A growing number of studies show that a significant proportion of patients, who meet the clinical criteria for the diagnosis of the vegetative state, demonstrate evidence of covert awareness through successful performance of neuroimaging tasks. Despite these important advances, the day-to-day life experiences of any such patient remain unknown. This presents a major challenge for optimizing the patient’s standard of care and quality of life. We describe a patient who, following emergence from a state of complete behavioral (...) unresponsiveness and a clinical diagnosis of VS, reported rich memories of his experience during this time. This case demonstrates the potential for a sophisticated mental life enabled by preserved memory in a proportion of patients who, similarly, are thought to be unconscious. Therefore, it presents an important opportunity to examine the implications for patient QoL and standard of care, both during the period of presumed unconsciousness and after recovery. (shrink)

It has been argued that complex subjective sense of self is linked to the brain default-mode network (DMN). Recent discovery of heterogeneity between distinct subnets (or operational modules - OMs) of the DMN leads to a reconceptualization of its role for the experiential sense of self. Considering the recent proposition that the frontal DMN OM is responsible for the first-person perspective and the sense of agency, while the posterior DMN OMs are linked to the continuity of ‘I’ experience (including autobiographical (...) memories) through embodiment and localization within bodily space, we have tested in this study the hypothesis that heterogeneity in the operational synchrony strength within the frontal DMN OM among patients who are in a vegetative state (VS) could inform about a stable self-consciousness recovery later in the course of disease (up to six years post-injury). Using EEG operational synchrony analysis we have demonstrated that among the three OMs of the DMN only the frontal OM showed important heterogeneity in VS patients as a function of later stable clinical outcome. We also found that the frontal DMN OM was characterized by the process of active uncoupling (stronger in persistent VS) of operations performed by the involved neuronal assemblies. (shrink)

Background Decisions on limiting life-sustaining treatment for patients in the vegetative state (VS) are emotionally and morally challenging. In Germany, doctors have to discuss, together with the legal surrogate (often a family member), whether the proposed treatment is in accordance with the patient's will. However, it is unknown whether family members of the patient in the VS actually base their decisions on the patient's wishes. Objective To examine the role of advance directives, orally expressed wishes, or the presumed (...) will of patients in a VS for family caregivers' decisions on life-sustaining treatment. Methods and sample A qualitative interview study with 14 next of kin of patients in a VS in a long-term care setting was conducted; 13 participants were the patient's legal surrogates. Interviews were analysed according to qualitative content analysis. Results The majority of family caregivers said that they were aware of aforementioned wishes of the patient that could be applied to the VS condition, but did not base their decisions primarily on these wishes. They gave three reasons for this: (a) the expectation of clinical improvement, (b) the caregivers' definition of life-sustaining treatments and (c) the moral obligation not to harm the patient. If the patient's wishes were not known or not revealed, the caregivers interpreted a will to live into the patient's survival and non-verbal behaviour. Conclusions Whether or not prior treatment wishes of patients in a VS are respected depends on their applicability, and also on the medical assumptions and moral attitudes of the surrogates. We recommend repeated communication, support for the caregivers and advance care planning. (shrink)

Electroencephalogram (EEG) recordings are increasingly used to evaluate patients with disorders of consciousness (DOC) or assess their prognosis outcome in the short-term perspective. However, there is a lack of information concerning the effectiveness of EEG in classifying long-term (many years) outcome in chronic DOC patients. Here we tested whether EEG operational architectonics parameters (geared towards consciousness phenomenon detection rather than neurophysiological processes) could be useful for distinguishing a very long-term (6 years) clinical outcome of DOC patients whose EEGs were registered (...) within 3 months post-injury. The obtained results suggest that EEG recorded at third month after sustaining brain damage, may contain useful information on the long-term outcome of patients in vegetative state: it could discriminate patients who remain in a persistent vegetative state from patients who reach a minimally conscious state or even recover a full consciousness in a long-term perspective (6 years) post-injury. These findings, if confirmed in further studies, may be pivotal for long-term planning of clinical care, rehabilitative programs, medical-legal decisions concerning the patients, and policy makers. (shrink)

Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts (...) in long-term care of patients in VS/UWS. A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making. (shrink)

Recent theoretical advances describing consciousness from information and integration have highlighted the unique role of the thalamocortical system in leading to integrated information and thus, consciousness. Here, we examined the differential distributions of specific and nonspecific thalamocortical functional connections using resting-state fMRI in a group of healthy subjects and vegetative-state patients. We found that both thalamic systems were widely distributed, but they exhibited different patterns. Nonspecific connections were preferentially associated with brain regions involved in higher-order cognitive processing, (...) self-awareness and introspective mentalizing . In contrast, specific connections were prevalent in the ventral and posterior part of the prefrontal and precuneus, known involved in representing externally-directed attentions. Significant reductions of functional connectivity in both systems, especially the nonspecific system, were observed in VS. These data suggest that brain networks sustaining information and integration may be differentiated by the nature of their thalamic functional connectivity. (shrink)

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 within quasi-stationary segments, as well as the spatial synchrony between such segments and the strength of this synchrony) were used to predict recovery of consciousness 3 months later. Results: The number and strength of cortical functional connections between EEG segments were higher in patients who recovered consciousness (P < .05 – P < .001) compared with those who did not recover. Linear regression analysis confirms that EEG structure parameters are capable of predicting (P = .0025) recovery of consciousness 6 months post-injury, whereas the same analysis failed to significantly predict patient outcome based on aspects of their clinical history alone (P = .629) or conventional EEG spectrum power (P = .473). Conclusions: The result of this preliminary study demonstrates that structural strategy of EEG analysis is better suited for providing prognosis of consciousness recovery than existing methods of clinical assessment and of conventional EEG. Our results may be a starting point for developing reliable prognosticators in patients who are in vegetative state, with the potential to improve their day-to-day management, quality of life, and access to early interventions. (shrink)

Recent theoretical advances describing consciousness from information and integration have highlighted the unique role of the thalamocortical system in leading to integrated information and thus, consciousness. Here, we examined the differential distributions of specific and nonspecific thalamocortical functional connections using resting-state fMRI in a group of healthy subjects and vegetative-state patients. We found that both thalamic systems were widely distributed, but they exhibited different patterns. Nonspecific connections were preferentially associated with brain regions involved in higher-order cognitive processing, (...) self-awareness and introspective mentalizing. In contrast, specific connections were prevalent in the ventral and posterior part of the prefrontal and precuneus, known involved in representing externally-directed attentions. Significant reductions of functional connectivity in both systems, especially the nonspecific system, were observed in VS. These data suggest that brain networks sustaining information and integration may be differentiated by the nature of their thalamic functional connectivity. (shrink)

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 related to the level of consciousness expression in brain-damaged patients and healthy-conscious subjects. Specifically, results demonstrated that (a) decreased number of EEG microstate types was associated with altered states of consciousness, (b) unawareness was associated with the lack of diversity in EEG alpha-rhythmic microstates, and (c) the probability for the occurrence and duration of delta-, theta- and slow-alpha-rhythmic microstates were associated with unawareness, whereas the probability for the occurrence and duration of fast-alpha-rhythmic microstates were associated with consciousness. In conclusion, resting EEG has a potential value in revealing NCC. This work may have implications for clinical care and medical–legal decisions in patients with disorders of consciousness. (shrink)

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 patients in MCS demonstrated fast-alpha oscillation occurrence. Depending on the type and composition of EEG oscillations, the probability of their occurrence was either aetiology dependent or independent. The probability of EEG oscillations occurrence differentiated brain injuries with different aetiologies. Conclusions: Spontaneous EEG oscillations have a potential value in distinguishing patients in VS and MCS. Significance: This work may have implications for clinical care, rehabilitative programs and medical–legal decisions in patients with impaired consciousness states following coma due to acute brain injuries. (shrink)

