The permanent vegetative state: ethical crux, medical fiction?

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The permanent vegetative state: ethical crux, medical fiction?

In 1994 a Multi-Society Task Force made up of representatives of the American Academy of Neurology, the Child Neurology Society, the American Neurological Association, the American Association of Neurological Surgeons, and the American Academy of Pediatrics produced a Consensus Statement on the Medical Aspects of the Persistent Vegetative State (PVS).(1)

The vegetative state can be diagnosed according to the following

criteria: (1) no evidence of awareness of self or environment and an

inability to interact with others; (2) no evidence of sustained,

reproducible, purposeful, or voluntary behavioural responses to visual,

auditory, tactile, or noxious stimuli; (3) no evidence of language

comprehension or expression; (4) intermittent wakefulness manifested

by the presence of sleep-wake cycles; (5) sufficiently preserved

hypothalamic and brain-stem autonomic function to permit survival

with medical and nursing care; (6) bowel and bladder incontinence;

and (7) variably preserved cranial-nerve reflexes (pupillary, oculocephalic,

corneal, vestibulo-ocular, and gag), and spinal reflexes.... A

wakeful unconscious state that lasts longer than a few weeks is referred

to as a persistent vegetative state.(2)

This consensus statement built on the 1990 work of the American Medical Association's Council on Scientific Affairs and Council on Ethical and Judicial Affairs and presents the appearance of virtual unanimity among the governing elements of American medicine on a linked series of beliefs on the diagnosis, treatment, and ethical status of post-coma patients. These medical conventions are generally accepted unquestioningly as constituting a factual foundation for ethical debate in this area; ethicists like Ronald Dworkin and Peter Singer can thus use PVS as the basis for structures of ethical reasoning--limiting cases that eliminate confounding variables by providing practical examples of humanness combined with insentience.

The courts have also for some decades been prepared to take judicial cognizance of the condition in such cases as Gannon v. Albany Memorial Hospital.(3) In that case Carrie Coons, an eighty-six-year-old woman, was hospitalized after a massive stroke. Initially able to speak single words, her condition deteriorated until she was completely unresponsive. She was unable to eat or drink independently, was maintained by a gastrostomy tube, and the hospital physicians agreed that she was a PVS patient. ...

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