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Summary The Minimally Conscious State (MCS) is a state of diminished and disordered consciousness. It is distinct from the Vegetative State (VS) in that MCS patients do experience some level of awareness, although it remains controversial whether the concept of partial awareness or consciousness makes sense. The moral and legal status of MCS patients is contested, with a particularly noteworthy debate concerning whether consciousness makes a moral difference in right to die, end of life, and continuting care debates. With emerging technologies such as Deep Brain Stimulation being proposed as treatments that might increase the level of awareness in VS and MCS patients, there is ethical controversy about the use of these experimental therapies on unconsenting persons, as well as concerns about quality of life in states of impaired consciousness.
Key works The right to die debate, while considered more or less settled for persons in the VS, is more controversial in the case of MCS. Johnson argues that this controversy gets the problem backwards, and that there may well be more compelling reasons to end life sustaining measures in the MCS (Johnson 2011); Glannon claims that quality of life considerations and the burdens of treatment argue for the right to die in MCS (Glannon 2013). Kahane et al consider the moral significance of consciousness (Kahane & Savulescu 2009) in MCS; Gillett calls for a reassessment of the concept of futility in light of MCS (Gillett 2011). Glannon (Glannon 2008) and Schiff et al (Schiff 2009 ) consider  the ethics of deep brain stimulation as an experimental therapy for MCS and VS patients.
Introductions Giacino 2006; Wilkinson & Savulescu 2013; Jox & Kuehlmeyer 2013; Sheather 2013.
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  1. Stephen Ashwal (2003). Medical Aspects of the Minimally Conscious State in Children. Brain and Development 25 (8):535-545.
  2. James L. Bernat (2006). Chronic Disorders of Consciousness. Lancet 367 (9517):1181-1192.
  3. James L. Bernat (2002). Questions Remaining About the Minimally Conscious State. Neurology 58 (3):337-338.
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  4. Melanie Boly, Marie-Elisabeth E. Faymonville & Philippe Peigneux (2004). Auditory Processing in Severely Brain Injured Patients: Differences Between the Minimally Conscious State and the Persistent Vegetative State. Archives of Neurology 61 (2):233-238.
  5. J. Cole (2007). Comment on Laureys Et Al. Self-Consciousness in Non-Communicative Patients☆. Consciousness and Cognition 16 (3):742-745.
    Until comparatively recently, say the middle of the last century, spinal cord injury was fatal as pressure sores and other infections took their toll. Those with severe brain injuries, unable to move or even communicate, fared even worse; without movement or feeding such patients were nursed until nature took its course. Over the last few decades medical and nursing advances have enabled some of these vegetative patients to survive for considerable time, provoking, at times, ethical and legal dilemmas. Though they (...)
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  6. Diane Coleman, D. Alan Shewmon & J. T. Giacino (2002). "The Minimally Conscious State: Definition and Diagnostic Criteria": Comments and Reply. Neurology 58 (3):506-507.
  7. A. Demertzi, E. Racine, M.-A. Bruno, D. Ledoux, O. Gosseries, A. Vanhaudenhuyse, M. Thonnard, A. Soddu, G. Moonen & S. Laureys (2013). Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue. [REVIEW] Neuroethics 6 (1):37-50.
    Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial nutrition (...)
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  8. Michele Farisco (2013). The Ethical Pain. Neuroethics 6 (2):265-276.
    The intriguing issue of pain and suffering in patients with disorders of consciousness (DOCs), particularly in Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) and Minimally Conscious State (MCS), is assessed from a theoretical point of view, through an overview of recent neuroscientific literature, in order to sketch an ethical analysis. In conclusion, from a legal and ethical point of view, formal guidelines and a situationist ethics are proposed in order to best manage the critical scientific uncertainty about pain and suffering in DOCs (...)
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  9. Michele Farisco, Enrico Alleva, Flavia Chiarotti, Simone Macri & Carlo Petrini (2014). Clinicians' Attitudes Toward Patients with Disorders of Consciousness: A Survey. Neuroethics 7 (1):93-104.
    Notwithstanding fundamental methodological advancements, scientific information about disorders of consciousness (DOCs)—e.g. Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) and Minimally Conscious State (MCS)—is incomplete. The possibility to discriminate between different levels of consciousness in DOC states entails treatment strategies and ethical concerns. Here we attempted to investigate Italian clinicians’ and basic scientists’ opinions regarding some issues emerging from the care and the research on patients with DOCs. From our survey emerged that Italian physicians working with patients with DOCs give a central role (...)
