Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Science and Society
  • Published:

Constructing an ethical stereotaxy for severe brain injury: balancing risks, benefits and access

Abstract

Societal perceptions of the diagnosis and treatment of cognitive impairment after severe brain injury have been influenced by the legacies of the right-to-die movement and psychosurgery. Here I propose an ethical stereotaxy for severe brain injury that balances risks, benefits and access to this neglected population, in light of advances in cognitive neuroscience.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Figure 1: Widely varying patterns of resting metabolic activity observed in patients in a chronic persistent vegetative state.
Figure 2: Cortical processing in the persistent vegetative state.

References

  1. Winslade, W. J. Confronting Traumatic Brain Injury: Devastation, Hope and Healing (Yale Univ. Press, New Haven, Connecticut, 1998).

    Google Scholar 

  2. Schiff, N. D. Persistent vegetative state: a site map of the debate. In HMS Beagle: The BioMedNet Magazine (18 February, 2000) Issue 72 (http://news.bmn.com/hmsbeagle/76/viewpts/overview).

    Google Scholar 

  3. Bullinger, M. et al. Quality of life in patients with traumatic brain injury — basic issues, assessment and recommendations. Restor. Neurol. Neurosci. 20, 111–124 (2002).

    CAS  PubMed  Google Scholar 

  4. Phipps, E. & Whyte, J. Medical decision-making with persons who are minimally conscious. Am. J. Phys. Med. Rehabil. 78, 77–82 (1999).

    Article  CAS  Google Scholar 

  5. Phipps, E., DiPasquale, M., Blitz, C. L. & Whyte, J. Interpreting responsiveness in persons with severe traumatic brain injury: beliefs in families and quantitative evaluations. J. Head Trauma Rehabil. 12, 52–69 (1997).

    Article  Google Scholar 

  6. Fins, J. J. A proposed ethical framework for interventional cognitive neuroscience: a consideration of deep brain stimulation in impaired consciousness. Neurol. Res. 22, 273–278 (2000).

    Article  CAS  Google Scholar 

  7. Consensus conference. Rehabilitation of persons with traumatic brain injury. NIH Consensus Development Panel on Rehabilitation of Persons with Traumatic Brain Injury. J. Am. Med. Assoc. 282, 974–983 (1999).

  8. Cantor, N. L. Twenty-five years after Quinlan: a review of the jurisprudence of death and dying. J. Law Med. Ethics 29, 182–196 (2001).

    Article  CAS  Google Scholar 

  9. Cranford, R. E. Medical futility: transforming a clinical concept into legal and social policies. J. Am. Geriatr. Soc. 42, 894–898 (1994).

    Article  CAS  Google Scholar 

  10. Annas, G. J. The 'right to die' in America: sloganeering from Quinlan and Cruzan to Quill and Kevorkian. Duquesne Law Rev. 34, 875–897 (1996).

    PubMed  Google Scholar 

  11. Landmark article August 5, 1968: a definition of irreversible coma. Report of the ad hoc committee of the Harvard Medical School to examine the definition of brain death. J. Am. Med. Assoc. 205, 337–340 (1968).

  12. Stevens, M. L. Redefining death in America, 1968. Caduceus 11, 207–219 (1995).

    CAS  PubMed  Google Scholar 

  13. Beecher, H. K. Ethical problems created by the hopelessly unconscious patient. N. Engl. J. Med. 278, 1425–1430 (1968).

    Article  CAS  Google Scholar 

  14. Jennett, B. & Plum, F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1, 734–737 (1972).

    Article  CAS  Google Scholar 

  15. Jennett, B. The Vegetative State (Cambridge Univ. Press, Cambridge, UK, 2002).

    Book  Google Scholar 

  16. Bernat, J. L. A defense of the whole-brain concept of death. Hastings Cent. Rep. 28 (2), 14–23 (1998).

    Article  CAS  Google Scholar 

  17. Giacino, J. T. et al. The minimally conscious state: definition and diagnostic criteria. Neurology 58, 349–353 (2002).

