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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 2009; Illes & Sahakian 2011.
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  1. Recommendations for the Use of Uniform Nomenclature Pertinent to Patients with Severe Alterations in Consciousness.- - - 1995 - Arch Phys Med Rehabilation 76:205-209.
  2. Sensory Stimulation for Patients with Disorders of Consciousness: From Stimulation to Rehabilitation.Carlo Abbate, Pietro D. Trimarchi, Isabella Basile, Anna Mazzucchi & Guya Devalle - 2014 - Frontiers in Human Neuroscience 8.
  3. The Significance of a Wish.Felicia Ackerman - 1991 - Hastings Center Report 21 (4):27-29.
  4. Ethical Issues in Secure Care.Gwen Adshead - 2009 - In Annie Bartlett & Gillian McGauley (eds.), Forensic Mental Health: Concepts, Systems, and Practice. Oxford University Press.
  5. Minimally Invasive Dentistry: A Treatment Philosophy.Stefano Ardu - unknown
  6. Survey of Japanese Physicians' Attitudes Towards the Care of Adult Patients in Persistent Vegetative State.A. Asai, M. Maekawa, I. Akiguchi, T. Fukui, Y. Miura, N. Tanabe & S. Fukuhara - 1999 - Journal of Medical Ethics 25 (4):302-308.
  7. 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.Atsushi Asai - 2011 - 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 (...)
  8. Some Fundamental Questions About Human Life: Ethicalcomments of Japanese Physicians in Terms of the Appropriate Care of Patients in Persistent Vegetative State.Atsushi Asai - 2001 - Eubios Journal of Asian and International Bioethics 11 (3):66-67.
  9. Case Study 1: Hemodialysis For A Patient In Persistent Vegetative State.Atsushi Asai & Masashi Shirahama - 1997 - Eubios Journal of Asian and International Bioethics 7 (4):105-107.
  10. Artificial Hydration and Alimentation at the End of Life: A Reply to Craig.M. Ashby & B. Stoffell - 1995 - Journal of Medical Ethics 21 (3):135-140.
    Dr Gillian Craig (1) has argued that palliative medicine services have tended to adopt a policy of sedation without hydration, which under certain circumstances may be medically inappropriate, causative of death and distressing to family and friends. We welcome this opportunity to defend, with an important modification, the approach we proposed without substantive background argument in our original article (2). We maintain that slowing and eventual cessation of oral intake is a normal part of a natural dying process, that artificial (...)
  11. Medical Aspects of the Minimally Conscious State in Children.Stephen Ashwal - 2003 - Brain and Development 25 (8):535-545.
  12. Nutrition and Hydration.I. Assure You That May - forthcoming - Hastings Center Report.
  13. Audio-Visual Crossmodal fMRI Connectivity Differentiates Single Patients with Disorders of Consciousness.Demertzi Athena, Antonopoulos Georgrios, Voss Henning, Crone Julia, Schiff Nicholas, Kronbichler Martin, Trinka Eugen, De Los Angeles Carlo, Gomez Francisco, Bahri Mohammed, Heine Lizette, Tshibanda Luaba, Charland-Verville Vanessa, Whitfield-Gabrieli Susan & Laureys Steven - 2014 - Frontiers in Human Neuroscience 8.
  14. 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 (...)
  15. Emerging From an Unresponsive Wakefulness Syndrome: Brain Plasticity has to Cross a Threshold Level.Sergio Bagnato, Cristina Boccagni, Antonino Sant'Angelo, Alexander A. Fingelkurts, Andrew A. Fingelkurts & Giuseppe Galardi - 2013 - 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 (...)
  16. La vie vegetative des animaux. Heidegger deconstruction of animal life.Christiane Bailey - 2007 - 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 (...)
  17. Alla fine della vita: bioetica e medicina alla ricerca di un confine [At the end of life: bioethics and medicine looking for a boundary].Rosangela Barcaro - 2015 - Laboratorio Dell’ISPF [Online First] 1824-9817.
    Bioethics, neuroscience, medicine are contributing to a debate on the definition and criteria of death. This topic is very controversial, and it demonstrates clashing views on the meaning of human life and death. Official medical and legal positions agree upon a biological definition of death as irreversible cessation of integrated functioning of the organism as a whole, and whole-brain criterion to ascertain death. These positions have to face many criticisms: some scholars speak of logical and practical inconsistency, some others of (...)