Patients in a minimally conscious state (MCS) fall into a different diagnostic category than patients in the more familiar vegetative states (VS). Not only are MCS patients conscious in some sense, they have a higher chance for recovery than VS patients. Because of these differences, we ostensibly have reason to provide MCS patients with care that goes beyond what we provide to patients with some VS patients. But how to justify this differential treatment? I argue we can’t justify (...) it solely by looking to MCS patients’ actual levels of consciousness. We must look also to the ways in which these patients are potentially conscious. Specifically, I argue that certain sensible and well-regarded policy recommendations cannot be justified by looking solely to patients’ actual levels of consciousness, but that they can be justified by looking to patients’ potential for consciousness. Insofar then as we have prima facie reason to follow the recommendations, we also have prima facie reason to view the potential for consciousness as morally salient. If that is true, however, several important implications follow: first, if the potential for consciousness is morally salient, this translates into actual and pressing obligations to patients with disorders of consciousness generally. Second, if the potential for consciousness is morally salient, this has implications that go beyond our obligations to patients with disorders of consciousness. Indeed, if the potential for consciousness is morally salient, this adds an important layer of complexity to the normative landscape, a layer we may not have sufficiently noticed before. (shrink)

Behaviorally assessing residual consciousness of acutely comatose patients involves a high rate of false-negatives. That is, long-term behavioral assessment shows that 41% of vegetative state patients in fact have residual consciousness. Nonetheless, surrogates need to remove ventilation before the acute-phase passes away if they want to induce medico-legal death due to pragmatic factors, such as financial costs. So, surrogate decision-making regarding behaviorally nonresponsive acutely comatose patients involves a moral dilemma: should we ignore the chance that patients have residual (...) consciousness for the sake of pragmatic factors? This paper examines whether neural methods can resolve the moral dilemma. Neural methods are used to assess residual consciousness of behaviorally nonresponsive postcomatose patients. For instance, by instructing a vegetative state patient to imagine wiggling all of her toes, conscious- ness is ascribed if brain activities are localized in the supplementary motor area. Since the most extensive application of neural methods has been in chronic population, it is unclear whether such methods can resolve the moral dilemma. I argue that neural methods also involve a high rate of false-negatives because current tasks of neural methods are structurally misguided. Given the argument, there is no significant difference between behavioral and neural methods regarding the moral dilemma. (shrink)

A large, diverse sample of adults was interviewed about their conception of the ontological and functional properties of the mind as compared to the soul. The existence of the mind was generally tied to the human lifecycle of conception, birth, growth and death, and was primarily associated with cognitive as opposed to spiritual functions. In contrast, the existence of the soul was less systematically tied to the lifecycle and frequently associated with spiritual as opposed to cognitive functions. Participants were also (...) asked about three ethical issues: stem cell research, life support for patients in a persistent vegetative state and cloning. As expected, participants' beliefs about the ontology and function of the soul were linked to their judgments about these ethical issues whereas their beliefs about the mind were unrelated. Overall, the findings show that many adults do not espouse a simple body-mind dualism, and any tendency toward such dualism is unlikely to explain their beliefs in an afterlife. Instead, afterlife beliefs appear to be associated with the idea of an immaterial essence, potentially dissociable from the biology of life and death. (shrink)

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 of consciousness expression. We found that in minimally conscious patients and especially in vegetative patients neuronal assemblies got smaller, their life-span shortened and they became highly unstable. Furthermore, we demonstrated that the extent/volume and strength of operational synchrony among neuronal assemblies was smallest or even absent in VS patients, intermediate in MCS patients and highest in healthy fully-conscious subjects. All findings were similarly observed in EEG alpha as well as beta1 and beta2 frequency oscillations. The presented results support the basic tenets of Operational Architectonics theory of brain-mind functioning and suggest that EEG operational architectonics analysis may provide an objective and accurate means of assessing signs of (un)consciousness in patients with severe brain injuries. Therefore this methodological approach may complement the existing “gold standard” of behavioral assessment of this population of challenging patients and inform the diagnostic and treatment decision-making processes. (shrink)

