At the end of the last chapter, I argued that someone who is in a permanent vegetative state should be treated differently from someone who is terminally ill or someone who is minimally conscious. In doing so, I have opened myself to the charge that I endorse “quality-of-life” distinctions—a perspective that disability rights groups decry and a number of courts have cautioned us against.
Why are quality-of-life assessments disturbing? Because when a life or death decision is made based on quality of life, it seems that the decision-maker is saying that the life has no value or too little value. And therefore others should not undergo the cost, the pain, and the trouble associated with keeping the individual alive.
Quality-of-life assessments are not as much of a problem when patients are competent to make decisions for themselves, because if they choose to refuse treatment based on quality of life, it is their own assessment of that quality that is controlling. Of course, the issue is not entirely absent with competent patients, either, because if they are refusing treatment when their prognosis for a healthy life is good, then doctors and others will question their competency— or perhaps merely insist upon a delay in order for them to be talked around to a different point of view. If the prognosis for a healthy life is poor, however, then doctors and others may confirm the wisdom of a patient's decision.
But when patients are incompetent and others are making the decision about life-sustaining treatment, then families, doctors, and courts (in individual cases) and legislators (in setting general legal parameters) are, to some extent, unavoidably, judging the quality of people's lives to determine whether that quality is high enough to be worth the burdens of continued treatment.