing parents (Lentz, 1992). As a parent this can be a very traumatic experience if they are unfamiliar with deaf culture and signed language. With the recent technology of cochlear implants, some assume that having a cochlear implant eliminates deafness when in fact it does not. Visual cues are still depended on in communication and when the implant is switched off or removed, the person is still deaf, relying on non auditory means of communication (Cochlear Implant FAQ, 2007).

While there are minimal risks involved in the procedure, the Center for Disease and Control does mandate bacterial meningitis vaccinations to anyone with a cochlear implant. Worldwide there are 90 reports of people contracting meningitis after a cochlear implant, a 0.15% probability (Meningitis, 2007). The bigger concern from the surgery isn’t the risk of the disease, but the irreversibility of the procedure. Puncturing the cochlea to insert the electrode array permanently damages the ears natural way of stimulating auditory nerve cells. If the electrode array fails to function, hearing ability is permanently lost. If not educated about the reality of hearing via an electrode array, many are disappointed and want to switch the cochlear implant off. Fortunately pre-surgical education of the device ensure accurate expectations and post-op therapy can adjust the array and train the mind to interpret the sound as speech and signals instead of meaningless noise.

Social Perspectives

Much more is known about the implants now than when first popular in the early 1990’s. Many in the Deaf community were afraid that making everyone hearing would eliminate their beautiful cohesive culture and signed language. Today, however, most consider cochlear implants to be a respectable personal choice. Many admired professionals and leaders in the Deaf community have received cochlear implants. It is sometimes compared to other choices and advances in technology that have aided the Deaf community communicate with the hearing world such as video relay services, TTYs, text messaging, closed captioning, and hearing aids. The main concern is promoting informed decisions of parents who are considering cochlear implants for their young children. There are many pros and cons to the procedure as well as myths and false assumptions about deafness. Many feel that more examples of successful Deaf adults need to be visible in today’s media and professional world (Cochlear Implant FAQ, 2007). They can share with the parents the option of the deaf community and cohesive culture.

Who is to decide

Ultimately, many factors contribute to the cochlear implant decision; duration of deafness, age of onset, age of implantation, and other physiological factors related to the deafness (Loizou, 1998). The patient along with a cochlear implant team of medical professionals, speech therapists as well as members of the deaf community should take time to weigh all of the pros and cons. The right decision is one that does not disregard the social and developmental involvement of the device, keeping the well-being of the implantee at the utmost priority.





References