- The Washington Times - Thursday, March 24, 2005

In the hubbub over Terri Schiavo, which largely involves legal wrangling, some deeper questions are being cast aside in the media frenzy of “breaking news from the courthouse” and “headlines from the judge’s chambers.”

Has society properly addressed issues of Coma and its frequent sequels, the Persistent Vegetative State and the Minimally Conscious State? Beyond that, has society properly addressed the definition of “self” and “consciousness”?

Such rhetorical questions carry the obvious answers “no” and underlie a defect in this very important debate about a young woman and who she is.

Consciousness has no strict definition. However, awareness or consciousness of one’s surroundings must be distinguished from self-awareness or consciousness of being. In other words, a mouse is aware an attacker’s bite is painful, but it is not aware what that pain signifies for itself as a “mouse living this life on Earth.” In a similar vain, for the most part, only certain apes and dolphins can “identify themselves” in the mirror. Studies have shown such animals attempt to remove marks others make on their faces because they recognize themselves as “individuals” with a change in appearance.

As many realize, other animals often will not quite “understand who that animal is in the mirror” when seeing reflections of themselves. The use of the term “themselves” in this regard is even suspect for mammals with limited evidence for comprehending the concept of existence.

Difficulties arise in grading awareness and self-awareness in any human who cannot communicate and has brain damage confirmed by neurological testing such as MRI and neurophysiologic studies such as EEG. This is part of the difficulty in evaluating Mrs. Schiavo. Obviously, there is a loss of her ability to convey understanding of her surroundings and, more critically, of her self. Suffice it to say it would be reasonable to assume had she some consciousness and fall into the Minimally Conscious State category, she would maintain her personhood at a higher level than in a Persistent Vegetative State where she would not evince any self-awareness.

Our problem with Terri and others like her is, first, well-meaning physicians’ opinions might differ about whether she is minimally conscious or fully vegetative.

However, more critically, neurologist and leading coma researcher Dr. Calixto Machado has remarked, “The subjective dimension of awareness is impossible to test because it involves ‘internal awareness’ or a state of mind that is immeasurable as a result of the individual existing in full or partial disconnection from the environment.”

Yes, brain activity can be measured, but “the mind” is an abstraction as is any “state of mind.” There is no way, for example, any brain scan or test will adequately determine the “self-pity” neurochemistry, or brain electrical circuitry for the particular thought pattern involved in a patient in the throes of self-pity. Parenthetically, this is part of psychiatry’s problem with defining “depression.” No biological study can define this “state of mind” the way an EKG reveals a myocardial infarction.

Terri Schiavo suffered anoxic coma in 1990 due to a cardiac event not clearly explained. Anoxic coma is a common trigger for chronic neurological situations such as hers, albeit rather murky in terms of definitively labeling her “state of mind.”

Though there will always be difficulty defining a subjective ability such as appreciating a sense of self, one thing should be clear: We need better therapies for anoxic coma and long-term effects of anoxic brain damage. Dr. Machado has also noted, “The multisensory stimulation approach, the use of deep brain stimulation and the implementation of prosthetics to treat cognitive disabilities have provided new hope for cognitive rehabilitation of vegetative and minimally conscious patients. Beyond these advances, the use of neural stem cells is a potential and promising method for brain repair.”

In the short run, perhaps a not-for-profit pharmaceutical industry initiative would be a worthy idea, to develop effective medications that can promote brain activity for those who have suffered the consequences of oxygen loss to the cerebrum. We have no such drugs at present.

Kenneth Gross, M.D., is a diplomate of the American Board of Neurology and Psychiatry in Miami, Fla.

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