Definition of the problem: The report supplies the national part of a European survey in which doctors that are involved in the treatment of patients in `Persistent Vegetative State' (PVS) are being interviewed. The questions concern decision-situations the doctors are frequently confronted with in the treatment of PVS-patients. The questionnaire is designed as a decisiontree in order to bring about the exact delineations that govern the decisions. Therefore the result of the survey only portrays which delineations are (...) in fact being accepted (and does not allow any conclusion concerning which norms should guide the decisions). Whether these factual delineations correspond to ethical-normative criteria that derive from guiding principles – such as human dignity – is being discussed in the part reflecting on the survey. It is crucial to an adequate interpretation of the survey results to keep in mind that the doctors were not being asked about what they actually did in the situations described; the survey was designed to bring about what the doctors' basic attitudes towards the problems are.Arguments: The reason this methodological approach to the problem was chosen is that an ethical evaluation can only take place when the action-guiding convictions of the agents concerned are known. The goal of the survey was to make a provisional orientation concerning the basic attitudes possible. Compared to other countries taking part in, the survey result in Germany confirms the hypotheses that doctors from different European countries – concerning the decisions of withdrawing treatment or withholding treatment – are guided by different basic attitudes.Conclusion: As it has become apparent that important national differences concerning the action-guided attitudes of the doctors exist, it would not be advisable to recommend that European guidelines for all countries should be set up for such cases. The decisions taken depend on the guiding ethical assumptions; they can only be decisions for the very case they were derived at. (shrink)

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be (...) kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)

: This article begins with a discussion of persistent vegetative state (PVS), focusing on concerns related to both diagnosis and prognosis and paying special attention to the 1994 Multi-Society Task Force report on the medical aspects of PVS. The article explores the impact of diagnostic and prognostic uncertainties on prospective thinking regarding the possibility of PVS and considers the closely related question of how prospective thinkers might craft advance directives in order to deal most effectively with this (...) possibility. (shrink)

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these (...) patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation. (shrink)

"Best interests" is widely accepted as the appropriate foundation principle for medico-legal decisions concerning treatment withdrawal from patients in persistent vegetative state (PVS). Its application appears to progress logically from earlier use regarding legally incompetent patients. This author argues, however, that such confidence in the relevance of the principle of best interests to PVS is misplaced, and that current construction in this context is questionable on four specific grounds. Furthermore, it is argued that the resulting legal inconsistency (...) is distorting both the principle itself and, more particularly, individual patient interests. (shrink)

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be (...) kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these (...) patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation. (shrink)

A patient is diagnosed with the persistent vegetative state (PVS) when they show no evidence of the awareness of the self or the environment for an extended period of time. The chance of recovery of any mental function or the ability to interact in a meaningful way is low. Though rare, the condition, considering its nature as a state outwith the realm of the conscious, coupled with the trauma experienced by the patient's kin as well as (...) health care staff confronted with painful decisions regarding the patient's care, has attracted a considerable amount of discussion within the bioethics community. At present, there is a wealth of literature that discusses the relevant neurology, that elucidates the plethora of ethical challenges in understanding and dealing with the condition, and that analyses the real-world cases which have prominently featured in the mainstream media as a result of emotionally charged, divergent views concerning the provision of care to the patient. However, there is scarcely anything in the published scholarly literature that proposes concrete and practically actionable solutions to the now widely recognized moral conundrums. The present article describes a step in that direction. I start from the very foundations, laying out a sentientist approach which serves as the basis for the consequent moral decision-making, and then proceed to systematically identify and deconstruct the different cases of discord, using the aforementioned foundations as the basis for their resolution. A major intellectual contribution concerns the fluidity of the duty of care which I argue is demanded by the sentientist focus. The said duty is shown initially to have for its object the patient, which depending on the circumstances, can change to the patient's kin, or the health care staff themselves. In conclusion, the proposed framework represents the first comprehensive proposal regarding the decision-making processes involved in the deliberation on the provision of life sustaining treatment to a patient in a PVS. (shrink)

