About this topic
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. Medical Aspects of the Minimally Conscious State in Children.Stephen Ashwal - 2003 - Brain and Development 25 (8):535-545.
  2. Long-Lasting Coma.Sergio Bagnato, Cristina Boccagni, A. Sant'Angelo, Alexander A. Fingelkurts, Andrew A. Fingelkurts, C. Gagliardo & G. Galardi - 2014 - 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 (...)
  3. Chronic Disorders of Consciousness.James L. Bernat - 2006 - Lancet 367 (9517):1181-1192.
  4. Questions Remaining About the Minimally Conscious State.James L. Bernat - 2002 - Neurology 58 (3):337-338.
  5. Auditory Processing in Severely Brain Injured Patients: Differences Between the Minimally Conscious State and the Persistent Vegetative State.Melanie Boly, Marie-Elisabeth E. Faymonville & Philippe Peigneux - 2004 - Archives of Neurology 61 (2):233-238.
  6. Eye Gaze and Conscious Processing in Severely Brain-Injured Patients.Camille Chatelle, Steven Laureys, Steve Majerus, Caroline Schnakers, Paula M. Niedenthal, Martial Mermillod, Marcus Maringer & Ursula Hess - 2010 - 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).
  7. Comment on Laureys Et Al. Self-Consciousness in Non-Communicative Patients☆.J. Cole - 2007 - 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 (...)
  8. "The Minimally Conscious State: Definition and Diagnostic Criteria": Comments and Reply.Diane Coleman, D. Alan Shewmon & J. T. Giacino - 2002 - Neurology 58 (3):506-507.
  9. Persistent Vegetative State, Akinetic Mutism and Consciousness.Will Davies & Neil Levy - 2016 - In Walter Sinnott-Armstrong (ed.), Finding Consciousness: The Neuroscience, Ethics, and Law of Severe Brain Damage. Oxford University Press. pp. 122-136.
  10. Attitudes Towards Disorders of Consciousness: Do Europeans Disentangle Vegetative From Minimally Conscious State?Demertzi Athina, Bruno Marie-Aurelie, Ledoux Didier, Vanhaudenhuyse Audrey, Gosseries, M. Boly, C. Schnakers, Moonen Gustave & Laureys Steven - unknown
  11. Pain Perception in Disorders of Consciousness: Neuroscience, Clinical Care, and Ethics in Dialogue. [REVIEW]A. Demertzi, E. Racine, M.-A. Bruno, D. Ledoux, O. Gosseries, A. Vanhaudenhuyse, M. Thonnard, A. Soddu, G. Moonen & S. Laureys - 2013 - 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 (...)
  12. The Ethical Pain.Michele Farisco - 2013 - 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 (...)
  13. Clinicians' Attitudes Toward Patients with Disorders of Consciousness: A Survey.Michele Farisco, Enrico Alleva, Flavia Chiarotti, Simone Macri & Carlo Petrini - 2014 - 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 (...)
  14. The Value of Spontaneous EEG Oscillations in Distinguishing Patients in Vegetative and Minimally Conscious States.Alexander A. Fingelkurts, Andrew A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2013 - In Eror Basar & et all (eds.), Application of Brain Oscillations in Neuropsychiatric Diseases. Supplements to Clinical Neurophysiology. Elsevier. pp. 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 (...)
  15. EEG Oscillatory States as Neuro-Phenomenology of Consciousness as Revealed From Patients in Vegetative and Minimally Conscious States.Alexander A. Fingelkurts, Andrew A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2012 - 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 (...)
  16. Longitudinal Dynamics of 3-Dimensional Components of Selfhood After Severe Traumatic Brain Injury: A qEEG Case Study.Andrew A. Fingelkurts & Alexander A. Fingelkurts - 2017 - Clinical EEG and Neuroscience.
    In this report, we describe the case of a patient who sustained extremely severe traumatic brain damage with diffuse axonal injury in a traffic accident and whose recovery was monitored during 6 years. Specifically, we were interested in the recovery dynamics of 3-dimensional components of selfhood (a 3-dimensional construct model for the complex experiential selfhood has been recently proposed based on the empirical findings on the functional-topographical specialization of 3 operational modules of brain functional network responsible for the self-consciousness processing) (...)
