HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

SPECIAL ARTICLES: J.T. Giacino, S. Ashwal, N. Childs, R. Cranford, B. Jennett, D.I. Katz, J.P. Kelly, J.H. Rosenberg, J. Whyte, R.D. Zafonte, and N.D. Zasler The minimally conscious state: Definition and diagnostic criteria Neurology 2002; 58: 349-353 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Reply to Letters to the Editor by Burke and Machado

Douglas Katz, JT Giacino, S Ashwal, N Childs, R Cranford, B Jennett, JP Kelly, JH Rosenberg, J Whyte, R Zafonte and ND Zasler   (24 June 2002)

The minimally conscious state: Definition and diagnostic criteria

Calixto Machado   (24 June 2002)

The minimally conscious state: Definition and diagnostic criteria

Joseph J Fins, Nicholas D. Schiff   (24 June 2002)

The minimally conscious state: Definition and diagnostic criteria

William J Burke   (24 June 2002)

Reply to Letters to the Editor by Burke and Machado 24 June 2002
Douglas Katz Boston University School of Medicine Boston MA, JT Giacino, S Ashwal, N Childs, R Cranford, B Jennett, JP Kelly, JH Rosenberg, J Whyte, R Zafonte and ND Zasler Send Correspondence to journal: Re: Reply to Letters to the Editor by Burke and Machado dkatz{at}bu.edu Douglas Katz, et al.	In response to Dr. Burke’s letter, we reiterate that the primary objective of the Aspen Group was to distinguish individuals who demonstrate discernible, albeit limited, behavioral evidence of consciousness (i.e. minimally conscious state) from those who are clinically unconscious (i.e. vegetative state). This project’s impetus grew out of concern that clinical management of patients in acute MCS was often no different than for patients in VS. Consequently, some individuals with at least partial preservation of consciousness were not afforded the opportunity to receive aggressive rehabilitative treatment--a situation we believe that prevails. Our motivation was further bolstered by preliminary empirical evidence showing that although VS and MCS patients have similar degrees of neurobehavioral disability early after injury, functional outcome at one year is significantly more favorable in some MCS subgroups. [2, 3] From a scientific standpoint, we are at a loss to understand Dr. Burke’s portrayal of the MCS diagnosis as a mechanism for achieving “eugenics.” The Aspen Group is comprised largely of clinicians who have been providing acute and long-term care for individuals with catastrophic brain injury for many years. The affiliations and experience of the authors of the MCS article [1] should be considered when judging Dr. Burke’s allegations. We acknowledge that the definition and recommendations that we have proposed for MCS represent little more than a starting point, but one we hope will direct attention to this condition and facilitate further scientific inquiry. We appreciate Dr. Machado’s comments. He raises some issues that get at some key problems in understanding and defining consciousness and disorders of consciousness. One problem is semantics and how various terms are used in describing consciousness. He points out that consciousness is composed of two components, arousal and awareness and suggests that the term ‘minimally aware state’ be used in place of ‘minimally conscious state’, since awareness, but not arousal is the relevant component in this condition. Different authors use the terms, arousal, awareness and consciousness differently in relation to each other. Some emphasize the distinctness of arousal or wakefulness and consciousness. [4] Some use the terms awareness and consciousness almost synonymously (e.g., consciousness = awareness of self and environment). Some consider awareness subordinate to consciousness. Others define awareness as a state in which information is available for the individual to report on and act on. [5] Even others note that using this definition; computers may demonstrate awareness, but not consciousness. [6] Therefore, the appropriateness of one term over another may depend on the semantic nuances intended by the author. In order to avoid this problem, diagnostic terms, such as vegetative state and minimally conscious state (MCS), require well-defined criteria so that there is some uniformity in their use for clinical and research purposes. The main goal of our paper was to propose such criteria for MCS. [1] References : 1. Giacino JT, Ashwal S, Childs N et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002;58;349-353. 2. Giacino JT, Kalmar K. The vegetative and minimally conscious states: a comparison of clinical features and functional outcome. Journal of Head Trauma Rehabilitation 1997;12:36-51. 3. Francisco GE, Yablon SA, Ivanhoe CB, et al. Outcome among vegetative and minimally responsive patients with severe acquired brain injury. American Journal of Physical Medicine and Rehabilitation 1996;75:158. Abstract. 4. Damasio A. The feeling of what happens. San Diego: Harcourt, 1999. 5. Chalmers DJ. The conscious mind. Oxford: Oxford University Press, 1996. 6. Zeman A. Consciousness. Brain 2001;124:1263-1289.
The minimally conscious state: Definition and diagnostic criteria 24 June 2002
Calixto Machado Institute of Neurology and Neurosurgery Ciudad de La Habana Cuba Send Correspondence to journal: Re: The minimally conscious state: Definition and diagnostic criteria braind{at}infomed.sld.cu Calixto Machado	Normal conscious behavior requires arousal that depends on the function of the ascending reticular activating system (ARAS) and, awareness or content of consciousness that represents the sum of the cognitive, affective, and other higher brain functions, related to "complex physical and psychologic mechanisms by which limbic systems and the cerebrum enrich and individualize human consciousness". [1] Nonetheless, arousal cannot simply be related to the function of the ARAS, and awareness related to the function of the cerebral cortex, because substantial interconnections among the brainstem, subcortical structures and the neocortex are indispensable for both components of human consciousness. Hence, consciousness does not bear a simple one-to- one relationship with higher or lower brain structures.