Ethical issues in diagnosis and management of patients in the permanent vegetative state
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7282.352 (Published 10 February 2001) Cite this as: BMJ 2001;322:352
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Dear Sir,
I thank Dr Woodcock for drawing attention to the fact that killing
someone with the primary intention of obtaining organs for transplantation
is both illegal and immoral.
However I was trying to make a different point, namely that the
autonomy of the patient (person in PVS) might be reduced by using a mode
of death that precluded use of their organs by others. If the individual
strongly believed that others should be able to use their organs after
death, then it is at least arguable that to enable a mode of death which
still allowed organs to be used would show them more respect than simply
allowing them to die from dehydration. Neither mode of death is ideal,
but one allows their wishes to be fulfilled and the other does not.
Thus I am suggesting that one should intend to maximise the
fulfilment of the patient's wishes, not the satisfaction of the needs of
Society. Of course it must also be recognised that positive killing has
negative aspects, such as distressing health professionals.
My article intended simply to point out that there are two or more
sides to each choice made in the management of patients in PVS. There is
no obvious correct choice, and after ten years of experience a further
debate is needed even if only to validate current practice.
Yours,
Derick Wade
Competing interests: No competing interests
Professor Wade considers the possibility of killing patients in
permanent vegetative state for the sakes of relatives, health staff and
organ procurement. He opines that 'The situation is similar to treating
terminal distress in a conscious patient.'(1) For the benefit of lay
readers of the Journal I think it should be made very clear that killing
patients for the sake of others, with or without their consent and
including those in permanent vegetative state, is a criminal offence which
should not be contemplated. The analogy was unfortunate. However, his view
that death through omission of nutrition is unsatisfactory was shared by
an expert witness in the Bland case, and the Judge, Sir Stephen Brown,
allowed that sedative drugs could be given to Bland to minimise the
distressing response to this mode of death (2). Palliative drug treatment
for PVS patients who are no longer being nourished would seem therefore to
be legal, even if it is illogical.
Dame Elizabeth Butler Sloss considered two cases of proposed
withdrawal of artificial nutrition and hydration from patients in
vegetative states last year (3) when the Human Rights Act (1998) came into
force. She confirmed that the U.K. law established in Airedale NHS Trust v
Bland (1993) AC 789 is not incompatible with the European Convention on
Human Rights. Specifically, she confirmed that PVS patients are alive and
so Article 2 (Right to life) lays on the state a positive obligation to
refrain from taking that life intentionally, but no obligation to prolong
it. Importantly, she ruled that where a responsible clinical decision was
made to withhold treatment on the ground that it was not in the patient's
best interests, and that clinical decision was in accordance with a
respectable body of medical opinion, the state's positive obligation under
Art.2 of the Convention was discharged.
It is therefore crucial that medical opinions, especially as
expressed in prestigious medical journals, should at all times be
unambiguously stated and every effort must be made to maintain the respect
of the public.
1 Wade DT. Ethical issues in diagnosis and management of patients in
the permanent vegetative state. BMJ 2001; 322: 352-4
2 Airedale v Bland [1993] 1 All ER 821, 828.
3 NHS Trust A v Mrs M : NHS Trust B v Mrs H (2000) Times Law Reports
29/11/2000.
Competing interests: No competing interests
Wade (1) explores the ethical issues associated with the withdrawal
of gastrostomy feeding in patients in a persistent vegetative state. I
agree with his statement that, "The main bone of contention is likely to
centre on justice - is it equitable to allocate so much scare resource to
one person who is unaware for most of the time?" A Christian ethical
perspective is far from universally accepted. It does, however, alter the
cost-benefit analysis and provide an alternative to the limited
utilitarian conclusion of this article.
Both the 'costs' and the 'benefits' of the equation are altered if
you accept the ethics of justice expressed by Jesus (2), "The King … will
say to those on his left, 'Depart from me you cursed into the fire
prepared for the devil and his angels. For I was hungry and you gave me
nothing to eat, I was thirsty and you gave me nothing to drink…'
"They also will answer, 'Lord, when did we see you hungry or thirsty
… and did not help you?'
"He will reply, 'I tell you the truth, whatever you did not do for
one of the least of these, you did not do for me.'
"Then they will go away to eternal punishment, but the righteous to
eternal life."
There is parallelism in that both groups are unaware of the spiritual
implications of the situation.
Dr Hugo van Woerden
18 Dan-y-deri, Bedwas, Gwent.
CF83 8HR
1 Wade DT . Ethical issues in diagnosis and management of patients
in the permanent vegetative state. BMJ 2001;322:352-4.
2 The Holy Bible, New International Version. Matthew 25:41-6. New
York: New York Bible Society International, 1978.
Competing interests: No competing interests
Dear Sir,
I would like to pespond to the two points raised by Mr Roger Goss.
Uncertainty
All medical diagnoses are subject to some uncertainty. Some, such as
carcinoma are usually confirmed as certainly as possible through
histological examination of tissue, but others such as stroke are only
confirmed by Xray imaging where uncertainty still remains.
Furthermore in the absence of any agreed, definitive 'test', one can
never achieve certainty.
