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Summary The vegetative state (VS) and coma are categorized as disorders of consciousness. Both are states of unconsciousness, in which patients are defined as being unaware; the VS is a state of wakeful unconsciousness, in which patients experience sleep/wake cycles, which distinguishes it from coma. It has long been suspected that the rate of misdiagnosis in the VS is as high as 40%. That is, ~40% of patients diagnosed as unconsciousness may in fact be conscious. Recent neuroscientific developments, particularly in functional neuroimaging, have identified patients who are functionally locked in, unable to respond behaviorally, but able to wilfully modulate their brain activity to indicate that they are conscious. This has resulted in an effort to rename the VS as Unresponsive Wakefulness Syndrome (UWS), both to more accurately describe the condition, and to remove the stigma and negative associations of the term "vegetative" (and the pejorative "vegetable").The key ethical issues with VS and Coma are the right to die and the value of life in a state of unconsciousness, along with ancillary questoins about precedent autonomy. Other ethical issues include the high rate of misdiagnosis, controversy concerning the concept of brain-based "behavior," and questions about quality of life and the best interests of unconscious persons.
Key works After years of clinical neglect and nihilism, a veritable explosion of research into disorders of consciousness in recent years has prompted considerable bioethical debate, as well as reconsideration of key concepts in consciousness studies. Capron provides an overview of the issues and debates here (Capron 1991). Shewmon interrogates the concept of the vegetative state (Shewmon 2004) here; Stins and Laureys (Stins & Laureys 2009); Monti et al (Monti et al 2010), and Owen et al (Owen et al 2007) discuss the ramifications of brain-based "behavior" and the detection of covert consciousness through functional imaging paradigms. Brukamp ( Brukamp 2013) considers whether a new right attaches to patients with disorders of consciousness, in light of recent neuroscientific evidence: a right to the right diagnosis. Panksepp considers the status of the "mind" in the VS (Panksepp et al 2007); and Levy&Savulescu evaluate the moral significance of phenomenal consciousness in ethical debates.
Introductions Knight 2008; Jox & Kuehlmeyer 2013; Jennett 2006; Goodman 2010; Illes & Sahakian 2011.
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  1. - - (1995). Recommendations for the Use of Uniform Nomenclature Pertinent to Patients with Severe Alterations in Consciousness. Arch Phys Med Rehabilation 76:205-209.
  2. A. C. Armstrong (1907). Alkins's The Persistent Problems of Philosophy. [REVIEW] Journal of Philosophy 4 (16):440.
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  3. A. Asai, M. Maekawa, I. Akiguchi, T. Fukui, Y. Miura, N. Tanabe & S. Fukuhara (1999). Survey of Japanese Physicians' Attitudes Towards the Care of Adult Patients in Persistent Vegetative State. Journal of Medical Ethics 25 (4):302-308.
    OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what (...)
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  4. Atsushi Asai (2011). A Question In End-of-Life Medicine In Japan: Three Levels Structure Analysis Of The Ethics Of Provision Of Permanent And Active Artificial Nutrition And Hydration For Elderly Who Cannot Eat. Eubios Journal of Asian and International Bioethics 21 (1-2):37-40.
    This article will focus on issues concerning the provision of artificial nutrition and hydration to patients who are extremely old, completely bedridden, and totally dependent on others. These patients have no advance directives, no malignancy, suffer from persistent but unstable disturbance of consciousness as well as severe cognitive impairment, and cannot eat sufficient amounts of food to maintain their lives. Should ANH be provided? Some would agree while others would maintain otherwise. The underlying values and normative theory behind each argument (...)
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  5. Atsushi Asai & Masashi Shirahama (1997). Case Study 1: Hemodialysis For A Patient In Persistent Vegetative State. Eubios Journal of Asian and International Bioethics 7 (4):105-107.
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  6. Stephen Ashwal (2003). Medical Aspects of the Minimally Conscious State in Children. Brain and Development 25 (8):535-545.
  7. I. Assure You That May (forthcoming). Nutrition and Hydration. Hastings Center Report.
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  8. Sergio Bagnato, Cristina Boccagni, A. Sant'Angelo, Alexander A. Fingelkurts, Andrew A. Fingelkurts, C. Gagliardo & G. Galardi (2014). Long-Lasting Coma. Functional Neurology 29 (3):201-205.