Should a patient in a persistent vegetative state live? Is the life of a patient in a mere biological state worthwhile maintaining? I would argue that the life of a PVS patient is instrumentally valuable in so far as it can satisfy the family’s preference to keep it alive. A PVS patient should live if the patient’s family desires it Conversely, the PVS patient should be allowed to die or be actively killed if no one desires (...) him or her to live. Mere biological life has no value at all when no one finds it valuable and it is morally permissible to destroy something valueless to everyone.Under what circumstances should the desires of a PVS patient’s family be disregarded? Their desire to keep the patient alive should not be unlimited if that would evidently harm other patients. The objection based on just resource allocation could set the limits of a family’s desire to keep the patient in a certain condition. I would argue that when only one bed is available in intensive care unit, the life and interests of conscious patient should override these of PVS patients and preferences of the family to keep the PVS patient alive. This is because harm that the conscious patient suffers is much more serious than that suffered by the family.Whether to use organs of PVS patients is also discussed. Is the family’s donating the patients’ organs a minimum duty of no harm or an act of beneficence? It is uncertain. It might be a supererogatory action for the family to do so in a certain situation. (shrink)

This article looks at the late John Paul II's allocution on artificial nutrition and hydration (ANH) and the implications his statement will have on the ordinary-extraordinary care distinction. The purpose of this article is threefold: first, to examine the medical condition of a persistent vegetative state (PVS); second, to examine and analyze the Catholic Church's tradition on the ordinary-extraordinary means distinction; and third, to analyze the ethics behind the pope's recent allocution in regards to PVS patients as (...) a matter of conscience. Rather than providing clarification, I argue that the papal allocution has raised many difficult questions. People in situations where decisions must be made about withdrawal or continued ANH are in need of guidance. Moreover, additional analysis is needed to determine whether the papal allocution is in conflict with the traditional Catholic medical ethics understanding of the ordinary-extraordinary care distinction. (shrink)

In this article we will be arguing in favour of legislating to protect doctors who bring about the deaths of PVS patients, regardless of whether the death is through passive means or active means. We will first discuss the ethical dilemmas doctors and lawmakers faced in the more famous PVS cases arising in the US and UK, before exploring what the law should be regarding such patients, particularly in Australia. We will continue by arguing in favour of allowing euthanasia in (...) the interests of PVS patients, their families, and finally the wider community, before concluding with some suggestions for how these ethical arguments could be transformed into a set of guidelines for medical practice in this area. (shrink)

Ford, Norman In 1972 Brian Jennett and Fred Plum recommended the term 'persistent vegetative state' to describe a state of continuing 'wakefulness without awareness', which can follow a variety of severe insults to the brain. Their description of the syndrome has stood the test of time, but PVS continues to be a source of medical, legal, and ethical debate.

Would Aquinas hold the view that a patient in a persistent vegetative state (PVS) is something other than a human being? Some recent interpreters have argued for this position. I contend that this reading is grounded in a false symmetry between the three stages of Aquinas’s embryology and the (alleged) three-stage process of death. Instead, I show that there are textual grounds for rejecting the view that the absence of higher brain activity in a patient would lead (...) Aquinas to say that the patient no longer has a rational soul. On my reading of Aquinas, the patient in PVS has a rational soul and is unequivocally a human being. (shrink)

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive (...) awareness of those feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness. (shrink)

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and (...) communication, with a life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient. (shrink)

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life (...) of a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome. (shrink)

Several methods have been reported for extracting sperm from a man after he dies or enters a persistent vegetative state. Although such sperm retrieval could be performed for nonprocreative purposes, such as research, in this paper I focus on cases involving procreative intent. Since 1980, more than ninety cases have occurred in which family members requested sperm retrieval from patients who died or were irreversibly unconscious, with the intent that a wife, girlfriend, or other woman would be (...) inseminated. Recently, the first report of pregnancy and birth following postmortem sperm retrieval appeared in the media.In these cases, death or PVS typically is caused by anoxic injuries, trauma, or rapidly progressing infections. (shrink)

Several methods have been reported for extracting sperm from a man after he dies or enters a persistent vegetative state. Although such sperm retrieval could be performed for nonprocreative purposes, such as research, in this paper I focus on cases involving procreative intent. Since 1980, more than ninety cases have occurred in which family members requested sperm retrieval from patients who died or were irreversibly unconscious, with the intent that a wife, girlfriend, or other woman would be (...) inseminated. Recently, the first report of pregnancy and birth following postmortem sperm retrieval appeared in the media.In these cases, death or PVS typically is caused by anoxic injuries, trauma, or rapidly progressing infections. (shrink)

