Vegetative State and Coma

Should we allocate costly health care to patients diagnosed with disorders of consciousness (DoC), such as patients diagnosed as being in a vegetative state or minimally conscious state? Peterson, Aas, and Wasserman (2021) argue that we should in their paper “What justifies the allocation of health care resources to patient with disorders of consciousness?” Their key insight is that the expected benefits to this patient population helps to justify such allocations. However, their insight is attached to a consequentialist framework aimed (...) at maximizing aggregate social welfare. An alleged virtue of their framework over Braddock’s (2017) approach is their agnosticism about the moral status and rights of DoC patients. In this commentary, however, we argue that their agnosticism is the biggest problem with their approach: failing to treat DoC patients as persons with rights runs the moral risk of violating their rights, which is more serious than the risk of failing to maximize social utility. A better approach that reduces moral risk would incorporate Braddock’s (2017) precautionary presumption of personhood. We should stand in solidarity with DoC patients and treat them as persons with dignity and rights. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by appealing (...) to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)

Aim: To elicit preferences for prognostic information, attitudes towards withdrawal of life-sustaining treatment (WLST) and perspectives on acceptable quality of life after post-anoxic coma within the adult general population of Germany, Italy, the Netherlands and the United States of America. Methods: A web-based survey, consisting of questions on respondent characteristics, perspectives on quality of life, communication of prognostic information, and withdrawal of life-sustaining treatment, was taken by adult respondents recruited from four countries. Statistical analysis included descriptive analysis and chi2-tests for (...) dierences between countries. Results: In total, 2012 respondents completed the survey. In each country, at least 84% indicated they would prefer to receive early prognostic information. If a poor outcome was predicted with some uncertainty, 37-54% of the respondents indicated that WLST was not to be allowed. A conscious state with severe physical and cognitive impairments was perceived as acceptable quality of life by 17–44% of the respondents. Clear differences between countries exist, including respondents from the U.S. being more likely to allow WLST than respondents from Germany (OR = 1.99, p < 0.001) or the Netherlands (OR = 1.74, p < 0.001) and preferring to stay alive in a conscious state with severe physical and cognitive impairments more than respondents from Italy (OR = 3.76, p < 0.001), Germany (OR = 2.21, p < 0.001), or the Netherlands (OR = 2.39, p < 0.001). Conclusions: Over one-third of the respondents considered WLST unacceptable when there is any remaining prognostic uncertainty. Respondents had a more positive perspective on acceptable quality of life after coma than what is currently considered acceptable in medical literature. This indicates a need for a closer look at the practice of WLST based on prognostic information, to ensure responsible use of novel prognostic tests. (shrink)

The minimally conscious state presents unique ethical, legal, and decision-making challenges because of the combination of diminished awareness, phenomenal experience, and diminished or absent comm...

When does a human being cease to exist? For millennia, the answer to this question had remained largely unchanged: death had been diagnosed when heartbeat and breathing were permanently absent. Only comparatively recently, in the 1950s, rapid developments in intensive-care medicine called into question this widely accepted criterion. What had previously been deemed a permanent cessation of vital functions suddenly became reversible. -/- A new criterion of death was needed. It was suggested that the destruction of the brain could indicate (...) the death of the organism in the presence of external life support. Soon the so-called brain death became the new worldwide standard. In recent years, however, doubts about this neurological criterion have been growing. Is brain death really our death? -/- This is the question that this thesis seeks to answer. To this end, we shall connect the medical debate about the definition of death to the philosophical debate about personal identity. While we will find that the destruction of its brain does in fact not correspond to an organism’s death, we shall also ask whether the assumption that we are essentially organisms is correct. May brain death be the ceasing to exist of a different entity? -/- Substituting clinical case reports and considerations about human physiology for the use of thought experiments, the thesis takes a novel and philosophically unconventional approach to the problem of what we essentially are. We shall analyse various pathological conditions and their respective effects on the bodily and mental characteristics of our existence. We will conclude that brain death is indeed our death – but for reasons entirely different from those cited in the original justification of this criterion. (shrink)

