Book Review

The Vegetative State: Medical Facts, Ethical and Legal Dilemmas

N Engl J Med 2002; 347:1386-1387October 24, 2002

Article

The Vegetative State: Medical Facts, Ethical and Legal Dilemmas
By Bryan Jennett. 228 pp. Cambridge, United Kingdom, Cambridge University Press, 2002. $43. ISBN: 0-521-44158-7

Americans are fascinated with the mysteries of consciousness. Periodic accounts of unexpected awakenings stimulate media attention. They fill the pages of our newspapers, headline the nightly news, and provide plots for Hollywood. The ethical and legal issues concerning the care of those who do not recover consciousness made Karen Quinlan and Nancy Cruzan household names. The state of wakeful unconsciousness — the persistent vegetative state — was described and labeled by Jennett and Plum in 1972. In this book, Jennett presents a comprehensive overview of the medical knowledge and legal history of the vegetative state over the past 30 years and the ethical issues surrounding it. The author, a neurosurgeon and collaborator on the widely accepted Glasgow Coma Scale and Glasgow Outcome Scale, is uniquely qualified for the undertaking.

The book begins with a review of terminology. The vegetative state is a condition of complete unawareness of the self and the environment, accompanied by sleep–wake cycles. The qualifier “persistent,” which is sometimes added to the term, has a variety of definitions. Some have objected to its use, claiming that it is ambiguous and arbitrary and suggests irreversibility. It is thus noteworthy that Jennett entitles his book simply The Vegetative State. In doing so, he acknowledges that the word “persistent” may engender confusion between diagnosis and prognosis. Unfortunately, although he avoids one pitfall in terminology, he creates another by using the acronym “PVS” to denote “permanent vegetative state” rather than the customary “persistent vegetative state.” This unconventional usage itself carries the potential to aggravate the confusion over terminology, diagnosis, and prognosis.

The chapter on diagnosis of the vegetative state discusses the evolution of its descriptive features from early clinical and epidemiologic surveys to later professional groups' formal codification of the criteria for diagnosis. The many tables listing these features and the accompanying discussion are useful. Recent literature reporting fragments of complex behavior in patients who meet all the criteria for the vegetative state is discussed. The author mentions the theoretical and practical difficulties of clinically proving a negative — a patient's lack of awareness of the self and the environment. A discussion of the use of single-subject design protocols to determine awareness in difficult cases would have completed an otherwise comprehensive review of the diagnosis of the vegetative state.

The probability of recovery from the vegetative state is of obvious concern to families and clinicians. Long-term survival in the vegetative state is also at times of concern to litigants. The chapter on prognosis and expectations of life in the vegetative state is welcome. It includes a balanced discussion of the limitations of the frequently cited Multi-Society Task Force on the Persistent Vegetative State, whose findings were published in the Journal in 1994. When the probability of recovery of consciousness is very unlikely, the condition may be labeled a permanent vegetative state. The Multi-Society Task Force concluded from analysis of the available data that a vegetative state continuing 3 months after nontraumatic brain injury and 12 months after traumatic brain injury could be declared permanent.

More than half of Jennett's book deals with the ethical and legal issues surrounding treatment withdrawal in the permanent vegetative state. He gathered relevant material from journals in widely scattered specialties to produce a comprehensive review of the principles of medical ethics and legal issues. This book provides fascinating insight into international variations in ethics and legal precedents for withdrawal of care in the United States and 16 other countries and regions.

It is of interest that societal and physician attitudes toward the value of existence in a permanent vegetative state evolved in the United States before it did in the rest of the world. The Karen Quinlan case went to court 16 years before the first court case in Britain. In the United States, the concepts of patient autonomy and patient rights and the rejection of unilateral physician decision making as unacceptable paternalism are well entrenched. A consequence of these and other principles is the concept of proxy decision making and advance directives. The Patient Self-Determination Act of 1990 requires hospitals and nursing homes to inform patients of their right to refuse treatment and to make a directive or appoint a proxy. In contrast, in Japan, a survey of physicians found that only 17 percent would withdraw artificial nutrition and hydration from a 70-year-old patient who had been vegetative for two years, even if the patient and family had requested that they be withdrawn. In Britain, there is no legal statute recognizing advance directives, and all cases in which withdrawal of artificial nutrition and hydration from a vegetative patient is sought require court approval. An unpublished survey of physicians' attitudes regarding the permanent vegetative state, with respondents from seven European countries, is referenced in several contexts in this book and is alone worth the price of the book.

The author includes an introduction to the minimally conscious state, which is defined as a state of severely altered consciousness in which minimal but definite behavioral evidence of awareness of the self or of the environment is demonstrated. The next medicolegal chapter will inevitably be written about withdrawal of treatment in the minimally conscious state. Jennett prepares his readers to participate in its writing.

Nancy Childs, M.D.
Texas NeuroRehab Center, Austin, TX 78745