Detecting conscious awareness in a patient emerging from a coma state is problematic, because our standard attributions of conscious awareness rely on interpreting bodily movement as intentional action. Where there is an absence of intentional bodily action, as in the vegetative state, can we reliably assume that there is an absence of conscious awareness? Recent neuroimaging work suggests that we can attribute conscious awareness to some patients in a vegetative state by interpreting their brain activity as intentional mental (...) action. I suggest that this change of focus, from the interpretation of motor behaviour as intentional bodily action to the interpretation of neural activity as intentional mental action, raises philosophical issues that affect the interpretation of the neuroimaging data. (shrink)

Aim: To elicit preferences for prognostic information, attitudes towards withdrawal of life-sustaining treatment (WLST) and perspectives on acceptable quality of life after post-anoxic coma within the adult general population of Germany, Italy, the Netherlands and the United States of America. Methods: A web-based survey, consisting of questions on respondent characteristics, perspectives on quality of life, communication of prognostic information, and withdrawal of life-sustaining treatment, was taken by adult respondents recruited from four countries. Statistical analysis included descriptive analysis and chi2-tests (...) for dierences between countries. Results: In total, 2012 respondents completed the survey. In each country, at least 84% indicated they would prefer to receive early prognostic information. If a poor outcome was predicted with some uncertainty, 37-54% of the respondents indicated that WLST was not to be allowed. A conscious state with severe physical and cognitive impairments was perceived as acceptable quality of life by 17–44% of the respondents. Clear differences between countries exist, including respondents from the U.S. being more likely to allow WLST than respondents from Germany (OR = 1.99, p < 0.001) or the Netherlands (OR = 1.74, p < 0.001) and preferring to stay alive in a conscious state with severe physical and cognitive impairments more than respondents from Italy (OR = 3.76, p < 0.001), Germany (OR = 2.21, p < 0.001), or the Netherlands (OR = 2.39, p < 0.001). Conclusions: Over one-third of the respondents considered WLST unacceptable when there is any remaining prognostic uncertainty. Respondents had a more positive perspective on acceptable quality of life after coma than what is currently considered acceptable in medical literature. This indicates a need for a closer look at the practice of WLST based on prognostic information, to ensure responsible use of novel prognostic tests. (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)

Following coma, some patients will recover wakefulness without signs of consciousness (only showing reflex movements, i.e., the vegetative state) or may show non-reflex movements but remain without functional communication (i.e., the minimally conscious state). Currently, there remains a high rate of misdiagnosis of the vegetative state (Schnakers et. al. BMC Neurol, 9:35, 8) and the clinical and electrophysiological markers of outcome from the vegetative and minimally conscious states remain unsatisfactory. This should incite clinicians to use multimodal assessment to (...) detect objective signs of consciousness and validate para-clinical prognostic markers in these challenging patients. This review will focus on advanced magnetic resonance imaging (MRI) techniques such as magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI (fMRI studies in both “activation” and “resting state” conditions) that were recently introduced in the assessment of patients with.. (shrink)

THE PRIMARY AIM OF THIS ESSAY is to advance discussion on how best to treat comatose patients. Its principal conclusion will be Some purportedly irreversibly comatose humans ought to be kept alive indefinitely. Of course, merely keeping such patients alive is not how best to treat them. How they are being treated while being kept alive is of paramount importance. Note that is compatible with the truth of All comatose humans ought to be kept alive indefinitely. I shall (...) say nothing more about. It will serve my present purpose if I can adequately defend, where "some" is to be understood in the usual manner, namely, as "at least one." The term "indefinitely," as one might surmise, is meant to convey some unspecified period of time. (shrink)

