The ethics in disorders of consciousness

The introduction of the mechanical ventilator in the 1950s and the development
of intensive care in the 1960s permitted many patients to sustain their vegetative
functions and survive severe injuries. Despite such advances, in many cases
patients were found to suffer from altered states of consciousness which had
never been encountered before as these patients would normally have died from
apnea [1]. The imminent ethical impact of these profound states of unconsciousness
was reflected in the composition of the first bioethical committees discussing
the redefinition of life and the concept of therapeutic obstinacy. In 1968, the Ad
Hoc Committee of Harvard Medical School published a milestone paper for the
redefinition of death as irreversible coma and brain failure [2]. The committee
was comprised of ten physicians, a theologian, a lawyer and a historian of science,
betokening the medical, legal and societal debates that were to follow. We will
here give a brief overview of some ethical issues related to the concept of consciousness
and the medical management of patients with disorders of consciousness,
such as comatose, vegetative and minimally conscious states that may be
encountered in the intensive care setting. We will emphasize the problem of pain
management and end-of life decision-making.