Brain, Vol. 125, No. 12, 2782,
December 2002
© 2002 Oxford University Press
Book Review |
THE VEGETATIVE STATE: MEDICAL FACTS, ETHICAL AND LEGAL DILEMMAS
National Hospital of Neurology and Neurosurgery, London, UK
THE VEGETATIVE STATE: MEDICAL FACTS, ETHICAL AND LEGAL DILEMMAS
By Bryan Jennett
2002. Cambridge: Cambridge University Press
Price £29.92. ISBN 0521441587.
It has been recognised for many years that, following severe brain injury, the awareness and cognitive responsiveness aspects of consciousness may be severely or totally impaired. Jennett and Plum described this as ‘the persistent vegetative state’ in 1972. Since the first paper, the vegetative state has increasingly been recognised because better techniques of resuscitation and supportive care of acute brain injuries have led to a higher proportion of patients surviving with profound cognitive impairment. Furthermore, better nursing care of dependent patients has meant that some patients may survive for prolonged periods with severe dementia.
The implications of the vegetative state to society are potentially immense in both financial and emotional terms, and there has been increasing recognition of the difficulties in medical, legal and ethical aspects of managing patients with this condition. In the UK these difficulties were thrown into sharp perspective in the 1990s by the case of Tony Bland, who suffered a profound hypoxic cerebral injury during the Hillsborough disaster of 1989. For many months the debate concerning his management was played out against the full glare of the international media, the distress being compounded by the regular appearance of photographs of Tony Bland and his parents. The decision to withdraw artificial nutrition and hydration via gastrostomy was eventually made by the High Court and upheld after appeal to the Law Lords and the House of Lords.
It is against a background of increasing disquiet about the approach of society towards the management of patients in the persistent vegetative state that Bryan Jennett has written an admirably pragmatic and helpful overview of the present position concerning the diagnosis and management of the vegetative state in the UK. Jennett is uniquely placed to have completed this single author text having defined the condition and been involved in the medical and legal management of many of the high profile cases.
The text reviews the history of the condition and considers clinical aspects, prognosis and pathology. The second half of the book presents a meticulous, detailed and critical account of the underlying ethical principles of management and the existing case law in the UK and the rest of the world. This has been put together with painstaking care and attention to accuracy. Although the book is entirely Jennett’s work it is clear that his comments are coloured by discussion with ethicists and lawyers.
The clinical section is particularly helpful for those who face the practical difficulty at the bedside of determining whether a patient is in the vegetative state. Concerns often relate to the presence of emotional or pain responses and varying following or alerting responses that may be considered volitional. Jennett informs each of these areas with the existing literature and, to some extent, his own view on interpretation. The chapter concerning medical management of the severely disabled patient is superficial but does emphasise the importance and difficulty of ensuring that the family is involved in the process even if they have widely differing understanding, acceptance and wishes. The book does not attempt to deal with the practical difficulties that most physicians face—the appropriate diagnosis and management of the patient with severe cognitive impairment who shows some evidence of awareness and responsiveness. These patients may be considered to be in a ‘minimally responsive state’ but clinicians remain uncertain about their prognosis and appropriate management. This area is poorly served both in the medical literature and in case law. Clearly advanced directives may have an important role in guiding management but their legal standing remains uncertain.
The strength of this text likes in the overall coherence and unparalleled experience of the author. The book is easy to read and should be compulsory reading for those doctors who have to manage patients with profound cognitive impairment.
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