Abstract
The ethical issues accrued from the study and management of severely brain-injured patients are varied and multi-faceted. The medical, legal and public controversies are partly shaped by how different people think about these issues and in many cases are culturally-dependent. An ethical framework needs to be shaped to guide clinicians and caregivers in terms of clinical diagnosis, prognosis, and medical management. In this chapter, we will give a brief overview of some ethical issues related to the concept of consciousness and the medical management of patients with disorders of consciousness such as comatose, vegetative/unresponsive and minimally conscious states that may be encountered in the intensive care setting. We will emphasize the problem of pain management and end-of-life decision-making.
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Laureys S, Boly M. What is it like to be vegetative or minimally conscious? Curr Opin Neurol. 2007;20:609–13.
Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA. 1968;205:337–40.
Zeman A. Consciousness. Brain. 2001;124:1263–89.
Demertzi A, Liew C, Ledoux D, et al. Dualism persists in the science of mind. Ann N Y Acad Sci. 2009;1157:1–9.
Posner J, Saper C, Schiff N, Plum F, editors. Plum and Posner’s diagnosis of stupor and coma. 4th ed. New York: Oxford University Press; 2007.
Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet. 1972;1:734–7.
Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;58:349–53.
Schnakers C, Vanhaudenhuyse A, Giacino JT, et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment. BMC Neurol. 2009;9:35.
Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Detecting awareness in the vegetative state. Science. 2006;313:1402.
Monti MM, Vanhaudenhuyse A, Coleman MR, et al. Willful modulation of brain activity in disorders of consciousness. N Engl J Med. 2010;362:579–89.
Horne M (2009) Are people in a persistent vegetative state conscious? Monash Bioeth Rev. 28:12–1–12.
Kahane G, Savulescu J. Brain damage and the moral significance of consciousness. J Med Philos. 2009;34:6–26.
International Association for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms, Task force on taxonomy. Seatle: IASP Press; 1994.
Demertzi A, Schnakers C, Ledoux D, et al. Different beliefs about pain perception in the vegetative and minimally conscious states: a European survey of medical and paramedical professionals. Prog Brain Res. 2009;177:329–38.
Fins JJ. Affirming the right to care, preserving the right to die: disorders of consciousness and neuroethics after Schiavo. Palliat Support Care. 2006;4:169–78.
Ahronheim JC, Gasner MR. The sloganism of starvation. Lancet. 1990;335:278–9.
The Medical Task Force on Anencephaly. The infant with anencephaly. N Engl J Med. 1990;322:669–74.
McQuillen MP. Can people who are unconscious or in the “vegetative state” perceive pain? Issues Law Med. 1991;6:373–83.
Schnakers C, Chatelle C, Vanhaudenhuyse A, et al. The Nociception Coma Scale: a new tool to assess nociception in disorders of consciousness. Pain. 2010;148:215–9.
Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage. 2002;17:732–41.
Boly M, Faymonville ME, Schnakers C, et al. Perception of pain in the minimally conscious state with PET activation: an observational study. Lancet Neurol. 2008;7:1013–20.
Demertzi A, Vanhaudenhuyse A, Bruno MA, et al. Is there anybody in there? Detecting awareness in disorders of consciousness. Expert Rev Neurother. 2008;8:1719–30.
Poldrack RA. The role of fMRI in cognitive neuroscience: where do we stand? Curr Opin Neurobiol. 2008;18:223–7.
Schnakers C, Zasler ND. Pain assessment and management in disorders of consciousness. Curr Opin Neurol. 2007;20:620–6.
Bernat JL. Ethical issues in the perioperative management of neurologic patients. Neurol Clin. 2004;22:457–71.
Youngner SJ. Do-not-resuscitate orders: no longer secret, but still a problem. Hastings Cent Rep. 1987;17:24–33.
Laureys S. Science and society: death, unconsciousness and the brain. Nat Rev Neurosci. 2005;6:899–909.
Boveroux P, Kirsch M, Boly M, et al. Évaluation du pronostic neurologique dans les encéphalopathies postanoxiques. Réanimation. 2008;17:613–7.
Bernat JL, Beresford HR. The controversy over artificial hydration and nutrition. Neurology. 2006;66:1618–9.
Rosner F. Why nutrition and hydration should not be withheld from patients. Chest. 1993;104:1892–6.
Steinbrook R, Lo B. Artificial feeding–solid ground, not a slippery slope. N Engl J Med. 1988;318:286–90.
Royal College of Physicians. The vegetative state: guidance on diagnosis and management. Clin Med. 2003;3:249–54.
Demertzi A, Ledoux D, Bruno MA, et al. Attitudes towards end-of-life issues in disorders of consciousness: a European survey. J Neurol. 2011;258(6):1058–65.
Bernat JL, Steven L. The concept and practice of brain death. Prog Brain Res. 2005;150:369–79.
Bernat JL. Ethical issues in neurology. 2nd ed. Boston: Butterworth Heinemann; 2002.
Brierley JB, Graham DI, Adams JH, Simpsom JA. Neocortical death after cardiac arrest. A clinical, neurophysiological, and neuropathological report of two cases. Lancet. 1971;2:560–5.
Bernat JL. A defense of the whole-brain concept of death. Hastings Cent Rep. 1998;28:14–23.
Engelhardt K. Organ donation and permanent vegetative state. Lancet. 1998;351:211.
Truog RD, Robinson WM. Role of brain death and the dead-donor rule in the ethics of organ transplantation. Crit Care Med. 2003;31:2391–6.
Bernat JL. Clinical ethics and the Law. In: Bernat JL, editor. Ethical issues in neurology. Boston: Butterworth Heinemann; 2002. p. 79–107.
Bernat JL. The persistent vegetative state and related states. In: Bernat JL, editor. Ethical issues in neurology. Boston: Butterworth Heinemann; 2002. p. 283–305.
Emanuel EJ, Emanuel LL. The economics of dying. The illusion of cost savings at the end of life. N Engl J Med. 1994;330:540–4.
Jennett B. Editorial: resource allocation for the severely brain damaged. Arch Neurol. 1976;33:595–7.
Beresford HR. The Quinlan decision: problems and legislative alternatives. Ann Neurol. 1977;2:74–81.
Quill TE. Terri Schiavo –a tragedy compounded. N Engl J Med. 2005;352:1630–3.
Wijdicks EFM. Law and bioethics. In: Wijdicks EFM, editor. The comatose patient. New York: Oxford University Press; 2008. p. 201–16.
Jennett B. Ethical issues. In: Jennett B, editor. The vegetative state: medical facts, ethical and legal dilemmas. Cambridge: Cambridge University Press; 2002. p. 97–125.
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Demertzi, A. et al. (2012). The Ethics of Managing Disorders of Consciousness. In: Schnakers, C., Laureys, S. (eds) Coma and Disorders of Consciousness. Springer, London. https://doi.org/10.1007/978-1-4471-2440-5_14
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DOI: https://doi.org/10.1007/978-1-4471-2440-5_14
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