    Article  Google Scholar 

  18. Jennett, B., Adams, J. H., Murray, L. S. & Graham, D. I. Neuropathology in vegetative and severely disabled patients after head injury. Neurology 56, 486–490 (2001).

    Article  CAS  Google Scholar 

  19. Schiff, N. D. et al. Residual cerebral activity and behavioural fragments can remain in the persistently vegetative brain. Brain 125, 1210–1234 (2002).

    Article  Google Scholar 

  20. Menon, D. K. et al. Cortical processing in persistent vegetative state. Wolfson Brain Imaging Centre Team. Lancet 352, 200 (1998).

    Article  CAS  Google Scholar 

  21. Wilson, B. A., Gracey, F. & Bainbridge, K. Cognitive recovery form 'persistent vegetative state': psychological and personal perspectives. Brain Inj. 15, 1083–1092 (2001).

    Article  CAS  Google Scholar 

  22. Schiff, N. D. & Plum, F. Cortical function in the persistent vegetative state. Trends Cogn. Sci. 3, 43–44 (1999).

    Article  CAS  Google Scholar 

  23. van Domburg, P. H., ten Donkelaar, H. J. & Notermans, S. Akinetic mutism with bithalamic infarction. Neurophysiological correlates. J. Neurol. Sci. 139, 58–65 (1996).

    Article  CAS  Google Scholar 

  24. Kampfl, A. et al. Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. Lancet 351, 1763–1767 (1998).

    Article  CAS  Google Scholar 

  25. Laureys, S., Faymonville, M. E., Moonen, G., Luxen, A. & Maquet, P. PET scanning and neuronal loss in acute vegetative state. Lancet 355, 1825–1826 (2000).

    Article  CAS  Google Scholar 

  26. Laureys, S. et al. Brain function in the vegetative state. Acta Neurol. (Belg.) 102, 177–185 (2002).

    Google Scholar 

  27. Hirsch, J. et al. fMRI reveals intact cognitive systems in minimally conscious patients. Soc. Neurosci. Abstr. 27, 529.14 (2001).

    Google Scholar 

  28. Strauss, D. J., Ashwal, S., Day, S. M. & Shavelle, R. M. Life expectancy of children in vegetative and minimally conscious states. Pediatr. Neurol. 23, 312–319 (2000).

    Article  CAS  Google Scholar 

  29. Callahan, D. Necessity, futility and the good society. J. Am. Geriatr. Soc. 42, 866–867 (1994).

    Article  CAS  Google Scholar 

  30. Zarkovich, E. & Upshur, R. E. The virtues of evidence. Theor. Med. Bioeth. 23, 403–412 (2002).

    Article  Google Scholar 

  31. Giacino, J. T. et al. Development of practice guidelines for assessment and management of the vegetative and minimally conscious states. J. Head Trauma Rehabil. 12, 79–89 (1997).

    Article  Google Scholar 

  32. Cranford, R. E. The vegetative and minimally conscious states: ethical implications. Geriatrics 53, S70–S73 (1998).

    PubMed  Google Scholar 

  33. Shewmon, D. A. The minimally conscious state: definition and diagnostic criteria. Neurology 58, 506–507 (2002).

    Article  Google Scholar 

  34. Payne, K., Taylor, R. M., Stocking, C. & Sachs, G. A. Physicians' attitudes about the care of patients in the persistent vegetative state: a national survey. Ann. Intern. Med. 125, 104–110 (1996).

    Article  CAS  Google Scholar 

  35. Coleman, D. The minimally conscious state: definition and diagnostic criteria. Neurology 58, 506–507 (2002).

    Article  Google Scholar 

  36. Cicerone, K. D. et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch. Phys. Med. Rehabil. 81, 1596–1615 (2000).

    Article  CAS  Google Scholar 

  37. Schiff, N. D. & Pulver, M. Does vestibular stimulation activate thalamocortical mechanisms that reintegrate impaired cortical regions? Proc. R. Soc. Lond. B 266, 421–423 (1999).

    Article  CAS  Google Scholar 

  38. Schiff, N. D., Plum, F. & Rezai, A. R. Developing prosthetics to treat cognitive disabilities resulting from acquired brain injuries. Neurol. Res. 24, 116–124 (2002).