When an individual is comatose while parts of her brain remain functional, the question arises as to whether any mental characteristics are still associated with this brain, that is, whether the person still exists. Settling this uncertainty requires that one becomes clear about two issues: the type of functional loss that is associated with the respective profile of brain damage and the persistence conditions of persons. Medical case studies can answer the former question, but they are not concerned with the (...) latter. Conversely, in the philosophical literature, various accounts of personal identity are discussed, but usually detached from any empirical basis. Only uniting the two debates and interpreting the real-life configurations of brain damage through the lens of the philosophical concepts enables one to make an informed judgment regarding the persistence of comatose persons. Especially challenging are cases in which three mental characteristics that normally occur together—wakefulness, awareness and memory storage—come apart. These shall be the focus of this paper. (shrink)

People in unresponsive wakefulness syndrome/vegetative state or minimally conscious state are characterized by the alteration – or the complete loss – of self-awareness and consciousness of the external environment. According to the functionalist and brain-centred approach, this kind of clinical situations also implies the loss of the moral status of person. This paper critically discusses this perspective and proposes an alternative paradigm of personhood concerning the disorders of consciousness (DOC). After a preliminary analysis, I will compare the function-based approach with (...) the pragmatic perspective, arguing that the latter seems to deal better with the evaluation of the status of personhood in patients with disorders of consciousness, and specifically criticising the functionalist view from both the theoretical and ethical levels. Nevertheless, I will claim that the pragmatic view only works as a provisional approach, falling back into the functionalist perspective once the uncertainty of the clinical diagnosis is resolved or decreased. I will thus propose an ontological personalist approach that avoids the radical separation of the concepts of person and human being, considering personhood as an intrinsic condition of human existence, instead of an emerging property from certain contingent faculties or decisions made by a community of moral subjects. In this sense, the patient with DOC is understood as a human being with some damaged features (rationality, consciousness, self, etc.) but still a person worthy of care and attention precisely because of her/his human nature in a fragile and non-autonomous condition. Moreover, I will argue that such an ontological personalism could guide healthcare professionals towards a proactive attitude for the wellbeing of these patients. (shrink)

Would Aquinas hold the view that a patient in a persistent vegetative state (PVS) is something other than a human being? Some recent interpreters have argued for this position. I contend that this reading is grounded in a false symmetry between the three stages of Aquinas’s embryology and the (alleged) three-stage process of death. Instead, I show that there are textual grounds for rejecting the view that the absence of higher brain activity in a patient would lead Aquinas to say (...) that the patient no longer has a rational soul. On my reading of Aquinas, the patient in PVS has a rational soul and is unequivocally a human being. (shrink)

While the presence or absence of consciousness plays the central role in the moral/ethical decisions when dealing with patients with disorders of consciousness (DOC), recently it is criticized as not adequate due to number of reasons, among which are the lack of the uniform definition of consciousness and consequently uncertainty of diagnostic criteria for it, as well as irrelevance of some forms of consciousness for determining a patient’s interests and wishes. In her article, Dr. Specker Sullivan reexamined the meaning of (...) consciousness in the DOC taxonomy and proposed to go away from the routinely used clinical definition of consciousness as “wakeful awareness”, and adopt the meaning that is common in the Eastern tradition which is a form of “pure experience” (Specker Sullivan 2018). She further argued that understanding consciousness as a “pure experience” is ethically relevant for DOC patients. This suggestion is original, novel and important since it preserves the importance of the notion of consciousness for the clinical practice while simultaneously offering an additional ethical tool for the moral decisions in medicine. At the same time, without placing such Eastern notion in the Western tradition it is difficult to see how pure experience could be usefully operationalized to make sense in the clinical practice with DOC patients. It is so because pure experience is a subjective phenomenon which is completely inaccessible in noncommunicative DOC patients and also it does not express behaviorally (Monti et al 2010), therefore some objective-like operationalization is needed. This is why the fusion of Eastern and Western traditions is required to gain the full potential of Dr. Specker Sullivan’s suggestion. We propose that such fusion could be achieved on the basis of the Operational Architectonics (OA) theory of brain-mind functioning (Fingelkurts et al. 2010; 2013a) which suits ideally the purpose due its compatibility with both Western and Eastern traditions of consciousness. (shrink)