The reflections put forward in this text concern the clinical and practical difficulties posed by the existence of patients in PVS, and the essential ethical issues raised, combining these ethical questions with practical and theoretical experience.Section 1 presents the methodology of the ethical reflection as we see it.Section 2 describes the clinical condition of patients in PVS. Section 3 develops the ethical difficulties relative to PVS from the French point of view. Section 4 illustrates the relevance of debating the ethical (...) significance of such problematic situations, whilst defending a practical position based on a philosophical conviction. Section 5 points out the limits of ethical reflection in a biomedical context, and calls for reflection closer to the source of the problems described. For a comprehensive appraisal of biomedical rationality, the final section suggests combining the bioethical debates with traditional philosophical ethical reflection so as to get a clearer understanding of the real, if limited, relevance of these debates. (shrink)

The reflections put forward in this text concern the clinical and practical difficulties posed by the existence of patients in PVS, and the essential ethical issues raised, combining these ethical questions with practical and theoretical experience.Section 1 presents the methodology of the ethical reflection as we see it.

Airedale NHS Trust v Bland establishes three principles among which is the controversial idea that people in a PVS, though not dying, have no best interests and no meaningful life. Accordingly, it is argued, they may have their food and fluids, whether delivered by tube or manually, removed, with the result that they die. Laing challenges this view arguing that not only is this bad medical science, it is unjustly discriminatory and at odds with our duties to the severely disabled. (...) Laing highlights research by Keith Andrews et al and points out that Andrew Devine, in the same Hillsborough disaster, woke up some years after Tony Bland was decided.(Post script) Laing argues elsewhere that after the Mental Capacity Act 2005 the case has become a dangerous springboard for new third parties' to require the removal of food and fluids from the vulnerable incapacitated. (shrink)

In a recent paper, Gray, Knickman, and Wegner present three experiments which they take to show that people perceive patients in a persistent vegetative state to have less mentality than the dead. Following on from Gomes and Parrott, we provide evidence to show that participants' responses in the initial experiments are an artifact of the questions posed. Results from two experiments show that, once the questions have been clarified, people do not ascribe more mental capacity to the (...) dead than to PVS patients. There is no reason to think that people perceive PVS patients as more dead than dead. (shrink)

Patients with 'persistent vegetative state' (PVS) are often cited in the discussions of ethicists as examples of human beings who are unconscious and do not experience life, and a number of theoretical and practical recommendations have been made on that basis. This article examines the evidence and the theoretical rationale for the belief that people with PVS are unconscious and finds them wanting. This conclusion is related to the practice of the discipline of ethics.

In a recent paper, Gray, Knickman, and Wegner present three experiments which they take to show that people judge patients in a persistent vegetative state to have less mental capacity than the dead. They explain this result by claiming that people have implicit dualist or afterlife beliefs. This essay critically evaluates their experimental findings and their proposed explanation. We argue first that the experiments do not support the conclusion that people intuitively think PVS patients have less mentality (...) than the dead. And second, we provide an alternative explanation of our ascriptions of mentality to the dead and PVS patients, one which turns on Epicurean considerations about the nature of death. (shrink)

How should we treat patients diagnosed as being in a persistent vegetative state (PVS) or minimally conscious state (MCS)? More specifically, should we treat them as having the full moral status of persons? Yes, or so we argue. First, we introduce the medical conditions of PVS, MCS, and the related conditions of Locked-in Syndrome and covert awareness. Second, we characterize the main argument for thinking diagnosed PVS patients are not persons. Third, we contend that this argument (...) is defeated by mounting empirical evidence for the considerable uncertainty of PVS diagnoses. Fourth, we characterize a new argument for PVS non-personhood suggested by Neil Levy and Julian Savulescu, one intended to accommodate the diagnostic uncertainty. According to this argument, even if diagnosed PVS patients are in fact MCS, it makes no difference because MCS patients are probably not persons either. Fifth, we challenge the new argument by assembling reasons for doubting the claim that MCS patients are not persons. The outcome is that it is fairly uncertain whether diagnosed PVS and MCS patients are persons or not. What should we do in light of this uncertainty? Sixth, we develop and support a guiding precautionary principle, which we call Precautionary Personhood. Finally, we apply the principle to the case of diagnosed PVS and MCS patients: we argue that given substantial uncertainty about their personhood we should go ahead and treat these patients as if they are persons. (shrink)

