Terminology

With the advent of those new technologies neurological specialists became aware of certain new neurological syndromes, to which an array of confusing and inconsistent terms were applied.

Several landmark medical events stand out in the early days of the new neurologic syndromes. In 1959 the French first described the syndrome of brain death (coma dépasse) (Mollaret and Coulon), in 1968 a special committee of the Harvard Medical School formulated specific neurological criteria to diagnose brain death ("Definition of Irreversible Coma"), and in 1972 Bryan Jennett of Scotland and Fred Plum of the United States first used the term persistent vegetative state, or PVS (Jennett and Plum).

A variety of terms have been used to describe the medical syndrome of brain death: cerebral death, coma dépassé, and irreversible coma. Terms used as imprecise equivalents for the persistent vegetative state have included apallic state, neocortical death, irreversible coma, and permanent unconsciousness It also became necessary to distinguish the new neurological syndromes from common and well-accepted neurological conditions such as coma and dementia. Many newer terms, for example, persistent vegetative state, were used solely to describe the clinical condition. Others, such as the apallic state and neocortical death, were used in an attempt to correlate the loss of neurological functions with the underlying pathological changes in the brain.

As of 1994 there were two different legal/philosophical positions about what it means to be dead in terms of brain functions. Proponents of the whole-brain-oriented position consider a person dead if there is an irreversible loss of all the functions of the entire brain (brain death). Under the other position, which is not law in any jurisdiction in 2003, a person will be pronounced dead when there is an irreversible loss of higher brain functions (permanent unconsciousness).

Dilemmas surrounding these new syndromes, such as when it is appropriate to stop treatment and when death has occurred, have raised fundamental questions about the meaning of medical concepts such as consciousness, awareness, self-awareness, voluntary interactions with the environment, purposeful movement, pain, and psychological and physical suffering.

Neurological specialists are achieving a much greater understanding of these syndromes and their similarities and differences and are reaching a degree of consensus on terminology. However, they have not reached universal agreement on several major issues related primarily to the persistent vegetative state. A historical example illustrates how difficult it can be to reach consensus on terminology. The Harvard Committee ("Definition of Irreversible Coma,") equated irreversible coma with brain death, as did many neurological specialists in the 1970s. Others, equally knowledgeable and experienced, equated irreversible coma with the persistent vegetative state. Still others used the term in a much broader fashion to denote any form of permanent unconsciousness. Because this term has gathered so many different and contradictory meanings, the only reasonable alternative for neurological specialists was to drop it entirely.

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