Cet article propose un regard sur la place des familles au chevet des patients comateux et leur rôle potentiel dans le processus d’éveil, notamment en ce qui concerne le travail de mémoire et le partage d’affect, principalement la honte. Il s’appuie sur l’expérience de travail de plusieurs années d’un psychologue en service de réanimation adulte. La réanimation est un lieu dans lequel la place de chaque objet est pensée en fonction de son utilité pour le soin du patient, mais (...) peu dans la perspective du lien à l’entourage. Certains objets comme la famille sont porteurs de complexité à résonances affectives. L’article montre que cette complexité, si elle est accompagnée par le psychologue et l’équipe soignante, peut jouer un rôle favorable dans le processus d’éveil et dans le travail de réappropriation de son vécu par le patient. (shrink)

Cet article propose un regard sur la place des familles au chevet des patients comateux et leur rôle potentiel dans le processus d’éveil, notamment en ce qui concerne le travail de mémoire et le partage d’affect, principalement la honte. Il s’appuie sur l’expérience de travail de plusieurs années d’un psychologue en service de réanimation adulte. La réanimation est un lieu dans lequel la place de chaque objet est pensée en fonction de son utilité pour le soin du patient, mais (...) peu dans la perspective du lien à l’entourage. Certains objets comme la famille sont porteurs de complexité à résonances affectives. L’article montre que cette complexité, si elle est accompagnée par le psychologue et l’équipe soignante, peut jouer un rôle favorable dans le processus d’éveil et dans le travail de réappropriation de son vécu par le patient. (shrink)

The essay examines Robin Cook’s Coma and Priscille Sibley’s The Promise of Stardust that dramatize the reified and disposable status of the brain-dead patients who are classified as nonpersons. The essay argues that the man-machine entanglement as depicted in the novels constructs a deterritorialized and entangled form of subjectivity that intervenes in the dominant biomedical understanding of personhood and agency that we notionally associate with a conscious mind. The essay concludes its arguments by discussing Alexander Beliaev’s Professor Dowell’s (...) Head which depicts human subjectivity as an essentially embodied and distributive phenomenon and interrogates the Cartesian mind body dualism embedded in the dominant biomedical narratives. (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)

In the care of patients with disorders of consciousness (DOC), some ethical difficulties stem from the challenges of accurate diagnosis and the uncertainty of prognosis. Current neuroimaging research on these disorders could eventually improve the accuracy of diagnoses and prognoses and therefore change the context of end-of-life decision making. However, the perspective of healthcare professionals on these disorders remains poorly understood and may constitute an obstacle to the integration of research. We conducted a qualitative study involving healthcare professionals from (...) an acute care university medical center. A short questionnaire captured demographic data as well as the experience of participants with DOC patients. A semi-structured interview was used to explore attitudes toward ethical issues identified in a previous literature review. Qualitative content analysis of interviews was conducted with the NVivo software. Accurate diagnosis among DOC is often regarded as a challenge, but this was generally not the case for our participants because most reported high confidence in DOC diagnoses. However, participants reported struggling with prognosis, especially because of its essential role for end-of-life decision making and communication with families. Variability of opinion between healthcare professionals was reported and identified by some as a minor issue while others stressed how families struggle with different medical opinions. End-of-life decision making encompassed a large proportion of ethical challenges in these patients, and the removal of artificial nutrition and hydration created significant discomfort in a minority of participants. The concept of futility was subject to wide-ranging understandings with both favorable and unfavorable opinions. Our data suggest that to ensure the incorporation of new evidence-based advances, attention should be directed to the real-world practices and challenges of accurate diagnosis and prognosis. Given pervasive challenges in end-of-life care, we recommend improved training of healthcare professionals in the care of patients with DOC, particularly in end-of life care, understanding the context of decision making, and determining how to optimally integrate new neuroscience research on the care of patients with DOC. (shrink)

The clinical and para-clinical examination of residual self-consciousness in non-communicative severely brain damaged patients remains exceptionally challenging. Passive presentation of the patient’s own name and own face are known to be effective attention-grabbing stimuli when clinically assessing consciousness at the patient’s bedside. Event-related potential and functional neuroimaging studies using such self-referential stimuli are currently being used to disentangle the cognitive hierarchy of self-processing. We here review neuropsychological, neuropathological, electrophysiological and neuroimaging studies using the own name and own face paradigm (...) obtained in conscious waking, sleep, pharmacological coma, pathological coma and related disorders of consciousness. Based on these results we discuss what we currently do and do not know about the functional significance of the neural network involved in “automatic” and “conscious” self-referential processing. (shrink)

