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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
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customer support REFERENCES * Winslade, W. J. _Confronting Traumatic Brain Injury: Devastation, Hope and Healing_ (Yale Univ. Press, New Haven, Connecticut, 1998). Google Scholar * 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 * 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 * 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 * 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 * 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 * 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). * 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 * 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 * 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 * 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). * Stevens, M. L. Redefining death in America, 1968. _Caduceus_ 11,
207–219 (1995). CAS PubMed Google Scholar * Beecher, H. K. Ethical problems created by the hopelessly unconscious patient. _N. Engl. J. Med._ 278, 1425–1430 (1968). Article CAS Google
Scholar * 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 * Jennett, B.
_The Vegetative State_ (Cambridge Univ. Press, Cambridge, UK, 2002). Book Google Scholar * Bernat, J. L. A defense of the whole-brain concept of death. _Hastings Cent. Rep._ 28 (2), 14–23
(1998). Article CAS Google Scholar * Giacino, J. T. et al. The minimally conscious state: definition and diagnostic criteria. _Neurology_ 58, 349–353 (2002). Article Google Scholar *
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 * 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 * Menon, D. K. et al. Cortical processing in persistent vegetative state. Wolfson Brain Imaging Centre Team. _Lancet_ 352, 200 (1998). Article CAS Google Scholar * 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 * Schiff, N. D. & Plum, F. Cortical function in the persistent vegetative state. _Trends Cogn. Sci._ 3, 43–44 (1999). Article CAS Google Scholar * 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 *
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 *
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
* Laureys, S. et al. Brain function in the vegetative state. _Acta Neurol. (Belg.)_ 102, 177–185 (2002). Google Scholar * Hirsch, J. et al. fMRI reveals intact cognitive systems in
minimally conscious patients. _Soc. Neurosci. Abstr._ 27, 529.14 (2001). Google Scholar * 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 * Callahan, D. Necessity, futility and the good society. _J. Am. Geriatr.
Soc._ 42, 866–867 (1994). Article CAS Google Scholar * Zarkovich, E. & Upshur, R. E. The virtues of evidence. _Theor. Med. Bioeth._ 23, 403–412 (2002). Article Google Scholar *
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 * Cranford, R. E. The vegetative and minimally conscious states: ethical implications. _Geriatrics_ 53, S70–S73 (1998). PubMed Google Scholar * Shewmon, D. A. The minimally
conscious state: definition and diagnostic criteria. _Neurology_ 58, 506–507 (2002). Article Google Scholar * 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 * Coleman, D. The minimally
conscious state: definition and diagnostic criteria. _Neurology_ 58, 506–507 (2002). Article Google Scholar * 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 * 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 * 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 * 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 * 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 *
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 *
Schneiderman, L. J. The futility debate: effective versus beneficial intervention. _J. Am. Geriatr. Soc._ 42, 883–886 (1994). Article CAS Google Scholar * Smothers, R. Injured in
'88, Officer awakes in '96. _New York Times_ (New York, February 16, 1995). * 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 * 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 * 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). * 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 * Young, R. F. Brain stimulation. _Neurosurg. Clin. N. Am._ 1, 865–879 (1990). Article CAS
Google Scholar * Kopell, B. H. & Rezai, A. The continuing evolution of psychiatric neurosurgery. _CNS Spectrums_ 5 (10), 20–31 (2000). Article Google Scholar * 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 * Rapoport, J. L.
& Inoff-Germain, G. Medical and surgical treatment of obsessive–compulsive disorder. _Neurol. Clin._ 15, 421–428 (1997). Article CAS Google Scholar * Greenberg, B. D. Update on deep
brain stimulation. _J. ECT_ 18, 193–196 (2002). Article Google Scholar * 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). * Delgado, J. M. & Anshen, R. N. (eds) _Physical Control of the Mind: Toward a Psychocivilized
Society_ (Harper and Row, New York, 1969). Google Scholar * Gaylin, W. M., Meister, J. S. & Neville, R. C. (eds) _Operating on the Mind: The Psychosurgery Conflict_ (Basic Books, New
York, 1975). Google Scholar * 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 * Editorial. The future of mind control. _The Economist_ (London, May 25, 2002). * Safire, W. The but-what-if factor. _The New York Times_ (New York) A25 (May 16,
2002). * El-Hai, J. The lobotomist. _The Washington Post Magazine_ (Washington) 16–31 (February 4, 2001). * Herbert, W. Psychosurgery redux. _US News & World Report_ (Washington) 63
(November 3, 1997). * Carmichael, M. Healthy shocks to the head. _Newsweek_ (Washington) 56–58 (June 24, 2002) * Fins, J. J. The ethical limits of neuroscience. _Lancet Neurol._ 1, 213
(2002). Article Google Scholar * The National Research Act. Public Law 93-348 (July 12, 1974) (http://www.fas.harvard.edu/∼research/PL93-348.html). * 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). * 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 * Donnelly, J. The incidence of psychosurgery in the United States, 1971–1973. _Am. J. Psychiatry_ 135, 1476–1480 (1978). Article CAS Google Scholar * Blatte, H. State prisons
and the use of behavior control. _Hastings Cent. Rep._ 4 (4), 11 (1974). Article CAS Google Scholar * Culliton, B. J. Psychosurgery: National Commission issues suprisingly favorable
report. _Science_ 194, 299–301 (1976). Article Google Scholar * 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). * Michels, R. Are research ethics bad for our mental health? _N. Engl. J.
Med._ 340, 1427–1430 (1999). Article CAS Google Scholar * 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 * 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 * Vanderpool, H. Y. & Weiss, G. B. False data and the therapeutic misconception. _Hastings Cent. Rep._ 17 (2),
16–19 (1987). Article CAS Google Scholar * Fins, J. J. & Schiff, N. D. Diagnosis and treatment of traumatic brain injury. _J. Am. Med. Assoc._ 283, 2392 (2000). Article CAS Google
Scholar * 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 * Osborn, C. L. _Over my Head_ (Andrews McNeal Publishing, Kansas City, Kansas, 1998). Google Scholar * 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 * the Weill Medical College of Cornell University and the Hastings Center, 525 East 68th Street, F-173, New York, 10021, New York, USA Joseph
J. Fins Authors * Joseph J. Fins View author publications You can also search for this author inPubMed Google Scholar 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
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