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 of ethical principles and three personality tests.ResultsMore supported treatment withdrawal from VS (40.2 % agreed, 17.6 % disagreed) than MCS (20.6 %, 41.2 %) or LIS (25.3 %, 35.8 %). Agreement with treatment withdrawal was negatively correlated with religiosity (r = −0.272, P < 0.001), though showed no significant relationship with need for cognition or empathy, and only a partial association with utilitarian judgment in a standard moral dilemma. Support for treatment withdrawal was most strongly associated with endorsement of the importance of patient autonomy, dignity, suffering, best interests. Distributive justice was not given significant weight by most. Importantly, agreement with treatment withdrawal was noticeably higher when considered from a first as opposed to third person perspective for VS (Z = −6.056, P < 0.001), MCS (Z = −6.746, P < 0.001) and LIS (Z = −6.681, P < 0.001).ConclusionLay attitudes to withdrawal of treatment in brain damaged patients are largely shaped by values similar to those central to the secular ethical debate. Neither traditional values such as the sanctity of life nor utilitarian values relating to resource allocation seem to play a central role. Far greater weight is given to autonomy, which may explain why participants were far more willing to endorse withdrawal of treatment when the issue was presented in the first person, or in relation to a concrete case involving a patient’s explicit wishes. Surveys focusing on abstract cases presented in the third person may not provide an accurate picture of lay attitudes to these critical ethical questions. (shrink)

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 is required in LLC. This description may be useful for the identification of other patients suffering from this severe disorder of consciousness, which raises important ethical issues. (shrink)

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 to ethics. Current Italian regulation regarding basic research conducted in patients with DOCs apparently risks to be inadequate to support scientific advancement, and would deserve a different assessment compared to ordinary treatments. We think the results of our survey deserve attention from an international audience because they exemplify the difficulty to define a shared approach to the issues related to patients with DOCs and the necessity to better assess both the ordinary and experimental treatment of patients with DOCs at the ethical and legal level. (shrink)

Dr. Vukov analyzing patients with disorders of consciousness, proposed that medical well-regarded policy recommendations cannot be justified by looking solely to patients’ actual levels of consciousness (minimally conscious state – MCS versus vegetative state – VS), but that they can be justified by looking to patients’ potential for consciousness. One objective way to estimate this potential (actual physical possibility) is to consider a neurophysiologically informed strategy. Ideally such strategy would utilize objective brain activity markers of consciousness/unconsciousness. The (...) Operational Architectonics (OA) theory of brain-mind functioning is an example of such a strategy. Besides being mathematically simple, neurophysiologically accurate, and compatible with the cognitive/phenomenal perspectives on consciousness, application of OA strategy to quantitative EEG analysis of patients in VS and MCS revealed that the absence of consciousness in VS is paralleled by impairment of overall EEG operational architecture. Specifically, neuronal assemblies become smaller, their life span shortened, and they became highly unstable and functionally disconnected (desynchronized). At the same time, fluctuating (minimal) awareness in patients in MCS was paralleled by partial restoration of EEG operational architecture (increased size, life span, and stability of neuronal assemblies, together with an increased number and strength of functional connections among them), approaching the level found in healthy fully conscious participants. Moreover OA strategy to EEG analysis allowed predicting the emergence of consciousness in VS patients after six years following the brain trauma. Therefore, the OA methodology could reliably predict which patients may regain consciousness, and thus determine which patients may have the potential for consciousness. (shrink)

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 and ensure the best possible care for the patient. (shrink)

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 and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