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  10. Alexander A. Fingelkurts, Andrew A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2013). The Value of Spontaneous EEG Oscillations in Distinguishing Patients in Vegetative and Minimally Conscious States. In Eror Basar & et all (eds.), Application of Brain Oscillations in Neuropsychiatric Diseases. Supplements to Clinical Neurophysiology. Elsevier. 81-99.
    Objective: The value of spontaneous EEG oscillations in distinguishing patients in vegetative and minimally conscious states was studied. Methods: We quantified dynamic repertoire of EEG oscillations in resting condition with closed eyes in patients in vegetative and minimally conscious states (VS and MCS). The exact composition of EEG oscillations was assessed by the probability-classification analysis of short-term EEG spectral patterns. Results: The probability of delta, theta and slow-alpha oscillations occurrence was smaller for patients in MCS than for VS. Additionally, only (...)
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  11. Alexander A. Fingelkurts, Andrew A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2012). EEG Oscillatory States as Neuro-Phenomenology of Consciousness as Revealed From Patients in Vegetative and Minimally Conscious States. Consciousness and Cognition 21 (1):149-169.
    The value of resting electroencephalogram (EEG) in revealing neural constitutes of consciousness (NCC) was examined. We quantified the dynamic repertoire, duration and oscillatory type of EEG microstates in eyes-closed rest in relation to the degree of expression of clinical self-consciousness. For NCC a model was suggested that contrasted normal, severely disturbed state of consciousness and state without consciousness. Patients with disorders of consciousness were used. Results suggested that the repertoire, duration and oscillatory type of EEG microstates in resting condition quantitatively (...)
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  12. Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2013). Prognostic Value of Resting-State EEG Structure in Disentangling Vegetative and Minimally Conscious States: A Preliminary Study. Neurorehabilitation and Neural Repair 27 (4):345-354.
    Background: Patients in a vegetative state pose problems in diagnosis, prognosis and treatment. Currently, no prognostic markers predict the chance of recovery, which has serious consequences, especially in end-of-life decision-making. -/- Objective: We aimed to assess an objective measurement of prognosis using advanced electroencephalography (EEG). -/- Methods: EEG data (19 channels) were collected in 14 patients who were diagnosed to be persistently vegetative based on repeated clinical evaluations at 3 months following brain damage. EEG structure parameters (amplitude, duration and variability (...)
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  13. Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2012). DMN Operational Synchrony Relates to Self-Consciousness: Evidence From Patients in Vegetative and Minimally Conscious States. Open Neuroimaging Journal 6:55-68.
    The default mode network (DMN) has been consistently activated across a wide variety of self-related tasks, leading to a proposal of the DMN’s role in self-related processing. Indeed, there is limited fMRI evidence that the functional connectivity within the DMN may underlie a phenomenon referred to as self-awareness. At the same time, none of the known studies have explicitly investigated neuronal functional interactions among brain areas that comprise the DMN as a function of self-consciousness loss. To fill this gap, EEG (...)
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  14. Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2012). Toward Operational Architectonics of Consciousness: Basic Evidence From Patients with Severe Cerebral Injuries. Cognitive Processing 13 (2):111-131.
    Although several studies propose that the integrity of neuronal assemblies may underlie a phenomenon referred to as awareness, none of the known studies have explicitly investigated dynamics and functional interactions among neuronal assemblies as a function of consciousness expression. In order to address this question EEG operational architectonics analysis (Fingelkurts and Fingelkurts, 2001, 2008) was conducted in patients in minimally conscious (MCS) and vegetative states (VS) to study the dynamics of neuronal assemblies and operational synchrony among them as a function (...)
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  15. Joseph J. Fins (2005). Rethinking Disorders of Consciousness: New Research and its Implications. Hastings Center Report 35 (2):22-24.
  16. Joseph J. Fins, Nicholas D. Schiff & Kathleen M. Foley (2007). Late Recovery From the Minimally Conscious State: Ethical and Policy Implications. Neurology 68 (4):304-307.
