I've found it fascinating the kinds of emotions the story about the zolpidem treatment for persistent vegetative state elicits in people. This is clearly a story that hits us in the gut even more powerfully than in the mind. It's a story that leads to difficult questions for those of us who have long advocated for the right to choose one's own course of treatment, including the cessation of treatment.

By far the most common reaction among my friends and colleagues -- and even from me -- has been some variation on rethinking decisions to ask loved ones to "pull the plug" on them if they ever entered a PVS. It's as if all of the concerns around quality of life, expense and misery for caregivers, and loss of both cognition and identity fly out the window at the first sign that a PVS may not have to be so persistent. But people entering a vegetative state do so because of serious trauma -- you don't come out of that fit and ready for work. It's entirely possible that issues around quality of life, expense and misery, etc., could end up being at least as great if not greater once someone comes out of a vegetative state. I'm not saying don't use zolpidem or anything of the kind, only that making choices like this requires a realistic appraisal of the situation.

I've seen a couple of sites linking to my piece (or the BoingBoing entry) that specifically call out the Terry Schiavo case as a situation in which knowledge of this potential treatment would have made a difference. Sadly, it wouldn't have: Schiavo's brain tissue was so thoroughly atrophied that there would have been little for the zolpidem to stimulate. If anything, the Schiavo case is a powerful reminder that zolpidem and the inevitable follow-on treatments won't work on every patient. Initially, it might appear that in such cases there would be no reason not to try the drug anyway, just in case -- but that could well lead to a nightmare scenario where the patient is "conscious" in the sense of responsive to noise, touch and other external stimuli (so clearly no longer technically in a vegetative state) but utterly without cognitive function, memories or any other sign of the previous identity. If all that is left is the lower brain function, is this person still alive? Is he or she still the person we knew, just because he or she once lived in that body?

For those of us who believe that people should have a right to end their own suffering -- or to authorize a loved one to carry out those wishes, if necessary -- the accidental success of this treatment opens up big questions around what constitutes brain death. If a doctor administers zolpidem and reawakens a PVS patient into functional awareness, that's wonderful. If the zolpidem doesn't work, what then? It may be that (say) prozac or xanax has the right chemical trigger to stimulate brain activity in some of the remaining people; how many caregivers would be able to allow a loved one to die with some measure of dignity if such a treatment seemed tantalizingly possible? How many PVS patients will remain unconscious for years to come, well after family might have otherwise agreed to let them pass on, because of the chance that a new drug might help?

Some people have described the ability for a cheap sleeping pill to awaken people thought to be lost as miraculous. But too often, miracles can be accompanied by lasting pain and regret.