Morally Right for Doctors to Let a Patient in a Persistent Vegetative State

Introduction

What is persistent vegetative state (PVS)?

Is it morally right for doctors to let a patient in a persistent vegetative state (PVS) die? Before going in depth into this question, let me explain what is PVS. It is a term to describe the behaviour features of patients who have suffered serious brain damage which has resulted in the cerebral cortex to malfunction. These patients are unconscious, in the way that they make no responses which indicate any meaningful interaction with the surroundings, and remain unaware of themselves or their environment. Without the thinking, feeling and motivating part of the brain, they cannot obey a command, nor speak a single word. However, some patients may appear to be awake at times but always unaware due to functioning of the more primitive parts of the brain that are responsible for periodic wakefulness and for wide range of reflex activities. The eyes will roam around when open but do not fix or follow for long while the spastic paralysed limbs never move voluntarily or purposefully. By contrast, they can withdraw with reflex from a painful stimulus that may induce a grimace or a groan but there is no evidence that pain or suffering is experienced. Occasional yawning, smiling, weeping and sometimes laughing can occur but these are unrelated to appropriate stimuli. Reflex swallowing, chewing and gagging may still take place and breathing is normal with no need for a ventilator. [1]

There are several factors determine the potential for recovery, the most important of which is how long the patient has been vegetative. Other factors are the cause of brain damage in which traumatic cases recover better than non-traumatic, and patient’s age in which younger patients do better than older, particularly after trauma. During the first year, patients who are vegetative have a considerable mortality and it is higher after non-traumatic damage and in adults. The average survival in the vegetative state is 3-4 years but cases are recorded living for 10-20 years, one for 37 years and another 40 years. There is higher chance of prolonged survival once the patient has survived the first year. Eventually, death of PVS patient is usually due to pulmonary or urinary tract infection. The duration of survival may depend on how vigorously such complications are treated. A number of patients who are vegetative for a period after an acute trauma do regain consciousness. Yet, a distinction should be made between recovery of some restricted degree of consciousness and the restoration of useful function. A lot of the patients who recover after being vegetative for several months never speak or are capable of only infrequent monosyllabic utterances or of obeying occasional commands. They do not become fully interactive persons with a quality of life that can be enjoyed even at a limited level. [2]

Euthanasia

Euthanasia originates from the Greek word eu thanatos meaning good or easy death. [3] It is the intentionally killing of a patient, by act or omission, as part of his or her medical care. [1] It is also known as mercy killing. Euthanasia which is being carried out when a patient is in a vegetative state and therefore not competent to express his preference to live or die is known as non-voluntary euthanasia. Besides non-voluntary euthanasia, there are two other types which are voluntary and involuntary. Voluntary euthanasia is when a patient requests death himself whereas involuntary euthanasia is when death is against patient’s competent wishes even though the doctor permits or imposes death for the patient’s benefit. [3] Under some circumstances, the practice of euthanasia is morally required by the two most widely regarded principles that guide medical practice which are respect for patient autonomy and promoting patient’s best interests. In many countries that value patient’s individual liberty, competent adults are allowed to refuse any medical treatment even if such treatment is in the patient’s best interest as well as life-saving. For example, a patient who is a Jehovah’s Witness may refuse a life-saving transfusion. The doctor will be regarded as violating the bodily integrity of the person without consent if doctors are to impose treatment against the will of a competent patient. On the other hand, as patient in vegetative state is unable to come to a decision about his or her medical treatment, health professionals have to come to judgments based on patient’s best interests only, taking into account the views of the relatives, lawyers, as well as the general public.

Ethical Issues

An ethical approach to the management of patients whose vegetative state is considered to be permanent can be regarded as a logical extension of the increasing acceptance that it is good medical practice to withhold or withdraw any treatment regarded as being of no benefit to hopelessly ill patients. In this modern world, the development of live-saving and life-sustaining technologies associated with intensive care units have led to concern that these were sometimes be used inappropriately to prolong life or some may put it, to prolong the process of dying. In 1957, a group of anaesthetists asked Pope Pius XII whether they needed to maintain technological support for patients who were not expected to regain cerebral function. He replied that it is not an obligation to use ‘extraordinary measures’, by which were meant those that were being burdensome rather than beneficial. [4] The phrase ‘death with dignity’ was first emerged ten years later when some intensivists were writing about limiting treatment for hopelessly ill patients. [5] In the year when PVS was described, speaking to a British Medical Association (BMA) meeting, the Bishop of Durham (1972) questioned ‘what degree of respect we should grant vegetative patients as compared with the lives of others who are much more evidently alive and communicable with other members of society.’ It was said that the so-called principle of respect for life needs to be qualified and married to an explicit concept of personality and linked to ideas about the quality of life. [6]

