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Commentary on Derick Wade's ‘Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness’ and Zoe Fritz’ ‘Can ‘Best Interests’ derail the trolley?’ Examining withdrawal of clinically assisted nutrition and hydration in patients in the permanent vegetative state 
  1. Stephen Holland
  1. Correspondence to Dr Stephen Holland, Philosophy Department, University of York, York YO1 5DD, UK; stephen.holland{at}

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Wade describes diagnostic and prognostic uncertainties encountered in trying to categorise patients with a prolonged disorder of consciousness (DOC). That DOCs are diagnostically controversial is well documented.1 Nonetheless, Wade's paper provides informative details and a neurologist's insights. But exactly what follows from difficulties in reliably diagnosing DOCs? Wade ‘concludes that this arises because consciousness forms a spectrum, so that no single test will ever define someone's state with certainty’. In other words, DOCs are impossible to diagnose because consciousness is a spectrum of awareness along which everyone is moving.

This is highly questionable. Although it is clearly true that ‘awareness … covers a range from heightened awareness to complete unresponsiveness’, it does not follow that everyone's level of awareness is in a constant state of flux. Colours form a spectrum, but it does not follow that everything is constantly changing colour. Likewise, the position on a spectrum of consciousness occupied by some DOC patients could now be fixed.

Not only is this possible, it is highly probable. For one thing, it is a priori feasible for a human brain to be malformed or damaged in such a way that consciousness is permanently either lacking or minimal. And there are real world instances: an anencephalic infant lacking a cerebrum and cerebellum does not have a fluctuating level of awareness; nor does a …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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