La clase de filosofía, desde la perspectiva del docente, no debe considerarse como una mera actividad transeúnte o predicamental. El presente estudio quiere examinarla, siguiendo la metafísica de la vida de Tomás de Aquino, como una obra vital, que requiere, por un lado, que el profesor se haga una sola cosa —una sola vida, podemos decir— con la doctrina que va a explicar y, por el otro, que esta intelección actual, sin movimiento alguno, dé lugar a la «concepción» y al (...) «parto» de lo entendido en una palabra del corazón, la cual, por su dinamismo intrínseco, tiende, a su vez, a manifestarse exteriormente en una palabra sonora, en un «verbum vocis». Esta exteriorización, por la cual aquella íntima operación que constituye la vida del que filosofa se corporeiza en forma de «diálogo», es, precisamente, la clase de filosofía. La técnica pedagógica debe tener en cuenta el orden intrínseco por el cual la vida humana, mediante la formación de una palabra del corazón, procede a su propia perfección, y no debe olvidar que el perfeccionamiento vital del profesor es causa (instrumental) del perfeccionamiento vital del alumno; es decir, quien no «produce», quien no «engendra», quien no «crea» interiormente lo que está explicando —independientemente de si se trata o no de una novedad— difícilmente ofrecerá unos medios adecuados para que el alumno conciba y dé a luz, en la intimidad de su mente, a un «verbum cordis». (shrink)

En este libro, que se titula «Sobre los nombres divinos [De divinis nominibus]», siguiendo la costumbre de aquellos que han transmitido la ciencia magistralmente [artificiose], Dionisio empieza, en primer lugar, presentando algunas consideraciones necesarias para todo el estudio sucesivo, y, en segundo lugar, prosigue exponiendo el objeto principal [de su tratado] en el capítulo tercero.

En contra de les aparences, la meva intenció és ridiculitzar i desactivar l’estratègic ús de referències a personatges de ficció per part dels mass media, els quals pretenen identificar el fundador de WikiLeaks amb tot aquest projecte —quelcom que facilita tant la deslegitimació com la mercantilització. Així, aquest article qüestiona la dominant personalització de la web de filtracions en Julian Assange, tot mostrant algunes de les més rellevants diferències i/o contradiccions entre el rerefons normatiu de WikiLeaks i la pseudo-filosofia política (...) de l’australià. La meva tesi és que la justificació de la il·legal revelació d’informació secreta i confidencial com a pràctica de desobediència civil es posa en perill per la contaminació de postulats utilitaristes i neoliberals. (shrink)

En este artículo se investigan los presupuestos ontológicos de aquellos nombres divinos que pueden predicarse de Dios y de las criaturas. En un primer momento, se destaca la anterioridad metafísica del ente como atributo de Dios. Después, al descubrir que el ente es un concepto análogo, se examinan las distintas modalidades de analogía confrontando dos textos: Summa contra Gentiles, I, cap. 34 y De Veritate, q.2, a.11. Finalmente, se muestra que la analogía de proporcionalidad es la que debe preferirse para (...) predicar algo acerca de Dios, y se pone de manifiesto en qué medida se funda sobre la cuarta vía «ex gradibus qui in rebus inveniuntur». (shrink)