  17. Joseph T. Giacino (2006). The Minimally Conscious State: Defining the Borders of Consciousness. In Steven Laureys (ed.), Boundaries of Consciousness. Elsevier.
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  18. Joseph T. Giacino & Childs N. Ashwal S. (2002). The Minimally Conscious State: Definition and Diagnostic Criteria. Neurology 58 (3):349-353.
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  19. Joseph T. Giacino & Kathleen Kalmar (2005). Diagnostic and Prognostic Guidelines for the Vegetative and Minimally Conscious States. Neuropsychological Rehabilitation. Vol 15 (3-4):166-174.
  20. Joseph T. Giacino & Kathleen Kalmar (1997). The Vegetative and Minimally Conscious States: A Comparison of Clinical Features and Functional Outcome. Journal of Head Trauma Rehabilation 12:36-51.
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  21. Joseph T. Giacino & Charlotte T. Trott (2004). Rehabilitative Management of Patients with Disorders of Consciousness: Grand Rounds. Journal of Head Trauma Rehabilitation 19 (3):254-265.
  22. Joseph T. Giacino & J. T. Whyte (2005). The Vegetative and Minimally Conscious States: Current Knowledge and Remaining Questions. Journal of Head Trauma Rehabilation 20 (1):30-50.
  23. H. Gill-Thwaites & R. Munday (2004). The Sensory Modality Assessment and Rehabilitation Technique (SMaRT): A Valid and Reliable Assessment for Vegetative State and Minimally Conscious State Patients. Brain Injury 18 (12):1255-1269.
  24. Jacob Gipson, Guy Kahane & Julian Savulescu (2014). Attitudes of Lay People to Withdrawal of Treatment in Brain Damaged Patients. Neuroethics 7 (1):1-9.
    BackgroundWhether patients in the vegetative state (VS), minimally conscious state (MCS) or the clinically related locked-in syndrome (LIS) should be kept alive is a matter of intense controversy. This study aimed to examine the moral attitudes of lay people to these questions, and the values and other factors that underlie these attitudes.MethodOne hundred ninety-nine US residents completed a survey using the online platform Mechanical Turk, comprising demographic questions, agreement with treatment withdrawal from each of the conditions, agreement with a series (...)
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  25. W. Glannon (2013). Burdens of ANH Outweigh Benefits in the Minimally Conscious State. Journal of Medical Ethics 39 (9):551-552.
    In the case of the minimally conscious patient M, the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration (ANH) from her. The Court reasoned that the sanctity of life was the determining factor and that it would not be in M's best interests for ANH to be withdrawn. This paper argues that the Court's reasoning is flawed and that continued ANH was not in this patient's best interests and thus should have been (...)
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  26. Walter Glannon (2008). Neurostimulation and the Minimally Conscious State. Bioethics 22 (6):337–345.
    Neurostimulation to restore cognitive and physical functions is an innovative and promising technique for treating patients with severe brain injury that has resulted in a minimally conscious state (MCS). The technique may involve electrical stimulation of the central thalamus, which has extensive projections to the cerebral cortex. Yet it is unclear whether an improvement in neurological functions would result in a net benefit for these patients. Quality-of-life measurements would be necessary to determine whether any benefit of neurostimulation outweighed any harm (...)
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  27. Jean-Michel Guérit (2005). Neurophysiological Patterns of Vegetative and Minimally Conscious States. Neuropsychological Rehabilitation. Vol 15 (3-4):357-371.
  28. Jakob Hohwy & David Reutens (2009). A Case for Increased Caution in End of Life Decisions for Disorders of Consciousness. Monash Bioethics 28 (2):13.1-13.13.
    Disorders of consciousness include coma, the vegetative state and the minimally conscious state. Such patients are often regarded as unconscious. This has consequences for end of life decisions for these patients: it is much easier to justify withdrawing life support for unconscious than conscious patients. Recent brain imaging research has however suggested that some patients may in fact be conscious.
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  29. E. Jackson (2013). The Minimally Conscious State and Treatment Withdrawal: W V M. Journal of Medical Ethics 39 (9):559-561.
    This short comment on the Court of Protection decision in W v M draws attention to the primacy the judge gave to the preservation of life and discusses the relative lack of weight accorded to M's previously expressed views.
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  30. L. Syd M. Johnson (2011). The Right to Die in the Minimally Conscious State. Journal of Medical Ethics 37 (37):175-178.
