Across three continents, brain-damaged patients are reporting remarkable improvements after taking a pill that should make them fall asleep but that, instead, appears to be waking up cells in their brains that were thought to have been dead. In the next two months, trials on patients are expected to begin in South Africa aimed at finding out exactly what is going on inside their heads. Because, at the moment, the results are baffling doctors. [...]

I see Louis before his daily medication, yet he is conscious where once he would have been comatose. Almost blind because of a separate and deteriorating condition, there is a droop to one side of his mouth and brow because of brain damage. His right arm is twisted awkwardly into his side.

Louis is given a pill, and I watch. It is 8.30am. After nine minutes the grey pallor disappears and his face flushes. He starts smiling and laughing. After 10 minutes he begins asking questions. [...] A couple of minutes later, his right arm becomes less contorted and the facial drooping lessens. After 15 minutes he reaches out to hug Sienie.

These aren't people in regular comas (unconscious, but with measurable low-level brain activity), these are people in PVS, with brain scans showing zero activity in large parts of the brain. After taking zolpidem, these dead sections wake back up.

It appears that the recipients need to take the drug daily to maintain consciousness, but some patients are going on 7 years without any signs of decline (unlike with L-dopa, as in "Awakenings"). It doesn't restore necrotic brain cells, but it does seem to stimulate dormant ones, even in people with non-PVS brain damage. As in:

I meet 22-year-old Janli de Koch, whose eyesight was damaged in a car accident in Switzerland in December 2004. The injury resulted in a restriction of her visual field to two corners of her eyes; she cannot see below a certain point, so that she bumps into things and falls over. Last month, she was prescribed zolpidem and now says she can already see more than she used to.

Recipients are also showing improvement in motor function and balance.

It's clear from the details in the Guardian article that application of zolpidem to treat PVS does not need to happen immediately, nor only to "mildly" damaged individuals. One of the recipients described in the piece was brain damaged at birth (not PVS), and successfully treated as a teenager. Moreover, the chemical stimulates parts of the brain considered to be "dead" (but not necrotic).

The implications here are profound, and unsettling. Not for the recipients of the treatment, of course -- they and their families will celebrate their return. But what about people who have "pulled the plug" on loved ones in persistent vegetative states in recent years? Do they read this news with the horrible realization that the now-dead partner or relative might have been saved with a $5 pill? What are the legal implications? The first use of zolpidem as an anti-PVS treatment was seven years ago, and has been replicated now dozens if not hundreds of times. Could a lawyer for family members opposed to the termination of care for a PVS patient sue the family members who chose to do so, and win?

What about the roughly 40% of PVS patients for whom the zolpidem treatment is ineffective? What is the underlying difference in condition? Aside from those cases where the trauma to the brain is so massive that stimulation into activity is physically impossible, would another drug with similar-but-not-identical chemistry be more effective?

It seems to me that termination of care for patients in persistent vegetative states should become even more infrequent, if it happens at all. Even if zolpidem is tried and fails, the chance that a similar drug -- or proper application of a zolpidem-derived treatment -- could awaken the PVS patient, even after years, is just too great to ignore. The legal and ethical landscape around brain damage has been irrevocably changed by this.

Zolpidem has been on the market now long enough to be found in generic form. The Guardian piece notes that the original discoverer of the drug, Sanofi-Adventis, has chosen not to participate in research trials on its use for brain damage; undoubtedly, they see little profit potential for expanded use of a drug they no longer control, no matter how miraculous. While I think they're making a terrible mistake (the PR benefits alone would be significant), the fact that the research is being carried out primarily in South Africa, a nation with a history of fighting big pharma control over major life-saving drugs, encourages me to think that this might end up as a functionally-free treatment for one of the most terrifying and demoralizing for the family medical conditions known.