Concerning the case of 'Mr. Stevens.' (Symposium: Current Controversies in the Right to Live, the Right to Die)

• Author: Davis, John Jefferson

The case presented for consideration concerns a "Mr. Stevens," a forty-nine year old man who received a severe head wound in an automobile accident. Various medical tests have been performed in the two-year period since the accident, and recent results indicate that a portion of Mr. Stevens's cerebral cortex has atrophied and has been replaced by cerebrospinal fluid. The remainder of his brain and brain-stem appear to be intact and capable of functioning normally.

Recent examinations by consulting neurologists have led these physicians to diagnose Mr. Stevens as being in a "persistent vegetative state" (PVS). He is being maintained in an intermediate care nursing facility, expenses being paid from damages awarded to him as a result of the accident. Three months after the accident a gastrostomy tube was inserted into his stomach to supply food and fluids. The physician described Mr. Stevens's ability to swallow at that time as "unsophisticated and reflexive," and there was concern that without the tube food or fluids could enter his lungs and cause further complications. The examining physicians agree that Mr. Stevens could live indefinitely in his present condition so long as artificial feeding and hydration are provided.

Mr. Stevens's wife has now petitioned a trial court to authorize the discontinuation of artificial feeding and hydration. She and three of the children agree that he "would not wish to live indefinitely in this way." They invoke in support of this request statements made in reference to his father-in-law, who died after a long illness, lingering for some time in a semi-comatose state somewhat similar to Mr. Stevens's present condition. Stevens had made the comment, heard by the entire immediate family, that it would be better for his father-in-law to "die now rather than linger endlessly in some mindless state." Afterward Mr. Stevens further commented that death had released his father-in-law "from the prison of his own useless body."

One year prior to his own accident Mr. Stevens had orally consented to the withholding of "heroic" treatment from his own father, who was almost totally incapacitated by Alzheimer's disease. Mr. Stevens's father continues to live and is able to receive food and fluids by mouth.

At the time of his accident Mr. Stevens was teaching high school English and history. His accident occurred as he was driving to a local university, where he was taking graduate courses in pursuit of a Ph.D. in English, with a view toward teaching English at the college level. His own immediate family and his present and former students all agree that he considered the "life of the mind" as requisite to the "fullest human existence."

The resolution of the case is complicated by the fact that Mr. Stevens's eldest daughter, who visits him as often as three times a week, is opposed to the removal of the feeding tube. She believes that it would be "wrong to starve her father to death" and that her father would "never want them to do something that was wrong." The nursing staff also objects to the discontinuation of artificial feeding, believing that Mr. Stevens is "higher functioning" than many of the other residents of the facility. In spite of the neurologists' diagnosis of a persistent vegetative state, both the eldest daughter and members of the nursing staff testify that Mr. Stevens appears to interact with them to some degree.

Given the incompetency of Mr. Stevens to make decisions concerning his own medical treatment, the trial court must resolve the dispute between Mrs. Stevens and the three children on the one hand, and the eldest daughter and the nursing staff on the other, both as to a matter of fact--the state of Mr. Stevens's consciousness--and a matter of interpretation--that is, the proper interpretation of what Mr. Stevens's wishes might be relative to his medical treatment, were he competent to make such a decision.

Several questions of clarification arise naturally in this case. Just how extensive is the damage to his cerebral cortex? Can the extent of the damage be quantified? Does Mr. Stevens show signs of any consciousness, however minimal, or does the diagnosis of PVS accurately reflect total absence of any self-awareness? It will become apparent during the course of the analysis that the distinction between even minimal sapience and total lack of any potential for present or future sapience can in fact make a significant moral difference in the decisions reached in Mr. Stevens's case.

It is the limited purpose of this article to clarify some of the ethical and theological issues that are involved, not to address the related legal issues of "substituted judgment" or the medical issues related to the reliability of the diagnostic criteria for PVS. Certain assumptions and conclusions from these fields will be utilized during the course of the study but, due to limitations of space and the author's competence, will not be extensively discussed.

History of the Discussion

The case of Nancy Beth Cruzan(1) has given much visibility to the matter of maintaining patients by artificial food and hydration, but discussions of such matters by ethicists and moral theologians long antedates the Cruzan case. As early as 1950, in an important article titled The Duty of Using Artificial Means of Preserving Life,(2) Fr. Gerald Kelly, S.J., specifically addressed the question of patients in a state of coma:

I am often asked whether such things as oxygen and intravenous feeding must be used to prolong the life of a patient, already well prepared for death, and now in a terminal coma. In my opinion, the circumstances of this case make it obvious that the non-use of artificial life sustainers is not the same as mercy killing; and I see no reason why even the most delicate professional standard should call for their use. In fact, it seems to me that, apart from very special circumstances, the artificial means not only need not but should not be used, once the coma is reasonably diagnosed as terminal. Their use creates expense and nervous strain without conferring any real benefit. It must be kept in mind, however, that it is for the physician to decide when the coma is terminal.(3)

Kelly is aware that in these circumstances a decision to discontinue artificial feeding might be construed as mercy killing but clearly believes that this is not actually the case. In the case he discusses, artificial feeding of the dying, comatose patient is seen as a useless treatment that confers no real benefit and hence is not morally obligatory. It should be noted, however, that Kelly addresses the case of the imminently dying, comatose patient; Mr. Stevens, on the other hand, may be irreversibly comatose but is not imminently dying.

In a 1958 doctoral dissertation at the Gregorian University in Rome, Daniel A. Cronin, the present Roman Catholic bishop of Fall River, Massachusetts, reviewed some fifty moral theologians from Aquinas to those writing in the early 1950s in his study titled "The Moral Law in Regard to the Ordinary and Extraordinary Means of Preserving Life."(4) Cronin concluded that Catholic teaching in such matters exhibited a consistent pattern: "Even natural means, such as taking of food and drink, can become optional if taking them requires great effort or if the hope of beneficial results (spes salutis) is not present."(5) In Cronin's conclusion the concept of "benefit to the patient" comes to the fore.

In 1962 John P. Kenny, O.P., professor of philosophy at Providence College in Providence, Rhode Island, addressed the issue of discontinuation of medical treatment for unconscious patients.(6) Would it be ethically permissible to remove a respirator from an unconscious patient who has shown no improvement after prolonged treatment? Kenny states his conclusion in the following way:

In a case of deep unconsciousness when the patient has received extreme unction, the physician may remove the artificial respiration apparatus before the blood circulation has come to a complete...