    The right to die has for decades been recognised for persons in a vegetative state, but there remains controversy about ending life-sustaining medical treatment for persons in the minimally conscious state (MCS). The controversy is rooted in assumptions about the moral significance of consciousness, and the value of life for patients who are conscious and not terminally ill. This paper evaluates these assumptions in light of evidence that generates concerns about quality of life in the MCS. It is argued that (...)
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  31. Ralf J. Jox & Katja Kuehlmeyer (2013). Introduction: Reconsidering Disorders of Consciousness in Light of Neuroscientific Evidence. Neuroethics 6 (1):1-3.
    Disorders of consciousness pose a substantial ethical challenge to clinical decision making, especially regarding the use of life-sustaining medical treatment. For these decisions it is paramount to know whether the patient is aware or not. Recent brain research has been striving to assess awareness by using mainly functional magnetic resonance imaging. We review the neuroscientific evidence and summarize the potential and problems of the different approaches to prove awareness. Finally, we formulate the crucial ethical questions and outline the different articles (...)
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  32. Guy Kahane & Julian Savulescu (2009). Brain-Damaged Patients and the Moral Significance of Consciousness. Journal of Medicine and Philosophy 34 (1):6-26.
    Neuroimaging studies of brain-damaged patients diagnosed as in the vegetative state suggest that the patients might be conscious. This might seem to raise no new ethical questions given that in related disputes both sides agree that evidence for consciousness gives strong reason to preserve life. We question this assumption. We clarify the widely held but obscure principle that consciousness is morally significant. It is hard to apply this principle to difficult cases given that philosophers of mind distinguish between a range (...)
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  33. Douglas Katz, Minimally Conscious States.
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  34. Robert T. Knight (2008). Consciousness Unchained: Ethical Issues and the Vegetative and Minimally Conscious State. American Journal of Bioethics 8 (9):1 – 2.
  35. Steven Laureys, Marie-Elisabeth E. Faymonville & M. Ferring (2003). Differences in Brain Metabolism Between Patients in Coma, Vegetative State, Minimally Conscious State and Locked-in Syndrome. European Journal of Neurology 10.
  36. Steven Laureys, Fabien Perrin & Marie-Elisabeth E. Faymonville (2004). Cerebral Processing in the Minimally Conscious State. Neurology 63 (5):916-918.
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  37. Neil Levy & Julian Savulescu (2009). Moral Significance of Phenomenal Consciousness. Progress in Brain Research.
    Recent work in neuroimaging suggests that some patients diagnosed as being in the persistent vegetative state are actually conscious. In this paper, we critically examine this new evidence. We argue that though it remains open to alternative interpretations, it strongly suggests the presence of consciousness in some patients. However, we argue that its ethical significance is less than many people seem to think. There are several different kinds of consciousness, and though all kinds of consciousness have some ethical significance, different (...)
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  38. Richard Malone, Caroline Schnakers & Kathleen Kalmar, Does the Four Score Correctly Diagnose the Vegetative and Minimally Conscious States?
    Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests for eye movements (...)
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  39. Lionel Naccache (2006). Is She Conscious? Science 313 (5792).
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  40. Quentin Noirhomme, Neuroimaging After Coma.
    Following coma, some patients will recover wakefulness without signs of consciousness (only showing reflex movements, i.e., the vegetative state) or may show non-reflex movements but remain without functional communication (i.e., the minimally conscious state). Currently, there remains a high rate of misdiagnosis of the vegetative state (Schnakers et. al. BMC Neurol, 9:35, 8) and the clinical and electrophysiological markers of outcome from the vegetative and minimally conscious states remain unsatisfactory. This should incite clinicians to use multimodal assessment to detect objective (...)
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  41. Quentin Noirhomme & Caroline Schnakers, A Twitch of Consciousness: Defining the Boundaries of Vegetative and Minimally Conscious States.
    Some patients awaken from their coma but only show reflex motor activity. This condition of wakeful (eyes open) unawareness is called the vegetative state. In 2002, a new clinical entity coined ‘‘minimally conscious state’’ defined patients who show more than reflex responsiveness but remain unable to communicate their thoughts and feelings. Emergence from the minimally conscious state is defined by functional recovery of verbal or nonverbal communication.1 Our empirical medical definitions aim to propose clearcut borders separating disorders of consciousness such (...)