Brad Mellon argues that persistent-vegetative-state cases, including the recent Terri Schiavo case, are ambiguous. By this he seems to mean that decisions about such cases are fraught with doubt and uncertainty and perhaps even that rational resolution of many such cases is impossible. Faced with such cases the most we can do is to live and cope with the ambiguity. I am more optimistic. With good will, and much clarification and discussion, rational agreement is possible in these (...) cases, including the Schiavo case. (shrink)

In the case of Re M, summarised in the paper by Julian Sheather, Justice Baker faced the difficult task of weighing up objectively whether or not it was in Mâs best interests to withdraw artificial feeding and to let her die.1 The judge concluded that M was ârecognisably aliveâ, and that the advantages of continued life outweighed the disadvantages. He compared her minimally conscious state favourably to that of a persistent vegetative state .2 It was clear (...) that artificial feeding would have been withdrawn if she had been in a PVS , but because she was in fact minimally conscious, the judge decided that treatment must continue. But does it make sense to treat MCS differently from PVS in this way? Is it better to be minimally conscious than unconscious? Similar questions have been raised before.3 In 2006, scientists reported results of sophisticated neuroimaging studies which suggested that some patients in persistent vegetative state , long thought to be unaware, had evidence of minimal consciousness.4 The question then was on the moral significance of this level of consciousness, and whether the presence of such evidence meant that treatment such as artificial nutrition must be continued.5 ,6There are several potential reasons why the presence of minimal consciousness might warrant continuing life-sustaining treatment. The first is that patients in minimally conscious state might have a better prognosis than those who are in PVS. There are relatively few studies …. (shrink)

Kevin O’Rourke argues that Aquinas’s concept of a “spiritual goal of life,” to which Pius XII refers in his famous allocution of 1957, serves as a basis for declaring that certain treatments, such as artificial nutrition and hydration [ANH] for patients in a persistent vegetative state [PVS], are “extraordinary” and thus morally optional. I examine whether O’Rourke properly interprets Aquinas’s concept in this regard and conclude that he is correct in his assessment and that ANH is properly (...) understood, in typical and properly diagnosed cases of PVS, as extraordinary treatment the use of which is not morally obligatory. (shrink)

: Although "brain death" and the dead donor rule—i.e., patients must not be killed by organ retrieval—have been clinically and legally accepted in the U.S. as prerequisites to organ removal, there is little data about public attitudes and beliefs concerning these matters. To examine the public attitudes and beliefs about the determination of death and its relationship to organ transplantation, 1351 Ohio residents ≥18 years were randomly selected and surveyed using random digit dialing (RDD) sample frames. The RDD telephone survey (...) was conducted using computer-assisted telephone interviews. The survey instrument was developed from information provided by 12 focus groups and a pilot study of the questionnaire. Three scenarios based on hypothetical patients were presented: "brain dead," in a coma, or in a persistent vegetative state (PVS). Respondents provided personal assessments of whether the patient in each scenario was dead and their willingness to donate that patient's organs in these circumstances. More than 98 percent of respondents had heard of the term "brain death," but only one-third (33.7%) believed that someone who was "brain dead" was legally dead. The majority of respondents (86.2%) identified the "brain-dead" patient in the first scenario as dead, 57.2 percent identified the patient in a coma as dead (Scenario 2), and 34.1 percent identified the patient in a PVS as dead (Scenario 3). Nearly one-third (33.5%) were willing to donate the organs of patients they classified as alive for at least one scenario, in seeming violation of the dead donor rule. Most respondents were not willing to violate the dead donor rule, although a substantial minority was. However, the majority of respondents were unaware, misinformed, or held beliefs that were not congruent with current definitions of "brain death." This study highlights the need for more public dialogue and education about "brain death" and organ donation. (shrink)

