Ever since Pope John Paul II and later the Congregation for the Doctrine of the Faith issued guidelines which encouraged, then presumed the use of feeding tubes for persons in the vegetative state to be measures of “ordinary care,” neuroscientists have been learning more about impaired states of awareness.
News media coverage of Terri Schiavo’s medical condition was not particularly helpful, especially since many reports confused “coma” with “vegetative state (VS).” It was clear from several videotapes of Terri that she was not in a coma, and that she was awake, but that wasn’t the medical problem. Was she ”awake but not aware,” – that is the true definition of vegetative state.
Medical researchers wondered if some patients who are now classified as being in a vegetative state might actually be conscious (that is aware, not simply awake) but unable to express themselves (due to paralysis, for example).
Dynamic MRI studies measured patterns of brain activity of persons diagnosed as being in the vegetative state after they were asked questions and to imagine specific scenarios. In a way, the scans read minds, even when the person couldn’t respond with externally visible signals. These scans detected willful and predictable brain activity in some patients who were thought incapable of it. Re-examination of some of these patients at the bedside revealed detectable signs of responsiveness to questions – responses which had been missed despite careful examination by experts. Physicians could find no signs of clinical responsiveness in one patient whose scan showed awareness. The only patients in the study who showed any signs of brain scan awareness had suffered traumatic brain injury, not stroke or oxygen deprivation.
The study supports the idea that a small percentage of patients thought to be in VS are actually aware and might be able to communicate if given the means to do so. Awareness may be present with subtle and missed clinical responses, or present without any detectable clinical signs. Researchers hope that further studies will enable such patients to report whether they are in pain, and perhaps to express their thoughts and influence their environment.
Recent church teaching that even persons in vegetative states should ordinarily receive tube feedings has been controversial. This study supports the idea that a significant number of persons diagnosed as being in the vegetative state are actually minimally conscious. Routine clinical examination fails to detect some of these patients.
It will be interesting to see whether ethicists and clinicians respond to this study with skepticism, indifference, or heightened concern that we are starving some patients who are aware by failing to feed them. On the other hand, I am sure it will occur to someone to ask such persons if they wish the feedings stopped. More information doesn't guarantee more wisdom.
The article from the New England Journal of Medicine is here.
A balanced interpretation of the Papal teachings and those of the CDF by the Catholic ethicist Daniel Sulmasy, MD, OFM is here.