    In this report, we describe the case of a patient who has remained in a comatose state for more than one year after a traumatic and hypoxic brain injury. This state, which we refer to as long-lasting coma (LLC), may be a disorder of consciousness with significantly different features from those of conventional coma, the vegetative state, or brain death. On the basis of clinical, neurophysiological and neuroimaging data, we hypothesize that a multilevel involvement of the ascending reticular activating system (...)
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  9. Sergio Bagnato, Cristina Boccagni, Antonino Sant'Angelo, Alexander A. Fingelkurts, Andrew A. Fingelkurts & Giuseppe Galardi (2013). Emerging From an Unresponsive Wakefulness Syndrome: Brain Plasticity has to Cross a Threshold Level. Neuroscience and Biobehavioral Reviews 37 (10):2721-2736.
    Unresponsive wakefulness syndrome (UWS, previously known as vegetative state) occurs after patients survive a severe brain injury. Patients suffering from UWS have lost awareness of themselves and of the external environment and do not retain any trace of their subjective experience. Current data demonstrate that neuronal functions subtending consciousness are not completely reset in UWS; however, they are reduced below the threshold required to experience consciousness. The critical factor that determines whether patients will recover consciousness is the distance of their (...)
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  10. Christiane Bailey (2007). La vie vegetative des animaux. Heidegger deconstruction of animal life. Phaenex 2 (2):81-123.
    The destruction of animality that takes place in Heidegger’s Fundamental Concepts of Metaphysics goes as far as to destroy the very idea of an animal life as distinct from plant life. “Life”, as Heidegger says in Being and Time, is “a specific mode of being”, that is to say, as the 1929-30 lecture course will show, that it is “the mode of being of animals and plants”. Conceived as a mere organism that does “nothing more than to live”, the animal (...)
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  11. Charles H. Baron (1991). Why Withdrawal of Life-Support for PVS Patients Is Not a Family Decision. Journal of Law, Medicine and Ethics 19 (1-2):73-75.
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  12. Claudio Bassetti (2001). Disturbances of Consciousness and Sleep-Wake Functions. In Julien Bogousslavsky & Louis R. Caplan (eds.), Stroke Syndromes. Cambridge University Press. 192-210.
  13. D. Bates & N. Cartlidge (1994). Disorders of Consciousness. In E. Critchley (ed.), The Neurological Boundaries of Reality. Farrand.
  14. J. Graham Beaumont & Pamela M. Kenealy (2005). Incidence and Prevalence of the Vegetative and Minimally Conscious States. Neuropsychological Rehabilitation 15 (3):184-189.
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  15. Tristan Bekinschtein, Cecilia Tiberti, Jorge Niklison, Mercedes Tamashiro, Melania Ron, Silvina Carpintiero, Mirta Villarreal, Cecilia Forcato, Ramon Leiguarda & Facundo Manes (2005). Assessing Level of Consciousness and Cognitive Changes From Vegetative State to Full Recovery. Neuropsychological Rehabilitation. Vol 15 (3-4):307-322.
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  16. James L. Bernat (2006). The Concept and Practice of Brain Death. In Steven Laureys (ed.), Boundaries of Consciousness. Elsevier.
  17. James L. Bernat (2006). Chronic Disorders of Consciousness. Lancet 367 (9517):1181-1192.
  18. James L. Bernat (2002). Questions Remaining About the Minimally Conscious State. Neurology 58 (3):337-338.
  19. James L. Bernat (1992). The Boundaries of the Persistent Vegetative State. Journal of Clinical Ethics 3 (3):176.
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  20. J. Andrew Billings, Larry R. Churchill & Richard Payne (2010). Severe Brain Injury and the Subjective Life. Hastings Center Report 40 (3):17-21.
  21. J. P. Bishop & E. L. Bedford (2011). Medically Assisted Nutrition and Hydration: The Vegetative State and Beyond. Christian Bioethics 17 (2):97-104.
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  22. J. P. Bishop & D. R. Morrison (2011). The Roman Catholic Church, Biopolitics, and the Vegetative State. Christian Bioethics 17 (2):165-184.