Dr. Vukov analyzing patients with disorders of consciousness, proposed that medical well-regarded policy recommendations cannot be justified by looking solely to patients’ actual levels of consciousness (minimally conscious state – MCS versus vegetative state – VS), but that they can be justified by looking to patients’ potential for consciousness. One objective way to estimate this potential (actual physical possibility) is to consider a neurophysiologically informed strategy. Ideally such strategy would utilize objective brain activity markers of consciousness/unconsciousness. The Operational Architectonics (OA) (...) theory of brain-mind functioning is an example of such a strategy. Besides being mathematically simple, neurophysiologically accurate, and compatible with the cognitive/phenomenal perspectives on consciousness, application of OA strategy to quantitative EEG analysis of patients in VS and MCS revealed that the absence of consciousness in VS is paralleled by impairment of overall EEG operational architecture. Specifically, neuronal assemblies become smaller, their life span shortened, and they became highly unstable and functionally disconnected (desynchronized). At the same time, fluctuating (minimal) awareness in patients in MCS was paralleled by partial restoration of EEG operational architecture (increased size, life span, and stability of neuronal assemblies, together with an increased number and strength of functional connections among them), approaching the level found in healthy fully conscious participants. Moreover OA strategy to EEG analysis allowed predicting the emergence of consciousness in VS patients after six years following the brain trauma. Therefore, the OA methodology could reliably predict which patients may regain consciousness, and thus determine which patients may have the potential for consciousness. (shrink)

意識是如此不可捉摸又抽象的概念，「測量」意識簡直就像科幻小說情節。科學家近年來在這方面已大有進展，藉由各項腦造影技術和實驗手法，能夠分析不同意識狀態下的大腦活動型態。.

Patients in a minimally conscious state (MCS) fall into a different diagnostic category than patients in the more familiar vegetative states (VS). Not only are MCS patients conscious in some sense, they have a higher chance for recovery than VS patients. Because of these differences, we ostensibly have reason to provide MCS patients with care that goes beyond what we provide to patients with some VS patients. But how to justify this differential treatment? I argue we can’t justify it solely (...) by looking to MCS patients’ actual levels of consciousness. We must look also to the ways in which these patients are potentially conscious. Specifically, I argue that certain sensible and well-regarded policy recommendations cannot be justified by looking solely to patients’ actual levels of consciousness, but that they can be justified by looking to patients’ potential for consciousness. Insofar then as we have prima facie reason to follow the recommendations, we also have prima facie reason to view the potential for consciousness as morally salient. If that is true, however, several important implications follow: first, if the potential for consciousness is morally salient, this translates into actual and pressing obligations to patients with disorders of consciousness generally. Second, if the potential for consciousness is morally salient, this has implications that go beyond our obligations to patients with disorders of consciousness. Indeed, if the potential for consciousness is morally salient, this adds an important layer of complexity to the normative landscape, a layer we may not have sufficiently noticed before. (shrink)

How should we treat patients diagnosed as being in a persistent vegetative state (PVS) or minimally conscious state (MCS)? More specifically, should we treat them as having the full moral status of persons? Yes, or so we argue. First, we introduce the medical conditions of PVS, MCS, and the related conditions of Locked-in Syndrome and covert awareness. Second, we characterize the main argument for thinking diagnosed PVS patients are not persons. Third, we contend that this argument is defeated by mounting (...) empirical evidence for the considerable uncertainty of PVS diagnoses. Fourth, we characterize a new argument for PVS non-personhood suggested by Neil Levy and Julian Savulescu, one intended to accommodate the diagnostic uncertainty. According to this argument, even if diagnosed PVS patients are in fact MCS, it makes no difference because MCS patients are probably not persons either. Fifth, we challenge the new argument by assembling reasons for doubting the claim that MCS patients are not persons. The outcome is that it is fairly uncertain whether diagnosed PVS and MCS patients are persons or not. What should we do in light of this uncertainty? Sixth, we develop and support a guiding precautionary principle, which we call Precautionary Personhood. Finally, we apply the principle to the case of diagnosed PVS and MCS patients: we argue that given substantial uncertainty about their personhood we should go ahead and treat these patients as if they are persons. (shrink)

