The historical origins of the vegetative state: Received wisdom and the utility of the text.

The persistent vegetative state (PVS) is one of the most iconic and misunderstood phrases in clinical neuroscience. Coined as a diagnostic category by Scottish neurosurgeon Bryan Jennett and American neurologist Fred Plum in 1972, the phrase "vegetative" first appeared in Aristotle's treatise On the Soul (circa mid-fourth century BCE). Aristotle influenced neuroscientists of the nineteenth and early-twentieth centuries, Xavier Bichat and Walter Timme, and informed their conceptions of the vegetative nervous system. Plum credits Bichat and Timme in his use of the phrase, thus putting the ancient and modern in dialogue. In addition to exploring Aristotle's definition of the "vegetative" in the original Greek, we put Aristotle in conversation with his contemporaries-Plato and the Hippocratics-to better apprehend theories of mind and consciousness in antiquity. Utilizing the discipline of reception studies in classics scholarship, we demonstrate the importance of etymology and historical origin when considering modern medical nosology.

[From the vegetative state to unresponsive wakefulness: a historical review]. / Del estado vegetativo al estado de vigilia sin respuesta: una revisión histórica.

INTRODUCTION: Over the last few decades, the terminology, diagnostic techniques and treatment of patients with altered levels of consciousness have varied considerably. At the same time, the percentage of patients in this clinical situation has undergone a marked increase. AIMS: The purpose of this study is to present a historical review of the different terms that have been used in the medical literature to describe patients with altered states of consciousness. The article also includes the different diagnostic criteria utilised by research groups that have focused their attention on this population. DEVELOPMENT: The concept of 'vegetative state', a term coined back in the sixties, has since been transformed and replaced by other terms with a less negative connotation, such as 'unresponsive wakefulness syndrome'. In parallel, new clinical categories (minimally conscious state or minimally conscious plus) have appeared since it has been acknowledged that there are patients with a low level of consciousness but who nevertheless show signs that are consistent with interaction with the environment by means of unmistakeably voluntary behaviours in response to orders or gestures. CONCLUSIONS: The wide spectrum of signs and symptoms shown by patients with altered levels of consciousness reflects the clinical and neuropathological heterogeneity of these states. The current tendency is to describe the state clinically, adding the aetiology and the date of the event that caused the clinical picture. This article focuses on the context of an effort made by the scientific community to highlight the needs of this growing population.

The vegetative and minimally conscious states: diagnosis, prognosis and treatment.

Severe acquired brain injury has profound impact on alertness, cognition, and behavior. Among those who survive the initial injury, a significant minority fail to fully recover self and environmental awareness, and go on to experience prolonged disorders of consciousness (DOC) that can last a lifetime. Although there are no standards of care to guide clinical management, a growing body of empirical evidence is beginning to accrue to inform clinical decision making. In this article, we review the state of the science as it pertains to diagnosis, prognosis, and treatment of patients with DOC.

Can we know what Terri Schiavo would have wanted?

What would Terri Schiavo have wanted? That remains an unanswered question for many who followed the media frenzy that attended the extraordinary court and legislative battles that preceded her death 13 days after her feeding tube was removed for the last time. What would she have directed her physicians to do if she had "miraculously" regained capacity and awareness of the consequences of her cardiac arrest that left her in a persistent vegetative state? Who would she have wanted to make that decision for her if she were unable to do so? How are we to understand the meaning of statements that she purportedly made about life-sustaining treatments approximately 20 years ago, and how can we apply them to the current situation? This article reflects on those questions from the perspective of two small exploratory studies. These studies considered the meanings and interpretation of statements by terminally ill patients concerning desire for hastened death and the relevance of previously made statements to their current clinical situation.

"A rose for Emily," a rose for Terri: the lifeless body as love object and the case of Theresa Marie Schindler Schiavo.

The precise circumstances of Theresa Schiavo's disability, the reasons advanced for preserving and ending her life and the covert personal agendas and unacknowledged political-economic forces that may have significantly affected the outcome were investigated and are presented.

Affirming the right to care, preserving the right to die: disorders of consciousness and neuroethics after Schiavo.

In this article, I attempt to untangle some of the cultural, philosophical, and ethical currents that informed the Schiavo case. My objective is to better apprehend what the Schiavo case means for end-of-life care in general and to assert that our discourse about the ethical issues attendant to brain injury will be impoverished if we limit our discussions about disorders of consciousness solely to the vegetative state. If we ignore emerging developments in neuroscience that are helping to elucidate the nature of these disorders and fail to broaden the conversation about brain injury, beyond the unmitigated futility of the permanent vegetative state, we will imperil others who might improve and be helped. Through such efforts we can help mitigate the tragedy of the Schiavo case and overcome the rhetoric that marked the national discourse in March 2005. Once the complexity of disorders of consciousness is appreciated, rhetorical statements about a right to die or a right to life are exposed as being incompatible with the challenge of providing care to such patients. This is especially true as neuroscience brings greater diagnostic refinement to their assessment and management, a topic addressed in this article, which specifically focuses on the clinical and ethical implications of the recently described minimally conscious state. Instead of staking out ideological positions that do not meet the needs of patients or families, we should strive to both preserve the right to die for those who are beyond hope while affirming the right to care to those who might benefit from coming advances in neuroscience. If we can achieve that delicate balance, we will be able to transcend the partisan debate that shrouded the life and death of Theresa Marie Schiavo and begin to articulate a palliative neuroethics of care for those touched by severe brain injury and disorders of consciousness.