NEUROETICA. LE GRANDI QUESTIONI, 2th edition, Padova
THE DIGNITY OF THE “PLANTS”: ETHICAL IMPLICATIONS IN THE MANAGEMENT OF PATIENTS WITH LOW LEVELS OF CONSCIOUSNESS Francesca Timpano, Annalisa Baglieri, Rosa Morabito, Maria Adele Marino, Silvia Marino, Placido Bramanti Centro Neurolesi “Bonino Pulejo”, Messina, Italy Neurobioimaging Laboratory
Introduction
Results
Recent functional Magnetic Resonance Imaging (fMRI) studies have raised the possibility that Vegetative State (VS) and Minimally Consciousness State (MCS) patients, even if severely brain damaged and non-responsive, retain some degree of consciousness, including processing of spoken words (1-2). The aim of this study is to assess the differences in brain activation between VS and MCS patients, in order to alert the clinicians and the whole society to regard these patients not in the same way as “plants”, but as persons with their rights and dignity.
• Significant activation of the primary auditory cortex (Heschl Gyrus) in both VS and MCS patients. • Significant activation of associative temporal areas (temporal planum and the posterior and lateral extension of Heschl Gyrus) only in MCS patients. L
R
VS
Z = 37
Materials and Methods
Z = 38
Z = 39
• 50 severely brain damaged patients: 23 in VS and 27 in MCS, 28 males and 22 females, mean age=49±7 years.
• All patients underwent a fMRI examination: a digitally recorded brief story told by a first-degree relative was administered by MRI-compatible noise attenuated headphones; a “block” design was used (30 seconds of auditory stimuli alternated with a 30-second rest period for a total of 10 paired blocks). • Image processing and statistical analysis for individual brain analyses were carried out using the FSL package. Cause VS (N=23)
19 TBI³, 2 Stroke, 2 Hypoxia
MCS (N=27)
23 TBI³, 2 Stroke, 2 Hypoxia
GCS¹
CUAS²
9+ -1
4+ -1
MCS
Figure 1. fMRI results in VS and MCS patients. Mean random effects statistical activation maps show the regions of significant activation during auditory stimuli (z > 2.3, p=0.01, corrected).
Discussion These evidences bring out important ethical reflections. In the clinical practice VS and MCS patients are often regarded as “vegetable beings”, with no carefulness to their emotional and phenomenological experience. On the basis of obtained results, it is important to encourage this field of research, in order to modify the way of treatment and management of VS and MCS patients and to approach them by a global model including not only biological aspects, but also psychological, social and environmental factors. References
11+ -1
6+ -1
¹Glasgow Coma Scale, ²Clinical Unawareness Assessment Scale, ³Traumatic Brain Injury
Table 1. Clinical data of VS and MCS patients
1. Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Using functional magnetic resonance imaging to detect covert awareness in the vegetative state. Archives of Neurology 2007; 64(8): 1098-102. 2. H. Di, S.M. Yu, X.C. Weng, S. Laureys, D. Yu, J.Q. Li, P.M. Qin, Y.H. Zhu, S..Z. Zhang, Y.Z. Chen. Cerebral response to patient’s own name in the vegetative and minimally conscious state. Neurology 2007; 68: 895-899.