  18. Why Withdrawal of Life-Support for PVS Patients Is Not a Family Decision.Charles H. Baron - 1991 - Journal of Law, Medicine & Ethics 19 (1-2):73-75.
  19. Disturbances of Consciousness and Sleep-Wake Functions.Claudio Bassetti - 2001 - In Julien Bogousslavsky & Louis R. Caplan (eds.), Stroke Syndromes. Cambridge University Press. pp. 192-210.
  20. Disorders of Consciousness.D. Bates & N. Cartlidge - 1994 - In E. Critchley (ed.), The Neurological Boundaries of Reality. Farrand.
  21. ZnO Nanorod-Based UV Photodetection and the Role of Persistent Photoconductivity.S. Bayan & D. Mohanta - 2012 - Philosophical Magazine 92 (32):3909-3919.
  22. Incidence and Prevalence of the Vegetative and Minimally Conscious States.J. Graham Beaumont & Pamela M. Kenealy - 2005 - Neuropsychological Rehabilitation 15 (3):184-189.
  23. Assessing Level of Consciousness and Cognitive Changes From Vegetative State to Full Recovery.Tristan Bekinschtein, Cecilia Tiberti, Jorge Niklison, Mercedes Tamashiro, Melania Ron, Silvina Carpintiero, Mirta Villarreal, Cecilia Forcato, Ramon Leiguarda & Facundo Manes - 2005 - Neuropsychological Rehabilitation. Vol 15 (3-4):307-322.
  24. Viscoelastic Properties of Bone as a Function of Hydration State Determined by Nanoindentation.A. K. Bembey, M. L. Oyen, A. J. Bushby & A. Boyde - 2006 - Philosophical Magazine 86 (33-35):5691-5703.
  25. Feeding Versus Artificial Nutrition and Hydration: At the Boundaries of Medical Intervention and Social Interaction.Sara M. Bergstresser & Erick Castellanos - 2015 - Ijfab: International Journal of Feminist Approaches to Bioethics 8 (2):204-225.
    In this article, we examine the emergence of a concept of medical feeding that emphasizes artificiality and medical technology. We discuss how this concept has been created in specific contrast to the daily provision of food and water; medical definitions retain clear disjunctures with cultural and religious beliefs surrounding food, gendered aspects of eating and feeding, and the everyday practices of social and family life in the United States. We begin with an examination of the historical processes involved in creating (...)
  26. Medically Assisted Nutrition and Hydration in Medicine and Moral Theology: A Contextualization of its Past and a Direction for its Future.John Berkman - 2004 - The Thomist 68 (1):69-104.
    Despite the expansive literature detailing various arguments for or against the use of MANH in caring for the dying and debilitated, the thesis of this paper is that a large part, if not the main thrust, of the debates over MANH have been inadequate and misguided on a number of different levels. The paper hopes to reorient and redirect the debate by attending to the medical history of MANH (part one) and recent medical developments with regard to MANH (part five), (...)
  27. Chronic Disorders of Consciousness.James L. Bernat - 2006 - Lancet 367 (9517):1181-1192.
  28. The Concept and Practice of Brain Death.James L. Bernat - 2006 - In Steven Laureys (ed.), Boundaries of Consciousness. Elsevier.
  29. Questions Remaining About the Minimally Conscious State.James L. Bernat - 2002 - Neurology 58 (3):337-338.
  30. The Boundaries of the Persistent Vegetative State.James L. Bernat - 1992 - Journal of Clinical Ethics 3 (3):176.
  31. In Whose Best Interests: Who Knows?Hazel Biggs - 2006 - Clinical Ethics 1 (2):90-93.
    Leslie Burke challenged the GMC guidelines on withholding and withdrawing artificial nutrition and hydration because he wanted to ensure that food and fluids were not withdrawn from him at a time when he might still be cognisant. This article reviews the case and the judgments at first instance and in the Court of Appeal. In the interests of patient autonomy it argues that the patient is best placed to decide what is in her or his best interests and that the (...)
