This chapter contains sections titled: The Concept of Brain Death and its Appeal A Critique of Brain Death What Kind of Entity Are We? Persistent Vegetative State References Further Reading.

: 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)

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)

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)

"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)

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)

Recently, brain imaging has provided controversial evidence of persisting awareness in some people whose brains are so severely injured that consciousness is minimal or absent, but in whom prolongation of life depends on the provision of continuing medical care. The clinicians understanding of the persistent vegetative state is briefly outlined and the evidence provided by brain imaging of awareness in this condition is reviewed. Information regarding consciousness in progressive acquired dementias are considered in the context of management (...) of these conditions. This leads to the conclusion that quality of consciousness was more important than its presence or absence in managing people with impaired consciousness. (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)

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)

How reliable is a diagnosis of irreversible unconsciousness? In a unique case in New York, a state Supreme Court judge vacated an order allowing removal of life‐sustaining treatment after Carrie Coons showed signs of recovery from a diagnosed vegetative state.

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.

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)

I argue that a version of Pascal's Wager applies to the persistent vegetative state with sufficient force that it ought to part of advance directives.

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)

An adaptation of Pascal’s Wager argument has been considered useful in deciding about the provision of life-sustaining treatment for patients in persistent vegetative state. In this article, I assess whether people making such decisions should resort to the application of Pascal’s idea. I argue that there is no sufficient reason to give it an important role in making the decisions.

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)

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)

This article critically examines the recent papal allocution on patients in a persistent vegetative state with regard to the appropriate conditions for considering “reformable statements.” In the first part of the article, the purpose and meaning of the allocution are assessed. O'Rourke concludes that given consideration of the individual patient's best interest, prolonging artificial nutrition and hydration is not, in every case, the best option. Although he stresses favorability for preservation of the life of the patient through (...) artificial nutrition and hydration, costs and benefits to the patient should be weighed. Ultimately, he argues in favor of leaving the decision to the patient, his caregivers, and others immediately involved in the case. (shrink)

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)

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)

sirThe finding that Japanese physicians are reluctant to withdraw artificial nutrition from patients in persistent vegetative state is of note because, as the authors of a recent paper in the journal point out, Japanese physicians cannot be described as being strongly subject to the Judaeo-Christian influence.1 Despite this, the Japanese physicians show the same reluctance ….

This article critically examines the recent papal allocution on patients in a persistent vegetative state with regard to the appropriate conditions for considering “reformable statements.” In the first part of the article, the purpose and meaning of the allocution are assessed. O'Rourke concludes that given consideration of the individual patient's best interest, prolonging artificial nutrition and hydration is not, in every case, the best option. Although he stresses favorability for preservation of the life of the patient through (...) artificial nutrition and hydration, costs and benefits to the patient should be weighed. Ultimately, he argues in favor of leaving the decision to the patient, his caregivers, and others immediately involved in the case. (shrink)

The Catholic moral tradition has consistently offered the distinction between ordinary and extraordinary means as a framework for making end-of-life decisions. Recent papal allocutions, however, have raised the question of whether providing artificial nutrition to patients in a persistent vegetative state is to be considered ordinary and thus morally obligatory in all cases. I argue that this “revisionist” position is contrary to Catholic teaching and that enforcing such a position would endanger the ability of Catholic health care (...) institutions to minister to all their constituents. (shrink)

Issues such as abortion, embryo research and euthanasia have been discussed exhaustively from the standpoint of Western philosophy and religion, but so far the voice of Buddhism has been little heard in the debate. Although widely respected for its benevolent and humanistic values, Buddhism has not so far shown how its ethical principles can be applied in a consistent manner to contemporary moral dilemmas. Drawing on both ancient and modern sources, this book sets out the basis of a Buddhist response (...) to the major ethical questions posed by modern medicine. (shrink)

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)