Si prescindiéramos de la composición acto-potencial entre «essentia» y «esse» en la línea del ente creado, necesariamente nos veríamos arrojados al monismo spinozista, esto es, a admitir que solamente hay una substancia (a) única, (b) infinita, (c) increada, (d) necesariamente existente, (e) acto puro, (f) identificada, en último término, con la misma substancia de Dios. En el capítulo LII del segundo libro de la Summa contra gentiles, Santo Tomás obtiene esos atributos divinos a partir de siete argumentos que tienen como (...) objetivo probar que, en el caso que no se aceptara la diferencia real entre essentia y esse en el ente finito —tanto material como inmaterial—, necesariamente deberíamos reconocer que sólo hay una substancia con los seis atributos anteriormente mencionados (cada argumento da lugar a un atributo distinto, exceptuando los dos primeros que desembocan en el mismo, a saber, el de la unicidad). En el artículo presente, siguiendo la interpretación de Norberto del Prado, nos proponemos exponer cómo puede refutarse el monismo spinozista desde la doctrina de Santo Tomás en dos etapas: la primera viene representada por el ya citado capítulo de la Summa contra gentes; la segunda, por la cuarta vía (Summa Theologiae, I, q.2, a.3). (shrink)

After severe brain injury, one of the key challenges for medical doctors is to determine the patient’s prognosis. Who will do well? Who will not do well? Physicians need to know this, and families need to do this too, to address choices regarding the continuation of life supporting therapies. However, current prognostication methods are insufficient to provide a reliable prognosis. -/- Functional Magnetic Resonance Imaging (MRI) holds considerable promise for improving the accuracy of prognosis in acute brain injury patients. (...) Nonetheless, research on functional MRI in the intensive care unit context is ethically challenging. These studies raise several ethical issues that have not been addressed so far. In this article, Prof. Charles Weijer and his co-workers provide a framework for researchers and ethics committees to design and review these studies in an ethically sound way. (shrink)

AimThe functional prognosis of patients after coma following either cardiac arrest or acute structural brain injury is often uncertain. These patients are associated with high mortality and disability. N20 and N70 somatosensory evoked potentials are used to predict prognosis. We evaluated the utility of SSEP as an early indicator of long-term prognosis in these patients.MethodsThis was a retrospective cohort study of patients admitted to the intensive care unit with a diagnosis of coma after CA (...) or ABI. An SSEP study was performed, including N20 and N70 at 24–72 h, after coma onset. Functional recovery was assessed 6–12 months later using the modified Glasgow scale. The study was approved by our local research ethics committee.ResultsIn the CA and ABI groups, the absence of N20 or N70 was a strong indicator of poor outcome. Conversely, the presence of N70 was an indicator of a good outcome.ConclusionSomatosensory evoked potentials are useful early prognostic markers with high specificity and sensitivity. Moreover, N70 has additional potential value for improving the prediction of good long-term functional outcomes.Clinical Trial Registration:[https://clinicaltrials.gov/], identifier [2018/01/001]. (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)

A 68-year-old patient who suffered from gastric cancer diagnosed 8 months earlier presented with multiple peritoneal and hepatic metastasis, despite several rounds of chemo- and radiotherapy. After admission to hospital, his general condition quickly became severely compromised. He was nearly emaciated, despite being on partial parenteral feeding. Four years earlier, due to a cardiac arrhythmia that was refractory to medication, the patient had a cardiac pacemaker implanted, regulated to go off at frequencies of below 70 beats per minute. Given the (...) patient's terminal situation, the team started developing some doubts about the pacemaker's effects during his dying process. The patient had mentioned his intention to donate his pacemaker after his death, but had not asked for its deactivation. The specialists were not sure about the effect of the pacemaker in unnecessarily prolonging the patient's final hour. Nevertheless, they opposed deactivation, which they considered ethically uncertain. The family, who had been initially for the deactivation, decided against it. The patient's condition was progressively deteriorating, as he was falling into a state of sopor and, later, into a coma. (shrink)

