The medical, ethical and legal issues surrounding the management of persistent vegetative state patients

Abstract

The persistent vegetative state (PVS) has emerged as one of the most challenging dilemmas in clinical medicine. It is a condition that necessarily follows a brain insult; resulting in total unconsciousness with partially preserved brainstem function. The irony of the condition is that, although PVS patients have lost all capacity for consciousness and cognition, their bodies usually remain in good health. With active treatment and nasogastric feeding, survival for many years is not uncommon. The economic and opportunity costs of their care is significant. Clinicians have reported that recovery of consciousness after twelve months in PVS is exceedingly rare: beyond this, patients are said to be in irreversible PVS (iPVS). In the last decade it has become increasingly accepted that withdrawal of nutrition and hydration is an appropriate way to end the life of one such patient.

The enigma of a 'living non-person' has received much attention III medical, ethical and legal commentary. Most is devoted to defending or damning the subjective, substituted judgment and best interests standards as they are used to justify treatment withdrawal. The main failing of the subjective and substituted judgment standards is that they are founded on prospective autonomy. As it will never be of consequence to the iPVS patient whether or not their wishes are followed, the principle of autonomy no longer applies to them. Similarly, the best interests standard focuses on what the interests of an iPVS patient are and who should decide them, rather than asking the question: Can a permanently unconscious patient have interests?

The theme of this report is that iPVS patients are neither persons nor corpses, but a separate unique group who should be recognised and treated as such. The underlying principle in determining legitimate goals of medicine is that without proven, presumed or prospective benefit, the pursuance ofan outcome is difficult to defend. In the case of a permanently unconscious patient, it is impossible to justify continued feeding at the expense of real benefit to other sentient patients. Furthermore, as iPVS patients are not persons, much of the emotionally-charged discourse surrounding euthanasia does not belong in discussions of nutrition withdrawal. In their case, 'Exactly what is dying?' becomes a more important question than 'How will they die?'

This report suggests that the decision to withdraw nutrition and hydration should be routinely made by the healthcare team once iPVS has been diagnosed; in accordance with 'good medical practice'. It is a decision based on the unique status of the iPVS patient. the impossibility of any present or future benefit to them, the subsequent futility of ongoing treatment, and the recognition that medical professionals are required to distribute health care in a wise and fair manner. lt calls on parliament to legally recognise iPVS patients as a unique group, qualifying neither as corpses nor citizens. In so doing it must repeal the applicability of criminal and common law principles to iPVS patients, replacing them with legislation endorsing specific guidelines for their management.