    Article  Google Scholar 

  39. Schiff, N. D. & Purpura, K. P. Towards a neurophysiologic foundation for cognitive neuromodulation through deep brain stimulation. Thal. Rel. Syst. 2, 55–69 (2002).

    Article  Google Scholar 

  40. Tsubokawa, T. & Yamamoto, T. in Textbook of Stereotactic and Functional Neurosurgery (eds Gildenberg, P. L. & Tasker, R. R.) 1979–1986 (McGraw-Hill Professional, New York, 1998).

    Google Scholar 

  41. Schneiderman, L. J., Jecker, N. S. & Jonsen, A. R. Medical futility: its meaning and ethical implications. Ann. Intern. Med. 112, 949–954 (1990).

    Article  CAS  Google Scholar 

  42. Schneiderman, L. J. The futility debate: effective versus beneficial intervention. J. Am. Geriatr. Soc. 42, 883–886 (1994).

    Article  CAS  Google Scholar 

  43. Smothers, R. Injured in '88, Officer awakes in '96. New York Times (New York, February 16, 1995).

  44. Burruss, J. W. & Chacko, R. C. Episodically remitting akinetic mutism following subarachnoid hemorrhage. J. Neuropsychiatry Clin. Neurosci. 11, 100–102 (1999).

    Article  CAS  Google Scholar 

  45. Speelman, J. D. & Bosch, D. A. Resurgence of functional neurosurgery for Parkinson's disease: a historical perspective. Mov. Disord. 13, 582–588 (1998).

    Article  CAS  Google Scholar 

  46. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N. Engl. J. Med. 345, 956–963 (2001).

  47. Kumar, R. et al. Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson's disease. Neurology 51, 850–855 (1998).

    Article  CAS  Google Scholar 

  48. Young, R. F. Brain stimulation. Neurosurg. Clin. N. Am. 1, 865–879 (1990).

    Article  CAS  Google Scholar 

  49. Kopell, B. H. & Rezai, A. The continuing evolution of psychiatric neurosurgery. CNS Spectrums 5 (10), 20–31 (2000).

    Article  Google Scholar 

  50. Roth, R. M., Flashman, L. A., Saykin, A. J. & Roberts, D. W. Deep brain stimulation in neuropsychiatric disorders. Curr. Psychiatry Rep. 3, 366–372 (2001).

    Article  CAS  Google Scholar 

  51. Rapoport, J. L. & Inoff-Germain, G. Medical and surgical treatment of obsessive–compulsive disorder. Neurol. Clin. 15, 421–428 (1997).

    Article  CAS  Google Scholar 

  52. Greenberg, B. D. Update on deep brain stimulation. J. ECT 18, 193–196 (2002).

    Article  Google Scholar 

  53. Fins, J. J. From psychosurgery to neuromodulation and palliation: history's lessons for the ethical conduct and regulation of neuropsychiatric research. Neurosurg. Clin. N. Am. (in the press).

  54. Delgado, J. M. & Anshen, R. N. (eds) Physical Control of the Mind: Toward a Psychocivilized Society (Harper and Row, New York, 1969).

    Google Scholar 

  55. Gaylin, W. M., Meister, J. S. & Neville, R. C. (eds) Operating on the Mind: The Psychosurgery Conflict (Basic Books, New York, 1975).

    Google Scholar 

  56. Valenstein, E. S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, New York, 1986).

    Google Scholar 

  57. Editorial. The future of mind control. The Economist (London, May 25, 2002).

  58. Safire, W. The but-what-if factor. The New York Times (New York) A25 (May 16, 2002).

  59. El-Hai, J. The lobotomist. The Washington Post Magazine (Washington) 16–31 (February 4, 2001).

  60. Herbert, W. Psychosurgery redux. US News & World Report (Washington) 63 (November 3, 1997).

  61. Carmichael, M. Healthy shocks to the head. Newsweek (Washington) 56–58 (June 24, 2002)

  62. Fins, J. J. The ethical limits of neuroscience. Lancet Neurol. 1, 213 (2002).

    Article  Google Scholar 

  63. The National Research Act. Public Law 93-348 (July 12, 1974) (http://www.fas.harvard.edu/research/PL93-348.html).

  64. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Use of psychosurgery in practice and research: report and recommendations of The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Fed. Regist. 42, 26318–26332 (1977).