Organ donation
I do not suggest that the mode of death is altered in order to increase
organ donation. I suggest that if it is known that the patient (person in
PVS) strongly wished their organs to be used after death, then one might
wish to respect their wishes by ensuring a mode of death that enabled
their wishes to be met.
The current mode of death deprives the person of their only remaining
altrusitic act.
Yours sincerely,
Derick Wade
Competing interests: No competing interests
LETTERS TO THE EDITOR
15 February 2001
Some ethical issues from a patient perspective
Editor – Wade seems to imply that some level of undefined, or is it
indefinable, uncertainty may be acceptable in declaring a patient to be in
a vegetative state. (1) Medical practitioners seem to take for granted a
level of error as inevitable which in any other industry would at best
result in independent regulation and at worst total shut-down.
Surely patients and relatives need re-assurance that the slightest doubt
in the diagnosis entitles the individual to the benefit of the doubt.
He also suggests that the primary reason for scrapping starving and
parching of patients to death, the description understood by non-medics,
is to increase the supply of organs for transplantation. Surely the best
justification is the elimination of a procedure perceived by some as cruel
and by others as unethical.
Roger M. Goss
Director – Patient Concern
P.O. Box 23732
London SW5 9FY
1. Wade D. Ethical issues in diagnosis and management of patients in
the permanent vegetative state. BMJ 2001; 322: 352-354 (10 February)
Competing interests: No competing interests
Moral Principles and the "Permanent" Vegetative State
One thing which stands out in Professor Wade’s article is the
vacuousness of the four-principles approach to medical ethics, which was
popularized by Beauchamp and Childress’ standard text in medical ethics
(1). The difficulty with this approach is that anyone can "plug" his or
her position on a moral issue into the principles of nonmalificence,
beneficence, autonomy, and justice and "discover" that, lo and behold,
those principles support what he or she believed in the first place! For
example, Professor Wade assumes a basically consequentialist, utilitarian
view of justice, which focuses on issues such as the financial costs of
maintaining PVS patients. There do exist alternative conceptions of
justice, such as the ancient position of justice as desert, as getting
what one deserves, which would frame the relevant issues differently. One
question which might arise from a justice as desert conception might be
the following: "Is it just to the PVS patient him/herself to remove
nutrition and hydration?" One could argue that the notion of justice as
desert fits the nature of medicine more comfortably than a utilitarian
conception, for it, like medicine, focuses on the individual human being.
Professor Wade strongly emphasizes the principle of autonomy, to the
point that he holds that despite the admitted diagnostic uncertainty
surrounding the PVS, a patient who previously expressed a wish that his or
her organs be removed after death and who is in a PVS should undergo organ
explantation; otherwise, that patient’s autonomous choice in favor of
organ donation has not been respected. However, the overriding nature of
autonomy is not self-evident, for the principle of autonomy was developed
as a product of the Enlightenment in Western culture, and is especially
emphasized in the thought of Immanuel Kant. It is not strongly emphasized
outside of the United States and Western Europe; e.g., it is not a major
focus of medical ethics in Japan. Even if good reasons could be found for
autonomy having such importance, it does not follow that a patient who
requests that organs be removed after death understands that that implies
removing his or her organs after the person is killed in a PVS. This is
particularly true given the admitted difficulties diagnosing the
"permanence" of a vegetative state. The very name "permanent vegetative
state" begs the question of whether the state is, in fact, "permanent." A
vegetative state is defined as "permanent" if it continues for 12 months
post-injury, but Childs and Mercer have reported a case of a patient in a
"permanent vegetative state" who showed improvement in consciousness
beginning 15 months after her injury (2), and referring to the Traumatic
Coma Data Bank (3), they give "a conservative estimate of the incidence of
improvement after post-traumatic permanent vegetative state [as] 14
percent (3 of 22 patients)" (2). With such uncertainty about the
"permanence" of such a condition, a strong case can be made against both
direct killing of these patients or the removal of nutrition and
hydration.
Finally, many religious and even non-religious conceptions of human
life hold that it is of intrinsic value and that the willful, direct
killing of a human being, even one who is disabled to the point of a
persistent vegetative state, is intrinsically morally wrong, regardless of
the consequences, and regardless of the "autonomous prior choice" of the
individual involved. Even if one does not accept such a view of the
sanctity of life, and even if one insists on appealing to utilitarian
considerations, an argument could still be made, as Professor Wade still
suggests, that killing PVS patients could lead to a lowered respect for
the lives of other, less severely disabled, people, so that some
individuals might justify their being killed as well. We have already
seen, in the past, the dangers of the assumption that there are lives "not
worthy to be lived" (4). Hopefully, those in the medical profession and
elsewhere will carefully consider their guiding assumptions before
removing nutrition and hydration or giving a deadly drug to a patient in a
"permanent" vegetative state.
1 Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th
ed. New York: Oxford University Press, 2001.
2 Childs NL, Mercer WN. Brief report: late improvement in
consciousness after post-traumatic vegetative state. N Engl J Med
1996;334:24-5.
3 Levin HS, Saydjan C, Eisenberg HM et al. Vegetative state after
closed-head injury: a Traumatic Coma Data Bank report. Arch Neurol
1991;48:580-5.
4 Alexander L. Medical science under dictatorship. Ethics & Med
1987;3:26-36.
Competing interests: No competing interests