How should we treat patients diagnosed with disorders of consciousness, such as patients diagnosed as minimally conscious or vegetative (yet who very well may be conscious)? Fischer and Truog (2017) argue that the consciousness and equal rights of these patients are relatively unimportant when deciding how we should treat them. That is, we should deemphasize their consciousness and equal rights and instead privilege the value judgments of the family/surrogate. We disagree. Drawing upon precautionary reasoning that we develop in Braddock (2017), (...) we contend that the consciousness and equal rights of these patients should be important factors in medical decision making, at least as important as the value judgments of the family/surrogate. (shrink)

This volume comprises various viewpoints representing a Catholic perspective on contemporary practices in medicine and biomedical research. The Roman Catholic Church has had a significant impact upon the formulation and application of moral values and principles to a wide range of controversial issues in bioethics. Catholic leaders, theologians, and bioethicists have elucidated and marshaled arguments to support the Church’s definitive positions on several bioethical issues, such as abortion, euthanasia, and reproductive cloning. Not all bioethical issues, however, have been definitively addressed (...) by Catholic authorities, and some Church teachings allow for differing applications in diverse circumstances. Moreover, as new biomedical technologies emerge, Church authorities rely on experts in science, medicine, philosophy, theology, law, and other disciplines to advise them. Such experts continue to debate issues related to reproduction, genetics, end-of-life care, and health care policy. This volume will be a valuable resource for scholars in bioethics or Catholic studies, who will benefit from the nuanced arguments offered based on the latest research. This volume is also instructive for students entering the field to become aware of the founding philosophical and theological principles informing the Catholic bioethical worldview. (shrink)

In this report, we describe the case of a patient who sustained extremely severe traumatic brain damage with diffuse axonal injury in a traffic accident and whose recovery was monitored during 6 years. Specifically, we were interested in the recovery dynamics of 3-dimensional components of selfhood (a 3-dimensional construct model for the complex experiential selfhood has been recently proposed based on the empirical findings on the functional-topographical specialization of 3 operational modules of brain functional network responsible for the self-consciousness processing) (...) derived from the electroencephalographic (EEG) signal. The analysis revealed progressive (though not monotonous) restoration of EEG functional connectivity of 3 modules of brain functional network responsible for the self-consciousness processing, which was also paralleled by the clinically significant functional recovery. We propose that restoration of normal integrity of the operational modules of the self-referential brain network may underlie the positive dynamics of 3 aspects of selfhood and provide a neurobiological mechanism for their recovery. The results are discussed in the context of recent experimental studies that support this inference. Studies of ongoing recovery after severe brain injury utilizing knowledge about each separate aspect of complex selfhood will likely help to develop more efficient and targeted rehabilitation programs for patients with brain trauma. (shrink)

_The Routledge Handbook of Neuroethics_ offers the reader an informed view of how the brain sciences are being used to approach, understand, and reinvigorate traditional philosophical questions, as well as how those questions, with the grounding influence of neuroscience, are being revisited beyond clinical and research domains. It also examines how contemporary neuroscience research might ultimately impact our understanding of relationships, flourishing, and human nature. The _Handbook_ features easy-to-follow chapters that appear here for the first time in print and—written by (...) 61 key scholars and fresh voices—represent the wide range of viewpoints in neuroethics. The volume spotlights new technologies and historical articulations of key problems, issues, and concepts, and includes cross-referencing between chapters to highlight the complex interactions of concepts and ideas within neuroethics. These features enhance the _Handbook_’s utility by providing readers with a contextual map for different approaches to issues, and a guide to further avenues of interest. (shrink)

