Ethical aspects of vegetative and minimally conscious states

The growing diffusion of life support procedures, including cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), allows physicians to keep a person alive almost indefinitely when the person's heart has stopped beating autonomously or spontaneous breathing is precluded. However, in some cases patients are brought back to life but remain in a vegetative state (VS) or in a minimally conscious state (MCS). This prompts reflections on the 'pros and cons' of life support procedures and on the recommended conduct to be adopted for the general management of patients who survive in a VS or MCS. Important issues to be debated include the choice of therapeutic management which guarantees for the patient the maximum possible physical and mental well-being; the distinction between 'worthwhile' and 'disproportionate' treatments; the patient's right to make decisions concerning his or her own health status; the possibility to make 'advance directives' when still healthy or when a life-threatening illness has been diagnosed; the role of relatives and caregivers in the choice of the best treatment for unconscious patients and the identification of ethically and scientifically valid criteria for the inclusion of unconscious patients in studies investigating experimental therapies.