Comatose Awareness as Medical Science Term Paper

Excerpt from Term Paper :

They do not show what people perceive, and, in the end, this is what consciousness is (18).

According to Steinberg, PET studies of vegetative patients have indicated "that the primary sensory cortices respond to pain and sounds, but that higher-order associative cortices do not. For minimally and fully conscious people, in contrast, sounds activate associative areas as well" (18).

A study of minimally conscious patients exposed patients to recorded narratives. Similar brain activity was found in both healthy control subjects and the patients. However, when the recording was played backwards, only the healthy controls' cortices were activated, indicating that only fully conscious brains are engaged by ambiguous stimuli.

Figure 1:

Source: Steinberg 17)

Leviton concurs with Davis and Gimenez's work. Arousal is surmised to be linked with cognition. but, he cites Plum and Posner as noting that the limits of consciousness are difficult to define quantitatively and satisfactorily. Self-awareness is inferred by appearance and actions. Some degree of arousal is needed for cognition (65).

When physicians talk to their patients who are comatose as if they are aware, Leviton notes, they sometimes get startling results. He cites John La Puma MD, the Director of the Center for Clinical Ethics at Lutheran General Hospital in Park Ridge Illinois, and his experience with talking with comatose patients. La Puma assumed that comatose patients hear, and therefore talking with them would have potential therapeutic value. He noted that many had "normal physiological responses to auditory stimuli" (66), and therefore not talking to comatose patients may give the patients the notion that they are dead, or nearly dead, becoming a self-fulfilling prophecy.

In contrast, if comatose patients hear, then some cognitive functions may still be present, despite the brain damage. Although they may be physiologically helpless, they may not be as vegetative as the medical community has previously assumed. This, as Leviton notes brings up a significant moral dilemma for the medical profession. "If the patient indeed isn't hopelessly vegetative, then medical decisions about life support must include his views. Most M.D.'s don't want even to consider it" (67).

Leviton provides anecdotal evidence purported by La Puma. The doctor has noted several examples of patients that have emerged from comas and commented on what he had said to them. In addition, a patient that had been in a coma for fifty-three days had informed her doctor that when he was tending to her while unconscious, she would wonder why he never said hello to her, nor acted as if she were there (67).

Leviton also cites Glenn Johnson, PhD., who agrees with La Puma's methods. He concurs that if a comatose patient can hear there may be cognitive function, and perhaps speaking with them can coax them back to physical functioning. Johnson has used hypnotic imagery and suggestion to help ease comatose patients back to cognition and movement. Johnson worked with a patient who had been comatose for four months, believing that her negative expectations due to long-term inactivity were obstructing her success (68).

Johnson hypnotized the patient by speaking softly into the woman's ear, and asking her to focus on one idea. He described her condition, told her family was near, and that she was in a hospital being cared for and would be alright. Nearly immediately, Johnson noticed that the woman regained some control over her eye gaze. He worked with her until she had regained about 95% of her eye gaze and then proceeded with asking her to try to speak. A few days later, the woman did begin speaking and came out of her coma. She knew everyone's name, and recognized Dr. Johnson's voice (Leviton 69).

Although some coma experts dismiss these anecdotal accounts. First-hand accounts by patients who have recovered from comas, such as Mary Kay Blakely, note that some comatose patients report having been able to hear and feel while in the coma, but not able to respond. Blakely notes that her "body was like a broken transmitter, able to receive but not send messages" (qtd. Leviton 69).

Borthwick and Crossley with Johnson and La Puma. They put forth the idea that just because a patient could not communicate that he or she was aware, did not preclude awareness itself.

If people do not communicate awareness, why do we not begin from the standpoint that this a deficit in communication, rather than leaping to a conclusion that there is a deficit in awareness - a conclusion that should only be reached, if at all, when all other explanations have been exhausted? We should in the first instance attempt to remedy communication problems and only then consider whether awareness is irrecoverable (388).

The reported scans of a young British woman, performed by British and Belgian researchers, has made top news lately in this continuing search for answers. The researchers studying the unnamed patient who had suffered brain injury from a car accident scanned her brain and found possible signs of consciousness, much in agreement with Owen's findings. When the British and Belgian researchers asked the patient to imagine playing tennis or walking through rooms of her home, the activity patterns they found were similar to those of healthy person given the same task. Several months following the scans, the patient is beginning to recover (Goldberg C1).

The findings from this research, as noted previously, are in agreement with similar brain scan findings by Owen. This research indicates not only further support the use of brain imaging techniques to probe beneath the unresponsive surface of comatose patients, but also indicates that these patients have some level of awareness. Functional MRIs are the latest tool in this research, as Goldberg notes, transforming the snapshot abilities of traditional MRI, into motion images that can track reactions over time (C1).

More research is needed; however it is likely that brain scanning will become a routine tool for diagnosing comatose patients. Goldberg notes that cases like Terri Schiavo, and the public's outrage in the removal of her feeding tube, are an indication of the high stakes involved. However, the patient reported in the current research is significantly different from Schiavo, who had been in a coma for 15 years. it's noted that "patients in prolonged vegetative states whose brains are scanned do not show the British patient's type of activity" (C1).

Goldberg cited Dr. Douglas Katz of Boston University as stating that these new findings indicate the possibility that not only is there some brain activation, in comatose patients, but even awareness at some level, that previously has gone undetected (C1).

However, in contrast, Dr. Stephen Laureys, one of the doctors that participated in the research, had a completely different outlook only two years earlier. In his paper regarding functional neuroimaging of patients in a vegetative state he noted, d) espite the metabolic impairment, external stimulation still induces neuronal activation as shown by both auditory and noxious stimuli. However, this activation is limited to primary cortices and dissociated from higher-order associative cortices, thought to be necessary for conscious perception (Laureys 338).

Analysis of Findings:

The question of whether or not a comatose person can understand their surroundings, if they have awareness, is one that is not simply answered. If one were to base their conclusion on simply anecdotal evidence, it would seem that yes, indeed, there is some level of awareness, despite the inability to communicate that awareness, while in a vegetative state. Some patients who have recovered from a coma have indicated that they were quite aware of their environment and the people around them. Some have expressed the frustration they felt when doctors did not address them like they were there, during their care while comatose. and, doctors too have related anecdotal experiences of patients recognizing the sound of their voice and recalling conversations that were had while the patient was comatose. These anecdotes seem to indicate that some comatose patients are definitely aware. However, anecdotal evidence is not replicable, and is not of sufficient quality to qualify for firm scientific evidence.

Once one turns to more quantifiable and replicable research, the answer to the question becomes a little less clear. Technology is only just being introduced to the point that imaging can occur of a patient's brain over a period of time, allowing researchers to note a reaction to a stimuli. Researchers are beginning to understand that it is not just injury to the cortex that can lead to coma, but also the thalamus as well. They have also drawn the conclusion that arousal is needed for cognition. However, whether or not higher-brain level functioning occurs in comatose patients is still up for debate.

The two recent studies, that of Owen, reported by Steinberg, and of Laureys and his Belgian colleague, reported by Goldberg, seem to be in agreement. Both found similar brain activity, thanks to the use of the latest in medical imaging technology, in both comatose and healthy control subjects, when reading sentences to them.…

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