title: The Right to Die in Chronic Disorders of Consciousness: Can We Avoid the Slippery Slope Argument?
abstract: Managing individuals with chronic disorders of consciousness raises ethical questions about the appropriateness of maintaining life-sustaining treatments and end-of-life decisions for those who are unable to make decisions for themselves. For many years, the positions fostering the "sanctity" of human life (i.e., life is inviolable in any case) have led to maintaining life-sustaining treatments (including artificial nutrition and hydration) in patients with disorders of consciousness, allowing them to live for as long as possible. Seldom have positions that foster "dignity" of human life (i.e., everyone has the right to a worthy death) allowed for the interruption of life-sustaining treatments in some patients with disorders of consciousness. Indeed, most ethical analyses conclude that the decision to interrupt life-sustaining therapies, including artificial nutrition and hydration, should be guided by reliable information about how the patient wants or wanted to be treated and/or whether the patient wants or wanted to live in such a condition. This would be in keeping with the principles of patient-centered medicine, and would conciliate the duty of respecting both the dignity and sanctity of life and the right to a worthy death. This "right to die" has been recognized in some countries, which have legalized euthanasia and/or physician-assisted suicide, but some groups fear that legalizing end-of-life decisions for some patients may result in the inappropriate use of euthanasia, both voluntary and nonvoluntary forms (slippery slope argument) in other patients. This review describes the current opinions and ethical issues concerning end-of-life decisions in patients with disorders of consciousness, with a focus on the impact misdiagnoses of disorders of consciousness may have on end-of-life decisions, the concept of "dignity" and "sanctity" of human life in view of end-of-life decisions, and the risk of the slippery slope argument when dealing with euthanasia and end-of-life decisions. We argue that the patient's diagnosis, prognosis, and wishes should be central to determining the most appropriate therapeutic approach and end-of-life decisions for that individual. Each patient's diagnosis, prognosis, and wishes should also be central to legislation that guarantees the right to die and prevents the slippery slope argument through the establishment of evidence-based criteria and protocol for managing these patients with disorders of consciousness.
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Rocco Salvatore
authors.initials: RS
authors.lastname: Calabrò
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Antonino
authors.initials: A
authors.lastname: Naro
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Rosaria
authors.initials: R
authors.lastname: De Luca
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Margherita
authors.initials: M
authors.lastname: Russo
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Lory
authors.initials: L
authors.lastname: Caccamo
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Manuli
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Alessia
authors.initials: A
authors.lastname: Bramanti
authors.affiliation: Drs. Calabró, Naro, de Luca, Russo, Manuli, A. Bramanti, and P. Bramanti are from the IRCCS Centro Neurolesi "Bonino-Pulejo" in Messina, Italy; and Dr. Caccamo is from the Department of Psychology, University of Padua, Padua, Italy.
authors.forename: Placido
authors.initials: P
authors.lastname: Bramanti
keywords: Artificial nutrition and hydration; euthanasia; minimally conscious state; right to die; sanctity of life; vegetative state