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  42. Fabien Perrin, Caroline Schnakers, Manuel Schabus, Christian Degueldre, Serge Goldman, Serge Brédart, Marie-Elisabeth E. Faymonville, Maurice Lamy, Gustave Moonen, André Luxen, Pierre Maquet & Steven Laureys (2006). Brain Response to One's Own Name in Vegetative State, Minimally Conscious State, and Locked-in Syndrome. Archives of Neurology 63 (4):562-569.
  43. Christophe Phillips & Rafael Malach, Identifying the Default-Mode Component in Spatial IC Analyses of Patients with Disorders of Consciousness.
    Objectives: Recent fMRI studies have shown that it is possible to reliably identify the defaultmode network (DMN) in the absence of any task, by resting-state connectivity analyses in healthy volunteers. We here aimed to identify the DMN in the challenging patient population of disorders of consciousness encountered following coma. Experimental design: A spatial independent component analysis-based methodology permitted DMN assessment, decomposing connectivity in all its different sources either neuronal or artifactual. Three different selection criteria were introduced assessing anticorrelation-corrected connectivity with (...)
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  44. Catherine Rodrigue, Richard J. Riopelle, James L. Bernat & Eric Racine (2013). Perspectives and Experience of Healthcare Professionals on Diagnosis, Prognosis, and End-of-Life Decision Making in Patients with Disorders of Consciousness. Neuroethics 6 (1):25-36.
    In the care of patients with disorders of consciousness (DOC), some ethical difficulties stem from the challenges of accurate diagnosis and the uncertainty of prognosis. Current neuroimaging research on these disorders could eventually improve the accuracy of diagnoses and prognoses and therefore change the context of end-of-life decision making. However, the perspective of healthcare professionals on these disorders remains poorly understood and may constitute an obstacle to the integration of research. We conducted a qualitative study involving healthcare professionals from an (...)
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  45. Nicholas D. Schiff (2006). Modeling the Minimally Conscious State: Measurements of Brain Function and Therapeutic Possibilities. In Steven Laureys (ed.), Boundaries of Consciousness. Elsevier.
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  46. Nicholas D. Schiff, D. Rodriguez-Moreno & A. Kamal (2005). FMRI Reveals Large-Scale Network Activation in Minimally Conscious Patients. Neurology 64:514-523.
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  47. J. C. Sheather (2013). Withdrawing and Withholding Artificial Nutrition and Hydration From Patients in a Minimally Conscious State: Re: M and its Repercussions. Journal of Medical Ethics 39 (9):543-546.
    In 2011 the English Court of Protection ruled that it would be unlawful to withdraw artificial nutrition and hydration from a woman, M, who had been in a minimally conscious state for 8 years. It was reported as the first English legal case concerning withdrawal of artificial nutrition and hydration from a patient in a minimally conscious state who was otherwise stable. In the absence of a valid and applicable advance decision refusing treatment, of other life-limiting pathology or excessively burdensome (...)
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  48. L. R. Talbot & H. A. Whitaker (1994). Brain-Injured Persons in an Altered State of Consciousness: Measures and Intervention Strategies. Brain Injury 8:689-99.
  49. Jukka Varelius (2011). Minimally Conscious State, Human Dignity, and the Significance of Species: A Reply to Kaczor. Neuroethics (Browse Results) 6 (1):85-95.
    Abstract In a recent issue of Neuroethics , I considered whether the notion of human dignity could help us in solving the moral problems the advent of the diagnostic category of minimally conscious state (MCS) has brought forth. I argued that there is no adequate account of what justifies bestowing all MCS patients with the special worth referred to as human dignity. Therefore, I concluded, unless that difficulty can be solved we should resort to other values than human dignity in (...)
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  50. Jukka Varelius (2011). Respect for Autonomy, Advance Directives, and Minimally Conscious State. Bioethics 25 (9):505-515.
    In this article, I consider whether the advance directive of a person in minimally conscious state ought to be adhered to when its prescriptions conflict with her current wishes. I argue that an advance directive can have moral significance after its issuer has succumbed to minimally conscious state. I also defend the view that the patient can still have a significant degree of autonomy. Consequently, I conclude that her advance directive ought not to be applied. Then I briefly assess whether (...)
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