Dramatic modern advances in emergency and resuscitation medicine, starting perhaps with the development of effective mechanical ventilators in the mid-20th century, have created a large class of persons who in earlier times would almost certainly have died, but who can now go on existing, suspended at least temporarily in a state somewhere between death and the conscious life they formerly pursued. A very wide range of brain injuries lead first to coma, in which the patient shows no sign of (...) conscious awareness, or even of wakefulness, in which eye openings and closings indicate the presence of a sleep/wake cycle unconsciously mediated by structures in the brain stem. Following emergence from coma, which may take days to months or more if it happens at all, patients typically show signs of wakefulness without conscious awareness – they are then in a so-called vegetative state (VS). For many this state becomes permanent, but some go on to a more recently described condition called the minimally conscious state (MCS), in which signs of conscious awareness can be detected by careful neurological examination (see Laureys & Tononi, 2009, chapter 14). A very few such persons ultimately progress to more or less full recovery, but another and particularly horrifying possible outcome is the “locked-in” state, in which a patient is fully conscious but has extremely little or no capacity for voluntary motor action. A famous modern example is that of Jean-Dominique Bauby, author of The Diving Bell and the Butterfly, who suffered a stroke to his upper brainstem and awakened 20 days later to find himself fully conscious but capable only of blinking his left eye. A tiny fraction of surgical patients find themselves in similarly terrifying conditions caused by the combination of muscle relaxants with insufficient levels of anesthetic agents (Kelly et al., 2007, p. 387 n. 18). (shrink)

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 survived, without overt behaviour or clear communication their carers were frequently unsure how much residual function remained. Now real progress is occurring in this area thanks to the application of neuro-scientific methods by some outstanding groups of workers. Subjects with severe brain injury may begin in complete, unresponsive coma but then ‘lighten’ to one of three categories. In vegetative state (VS), patients are apparently awake but without evidence of voluntary behaviour and have no apparent awareness of self or environment, whilst in minimally conscious state (MCS) patients have some behaviour beyond the reflex but are not able to communicate effectively. These conditions usually result from widespread brain damage at either or both cortical and subcortical levels due to injury or anoxia, though they can also be seen in end stage neurological conditions like Alzheimer’s. In locked in syndrome (LIS), patients ‘awake’ from coma, usually due to stroke, aware of their surroundings and their situation but unable to speak or move, beyond eye lid control and eye movement. For many, LIS will be recognised from Bauby’s extraordinary account in ‘The Diving Bell and the Butterfly,’ though, incidentally, it was presaged in Samuel Beckett’s novella ‘The Unnameable.’ LIS reflects a profound disconnection between brain and body, except for the upper cranial nerves involved in eyelid movement. The overriding question is how much awareness these patients have.. (shrink)

The blink response to visual threat is a standard bedside method for testing visual processing. In response to a sudden gesture directed toward the eyes, a person with a normal blink response will promptly contract both orbicularis oculi muscles to close the eyelids momentarily. There is no consensus as to whether blinking to visual threat (BVT) is purely reflex1 or a cognitively mediated behavior that heralds consciousness; i.e., is incompatible with the diagnosis of the vegetative state (VS).2,3 Some (...) authors stated that “one should be extremely cautious in making the diagnosis of the VS when there is . . . response to threatening gestures.”4 Others stated that “react(ion) to visual threat” is a “compatible but atypical feature” of VS.5 Similarly, other guidelines stated that the “threat response is usually absent” in VS.6 Finally, BVT was not mentioned in some workgroup criteria on the minimally conscious state.7 The aim of the study was to determine the incidence of BVT in patients whose clinical features are in all other respects typical of the VS, as assessed by means of validated testing.7 We also investigated whether the presence of BVT in patients considered vegetative is predictive of recovery of consciousness. (shrink)

Adequate assessment of (un)consciousness is not only of theoretical interest but also has a practical and ethical importance, especially when it comes to disorders of consciousness (DOC). Accurately determining the presence or absence of consciousness in patients with DOC allows informed decisions to be made about long-term care support, referral for rehabilitation, pain management and withdrawal of life support. We believe that a theoretical account of what conscious experience is and how it emerges within the brain will advance the search (...) for appropriate neuromarkers of the presence or absence of consciousness in non-communicative brain-damaged patients. (shrink)

