IF YOU sustained serious head injuries in a traffic accident yet could choose between being in a vegetative state and unaware of your plight, or minimally conscious 鈥� perhaps able to recognise voices, pain, signal to your family in a very limited way but little else 鈥� which would you choose? What if you were deciding on behalf of a close family member?
This dilemma has been highlighted by news of the rousing of a 26-year-old man from a vegetative state into a minimally conscious state, following a treatment called transcranial magnetic stimulation (see 鈥淢an roused from coma-like state after magnetic field treatment鈥�). It is too early to say whether TMS was directly responsible for the man鈥檚 awakening as some people spontaneously wake from a vegetative state.
Yet this recovery is the latest in a series of cases hinting that there is more we can do to help these unfortunate people. Last year, a man was woken from a minimally conscious state using an invasive technique called deep brain stimulation. There are also a growing number of reports of people in vegetative states being roused with, paradoxically, the sleeping drug zolpidem.
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To turn these hints into certainties, we need research into larger numbers of these patients. At present, clinicians are often working in the dark. We need to understand not only which techniques work, but also how to identify which patients will benefit, and what their prospects are.
If we are close to being able to bring people back from the brink, questions also need to be asked about when it is morally acceptable to do so 鈥� particularly if only partial recovery is expected. For the families involved, the answer seems obvious: any improvement is a source of hope 鈥� a sign that their child, partner or sibling is still with them.
Yet are patients raised to a minimally conscious state really better off? This month, a brain imaging study suggested that these patients react to pain in much the same way as healthy people, while those in vegetative states do not. Other work suggests that the brains of minimally conscious patients react to familiar voices and the sound of a baby crying in a similar way to conscious people. This implies that they are capable of emotional processing, though we do not know if their brains register these emotions on a conscious level. However, if a minimally conscious person experiences positive emotions, they may also experience fear, frustration, even despair.
Studies of these patients promise fresh hopes for their recovery, but only larger studies will demonstrate whether this truly represents an awakening.