    Compelled by recent public and politicized cases in which withdrawal of nutrition and hydration were at issue, this essay examines recent Church statements and argues that the distinction between private and public forms of human life is being lost. Effacing the distinction between the sphere of the home (oikos), where the maintenance of life (zoē) occurs, and the city (polis), where political and public life (bios) occurs, may have unforeseen and unwanted consequences. Through their well-intentioned efforts to preserve the sanctity (...)
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  23. J. Blandford (2011). An Examination of the Revisionist Challenge to the Catholic Tradition on Providing Artificial Nutrition and Hydration to Patients in a Persistent Vegetative State. Christian Bioethics 17 (2):153-164.
    The Catholic moral tradition has consistently offered the distinction between ordinary and extraordinary means as a framework for making end-of-life decisions. Recent papal allocutions, however, have raised the question of whether providing artificial nutrition to patients in a persistent vegetative state is to be considered ordinary and thus morally obligatory in all cases. I argue that this “revisionist” position is contrary to Catholic teaching and that enforcing such a position would endanger the ability of Catholic health care institutions to minister (...)
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  24. 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.
  25. Chris Borthwick (1995). Persistent Vegetative State: A Syndrome in Search of a Name, or a Judgement in Search of a Syndrome? Monash Bioethics Review 14 (2):20-25.
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  26. Sophie Botros (1995). Acts, Omissions, and Keeping Patients Alive in a Persistent Vegetative State. In Royal Institute of Philosophy Supplement. New York: Cambridge University Press. 99-119.
    There are many conflicting attitudes to technological progress: some people are fearful that robots will soon take over, even perhaps making ethical decisions for us, whilst others enthusiastically embrace a future largely run for us by them. Still others insist that we cannot predict the long term outcome of present technological developments. In this paper I shall be concerned with the impact of the new technology on medicine, and with one particularly agonizing ethical dilemma to which it has already given (...)
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  27. Sophie Botros (1995). Philosophy and Technology. New York: Cambridge University Press.
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  28. Joseph Boyle (2008). Towards Ethical Guidelines for the Use of Artificial Nutrition and Hydration. In C. Tollefsen (ed.), Artificial Nutrition and Hydration. Springer Press. 111--122.
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  29. Baruch Brody (1992). Special Ethical Issues in the Management of PVS Patients. Journal of Law, Medicine and Ethics 20 (1-2):104-115.
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  30. Kirsten Brukamp (2013). Right (to a) Diagnosis? Establishing Correct Diagnoses in Chronic Disorders of Consciousness. Neuroethics 6 (1):5-11.
    Chronic disorders of consciousness, particularly the vegetative and the minimally conscious states, pose serious diagnostic challenges to neurologists and clinical psychologists. A look at the concept of “diagnosis” in medicine reveals its social construction: While medical categorizations are intended to describe facts in the real world, they are nevertheless dependent on conventions and agreements between experts and practitioners. For chronic disorders of consciousness in particular, the terminology has proven problematic and controversial over the years. Novel research utilizing functional brain imaging (...)
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  31. Vanessa Carbonell (2013). Interactive Capacity, Decisional Capacity, and a Dilemma for Surrogates. AJOB Neuroscience 4 (4):36-37.
  32. Paolo Cattorini & Massimo Reichlin (1997). Persistent Vegetative State: A Presumption to Treat. Theoretical Medicine and Bioethics 18 (3).
    The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these (...)
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  33. Gastone G. Celesia (1997). Persistent Vegetative State: Clinical and Ethical Issues. Theoretical Medicine and Bioethics 18 (3).
    Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient (...)
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  34. Camille Chatelle, Steven Laureys, Steve Majerus, Caroline Schnakers, Paula M. Niedenthal, Martial Mermillod, Marcus Maringer & Ursula Hess (2010). Eye Gaze and Conscious Processing in Severely Brain-Injured Patients. Behavioral and Brain Sciences 33 (6):442.
    Niedenthal et al. discuss the importance of eye gaze in embodied simulation and, more globally, in the processing of emotional visual stimulation (such as facial expression). In this commentary, we illustrate the relationship between oriented eye movements, consciousness, and emotion by using the case of severely brain-injured patients recovering from coma (i.e., vegetative and minimally conscious patients).
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  35. Peter Clark (2006). Tube Feedings and Persistent Vegetative State Patients: Ordinary or Extraordinary Means? Christian Bioethics 12 (1):43-64.