  32. Severe Brain Injury and the Subjective Life.J. Andrew Billings, Larry R. Churchill & Richard Payne - 2010 - Hastings Center Report 40 (3):17-21.
  33. An Aristotelian Naturalist Perspective on Artificial Nutrition and Hydration.Paolo Biondi - 2016 - Diametros 50:138-151.
    This polemical note looks at the ethical issue of providing artificial nutrition and hydration to patients with advanced dementia from the perspective of an Aristotelian and naturalist ethics. I argue that this issue may be considered in terms of the Aristotelian notion of eudaimonia, well-being. I present a number of facts about the conditions of human life that contribute to eudaimonia. In addition, I present a number of facts about advanced dementia as well as clarify the goals of medicine. From (...)
  34. Medically Assisted Nutrition and Hydration: The Vegetative State and Beyond.J. P. Bishop & E. L. Bedford - 2011 - Christian Bioethics 17 (2):97-104.
  35. The Roman Catholic Church, Biopolitics, and the Vegetative State.J. P. Bishop & D. R. Morrison - 2011 - 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 (...)
  36. Normal Brain Response to Propofol in Advance of Recovery From Unresponsive Wakefulness Syndrome.Stefanie Blain-Moraes, Rober Boshra, Heung Kan Ma, Richard Mah, Kyle Ruiter, Michael Avidan, John F. Connolly & George A. Mashour - 2016 - Frontiers in Human Neuroscience 10.
  37. An Examination of the Revisionist Challenge to the Catholic Tradition on Providing Artificial Nutrition and Hydration to Patients in a Persistent Vegetative State.J. Blandford - 2011 - 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 (...)
  38. The Ordinary-Extraordinary Distinction Reconsidered: A Moral Context for the Proper Calculus of Benefits and Burdens.Thomas J. Bole Iii - 1990 - HEC Forum 2 (4):219-232.
  39. 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.
  40. Persistent Vegetative State: A Syndrome in Search of a Name, or a Judgement in Search of a Syndrome?Chris Borthwick - 1995 - Monash Bioethics Review 14 (2):20-25.
  41. Acts, Omissions, and Keeping Patients Alive in a Persistent Vegetative State.Sophie Botros - 1995 - In Royal Institute of Philosophy Supplement. New York: Cambridge University Press. pp. 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 (...)
  42. Philosophy and Technology.Sophie Botros - 1995 - New York: Cambridge University Press.
  43. The French Vegetative State.M. H. Boucand & P. Ver Le Gall - forthcoming - Hastings Center Report.
  44. Towards Ethical Guidelines for the Use of Artificial Nutrition and Hydration.Joseph Boyle - 2008 - In C. Tollefsen (ed.), Artificial Nutrition and Hydration. Springer Press. pp. 111--122.
  45. Commentary on" The Time Frame of Preferences, Dispositions, and the Validity of Advance Directives for the Mentally Ill".Dan W. Brock - 1998 - Philosophy, Psychiatry, and Psychology 5 (3):251-253.
  46. Is Futility a Futile Concept?B. A. Brody & A. Halevy - 1995 - Journal of Medicine and Philosophy 20 (2):123-144.
    This paper distinguishes four major types of futility (physiological, imminent demise, lethal condition, and qualitative) that have been advocated in the literature either in a patient dependent or a patient independent fashion. It proposes five criteria (precision, prospective, social acceptability, significant number, and non-agreement) that any definition of futility must satisfy if it is to serve as the basis for unilaterally limiting futile care. It then argues that none of the definitions that have been advocated meet the criteria, primarily because (...)
  47. Special Ethical Issues in the Management of PVS Patients.Baruch Brody - 1992 - Journal of Law, Medicine & Ethics 20 (1-2):104-115.
  48. Ethical Questions Raised by the Persistent Vegetative Patient.Baruch A. Brody - 1988 - Hastings Center Report 18 (1):33-37.
  49. Severe Organic Brain Syndrome.Eduardo Bruera - forthcoming - Journal of Palliative Care.
  50. Right (to a) Diagnosis? Establishing Correct Diagnoses in Chronic Disorders of Consciousness.Kirsten Brukamp - 2013 - 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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