Minimally Conscious versus Comatose States: Clinical Complexities and Halachic Bioethical Implications
Frank Lieberman, M.D., Professor of Neurology, Neurosurgery, and Medical Oncology, University of Pittsburgh School of Medicine
The care of patients with devastating brain injury raises difficult questions about the sanctity of human life, and to what extent the capacity for sentient being should determine which interventions are appropriate. The provision of hydration and nutrition, treatment of inter-current medical illness, cardiopulmonary resuscitation and assisted ventilation may all be decided with the implicit assumption that the presence or absence of sentient being can be reliably and accurately assessed with acceptable inter-observer variability. Recent investigations challenge this assumption and suggest that determination of minimally conscious states requires careful and serial neurologic examination. Functional neuro-imaging has demonstrated activation of neural networks in response to visual or auditory stimuli in patients who may not demonstrate behaviorally observable responses, further complicating the clinical diagnosis of minimally conscious states.
When the clinical distinction between minimally conscious states and coma is considered a dis-positive distinction regarding decisions about level of care, there is an implicit assumption that the capacity for conscious awareness is the characteristic which defines the patient as a human being, and justifies the attempt to prolong life even in a neurologically compromised state. While these distinctions are important, Jewish religious law does not recognize the presence of evidence of conscious awareness at the criterion which confers fundamental dignity to the patient as a human being. In this presentation, we discuss the current diagnostic approaches to differentiating minimally conscious states from coma. We contrast the bio-ethical decision making process resulting from the assumption that conscious awareness defines the patient as human and the halachic approach to decision making. We will examine the possibility that patients in a minimally conscious state may experience suffering that is spared patients who are comatose and that this may affect the priorities in balancing efforts to prolong life in patients with irreversible brain injury with the mandate to alleviate pain and suffering.
The care of patients with devastating brain injury raises difficult questions about the sanctity of human life, and to what extent the capacity for sentient being should determine which interventions are appropriate. The provision of hydration and nutrition, treatment of inter-current medical illness, cardiopulmonary resuscitation and assisted ventilation may all be decided with the implicit assumption that the presence or absence of sentient being can be reliably and accurately assessed with acceptable inter-observer variability. Recent investigations challenge this assumption and suggest that determination of minimally conscious states requires careful and serial neurologic examination. Functional neuro-imaging has demonstrated activation of neural networks in response to visual or auditory stimuli in patients who may not demonstrate behaviorally observable responses, further complicating the clinical diagnosis of minimally conscious states.
When the clinical distinction between minimally conscious states and coma is considered a dis-positive distinction regarding decisions about level of care, there is an implicit assumption that the capacity for conscious awareness is the characteristic which defines the patient as a human being, and justifies the attempt to prolong life even in a neurologically compromised state. While these distinctions are important, Jewish religious law does not recognize the presence of evidence of conscious awareness at the criterion which confers fundamental dignity to the patient as a human being. In this presentation, we discuss the current diagnostic approaches to differentiating minimally conscious states from coma. We contrast the bio-ethical decision making process resulting from the assumption that conscious awareness defines the patient as human and the halachic approach to decision making. We will examine the possibility that patients in a minimally conscious state may experience suffering that is spared patients who are comatose and that this may affect the priorities in balancing efforts to prolong life in patients with irreversible brain injury with the mandate to alleviate pain and suffering.