A crucial year in this story was 1976, when the New Jersey Supreme Court allowed the request of the Roman Catholic father of Karen Ann Quinlan, a comatose teenager, to have her ventilator stopped to let her die. Although the father’s request had the support of his parish priest, Karen Quinlan surprised many by continuing to breathe unaided, and was fed by artificial nutrition for nine more years. She lived in PVS until her death from complications of pneumonia in 1985. [7] The Quinlan case opened the way for a sequence of court cases in the USA, not only in withdrawing ventilation but on withholding surgery, cancer therapy and tube feeding. These cases included a variety of hopelessly ill patients, some of whom were competent and themselves requesting that treatment be limited. These court cases agreed with the blossoming interest in medical ethics with its four principles of respecting patient’s autonomy, beneficence, non-maleficence and having consideration for justice in the distribution of health care resources. [8]

Four principles of medical ethics

In order to respect for patient’s autonomy, it requires health professionals to help patients to come to their own decisions and to respect and follow those decisions even when it is believed that the patient’s decision is wrong. The principle of beneficence emphasizes the moral importance of doing well to the patients. Nonetheless, the two principles conflict when a competent patient chooses a course of action which is not benefiting him. The principle of non-maleficence is based on the Hippocratic Oath which states that we should not harm patients. A health professional must be fair to his patient, respect patient’s right and dignity as a person and give the patient the proper access to health care based on the principle of justice. [9] However, it is noticed that these principles do not include saving, preserving or prolonging life. In addition, the teleological principle of utility states that it is right if the actions or behaviours are to promote happiness or pleasure and wrong if they tend to produce unhappiness or pain.

Advanced directives

Increasing concern with patient-centred decision making by ethicists, supported by lawyers, leads to increasing emphasis on the right of patients to refuse treatment which is suppose to save or sustain their life. The living will and advanced directive movements are used to prolong that autonomy to patients when they are unable to refuse treatment that in prospect that they considered would not be acceptable to them. Therefore, decisions about stable vegetative patients with no advance directive is said to be even more challenging. To make things more complicated, many will start asking how true is verbal wish? In Terri Schiavo case, Pinellas-Pasco’s Sixth Judicial Circuit Court judge, George W. Greer’s decision to remove feeding tube and let her starve and dehydrate to death was partly based on hearsay evidence provided by her husband, Michael Schiavo, his brother and the sister-in-law, all of which surfaced close to ten years following to Terri’s collapse. [10] Definitely, some may argue that how these allege verbal wish could be used to decide Terri’s fate. This is because most guidelines on treatment-limiting decisions refer to death and preventing the suffering of dying patients being impendent. Although in truth many of the patients dying in intensive care units from which treatment is withdrawn are in fact unconscious and therefore not suffering, neither of these factors applies to the vegetative patient.

The golden ethical issue here is whether prolonging the life of a patient in vegetative state is considered bringing benefits to that patient permanently. In the Tony Bland case, the judges clearly stated that the sanctity of life principle has exceptions and this case could be one. Several religious commentators have also indicated that one is not morally obliged to save or prolong life which is devoid of almost all the attributes of a human being. [11] Nevertheless, some may choose to disagree and side the minority of vitalists who insist that life of any kind is itself a benefit. It does seem that there is now widespread acceptance, at least in Western countries, that it is a good ethical medical practice to withdraw or withhold treatment either at patient’s request or because it is considered not in patient’s best interest to prolong life in a vegetative state. But does prolonging vegetative life do any harm? Some emphasise the indignity of such a state and others say that memory of the patient may deteriorate by prolonged vegetative survival and question about the quality of life if recovery occurs. Others argue by saying that vegetative patients cannot experience indignity.

The question of harm to the relatives is not held to be a relevant ethical consideration, unless it is claimed that the patient would not have wished this burden on them. There are some who say that we should not deny patients’ altruism, because patient-centred ethic does not imply that the patients would be concerned only with their own interest. Moreover, in the absence of an advanced directive, it is tough to determine what a patient’s wishes would be and therefore it raises issue on this. Another issue for debate is whether tube-feeding is different from other forms of life-sustaining treatment. Some argue that supplying food and water represents basic care owed to everyone by everyone, and that it has symbolic significance in showing care for another human person. Besides, it is unjustified to classify this practice as medical treatment because it does nothing to reverse the pathology or to stimulate healing. However, like ventilation and dialysis, tube-feeding substitutes a lost physiological function which in this case is the ability to swallow effectively and sufficiently to maintain nutrition. In Tony Bland case, all nine judges agreed that tube-feeding was medical treatment, and that it could therefore be withheld, withdrawn or refused. Backing up by many ethicists, it is said that discontinuing tube-feeding does not offend any ethical principle, provided that prolongation of life does not hold any prospect of recovery. [11] Even it is unpleasant to witness death of a PVS patient after being withdrawn of tube-feeding, it is accepted that this can cause no suffering to the insentient patient. In addition, it is death that is peaceful and dignified.