[1,2] Giacino et al. stated that the vegetative state (VS) is “characterized by complete absence of behavioral evidence for self or environmental awareness…”, and described the minimally conscious state as patients with “inconsistence but discernible evidence of consciousness.” [3] Most authors mention human consciousness, without considering its two components. For example, higher brain theorists of death habitually describe the persistent or permanent vegetative state (VS) as patients with "irreversible loss of consciousness" or "permanent unconscious", but in these patients arousal is preserved, while awareness is apparently lost. [2,4] VS patients reflect the only situation in which an apparent dissociation of both components of consciousness is found. [2] I used the adjective “apparent” because of the following reflection. Can we deny the existence of internal awareness in VS, because these patients apparently seem to be disconnected from the external world? The subjective dimension of awareness is philosophically impossible to test, but physiologically it seems conceivable that subjective awareness might continue. [2] Karen Ann Quinlan's brain showed severe damage of the thalamus, with the cerebral hemispheres relatively spared. [5] We can ask ourselves if, in a case like this, other activating pathways, projecting to the cerebral cortex without relaying through the thalamus, could stimulate the cerebral cortex to provide internal awareness, even if physicians are unable to detect its manifestations. [2] Hence, the paper of Giacino et al. represents a remarkable effort to identify and diagnose a new syndrome of consciousness impairment, along a continuum of brain damage. Nonetheless, I would use the term minimally aware state instead of minimally conscious state. References: 1. Plum F. Coma and related global disturbances of the human conscious state. New York, Plenum Publishing Corporation. Cerebral Cortex. A. Peters. Ref Type: Serial (Book, Monograph) 1991;[9]:359-425. 2. Machado C. Consciousness as a definition of death: its appeal and complexity. Clin Electroencephalogr 1999; 30:156-164. 3. Giacino JT, Ashwal S, Childs N et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002; 58:349-353. 4. Truog RD, Fackler JC. Rethinking brain death. Crit Care Med 1992; 20:1705-1713. 5. Kinney HC, Korein J, Panigrahy A, Dikkes P, Goode R. Neuropathological findings in the brain of Karen Ann Quinlan. The role of the thalamus in the persistent vegetative state. N Engl J Med 1994; 330:1469-1475.
The minimally conscious state: Definition and diagnostic criteria 24 June 2002
Joseph J Fins New York Presbyterian Hospital-Weill Cornell Center New York, Nicholas D. Schiff Send Correspondence to journal: Re: The minimally conscious state: Definition and diagnostic criteria jjfins{at}mail.med.cornell.edu Joseph J Fins, et al.	The response engendered by the proposed criteria for the minimally conscious state by Giacino et. al. is at once predictable and paradoxical. [1, 2, 3] It is predictable in voicing concern that a new diagnostic category could be used to undermine the care of the severely disabled. Opponents contend that in the absence of an evidence base for these criteria, the consensus model used to generate these guidelines represents the consolidation of an ideological stance about the worth of these individuals. But is also paradoxical. This categorization could be a helpful tool in better understanding the continuum of brain states and designing research and therapies to improve and augment cognitive function. [1] By further distinguishing those in PVS from those who we suspect have elements of consciousness; we can collectively make a stronger distributive justice claim for enhanced services and more research to address the needs of patients and families with brain injury. Practically, this regard should translate into better diagnostic precision. The staggering public health need posed by traumatic brain injury, coupled with society's marginalization of the disabled, makes this an ethical imperative as medicine seeks to provide the benefits of science to these historically under-served individuals. [1] In this we disagree with Dr. Shewmon’s assertion that, “there is no clinical or research need for, and strong reasons against, inventing a new diagnostic ‘entity’ that inherently cannot not be meaningfully demarcated from ‘severe disability.” While the concerns of Ms. Coleman are understandable and laudable, it would be more productive if she broadened her advocacy to bring therapeutic or palliative care advances to those with brain injury. Similarly, researchers and clinicians should seek out the diverse views of the disability community. While we applaud advocacy for the disabled, it is important that it does not pre-empt the prerogative of properly authorized surrogates to make decisions to withdraw life-sustaining therapies in accord with the patient’s previously expressed preferences. References: 1. Giacino JT, Ashwal S, Childs N et al. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58:349-353. 2. Coleman D. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58:506-507. 3. Shewmon DA. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58:506-507. 4. Fins JJ. A proposed ethical framework for interventional cognitive neuroscience: A consideration of deep brain stimulation in impaired consciousness. Neurological Research 2000;22:273-278.
The minimally conscious state: Definition and diagnostic criteria 24 June 2002
William J Burke St. Louis University St. Louis, MO Send Correspondence to journal: Re: The minimally conscious state: Definition and diagnostic criteria sandi_moriarity{at}urmc.rochester.edu William J Burke	The definition of yet another dubious diagnosis, the minimally conscious state (MCS). [1] makes it apparent that a few members are hijacking the Academy to promote their own eugenic social agenda. The MCS diagnosis attempts to extend beyond the persistent vegetative state (PVS) justification for terminating the brain-injured disabled. [2, 3, 4] In the process, these social engineers are transforming neurologists into IQ police whose job it will be to interrogate their patients for the exact intelligence information required to avoid the death penalty. The warning of our fellow neurologist, Dr. Leo Alexander, who served on the staff of the Office of Chief Counsel for War Crimes at Nuremberg, holds true now as ever. Writing about the Holocaust, he states: “Whatever proportions these crimes [the Nazi war crimes] finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. Gradually, the sphere of those to be included in this category was enlarged…but it is important to realize that the infinitely small wedged- in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.” [5] References: 1. Giacino JT, Ashwal S, Childs N et al. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58:349-353. 2. In re the Conservatorship of Robert Wendland, Superior Court of California, County of San Joaquin, Case No. 65669. 3. Coleman D. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002;58:506-507. 4. Ibid, Shewmon DA. 5. Alexander L. Medical science under a dictatorship N Engl J Med 1949;241:44-49.