    This article looks at the late John Paul II's allocution on artificial nutrition and hydration (ANH) and the implications his statement will have on the ordinary-extraordinary care distinction. The purpose of this article is threefold: first, to examine the medical condition of a persistent vegetative state (PVS); second, to examine and analyze the Catholic Church's tradition on the ordinary-extraordinary means distinction; and third, to analyze the ethics behind the pope's recent allocution in regards to PVS patients as a matter of (...)
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  36. S. J. Rev Peter Clark (2006). Tube Feedings and Persistent Vegetative State Patients: Ordinary or Extraordinary Means? Christian Bioethics 12 (1):43-64.
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  37. 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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  38. 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.
  39. Allan Combs, David Kahn & Stanley Krippner (2000). Dreaming and the Self-Organizing Brain. Journal of Consciousness Studies 7 (7):4-11.
    We argue that the rapid eye movement dream experiences owe their structure and meaning to inherent self-organizing properties of the brain itself. Thus, we offer a common meeting ground for brain based studies of dreaming and traditional psychological dream theory. Our view is that the dreaming brain is a self-organizing system highly sensitive to internally generated influences. Several lines of evidence support a process view of the brain as a system near the edge of chaos, one that is highly sensitive (...)
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  40. R. B. Connors Jr (1993). US Catholic Bishops on Nutrition and Hydration: A Second Opinion. Journal of Clinical Ethics 4 (3):253.
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  41. Catherine Constable (2012). Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack. Bioethics 26 (3):157-163.
    In the United States, the decision of whether to withdraw or continue to provide artificial nutrition and hydration (ANH) for patients in a permanent vegetative state (PVS) is placed largely in the hands of surrogate decision-makers, such as spouses and immediate family members. This practice would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare. When there is ambiguity as to the patient's advanced wishes, the presumption has been that decisions should weigh in favor of (...)
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  42. Ronald Cranford (2005). Facts, Lies, and Videotapes: The Permanent Vegetative State and the Sad Case of Terri Schiavo. Journal of Law, Medicine and Ethics 33 (2):363-371.
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  43. C. M. de Giorgio & M. F. Lew (1991). Consciousness, Coma, and the Vegetative State: Physical Basis and Definitional Character. Issues in Law and Medicine 6:361-371.
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  44. 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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  45. Athena Demertzi & Mario Stanziano, Reaching Across the Abyss: Recent Advances in Functional Magnetic Resonance Imaging and Their Potential Relevance to Disorders of Consciousness.
    Disorders of consciousness (DOC) raise profound scientific, clinical, ethical, and philosophical issues. Growing knowledge on fundamental principles of brain organization in healthy individuals offers new opportunities for a better understanding of residual brain function in DOCs. We here discuss new perspectives derived from a recently proposed scheme of brain organization underlying consciousness in healthy individuals. In this scheme, thalamo-cortical networks can be divided into two, often antagonistic, global systems: (i) a system of externally oriented, sensory-motor networks (the ‘‘extrinsic’’ system); and (...)
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  46. Athina Demertzi, Eric Racine, Marie-Aurélie Bruno, Didier Ledoux, Olivia Gosseries, Audrey Vanhaudenhuyse, Marie Thonnard, Andrea Soddu, Gustave Moonen & Steven Laureys (forthcoming). Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue. Neuroethics.
  47. Peter H. Ditto (2008). What Would Terri Want? : Advance Directive and the Psychological Challenges of Surrogate Decision Making. In James L. Werth & Dean Blevins (eds.), Decision Making Near the End of Life: Issues, Development, and Future Directions. Brunner-Routledge.
  48. Jon B. Eisenberg (2008). Schiavo on the Cutting Edge: Functional Brain Imaging and its Impact on Surrogate End-of-Life Decision-Making. Neuroethics 1 (2):75-83.
    The article addresses the potential impact of functional brain imaging (functional magnetic resonance imaging and positron-emission tomography) on surrogate end-of-life decision-making in light of varying state-law definitions of consciousness, some of which define awareness behaviorally and others functionally. The article concludes that, in light of admonitions by neuroscientists that functional brain imaging cannot yet replace behavioral evaluation to determine the existence of consciousness, state legislatures, courts and drafters of written advance healthcare directives should consider treating behavior, not function, as the (...)
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  49. 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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  50. 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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