In recent times, issues of death and dying have become the focus of intense debate among the theologians, ethicists, lawyers and public at large. A number of controversial decisions of superior courts on these matters such as the Tony Bland case in the United Kingdom and Terri Schiavo case in the United States have certainly caught many media attentions. There are two main reasons for this debate. Firstly, the dramatic advances in medical technology and pharmacology have made it possible to sustain the lives of terminally or otherwise hopelessly ill patients for extended and often indefinite periods of time. Secondly, due to these advances, and the reorganization of medical care accompanying the new science and social conditions of death, people are more likely to die in relatively public places, such as hospitals or nursing homes, instead of that at home. Undoubtedly, these treatment decisions are of the utmost moral and legal significance and it is therefore unsurprising that there have emerged many sharply conflicting ethical frameworks for resolution of treatment dilemmas at life’s end.

Legal status in the UK

Non-voluntary euthanasia is illegal in all countries around the world, except that it is practised in the Netherlands under an agreement between physicians and districts attorneys that was approved by the Dutch National Association of Paediatricians. Why non-voluntary euthanasia is still not legalized in the UK? The current policy is based on the British Medical Association (BMA) and it insists that non-voluntary euthanasia should not be made legal in the UK. Doctors voted by an overwhelming majority against legalizing physician assisted suicide and euthanasia at the BMA’s annual conference in Belfast on 29 June 2006. It is stated that there would be pressure for all seriously ill people to consider this idea even they would not have considered this otherwise. Patients might feel it is an obligation to choose it for the wrong reasons. For instances, they might start worrying that they are being burdensome or concern about the financial implications of a long terminal illness. Besides, it could also weaken society’s prohibition on intentional killing and undermine safeguards against non-voluntary euthanasia of people who are both seriously ill and mentally impaired. Therefore, BMA opposes it for such reasons. Decisions about the patient’s best interests should be assessed by doctors, taking account of the views of the families. A decision to withdraw feeding tubes now requires judicial consideration for further legal pronouncements. In the event which the doctor might object to treatment withdrawal, the patient should be transferred to another doctor. [12]

Based on the text of the Medical Treatment (Prevention of Euthanasia) Bill, as presented to the House of Commons on the 15th December 1999, it is unlawful and therefore an offence to withdraw or withhold any medical treatment or nutrition and fluid if the purpose is to cause the death of the patient. However, the Bill left undisturbed decisions to withdraw or withhold medical treatment or food and fluid which would not be of benefit to the health of patient or would be too burdensome to the patient. The Bill clearly states that doctors are not required to strive officiously and inappropriately to keep dying patient alive. In addition, Article 2 of the European Convention on Human Rights backed up the provisions of the Bill, which states that no-one shall be deprived from his life intentionally. [13]

Unlike the United States and parts of Canada and Australia, the United Kingdom has no legislation for advance directives. The House of Lords Committee considered that legislative framework giving effects to advance directives in England was not necessary. It was said that there were increasing recognition of ethical obligations among doctors to comply with advance directives and because of the development of case law affording them legal recognition. Despite the fact that there has yet to be a definite court decision on the validating and scope of standard advance directives, a considerable amount can be gathered from both basic common law principles and a number of recent court decisions related to this issue, suggesting that English law does to a certain extent accept the two underlying propositions on which the enforceability of advance directives depends. [14] [15]

Conflict

Before concluding whether it is morally right for doctors to let a PVS patient die, is mercy killing wrong in principle in the first place? Consider the following medical situation. In order to ensure that the patient suffers pain to its minimum, morphine is sometimes given to patients close to death from a terminal illness. Besides relieving and preventing pain, it also reduces the depth and frequency of breathing. Yet, in some situations, although not all, morphine can have the predictable effect of shortening the patient’s life, as well as reducing pain. Therefore, a doctor who gives morphine to a terminally ill patient in order to reduce suffering of the patient, even though foreseeing the earlier death of the patient, would not have broken the law. In fact, it is said that in this kind of circumstances, giving morphine is often regarded as good clinical practice. On the other hand, in the case of giving potassium chloride instead of morphine, it is acknowledged to be unlawful as the intention is for the patient to die, even this is the means to reducing the patient’s suffering. Although in the case of morphine it will also cause earlier death, it is said to be foreseen but not intended. That is at any point, how the law in England and many other countries see it. [3]

Conclusion

In summary, the argument stating that mercy killing is wrong in principle put immense moral importance on the distinction between acts and omissions; and the distinction between intending and foreseeing the death. Opponents of euthanasia may eventually rest their case on one basic principle which states killing is always morally wrong. They may accept that there are difficult situations when killing one person may save many others and it is the right thing to do. But in the case of euthanasia, no one’s life will be saved and it is wrong as it is based on the wrongness of killing. Based on the three features of euthanasia which are that the doctor-in-charge has a clear duty of care to the person who dies; that there is no issue of harming one person to benefit another; and where death is in the best interests of the person who dies, I reject the view that it is immoral for doctors to let patients in PVS die. In my opinion, if it is in the best interests of a patient to die now rather than suffer a prolonged and painful dying, then killing by letting PVS patient die is no longer a wrong. In other words, when death is a benefit instead of harm, then killing by letting patient dies is not a wrong. I firmly think that if a suffering is the result of following our own moral principle then we need to reconsider very carefully at our own moral principle and ask whether we are applying it too rigidly.

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