Exile and PVS

By Schneiderman, Lawrence J. | The Hastings Center Report, May-June 1990 | Go to article overview

Exile and PVS


Schneiderman, Lawrence J., The Hastings Center Report


Why do we match the persistent vegetative state with what we frankly should call the persistent medicative state-a relentless use of artificial nourishment and other treatments to perpetuate unconscious existence? Given a patient's prior request, physicians are ethically free-and in most states legally bound-to end support for this form of life. Even in the absence of prior directions there is authoritative medical consensus to do so. Yet an estimated five to ten thousand patients in PVS are maintained in health care facilities.

This reluctance to terminate life support may represent nothing more than financial self interest or fear of litigation; but we cannot ignore a more morally supportable reason, namely the concern that social value judgments might decay into egregious public policy killings. Is there an argument sufficiently compelling to override this slippery slope objection?

One possible line of reasoning is exemplified by considering the patient in intractable pain from advanced metastatic cancer. To abolish the pain a physician might find it necessary to employ large doses of morphine--which could shorten the patient's life. Today there is general medical agreement that--barring patient preferences to the contrary--it is a greater act of beneficence, therefore the physician's duty, to alleviate suffering, even if the patient's life is shortened. Can this rationale be applied to the patient in PVS? Ironically, this argument is confounded by the very authorities, such as the AMA and the American Academy of Neurology, who while advocating treatment withdrawal, assert that: "Persistent vegetative state patients do not have the capacity to experience pain or suffering."

How then can we justify ending a life which is incapable of suffering? We cannot know of course that PVS patients do not suffer. We can only surmise this based on observations we make of external manifestations that correspond to inner states (so we are told) in conscious people. The patient does not smile or frown in response to the sounds of voices or music--therefore, we assume the patient is deriving no meaning or satisfaction from these stimuli. We observe none of the customary signs of awareness or recognition or emotions or thoughts. But even if this lack of awareness is not suffering, can we nonetheless conclude that the patient exists in a state so undesirable that it is perhaps worse than death? If so then we would have the moral warrant to end that state.

What do we know about the patient who is permanently unconscious? Only that he or she is isolated from any form of communication-as though exiled or banished from society, a condition once regarded as punishment equal to if not worse than death, because it is, in effect, dehumanizing.

From the earliest known time human beings have functioned as organic components within a community, connected to family, friends, work, rituals, customs, duties, and entertainments. …

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