  17. Longitudinal Dynamics of 3-Dimensional Components of Selfhood After Severe Traumatic Brain Injury: A qEEG Case Study.Andrew A. Fingelkurts & Alexander A. Fingelkurts - 2017 - Clinical EEG and Neuroscience.
    In this report, we describe the case of a patient who sustained extremely severe traumatic brain damage with diffuse axonal injury in a traffic accident and whose recovery was monitored during 6 years. Specifically, we were interested in the recovery dynamics of 3-dimensional components of selfhood (a 3-dimensional construct model for the complex experiential selfhood has been recently proposed based on the empirical findings on the functional-topographical specialization of 3 operational modules of brain functional network responsible for the self-consciousness processing) (...)
  18. Longitudinal Dynamics of 3-Dimensional Components of Selfhood After Severe Traumatic Brain Injury: A qEEG Case Study.Andrew A. Fingelkurts & Alexander A. Fingelkurts - 2017 - Clinical EEG and Neuroscience.
    In this report, we describe the case of a patient who sustained extremely severe traumatic brain damage with diffuse axonal injury in a traffic accident and whose recovery was monitored during 6 years. Specifically, we were interested in the recovery dynamics of 3-dimensional components of selfhood (a 3-dimensional construct model for the complex experiential selfhood has been recently proposed based on the empirical findings on the functional-topographical specialization of 3 operational modules of brain functional network responsible for the self-consciousness processing) (...)
  19. Longitudinal Dynamics of 3-Dimensional Components of Selfhood After Severe Traumatic Brain Injury: A qEEG Case Study.Andrew A. Fingelkurts & Alexander A. Fingelkurts - 2017 - Clinical EEG and Neuroscience.
    In this report, we describe the case of a patient who sustained extremely severe traumatic brain damage with diffuse axonal injury in a traffic accident and whose recovery was monitored during 6 years. Specifically, we were interested in the recovery dynamics of 3-dimensional components of selfhood (a 3-dimensional construct model for the complex experiential selfhood has been recently proposed based on the empirical findings on the functional-topographical specialization of 3 operational modules of brain functional network responsible for the self-consciousness processing) (...)
  20. The Chief Role of Frontal Operational Module of the Brain Default Mode Network in the Potential Recovery of Consciousness From the Vegetative State: A Preliminary Comparison of Three Case Reports.Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2016 - The Open Neuroimaging Journal 10:41-51.
    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 (...)
  21. Prognostic Value of Resting-State EEG Structure in Disentangling Vegetative and Minimally Conscious States: A Preliminary Study.Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2013 - 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 (...)
  22. DMN Operational Synchrony Relates to Self-Consciousness: Evidence From Patients in Vegetative and Minimally Conscious States.Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2012 - 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 (...)
  23. Toward Operational Architectonics of Consciousness: Basic Evidence From Patients with Severe Cerebral Injuries.Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi - 2012 - 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 (...)
  24. Rethinking Disorders of Consciousness: New Research and its Implications.Joseph J. Fins - 2005 - Hastings Center Report 35 (2):22-24.
  25. Late Recovery From the Minimally Conscious State: Ethical and Policy Implications.Joseph J. Fins, Nicholas D. Schiff & Kathleen M. Foley - 2007 - Neurology 68 (4):304-307.
  26. The Minimally Conscious State: Defining the Borders of Consciousness.Joseph T. Giacino - 2006 - In Steven Laureys (ed.), Boundaries of Consciousness. Elsevier.
  27. The Minimally Conscious State: Definition and Diagnostic Criteria.Joseph T. Giacino & Childs N. Ashwal S. - 2002 - Neurology 58 (3):349-353.
  28. Diagnostic and Prognostic Guidelines for the Vegetative and Minimally Conscious States.Joseph T. Giacino & Kathleen Kalmar - 2005 - Neuropsychological Rehabilitation. Vol 15 (3-4):166-174.
  29. The Vegetative and Minimally Conscious States: A Comparison of Clinical Features and Functional Outcome.Joseph T. Giacino & Kathleen Kalmar - 1997 - Journal of Head Trauma Rehabilation 12:36-51.