Background Evidence concerning how Japanese physicians think and behave in specific clinical situations that involve withholding or withdrawal of medical interventions for end-of-life or frail elderly patients is yet insufficient. Methods To analyze decisions and actions concerning the withholding/withdrawal of life-support care by Japanese physicians, we conducted cross-sectional web-based internet survey presenting three scenarios involving an elderly comatose patient following a severe stroke. Volunteer physicians were recruited for the survey through mailing lists and medical journals. The respondents answered questions (...) concerning attitudes and behaviors regarding decision-making for the withholding/withdrawal of life-support care, namely, the initiation/withdrawal of tube feeding and respirator attachment. Results Of the 304 responses analyzed, a majority felt that tube feeding should be initiated in these scenarios. Only 18% felt that a respirator should be attached when the patient had severe pneumonia and respiratory failure. Over half the respondents felt that tube feeding should not be withdrawn when the coma extended beyond 6 months. Only 11% responded that they actually withdrew tube feeding. Half the respondents perceived tube feeding in such a patient as a "life-sustaining treatment," whereas the other half disagreed. Physicians seeking clinical ethics consultation supported the withdrawal of tube feeding (OR, 6.4; 95% CI, 2.5–16.3; P < 0.001). Conclusion Physicians tend to harbor greater negative attitudes toward the withdrawal of life-support care than its withholding. On the other hand, they favor withholding invasive life-sustaining treatments such as the attachment of a respirator over less invasive and long-term treatments such as tube feeding. Discrepancies were demonstrated between attitudes and actual behaviors. Physicians may need systematic support for appropriate decision-making for end-of-life care. (shrink)

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).

Objectives: Recent fMRI studies have shown that it is possible to reliably identify the defaultmode network (DMN) in the absence of any task, by resting-state connectivity analyses in healthy volunteers. We here aimed to identify the DMN in the challenging patient population of disorders of consciousness encountered following coma. Experimental design: A spatial independent component analysis-based methodology permitted DMN assessment, decomposing connectivity in all its different sources either neuronal or artifactual. Three different selection criteria were introduced assessing anticorrelation-corrected connectivity (...) with or without an automatic masking procedure and calculating connectivity scores encompassing both spatial and temporal properties. These three methods were validated on 10 healthy controls and applied to an independent group of 8 healthy controls and 11 severely brain-damaged patients [locked-in syndrome (n ¼ 2), minimally conscious (n ¼ 1), and vegetative state (n ¼ 8)]. Principal observations: All vegetative patients showed fewer connections in the default-mode areas, when compared with controls, contrary to locked-in patients who showed nearnormal connectivity. In the minimally conscious-state patient, only the two selection criteria considering both spatial and temporal properties were able to identify an intact right lateralized BOLD connectivity pattern, and metabolic PET data suggested its neuronal origin. Conclusions: When assess-. (shrink)

Disorders of consciousness (DOC) are a family of related neurological syndromes characterized by deficits of varying degrees of wakefulness (e.g., sleep–wake cycles and arousal) or awareness (e.g., reacting to stimuli, interacting with the environment). Although coma rarely persists for more than a few weeks, some patients remain in a subsequent vegetative state or a minimally conscious state for months or years. Caring for patients with DOC raises ethical questions, but the perspectives of healthcare providers on these questions (...) remain poorly documented. We conducted a qualitative study involving healthcare providers with different backgrounds. Semistructured interviews were used to explore attitudes toward ethical issues. We found that contextual (e.g., time, resource allocation) and relational aspects (e.g., communication process, families) shaped how ethical challenges surfaced and were managed. We call for greater awareness of contextual, institutional and social aspects and focus on these issues in training programs. (shrink)

Conducting clinical research on subjects admitted to intensive care units is challenging, as they frequently lack the capacity to provide informed consent due to multiple factors including intensive care unit acquired delirium, coma, the need for sedation, or underlying critical illness. However, the presence of one or more of these characteristics does not automatically designate a potential subject as lacking capacity to provide their own informed consent. We review the ethical issues involved in obtaining informed consent for medical research (...) from mechanically ventilated, critically ill patients, in addition to the concerns that may arise when a legally authorized representative is asked to provide informed consent on behalf of these patients. (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)

Este artículo transmite dos ideas destacadas: por un lado, defiende la justicia y la verdad de la democracia deliberativa; por el otro, denuncia el carácter ficticio del paradigma «westfaliano». Las dos hipótesis aparecen gracias a las filtraciones éticas de WikiLeaks. De cara a evaluarlas, previamente examino de forma crítica la evolución de la concepción política de Jürgen Habermas. Mi aportación es reinterpretar su deliberacionismo como una combinación entre una teoría del poder y una de la opinión pública.

