In Albany, New York, 86-year-old Carrie Coons was hospitalized after a massive stroke. At first unable to speak single words, she eventually lapsed into a coma from which she did not recover. Physicians diagnosed her as being in a persistent vegetative state (PVS). Unable to eat, she was put on a feeding tube. Her sister maintained that Carrie would not want to be kept alive in this way.

PVS could be described as being wakeful but not conscious. However, there has been longstanding debate about an accurate definition. This confusion is reflected in Carrie Coons' case: a 1989 court ruling held that her condition was irreversible, that she was incapable of experiencing or appreciating life, and that the hospital should remove the feeding tube. After the court order, but before the hospital could comply, Carrie Coons took issue with the decision. She woke up and began to eat and speak.

Carrie Coons may be the most vivid illustration of the dilemmas presented by PVS. People in this condition appear to wake and sleep; they may grimace, make noises, move their limbs, even laugh. Although they may look alive to visitors, there is no clinical correlation whatever between this kind of "behavior" and the likelihood of recovery rather than slow death for a patient in a persistent vegetative state. There have also not been any reliable medical tests that correlate any measures of brain function with recovery from PVS. The only certain way to know which patients in coma will become persistently vegetative and which will recover is simply to wait and see what happens.

How best to deal with individuals in PVS has been a subject of intense debate for many years. They challenge the meaning of the term "medically futile." They raise exquisite ethical questions in an era when organs for transplant are in desperately short supply. Those who do not recover incur considerable medical care costs along their road to eventual death.

Recently the bedrock underlying this debate has shifted, with a report that identified, using positron emission tomography (PET), residual brain function in a patient who later recovered after months in a persistent vegetative state (Menon et al., 1998). Later the same research team from Cambridge, United Kingdom, went on to report a three-patient study that appears to confirm the association between this brain-function pattern and eventual recovery.

What are the implications for medical research and medical care? What should happen now? HMS Beagle gathered, in virtual space, the authors of the the PET study and several outside experts in neurology and ethics, so that they could discuss the shape of a future in which the term PVS may have a precise, and useful, clinical definition.