Some vegetative state patients show fMRI responses similar to those of healthy controls when instructed to perform mental imagery tasks. Many authors have argued that this provides evidence that such patients are in fact conscious, as response to commands requires intentional agency. I argue for an alternative reading, on which responsive patients have a deficit similar to that seen in severe forms of akinetic mutism. Akinetic mutism is marked by the inability to form and maintain intentions to act. Responsive patients (...) are likely still conscious. However, the route to this conclusion does not support attributions of intentional agency. I argue that aspects of consciousness, rather than broad diagnostic categories, are the more appropriate target of empirical investigation. Investigating aspects of consciousness provides a better method for investigating profound disorders of consciousness. 1 Introduction2 Responses in the Vegetative State2.1 The imaging evidence2.2 The need for models3 Responsive Patients and Akinetic Mutism3.1 Akinetic mutism3.2 Akinetic mutism as a deficit in intentions3.3 Arguments for the link3.4 Interim conclusion4 Other Models4.1 A deficit in ability?4.2 Modular intentions?5 Consciousness and Method5.1 Are they conscious?5.2 Aspects versus levels. (shrink)

Experience machines, popularized in print by Robert Nozick and on the screen by the Wachowskis’ film The Matrix, provide highly or perfectly realistic experiences that are more pleasant and less painful than those generated in real life.1 The recent surge in virtual reality and neuro-prosthetic technologies is making the creation of real-world experience machines seem inevitable and perhaps imminent.2 Given the likelihood of the near-future availability of such machines, it behooves ethicists to consider the moral status of their potential uses. (...) In this chapter, we investigate the use of experience machines in palliative and end-of-life care situations. We pair up various kinds of experience machines with patients in a range of conditions, to illuminate the moral problems and benefits of using experience machines in this way. We argue that the use of Nozickian experience machines to treat patients in most conditions would be morally problematic, most notably for the negative effects on patients’ characters and real-world relationships. Informed by this initial moral analysis, we describe an experience machine that is more closely related to a virtual reality game, and argue that it can avoid the moral problems encountered by Nozickian experience machines. In fact, we argue that this new kind of experience machine could improve some patients’ characters and relationships with real-world people. We conclude that some kinds of experience machines could benefit many patients, especially those in extreme pain and those not in the position to meaningfully interact with their loved ones in reality. We also note that certain kinds of experience machines could be useful for religious people, for whom the range of palliative and end-of-life care options is often thought to be relatively narrow. (shrink)

This polemical note looks at the ethical issue of providing artificial nutrition and hydration to patients with advanced dementia from the perspective of an Aristotelian and naturalist ethics. I argue that this issue may be considered in terms of the Aristotelian notion of eudaimonia, well-being. I present a number of facts about the conditions of human life that contribute to eudaimonia. In addition, I present a number of facts about advanced dementia as well as clarify the goals of medicine. From (...) these facts, I argue that we are not ethically obligated to provide ANH to this class of patients. (shrink)

It has been argued that complex subjective sense of self is linked to the brain default-mode network (DMN). Recent discovery of heterogeneity between distinct subnets (or operational modules - OMs) of the DMN leads to a reconceptualization of its role for the experiential sense of self. Considering the recent proposition that the frontal DMN OM is responsible for the first-person perspective and the sense of agency, while the posterior DMN OMs are linked to the continuity of ‘I’ experience (including autobiographical (...) memories) through embodiment and localization within bodily space, we have tested in this study the hypothesis that heterogeneity in the operational synchrony strength within the frontal DMN OM among patients who are in a vegetative state (VS) could inform about a stable self-consciousness recovery later in the course of disease (up to six years post-injury). Using EEG operational synchrony analysis we have demonstrated that among the three OMs of the DMN only the frontal OM showed important heterogeneity in VS patients as a function of later stable clinical outcome. We also found that the frontal DMN OM was characterized by the process of active uncoupling (stronger in persistent VS) of operations performed by the involved neuronal assemblies. (shrink)

Electroencephalogram (EEG) recordings are increasingly used to evaluate patients with disorders of consciousness (DOC) or assess their prognosis outcome in the short-term perspective. However, there is a lack of information concerning the effectiveness of EEG in classifying long-term (many years) outcome in chronic DOC patients. Here we tested whether EEG operational architectonics parameters (geared towards consciousness phenomenon detection rather than neurophysiological processes) could be useful for distinguishing a very long-term (6 years) clinical outcome of DOC patients whose EEGs were registered (...) within 3 months post-injury. The obtained results suggest that EEG recorded at third month after sustaining brain damage, may contain useful information on the long-term outcome of patients in vegetative state: it could discriminate patients who remain in a persistent vegetative state from patients who reach a minimally conscious state or even recover a full consciousness in a long-term perspective (6 years) post-injury. These findings, if confirmed in further studies, may be pivotal for long-term planning of clinical care, rehabilitative programs, medical-legal decisions concerning the patients, and policy makers. (shrink)