Le 31 mars 2005 décédait à l’âge de 41 ans Theresa Marie Schiavo. Elle était dans le coma depuis le 25 février 1990. La demande de son mari de cesser l’alimentation et l’hydratation artificielles provoqua un débat public sans précédent et une longue saga judiciaire au terme de laquelle la Cour acquiesça à sa demande. La doctrine catholique à propos des questions de fin de vie fit l’objet d’une discussion virulente. C’est dans ce contexte que cet article analyse la (...) discussion théologique américaine et les interventions romaines récentes à propos de l’alimentation et l’hydratation artificielles des patients en état végétatif permanent. (shrink)

En primer lugar, la presente comunicación describe brevemente un suceso un tanto insólito: el que una página web haya puesto en jaque al considerado gobierno nacional más poderoso del mundo. En segundo lugar, se ofrece una posible perspectiva teórica para interpretar tal acontecimiento: la teoría de la opinión pública, principalmente desde su articulación en el seno de la Teoría Crítica de Jürgen Habermas. En tercer lugar, se evalúan someramente las luces y las sombras tanto de WikiLeaks como de Habermas mediante (...) la comparación crítica. En general, este trabajo se propone iniciar el análisis de las potencialidades de internet como herramienta y espacio en favor de la democracia y la emancipación de una ciudadanía participativa y no encerrada en sus clásicos límites estatales. (shrink)

When information on a coma patient’s expected outcome is uncertain, a moral dilemma arises in clinical practice: if life-sustaining treatment is continued, the patient may survive with unacceptably poor neurological prospects, but if withdrawn a patient who could have recovered may die. Continuous electroencephalogram-monitoring is expected to substantially improve neuroprognostication for patients in coma after cardiac arrest. This raises expectations that decisions whether or not to withdraw will become easier. This paper investigates that expectation, exploring cEEG’s impacts (...) when it becomes part of a socio-technical network in an Intensive Care Unit. Based on observations in two ICUs in the Netherlands and one in the USA that had cEEG implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients. The analysis focuses on the way patient outcomes are constructed, the kind of decision support these outcomes provide, and how cEEG affects communication between professionals and relatives. We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others. It also raises new concerns. Since its actual impacts furthermore hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation. (shrink)

The case of Terri Schiavo, a young woman who spent 15 years in a persistent vegetative state, has emerged as a watershed in debates over end-of-life care. While many observers had thought the right to refuse medical treatment was well established, this case split a family, divided a nation, and counfounded physicians, legislators, and many of the people they treated or represented. In renewing debates over the importance of advance directives, the appropriate role of artificial hydration and nutrition, and the (...) responsibilities of family members, the case also became one of history's most extensively litigated health care disputes. The Case of Terri Schiavo assembles a team of first-hand participants and content experts to provide thoughtful and nuanced analyses. In addition to a comprehensive overview, the book includes contributions by Ms. Schiavo's guardian ad litem, a neurologist and lawyer who participated in the case, and scholars who examine issues related to litigation, faith, gender, and disability. The volume also includes a powerful dissent from the views of many scholars in the bioethics community. The book is intended for students, health care professionals, policy makers, and other in search of carefully reasoned analyses of the case that will shape our view of death and end-of-life medical care for decades. (shrink)

Gathers medical and legal documents, opinions from various perspectives, and a timeline of events in the Terri Shiavo case to provide a resource for examining the moral and ethical issues surrounding end-of-life decisions.

Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and (...) prognostication. These techniques are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to “yes” or “no” answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients. (shrink)