Advertisement

The Ethics of Managing Disorders of Consciousness

  • Athena Demertzi
  • Olivia Gosseries
  • Marie-Aurélie Bruno
  • Caroline Schnakers
  • Audrey Vanhaudenhuyse
  • Camille Chatelle
  • Vanessa Charland-Verville
  • Aurore Thibaut
  • Marie Thonnard
  • Steven Laureys
Chapter

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.

Keywords

Advance Directive Conscious State Minimally Conscious State Conscious Perception Intensive Care Setting 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Laureys S, Boly M. What is it like to be vegetative or minimally conscious? Curr Opin Neurol. 2007;20:609–13.PubMedCrossRefGoogle Scholar
  2. 2.
    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.CrossRefGoogle Scholar
  3. 3.
    Zeman A. Consciousness. Brain. 2001;124:1263–89.PubMedCrossRefGoogle Scholar
  4. 4.
    Demertzi A, Liew C, Ledoux D, et al. Dualism persists in the science of mind. Ann N Y Acad Sci. 2009;1157:1–9.PubMedCrossRefGoogle Scholar
  5. 5.
    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.Google Scholar
  6. 6.
    Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet. 1972;1:734–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Giacino JT, Ashwal S, Childs N, et al. The minimally conscious state: definition and diagnostic criteria. Neurology. 2002;58:349–53.PubMedCrossRefGoogle Scholar
  8. 8.
    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.PubMedCrossRefGoogle Scholar
  9. 9.
    Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Detecting awareness in the vegetative state. Science. 2006;313:1402.PubMedCrossRefGoogle Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    Horne M (2009) Are people in a persistent vegetative state conscious? Monash Bioeth Rev. 28:12–1–12.Google Scholar
  12. 12.
    Kahane G, Savulescu J. Brain damage and the moral significance of consciousness. J Med Philos. 2009;34:6–26.PubMedGoogle Scholar
  13. 13.
    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.Google Scholar
  14. 14.
    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.PubMedCrossRefGoogle Scholar
  15. 15.
    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.PubMedCrossRefGoogle Scholar
  16. 16.
    Ahronheim JC, Gasner MR. The sloganism of starvation. Lancet. 1990;335:278–9.PubMedCrossRefGoogle Scholar
  17. 17.
    The Medical Task Force on Anencephaly. The infant with anencephaly. N Engl J Med. 1990;322:669–74.CrossRefGoogle Scholar
  18. 18.
    McQuillen MP. Can people who are unconscious or in the “vegetative state” perceive pain? Issues Law Med. 1991;6:373–83.PubMedGoogle Scholar
  19. 19.
    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.PubMedCrossRefGoogle Scholar
  20. 20.
    Laureys S, Faymonville ME, Peigneux P, et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage. 2002;17:732–41.PubMedCrossRefGoogle Scholar
  21. 21.
    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.PubMedCrossRefGoogle Scholar
  22. 22.
    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.PubMedCrossRefGoogle Scholar
  23. 23.
    Poldrack RA. The role of fMRI in cognitive neuroscience: where do we stand? Curr Opin Neurobiol. 2008;18:223–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Schnakers C, Zasler ND. Pain assessment and management in disorders of consciousness. Curr Opin Neurol. 2007;20:620–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Bernat JL. Ethical issues in the perioperative management of neurologic patients. Neurol Clin. 2004;22:457–71.CrossRefGoogle Scholar
  26. 26.
    Youngner SJ. Do-not-resuscitate orders: no longer secret, but still a problem. Hastings Cent Rep. 1987;17:24–33.PubMedGoogle Scholar
  27. 27.
    Laureys S. Science and society: death, unconsciousness and the brain. Nat Rev Neurosci. 2005;6:899–909.PubMedCrossRefGoogle Scholar
  28. 28.
    Boveroux P, Kirsch M, Boly M, et al. Évaluation du pronostic neurologique dans les encéphalopathies postanoxiques. Réanimation. 2008;17:613–7.CrossRefGoogle Scholar
  29. 29.
    Bernat JL, Beresford HR. The controversy over artificial hydration and nutrition. Neurology. 2006;66:1618–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Rosner F. Why nutrition and hydration should not be withheld from patients. Chest. 1993;104:1892–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Steinbrook R, Lo B. Artificial feeding–solid ground, not a slippery slope. N Engl J Med. 1988;318:286–90.PubMedCrossRefGoogle Scholar
  32. 32.
    Royal College of Physicians. The vegetative state: guidance on diagnosis and management. Clin Med. 2003;3:249–54.Google Scholar
  33. 33.
    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.PubMedCrossRefGoogle Scholar
  34. 34.
    Bernat JL, Steven L. The concept and practice of brain death. Prog Brain Res. 2005;150:369–79.PubMedCrossRefGoogle Scholar
  35. 35.
    Bernat JL. Ethical issues in neurology. 2nd ed. Boston: Butterworth Heinemann; 2002.Google Scholar
  36. 36.
    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.PubMedGoogle Scholar
  37. 37.
    Bernat JL. A defense of the whole-brain concept of death. Hastings Cent Rep. 1998;28:14–23.PubMedGoogle Scholar
  38. 38.
    Engelhardt K. Organ donation and permanent vegetative state. Lancet. 1998;351:211.PubMedCrossRefGoogle Scholar
  39. 39.
    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.PubMedCrossRefGoogle Scholar
  40. 40.
    Bernat JL. Clinical ethics and the Law. In: Bernat JL, editor. Ethical issues in neurology. Boston: Butterworth Heinemann; 2002. p. 79–107.Google Scholar
  41. 41.
    Bernat JL. The persistent vegetative state and related states. In: Bernat JL, editor. Ethical issues in neurology. Boston: Butterworth Heinemann; 2002. p. 283–305.Google Scholar
  42. 42.
    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.PubMedCrossRefGoogle Scholar
  43. 43.
    Jennett B. Editorial: resource allocation for the severely brain damaged. Arch Neurol. 1976;33:595–7.PubMedCrossRefGoogle Scholar
  44. 44.
    Beresford HR. The Quinlan decision: problems and legislative alternatives. Ann Neurol. 1977;2:74–81.PubMedCrossRefGoogle Scholar
  45. 45.
    Quill TE. Terri Schiavo –a tragedy compounded. N Engl J Med. 2005;352:1630–3.PubMedCrossRefGoogle Scholar
  46. 46.
    Wijdicks EFM. Law and bioethics. In: Wijdicks EFM, editor. The comatose patient. New York: Oxford University Press; 2008. p. 201–16.Google Scholar
  47. 47.
    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.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2012

Authors and Affiliations

  • Athena Demertzi
    • 1
    • 2
  • Olivia Gosseries
    • 1
    • 2
    • 3
  • Marie-Aurélie Bruno
    • 1
    • 2
  • Caroline Schnakers
    • 1
    • 2
  • Audrey Vanhaudenhuyse
    • 1
    • 2
  • Camille Chatelle
    • 1
    • 2
  • Vanessa Charland-Verville
    • 1
    • 2
  • Aurore Thibaut
    • 1
    • 2
  • Marie Thonnard
    • 1
    • 2
  • Steven Laureys
    • 1
    • 2
  1. 1.Coma Science Group, Cyclotron Research CenterUniversity of LiègeLiègeBelgium
  2. 2.Department of NeurologyCHU University Hospital of LiègeLiègeBelgium
  3. 3.National Fund for Scientific ResearchLiègeBelgium

Personalised recommendations