Confusion surrounds Catholic teaching on the use of assisted nutrition and hydration, specifically the question of when, if ever, its refusal or removal is ethical. This paper focuses on two often-neglected considerations: the relationship between means and mechanism, and an assessment of proportionality of the mechanism from the patient’s perspective. The authors draw on two critical principles of Catholic moral teaching: only ordinary means are required, and proportionality is subject to the perspective of the patient, not just that of experts (...) or the culture. The mechanisms that provide food and water have distinct benefits and burdens. Their proportionality is properly subject to analysis by the patient or surrogate, who determines which mechanism is acceptable in the patient’s situation. (shrink)

Patients suffering from advanced dementia present ethicists and caregivers with a difficult issue: we do not know how they feel or how they want to be treated, and they have no way of telling us. We do not know, therefore, whether we ought to prolong their lives by providing them with nutrition and hydration, or whether we should not provide them with food and water and let them die. Since providing food and water to patients is considered to be basic (...) care that is morally required, it is usually only the provision of nutrition and hydration by artificial means that is considered to require ethical justification. Building on what I call a virtue-based conception of autonomy, I argue that, at least for some patients suffering from advanced dementia, even providing food and liquid by hand is morally wrong. (shrink)

I consider the current best interests of patients who were once thought to be either completely unaware (to be in PVS) or only minimally aware (MCS), but who, because of advanced fMRI studies, we now suspect have much more “going on” inside their minds, despite no ability to communicate with the world. My goal in this chapter is twofold: (1) to set out and defend a framework that I think should always guide thinking about the best interests of highly cognitively (...) compromised patients, and then (2) to defend a particular conclusion that applies to this specific patient population. The framework requires us to ask two questions: Is the individual suffering? Is the individual gaining any benefit from life? There must be benefit of some sort for life to be worth preserving, and the benefit must outweigh any suffering (if there is suffering present). I then argue it would be best overall to allow these patients to die. Either these patients are not really very aware at all, in which case they are most likely not suffering, but not benefiting from life either, or they are mentally intact enough to make benefit a theoretical possibility, but in fact they are not benefiting because they cannot communicate with anyone. Such patients would most likely suffer. As there is no way currently to address their suffering, we should allow them to die. No matter the truth about their cognitive lives, death would either be a neutral event, or a blessing. (shrink)

Bioethics, neuroscience, medicine are contributing to a debate on the definition and criteria of death. This topic is very controversial, and it demonstrates clashing views on the meaning of human life and death. Official medical and legal positions agree upon a biological definition of death as irreversible cessation of integrated functioning of the organism as a whole, and whole-brain criterion to ascertain death. These positions have to face many criticisms: some scholars speak of logical and practical inconsistency, some others of (...) invalid scientific theory about the supreme integrator. In this paper some criticisms are exposed and discussed in order to reconstruct the state of the art in bioethical debate. -/- . (shrink)

In this article, we examine the emergence of a concept of medical feeding that emphasizes artificiality and medical technology. We discuss how this concept has been created in specific contrast to the daily provision of food and water; medical definitions retain clear disjunctures with cultural and religious beliefs surrounding food, gendered aspects of eating and feeding, and the everyday practices of social and family life in the United States. We begin with an examination of the historical processes involved in creating (...) artificial nutrition and hydration as a medical concept, including the evolution of terminology and practices in relation to technology advancement, legal cases, and public discourse. We.. (shrink)

Ford, Norman In 1972 Brian Jennett and Fred Plum recommended the term 'persistent vegetative state' to describe a state of continuing 'wakefulness without awareness', which can follow a variety of severe insults to the brain. Their description of the syndrome has stood the test of time, but PVS continues to be a source of medical, legal, and ethical debate.