Wednesday, March 23, 2005

The 'Ringer'

The new tactic of the Pawn Masters is to bring in a ringer. In this case, the ringer is brought in as someone willing to take a dive.

Here is what happened and why it doesn't really matter. We'll also discuss the diagnosis of PVS, since most of this case hinges on the way the Pawn Masters would like to discredit this diagnosis, and misinformation is their best friend.

Today, in a last moment Hail Mary (not to bring too much religion into this discussion), Jeb Bush brought in a neurologist named Dr. Cheshire who studies he GI system and facial pain to diagnose TS. After spending an hour with her, he diagnosed her with something called Minimally Conscious State. It should also be pointed out, in the interests of full disclosure, that this doctor is a "fellow of the Center for Bioethics and Human Dignity, a nonprofit group founded by "more than a dozen leading Christian bioethicists," in the words of its Web site." [Today's NY Times]. Also, this doctor, reviewed her records, "but did not conduct an examination," [NYT again].

To this, one of the neurologists who has followed this case for several years and is considered a leader in his field, Dr. Crawford, said, "I have no idea who this Cheshire is," and added: "He has to be bogus, a pro-life fanatic. You'll not find any credible neurologist or neurosurgeon to get involved at this point and say she's not vegetative." [NYT]. Dr. Crawford's full report is here, on Pekin Prattles

That's what happened today. Let's examine the difference between Persistent Vegetative State (PVS) and Minimally Conscious State (MCS). It's gonna get boring, but I'll try to spice it up by using aggressive tones. Stick in there.

Might as well start with PVS. It is best to understand PVS in terms of how the brain works at its simplest levels. The human brain, at about 3 lbs, is the most complex object in the known universe. It is responsible for our thoughts, our perceptions, actions and emotions. The human brain is responsible for our bridges, songs, plays, bombs, systems of government and economics. It is amazing. But we're not talking about these things. We're talking about more mundane tasks the brain does (reminds me of being a resident). These tasks are so simple, like breathing, moving the eye muscles about (actually, that is not entirely true, keeping the eyes aligned is a very difficult task, but compared to writing a sonnet, appreciating the color red, or smelling a child, moving the eyes around is small potatoes), and rudimentary reflexes such as pursing the lips to stimulation, protecting the eyes, opening the eyes, putting us to sleep and waking us up.

The brain is composed of neurons. Neurons are relatively sensitive compared to other cells (like heart cells, kidney cells, and gut cells) in that they die easily when deprived of oxygen.

But sometimes the body lets the brain down. When neurons are robbed of blood, they quickly die. Unlike other tissues, for instance, skin, brain tissue does not regrow. When the brain is globally robbed of blood supply, the neurons whose activity is responsible for our "higher cortical functions" die. These neurons essentially account for everything that makes up our conscious life: our perceptions, our actions, and everything in between. When these die, there is no more content to consciousness.

That sounds funny, doesn't it? What must it be like to have no content to consciousness? And that's something that we can't answer except to say that it would be like nothing. Since 'what is it like to' demands a subjective experience, we cannot know what it is like to have no subjective experience.

So one could consider the mind of such a person to be dead.

But the body lives. The neurons who function to breath, maintain awareness, and do things like blink can survive the neurologic insult. As I mentioned, while not complex enough to serve as the material that processes the stuff of our consciousness, these neural networks are more complex than most robots built in MIT labs.

These surviving neurons keep the person alive and breathing. They make the person appear asleep during the night, and awake during the day. The person may appear to be alert. The neurons may move the eyes about. But there is no perception of a stimulus that occurs. And so clinical criteria have been developed. These clinical criteria do not, as has been reported by the pawn masters, depend on PET scans. It depends on an examination. This, of course, makes Dr. Cheshire-Ringer's assessment very doubtful, since he admits that he did not examine her. Now, some might call that malpractice, but actually it is a very clever ploy.

You see, if he did examine her, he would have had to actually say she fit the criteria of PVS. And apparently, as a bioethics doctor, this was the bridge he did not want to cross.

But wait, observant reader, you might ask, "Isn't making a diagnosis of PVS without actually examining a patient, especially when the American Academy of Neurology states 'PVS can be diagnosed...with a high degree of medical certainty...after careful repeated examinations' the height of unethical behavior?" That is a question indeed.

OK, but let's put that aside for now. Dr. Cheshire is obviously a poor cog in the machine, who wouldn't go as far as they wanted him to go. He deserves very slight credit for extending himself away from his beloved neuralgia and trying to maintain some degree of clinical honesty (if he doesn't examine her, he can say he didn't have all the information, so he maintains some plausible deniability). But I'd still like to take this opportunity to call him a fucking asshole. It is more than embarassing to see a doctor sacrifice himself for the Pawn Masters. The fact that, as a Pawn Master himself, he's already sunk so low is only slightly offsetting.

If there's a physics nerd out there, I do need some help:

If Dr. Cheshire is sitting on a train going at negative ethical light speed (with the rest of the Pawn Master express), and he then gets up and walks forward (as a man who uses his biologic and ethical credentials to advance sophistry), does he exceed negative ethical light speed, or does the entire universe collapse on itself?

Let's assume, without actually examining her, he found that things are not as they are. Let's assume things are not as they are. Diagnosis: Minimally Conscious State (MCS). The Pawn Masters are so busy fighting against PVS, and creating distinctions between olive green and camo green, and 6 and half dozen, that they'd like you to forget that MCS carries much the same consequences.

First, MCS: MCS is a new diagnostic category of diffuse neuronal damage. But, whereas in PVS, the damage was so severe to the higher levels that there is NO content to consciousness; in MCS, the damage is slightly less so and the surviving neurons allow for MINIMAL content to consciousness. This is determined by an examination in which the patients appear to have some awareness of external stimuli. In its broadest definition, MCS patients may even be able to answer yes/no to questions on an inconsistent basis.

Let's assume, again, that TS has MCS. What is the result of that? Well, we would then ask her next of kin, "would she have wanted to be alive given the state she is in presently?"

Where would that leave us?

I'd say we are there.

But in case anyone is wondering, the diagnosis is (still) PVS.


Blogger robgossip said...

very interesting read--just wanted to let u know that somebody was listening!

10:38 PM  
Anonymous Anonymous said...

I am most impressed by your entire blog. Thanks for posting.

10:39 PM  
Blogger marybishop said...

Doc says:It's gonna get boring, but I'll try to spice it up by using aggressive tones. Stick in there.
---Nice interjection of levity Doc -- and NO it was not boring at all in any way.

Doc: "A nonprofit group founded by "more than a dozen leading Christian bioethicists"

I ask, where are these people coming from? ( bible belt is my guess.)

Religion has no place in medicine and yet we now have the American COLLEGE of PEDIATRICIANS which most people confuse with the American ACADEMY of PEDIATRICS - real close in name.

The college has been around since 2003 or so with less than 100 members (southern religious righters) and the academy's been here for 75 years with over 60,000 members...

I get very angry at a group or a person who palms him/herself off as a REAL doctor when in fact they are only religious zealots with an MD degree.

4:28 AM  
Anonymous Anonymous said...

If you'd like to read Dr. Cheshire's entire affidavit, it is at

6:09 AM  
Blogger laurenbove said...

Doc, you had me at "I hate you" in that last post. I'm laughing as I write slay me.

If anyone would like to see the cat scan of TS compared with a healthy brain go here:

6:56 AM  

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