In the fifteen-year-long public saga of the Terri Schiavo case, one oftcited regrettable aspect of her health care noted in the media was her lack of advance care planning. The withdrawal of her gastrostomy tube was per the consent of her husband, Michael Schiavo, based on the substituted judgment of what she would have desired in a persistent vegetative state (PVS). Her parents, the Schindlers, attempted to assert that ending treatment in her state (which they disputed (...) as not being PVS violated her religious convictions.Many people were upset by the protracted public scrutiny of this private matter - citing the Schindler's public angst, the indignity of Ms. Schiavo's protracted treatment, the interference of politicians, and the financial injustice of devoting so much time and money to this case. All these points are less meritorious than this simple fact: an incapacitated patient had a substituted judgment rendered by her spouse (who was not found to have a conflict of interest),with corroboration by other witnesses for this refusal, and without any compelling contradictory evidence from the once-competent patient. (shrink)

: Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One (...) strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law—such as authorizing procuring surgeons to end the lives of patients by means of organ procurement—and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained. (shrink)

This paper challenges the recommendation of 1981 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research that all jurisdictions in the United States should adopt the Uniform Determination of Death Act, which endorses a whole-brain, rather than a higher-brain, definition of death. I argue that the Commission was wrong to reject the "personhood argument" for the higher-brain definition on the grounds that there is no consensus among philosophers or the general population as to what (...) constitutes "personhood". I claim that philosophers agree that some potential for cognitive function is necessary for personhood and that, when this is absent in cases of anencephaly and persistent vegetative state (PVS), the individual should be considered dead. I further argue that the lack of consensus among the general population is due in large measure to misunderstandings about the medical reality of PVS and beliefs influenced by feelings for a specific individual in PVS. I also examine and reject two tutiorist arguments which have been used to support the Commission's position: that the higher-brain definition would threaten the severely senile and severely retarded, and that there are not currently adequate medical techniques for determining when all higher-brain activities have ceased. Keywords: death, personhood, persistent vegetative state, anencephaly CiteULike Connotea Del.icio.us What's this? (shrink)

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of (...) consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population. (shrink)

The present study, “Learning to Cope With Ambiguity: Reflections on the Terri Schiavo Case” looks at the many complexities of dealing with Persistent Vegetative State (PVS). By its very nature PVS is ambiguous. It is difficult to diagnose and, even when the diagnosis appears to be certain, there is a multiplicity of ethical issues and treatment options to consider. There are four high profile PVS court cases that can help us understand the Schiavo situation. They are Karen (...) Ann Quinlan, Nancy Kruzan, Helga Wanglie, and Daniel Fiori. These cases share many common features with each other and with Schiavo. In the final analysis, the judicial decisions inevitably point us to the ongoing need to live and cope with ambiguity. (shrink)

The starting point for discussion in this paper is a case study, namely that of the controversy surrounding the case of withdrawing feeding from Eluana Englaro who had been in a permanent vegetative state (PVS) for seventeen years. I press the case for a recovery of classical prudence or practical wisdom, as understood by Thomas Aquinas, rather than beginning with deontological or utilitarian arguments. I suggest that prudence has relevance not just for specific issues concerned with cases involving (...) PVS, but also addresses wider problems raised by secular end-of-life ethical discourse, with its emphasis on individual choice on the one hand and concerns about the slippery slope towards more liberal legislation on the other hand. Greater attention to the hospice movement is, I suggest, ambiguous in ethical terms. Finally, I argue that one of the strengths of a Thomistic understanding of prudence is its deep connection with the life of grace as that informed by consideration of the work of the Holy Spirit. This incorporates a theological element without falling into the trap of a deontology that can be dismissed by those outside the household of faith, while allowing a Christian witness to persist in such a contested public arena. (shrink)

The author introduces and critically analyzes two recent, curious findings and their accompanying explanations regarding how the folk intuits the capabilities of the dead and those in a persistent vegetative state. The dead are intuited to survive death, whereas PVS patients are intuited as more dead than the dead. Current explanations of these curious findings rely on how the folk is said to conceive of death and the dead: either as the annihilation of the person, or that (...) person’s continuation as a disembodied being. The author argues that these two conceptions are incompatible and inconsistent with each other and the evidence. Contrariwise, the author argues that the folk intuition about dead-survivors and the living dead are more easily explained by appealing to cross-culturally established concepts: the folk biological concept of death the existential concept of death, and the concept of social death. (shrink)

