The Case of Mr. Stevens

By Cranford, Ronald E. | Issues in Law & Medicine, Fall 1991 | Go to article overview

The Case of Mr. Stevens


Cranford, Ronald E., Issues in Law & Medicine


If I were requested to testify at trial as a "bioethical expert" my services would generally be contingent on two conditions. First, under ideal circumstances, I would prefer to be retained by the trial court judge him or herself and not by the individual parties. Thus, I would hope to act as an impartial, disinterested expert whose role would be nonadversarial. Such an expert would not represent the views of individual parties but would act more as a true "friend of the court."

Second, I would testify not as a bioethical expert (which I am not) but as a clinical ethicist or a bedside etics consultant. These two types of experts should be carefully distinguished. Some professionals have great expertise in the theories and principles of bioethics--Robert Veatch, Richard McCormick, and Joseph Fletcher. Other professionals have more expertise and experience in the practical side of bioethics--Fred Abrams, Stuart Youngner, and myself. Some individuals, such as Joh Fletcher, have extensive knowledge and experience in both spheres. I do not mean to say that clinical ethicists lack knowledge of the theoretical side of bioethics nor that experts in theory are not aware of the practical aspects. But some of us are more qualified on the more pragmatic issues, while others are more skilled in theory.

As an expert then in clinical ethics rather than in theoretical ethics, my comments and guiding principles follow that are relevant to this case from an ethical perspective.

Accurate Facts

In any bioethical dilemma, it is important to get the fact straight. (1) Wrong facts, or a misunderstanding of the facts, will invariably lead to bad decisions.

To say that Mr. Stevens will live "indefinitely" is simply not true. A completely healthy, normally mentating forty-nine year old person will not live indefinitely. Patients in a persistent vegetative state, even if otherwise completely "healthy" (except for their noncognitive condition), will usually live about five to ten years, although some may live longer. Even with maximal treatment, the life expectancy of Mr. Stevens would be considerably decreased from a normal life expectancy. A normal life expectancy for a forty-nine year old in good health, both physical and mentally, would be into the late seventies or early eighties. In that context the life expectancy for Mr. Stevens will be considerably shortened. It is more likely than not that Mr. Stevens will not be alive in ten years and much more likely than not that will not be alive in twenty years.

Another important fact to get straight is that Mr. Stevens will not die of starvation if artificial nutrition and hydration are stopped. The American Academy of Neurology, in its amicus curiae brief to the U.S. Supreme Court in Cruzan, (2) stated unequivocally: "Nancy Cruzan . . . will not starve to death. Due to the nature of the PVS condition, she will not experience pain or suffer in any way, nor will she manifest significant physical indications of the dying process." (3) Mr. Stevens will die of acute dehydration, which would occur usually within one to two weeks, although it could take as little as three days or as long as thirty days. Starvation, on the other hand, usually takes six to ten weeks. (4)

Another important issue is whether the patient is truly in a persistent vegetative state (PVS) without signs of awareness or the capacity to experience pain or suffering. With respect to the issue of whether PVS patients experience suffering after treatment is stopped, the Council on Scientific Affairs and the Council on Ethical and Judicial Affairs of the American Medical Association concluded:

The most obvious contradiction to this projection [that PVS patients will suffer] is that, by definition, in PVS both the peron's capacity to perceive a wide range of stimuli and the neocortical or higher brain functions that are needed to generate a self-perceived affective response to any such stimuli are destroyed. …

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