In a recent study of a patient in a persistent vegetative state, [Owen, A. M., Coleman, M. R., Boly, M., Davis, M. H., Laureys, S., & Pickard, J. D. . Detecting awareness in the vegetative state. Science, 313, 1402] claimed that they had demonstrated the presence of consciousness in this patient. This bold conclusion was based on the isomorphy between brain activity in this patient and a set of conscious control subjects, obtained in various imagery tasks. (...) However, establishing consciousness in unresponsive patients is fraught with methodological and conceptual difficulties. The aim of this paper is to demonstrate that the current debate surrounding consciousness in VS patients has parallels in the artificial intelligence debate as to whether machines can think. Basically, used a method analogous to the Turing test to reveal the presence of consciousness, whereas their adversaries adopted a line of reasoning akin to Searle’s Chinese room argument. Highlighting the correspondence between these two debates can help to clarify the issues surrounding consciousness in non-communicative agents. (shrink)

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 and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/uws more respondents agreed with treatment withdrawal when they considered that VS/uws patients did not feel pain (77%) as compared to those who thought VS/uws did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

Persons who experience severe brain injury often suffer significant disorders of consciousness. Anoxic injuries from cardiac arrest or strokes and traumatic injuries from falls, vehicular crashes, or assaults can result in several conditions in which patients lose or have diminished consciousness for an extended period of time. Two such conditions that create considerable public confusion and controversy are the vegetative state and the minimally conscious state. Although these conditions have generated significant medical and academic research, the general (...) public and policymakers are often confused about the nature of VS and MCS. The most recent evidence for this confusion is the acrimonious public debate, the extensive media coverage, the prolonged litigation, and the attempts of various governmental officials to intervene in dealing with the plight of Terri Schiavo. (shrink)

The landscape of the Sundarbans today is a product of two countervailing forces: conversion of wetland forests to cropland vs. sequestration of the forests in reserves to be managed for long-term sustained yield of wood products. For two centures, land-hungry peasants strove to transform the native tidal forest vegetation into an agroecosystem dominated by paddy rice and fish culture. During the colonial period, their reclamation efforts were encouraged by landlords and speculators, who were themselves encouraged by increasingly favorable state (...) policies (land grants, tax incentives, cadastral surveys, and eventually colonization projects and subsidized irrigation) designed by revenue officials to maximize the rate of transformation of wetland forest to taxable agricultural land.In the late nineteenth century, as the rate of agricultural conversion increased, the colonial Forest Department succcessfully sought to preserve large areas of the remaining Sundarbans tidal forest by giving them legal status as Reserved or Protected Forests. These forests were intensively managed to provide a sustainable supply of timber and firewood for the increasing population of southern Bengal. Institutionalization of conflicting policies by the Revenue and Forest Departments reflected the escalating needs for both food and forest products as the colony grew. Today, supplies of some economically valuable trees have been depleted, and some mammals are locally extinct (although the Bengal tiger remains), but government policy in both Bangladesh and India now favors use of the Sundarbans as forest rather than its transformation to agricultural land. Further expansion of cropland to meet the grain demands of the burgeoning Bengali population in both nations has largely taken place outside the boundaries of the Sundarbans. Overexploitation of these forests for wood products remains a possibility, but large-scale clearing for rice paddies is unlikely under present policies. (shrink)

This article describes and reflects upon Australia's extensive, federally-mandated, environmental education program. This program is based on a National Conservation Strategy which went into effect in 1989. But the program has massive support on the state and local levels as well. In addition to traditional classroom study of the environment and environmental issues, Audtralian Students do composting, re-vegetation of local canyons, and other hands-on activities. In many areas of the students' deatiledreports become the data base for the government's environmental (...) monitoring program. A remarkable aspect of environmental education in Australia is the web of groups and individuals who are involved: local farmers, Aboriginal peoples, banks, local nurseries, and all levels of government, along with environmental organizations like Greening Astraila and Landcare.In contrast to Australia, the United States lacks a systematic educational program focused on the environment. The article concludes by summarizing the strengths of the Australian program and criticizing the American failure to establish such a program. Reasons for this failure are suggested. Finally, a general contrast is offered, showing the differences between two philosophies of education—the Technocratic Philosophy of Education vs. the Holistic Philosophy of Education. (shrink)