Is the being in an irreversible persistent vegetative state as the result of a horrible accident numerically identical to the human person, Lindsay, who existed before the accident? Many proponents of Thomistic metaphysics have argued that Aquinas’s answer to this question must be “yes.” In particular, it seems that Aquinas’s commitment to both Aristotelian hylomorphism and the unity of substantial form (viz., that each body/soul composite possesses one and only one substantial form) entails the position that the (...) human person remains alive as long as biological life persists. I argue, however, that although Aquinas does possess a deeply integrated account of human nature and is indeed committed to the claim that the person, Lindsay, exists as long as Lindsay’s body lives, there is good reason to suppose that he also holds that the body in the PVS is not Lindsay’s body in anything more than an equivocal sense. (shrink)

Is the being in an irreversible persistent vegetative state as the result of a horrible accident numerically identical to the human person, Lindsay, who existed before the accident? Many proponents of Thomistic metaphysics have argued that Aquinas’s answer to this question must be “yes.” In particular, it seems that Aquinas’s commitment to both Aristotelian hylomorphism and the unity of substantial form (viz., that each body/soul composite possesses one and only one substantial form) entails the position that the (...) human person remains alive as long as biological life persists. I argue, however, that although Aquinas does possess a deeply integrated account of human nature and is indeed committed to the claim that the person, Lindsay, exists as long as Lindsay’s body lives, there is good reason to suppose that he also holds that the body in the PVS is not Lindsay’s body in anything more than an equivocal sense. (shrink)

According to Jewish law, to make a judgment that a life has no purpose and is not worth saving is contrary to the concept of justiceTraditional medical practice dictates that when patients are unable to eat or drink enough to sustain their basic nutritional requirements, artificial feeding and hydration is indicated. Common clinical examples of this problem are patients with senile dementia and those in a persistent vegetative state . In recent decades, however, the practice of mandating (...) artificial feeding has been increasingly questioned. A combination of legal, ethical, and clinical considerations has resulted in broad support for withholding and withdrawing artificial nutrition. The guiding ethical principle in the current clinical standards is that patient autonomy must be honoured. In the context of an incompetent adult , advance directives or surrogate decision making are legally binding. Such requests to withhold artificial nutrition are considered appropriate and even encouraged.1 Such a view, however, is not unanimous. For example, Catholic writers have questioned the current consensus. The New Jersey Catholic Conference has written that withholding nutrition and hydration from such patients “ultimately results in starvation, dehydration, and death,” and that withdrawing such basic care from patients who are not dying but in a PVS “is a clear statement that the patient’s life has no moral value”.2 This question is also of great concern in Jewish law . In contrast to secular medical ethics, halachah requires that artificial feeding be given to patients with dementia or in a PVS. The following discussion gives an overview of the pertinent arguments that have led to the consensus in secular ethics that artificial feeding may be withheld from the severely demented and the halachic considerations that argue against this practice.CLINICAL ARGUMENTS IN FAVOUR OF WITHHOLDING ARTIFICIAL FEEDINGThe most obvious …. (shrink)

In this essay, I discuss the role that vocation plays in assessing the proportion of burdens to benefits in end-of-life options. I then look at the case of patients in a persistent vegetative state. What vocational considerations are relevant for persons considering what care to accept should they ever be in a PVS or for those caring for patients in such a state? Ultimately, I argue that the vocational shape of a patient’s life ought not to (...) be a consideration for a caregiver in favor of removing artificial nutrition and hydration. (shrink)

Those are the words of Pope John Paul II, speaking in March 2004 to an international congress held in Rome. The conference was on "Life-sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas," and it was organized by the World Federation of Catholic Medical Associations and the Pontifical Academy for Life. The pope was able to cut through all the ethical dilemmas. Although he acknowledged that a patient in a persistent vegetative state, or PVS, (...) "shows no evident sign of selfawareness or of awareness of the environment, and seems unable to interact with others or to react to specific stimuli," he said that they should be kept alive indefinitely. Such patients, he insisted, "retain their human dignity in all its fullness" and "the loving gaze of God the Father continues to fall upon them." For this reason, he said, it is obligatory to continue to provide them with food and water, even if this can only be done through a tube. The pope added that to withdraw the tube, knowing that it will lead to the death of the patient, is "euthanasia by omission.". (shrink)