  65. Mathew, S. J., Yudofsky, S. C., McCullough, L. B., Teasdale, T. A. & Jankovic, J. Attitudes toward neurosurgical procedures for Parkinson's disease and obsessive–compulsive disorder. J. Neuropsychiatry Clin. Neurosci. 11, 259–267 (1999).

    Article  CAS  Google Scholar 

  66. Donnelly, J. The incidence of psychosurgery in the United States, 1971–1973. Am. J. Psychiatry 135, 1476–1480 (1978).

    Article  CAS  Google Scholar 

  67. Blatte, H. State prisons and the use of behavior control. Hastings Cent. Rep. 4 (4), 11 (1974).

    Article  CAS  Google Scholar 

  68. Culliton, B. J. Psychosurgery: National Commission issues suprisingly favorable report. Science 194, 299–301 (1976).

    Article  Google Scholar 

  69. National Bioethics Advisory Commission. Research Involving Persons With Mental Disorders That May Affect Decisionmaking Capacity (Rockville, Maryland, December 1998) (http://www.georgetown.edu/research/nrcbl/nbac/capacity/TOC.htm).

  70. Michels, R. Are research ethics bad for our mental health? N. Engl. J. Med. 340, 1427–1430 (1999).

    Article  CAS  Google Scholar 

  71. Oldham, J. M., Haimowitz, S. & Delano, S. Protection of persons with mental disorders from research risk. Arch. Gen. Psychiatry 56, 688–693 (1999).

    Article  CAS  Google Scholar 

  72. Miller, F. G. & Fins, J. J. Protecting vulnerable research subjects without unduly constraining neuropsychiatric research. Arch. Gen. Psychiatry 56, 701–702 (1999).

    Article  CAS  Google Scholar 

  73. Vanderpool, H. Y. & Weiss, G. B. False data and the therapeutic misconception. Hastings Cent. Rep. 17 (2), 16–19 (1987).

    Article  CAS  Google Scholar 

  74. Fins, J. J. & Schiff, N. D. Diagnosis and treatment of traumatic brain injury. J. Am. Med. Assoc. 283, 2392 (2000).

    Article  CAS  Google Scholar 

  75. Cohadon, F., Richer, E., Bougiera, A., Deliack, P. & Loiseau, H. in Neurostimulation: an Overview (eds Lazrthesy, Y. & Upton, A. R. M.) 247–250 (Futura Publishing, Mount Kisco, New York, 1985).

    Google Scholar 

  76. Osborn, C. L. Over my Head (Andrews McNeal Publishing, Kansas City, Kansas, 1998).

    Google Scholar 

  77. Beecher, H. K. After the 'definition of irreversible coma'. N. Engl. J. Med. 281, 1070–1071 (1969).

    Article  CAS  Google Scholar 

Download references

Acknowledgements

I thank N. D. Schiff for his close reading and helpful comments, as well as A. Hudson and E. Kobylarz. An earlier version of this paper was presented as the 2002 Sheldon Berrol Memorial Chautauqua of the American Congress of Rehabilitation Medicine and American Society of Neurorehabilitation. J.J.F. is an unfunded co-investigator on a planning grant from the National Institute of Health for neuromodulation in patients in the MCS.

Author information

Authors and Affiliations

Authors

Related links

Related links

FURTHER INFORMATION

Report and Recommendations of the National Bioethics Advisory Commission

The National Research Act. Public Law 93-348

Rights and permissions

Reprints and permissions

About this article

Cite this article

Fins, J. Constructing an ethical stereotaxy for severe brain injury: balancing risks, benefits and access. Nat Rev Neurosci 4, 323–327 (2003). https://doi.org/10.1038/nrn1079

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrn1079

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing