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The substantia nigra (Latin for “black substance”) and the ventral tegmental area (VTA) are also located in the midbrain ( [link] ). Both regions contain cell bodies that produce the neurotransmitter dopamine, and both are critical for movement. Degeneration of the substantia nigra and VTA is involved in Parkinson’s disease. In addition, these structures are involved in mood, reward, and addiction (Berridge&Robinson, 1998; Gardner, 2011; George, Le Moal,&Koob, 2012).
The hindbrain is located at the back of the head and looks like an extension of the spinal cord. It contains the medulla, pons, and cerebellum ( [link] ). The medulla controls the automatic processes of the autonomic nervous system, such as breathing, blood pressure, and heart rate. The word pons literally means “bridge,” and as the name suggests, the pons serves to connect the brain and spinal cord. It also is involved in regulating brain activity during sleep. The medulla, pons, and midbrain together are known as the brainstem.
The cerebellum (Latin for “little brain”) receives messages from muscles, tendons, joints, and structures in our ear to control balance, coordination, movement, and motor skills. The cerebellum is also thought to be an important area for processing some types of memories. In particular, procedural memory, or memory involved in learning and remembering how to perform tasks, is thought to be associated with the cerebellum. Recall that H. M. was unable to form new explicit memories, but he could learn new tasks. This is likely due to the fact that H. M.’s cerebellum remained intact.
What would you do if your spouse or loved one was declared brain dead but his or her body was being kept alive by medical equipment? Whose decision should it be to remove a feeding tube? Should medical care costs be a factor?
On February 25, 1990, a Florida woman named Terri Schiavo went into cardiac arrest, apparently triggered by a bulimic episode. She was eventually revived, but her brain had been deprived of oxygen for a long time. Brain scans indicated that there was no activity in her cerebral cortex, and she suffered from severe and permanent cerebral atrophy. Basically, Schiavo was in a vegetative state. Medical professionals determined that she would never again be able to move, talk, or respond in any way. To remain alive, she required a feeding tube, and there was no chance that her situation would ever improve.
On occasion, Schiavo’s eyes would move, and sometimes she would groan. Despite the doctors’ insistence to the contrary, her parents believed that these were signs that she was trying to communicate with them.
After 12 years, Schiavo’s husband argued that his wife would not have wanted to be kept alive with no feelings, sensations, or brain activity. Her parents, however, were very much against removing her feeding tube. Eventually, the case made its way to the courts, both in the state of Florida and at the federal level. By 2005, the courts found in favor of Schiavo’s husband, and the feeding tube was removed on March 18, 2005. Schiavo died 13 days later.
Why did Schiavo’s eyes sometimes move, and why did she groan? Although the parts of her brain that control thought, voluntary movement, and feeling were completely damaged, her brainstem was still intact. Her medulla and pons maintained her breathing and caused involuntary movements of her eyes and the occasional groans. Over the 15-year period that she was on a feeding tube, Schiavo’s medical costs may have topped $7 million (Arnst, 2003).
These questions were brought to popular conscience 25 years ago in the case of Terri Schiavo, and they persist today. In 2013, a 13-year-old girl who suffered complications after tonsil surgery was declared brain dead. There was a battle between her family, who wanted her to remain on life support, and the hospital’s policies regarding persons declared brain dead. In another complicated 2013–14 case in Texas, a pregnant EMT professional declared brain dead was kept alive for weeks, despite her spouse’s directives, which were based on her wishes should this situation arise. In this case, state laws designed to protect an unborn fetus came into consideration until doctors determined the fetus unviable.
Decisions surrounding the medical response to patients declared brain dead are complex. What do you think about these issues?
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