Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State

By Wikler, Daniel | The Hastings Center Report, February-March 1988 | Go to article overview

Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State


Wikler, Daniel, The Hastings Center Report


Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State

How shall we regard those in persistent vegetative state? They are periodically awake, and their bodies breathe and digest on their own. These traits bespeak life. Yet they are not conscious and never will be: subjectively, this is death. Similarly, they may be, except neurologically and psychologically, quite healthy, capable of remaining in their condition for many years with only minimal care. Yet in considering treatment options we class them with the dying, perplexed over the permissibility of withholding care and letting patients die with dignity.

Given these uncertainties, should patients in persistent vegetative state be maintained? A growing societal consensus answers in the negative. I support this conclusion, but puzzle over the rationale for it. The kind of reasoning that has been used in deciding-to-die cases of the past two decades has, I believe, begun to fail us. New kinds of cases are being discussed in an old, increasingly obsolete vocabulary.

Persistent vegetative state, I further believe, is a case in point. Indeed, our consideration of persistent vegetative state permits two distinct views of its place in this evolution. In one aspect, it represents a relatively new kind of problem, the disposition of patients whose lives are stable but not worth living. But persistent vegetative state can also be seen as the last stage of another development: the changing definition of death. Likewise, persistent vegetative state can be conceived either as the lowest-functioning phase of life, or as the highest-functioning phase of death; the ethics of treatment can be discussed under either rubric. These two ways of construing the problem point to somewhat different laws and clinical practices, and the choice between them will affect our treatment not only of patients in persistent vegetative state but also of those in less debilitated conditions.

The Changing Context of Decisions About Dying

Moral problems concerning the treatment of patients in persistent vegetative state are almost always discussed in the context of debates over the disposition of the dying. But for both obvious and subtle reasons, these issues are different in character, and concepts that facilitate deliberation in one area may have less application to the other.

Nevertheless, our dilemma in deciding on treatment of vegetative patients benefits by taking into account the recent history of medical decisionmaking about dying. Though the numerous court cases and celebrated examples do not arrange themselves in any neat pattern, their character has gradually evolved. In particular, there have been important changes in the kinds of conditions considered for nontreatment, in the means considered to bring about death, and in the nature of the particular rights asserted by or on behalf of the patient. In each case, the trend is toward less specifically medical circumstances, measures, and roles. This, I contend, is a significant source of uncertainty in our reasoning about the ethics of withdrawing care from patients in persistent vegetative state as well as those with coma and dementia.

Conditions Not Treated: With the passage of time, elective nontreatment is being considered for patients with less serious and less terminal ailments. The earliest clinical cases concerned those in the most debilitated condition of all, death of the entire brain. The perceived need to justify nontreatment of the brain dead seems to have been a key factor in the redefinition of death, [1] a step that, in effect, licensed the withdrawal of care from these patients at the moment of diagnosis.

In the years since the new definition was proposed and enacted by most states, nontreatment has been judicially approved for patients in less dire circumstances. The Quinlan case involved what was diagnosed as persistent vegetative state, though at the time Karen Quinlan was thought to be dependent on a respirator. …

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