  30. Rehabilitative Management of Patients with Disorders of Consciousness: Grand Rounds.Joseph T. Giacino & Charlotte T. Trott - 2004 - Journal of Head Trauma Rehabilitation 19 (3):254-265.
  31. The Vegetative and Minimally Conscious States: Current Knowledge and Remaining Questions.Joseph T. Giacino & J. T. Whyte - 2005 - Journal of Head Trauma Rehabilation 20 (1):30-50.
  32. The Sensory Modality Assessment and Rehabilitation Technique (SMaRT): A Valid and Reliable Assessment for Vegetative State and Minimally Conscious State Patients.H. Gill-Thwaites & R. Munday - 2004 - Brain Injury 18 (12):1255-1269.
  33. Attitudes of Lay People to Withdrawal of Treatment in Brain Damaged Patients.Jacob Gipson, Guy Kahane & Julian Savulescu - 2014 - 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 (...)
  34. Burdens of ANH Outweigh Benefits in the Minimally Conscious State.W. Glannon - 2013 - 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 (...)
  35. Neurostimulation and the Minimally Conscious State.Walter Glannon - 2008 - 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 (...)
  36. Neurophysiological Patterns of Vegetative and Minimally Conscious States.Jean-Michel Guérit - 2005 - Neuropsychological Rehabilitation. Vol 15 (3-4):357-371.
  37. Withdrawal of Treatment From Minimally Conscious Patients.R. Heywood - 2012 - Clinical Ethics 7 (1):10-16.
    This article explores the taxing legal questions that are raised in the context of withdrawing life sustaining treatment from patients who are in a minimally conscious state. The Court of Protection, for the first time in England, was recently asked to rule on this issue. This paper analyses the legal and ethical implications of this decision moving forward.
  38. Conscious States: Where Are They in the Brain and What Are Their Necessary Ingredients?William Hirstein - 2013 - Mens Sana Monographs 11 (1):230.
    One of the final obstacles to understanding consciousness in physical terms concerns the question of whether conscious states can exist in posterior regions of the brain without active connections to the brain's prefrontal lobes. If they can, difficult issues concerning our knowledge of our conscious states can be resolved. This paper contains a list of types of conscious states that may meet this criterion, including states of coma, states in which subjects are absorbed in a perceptual task, states in brains (...)
  39. A Case for Increased Caution in End of Life Decisions for Disorders of Consciousness.Jakob Hohwy & David Reutens - 2009 - 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.
  40. The Minimally Conscious State and Treatment Withdrawal: W V M.E. Jackson - 2013 - 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.
  41. The Right to Die in the Minimally Conscious State.L. Syd M. Johnson - 2011 - 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 (...)
  42. The Minimally Conscious State: Ethics and Diagnostic Nosology.Md Joseph Fins - 2007 - Lahey Clinic Medical Ethics Journal 14 (3):1-5.
  43. Introduction: Reconsidering Disorders of Consciousness in Light of Neuroscientific Evidence.Ralf J. Jox & Katja Kuehlmeyer - 2013 - 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 (...)
  44. Brain-Damaged Patients and the Moral Significance of Consciousness.Guy Kahane & Julian Savulescu - 2009 - 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 (...)
  45. Minimally Conscious States.Douglas Katz - manuscript
  46. Consciousness Unchained: Ethical Issues and the Vegetative and Minimally Conscious State.Robert T. Knight - 2008 - American Journal of Bioethics 8 (9):1 – 2.
  47. The Boundaries of Consciousness: Neurobiology and Neuropathology.Steven Laureys - 2006 - Elsevier.
    The interest of this is threefold. First, patients with altered states of consciousness continue to represent a major clinical problem in terms of clinical assessment of consciousness and daily management.
  48. Differences in Brain Metabolism Between Patients in Coma, Vegetative State, Minimally Conscious State and Locked-in Syndrome.Steven Laureys, Marie-Elisabeth E. Faymonville & M. Ferring - 2003 - European Journal of Neurology 10.
  49. Cerebral Processing in the Minimally Conscious State.Steven Laureys, Fabien Perrin & Marie-Elisabeth E. Faymonville - 2004 - Neurology 63 (5):916-918.
  50. Moral Significance of Phenomenal Consciousness.Neil Levy & Julian Savulescu - 2009 - 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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