Ethical Questions Raised by the Persistent Vegetative Patient

Abstract

Ethical Questions Raised by the Persistent Vegetative Patient Ms. T is a twenty-eight-year-old patient diagnosed in a persistent vegetative state who has been in a hospital and/or its affiliated nursing home for the last two and one-half years. When she was twenty-five, she was in a motorcycle accident in which she suffered extensive head injuries. While she is able to breathe on her own and has some brainstem reflexes, she has been unresponsive since the time of her accident and has shown no other evidence of higher brain functioning, although she is certainly not brain dead. Most of the time she receives only nursing care: she regularly needs to have her airway suctioned to prevent secretions from blocking it, and she is regularly turned in bed to avoid bed sores. She is fed and she excretes through tubes. Her major medical needs arise from serious infections that require a careful workup and extensive antibiotic treatment. When necessary, she is transferred from the affiliated nursing home to the hospital, as was recently the case. Ms. T's parents have been devastated since their daughter's accident. Ms. T is their only child, and they had taken great pride in all of her achievements. They cannot bring themselves to accept the fact tht she will never recover. They feel certain that with full and comprehensive treatment, she can survive for years. Hoping for an eventual miracle or for some medical advance, they want this level of treatment to continue. As things stand now, the family's life centers around their regular extended daily visit, where they sit at their daughter's bedside. Often they talk to her, begging her to respond to them. The futility of the situation has been repeatedly conveyed to Ms. T's parents, but they have insisted in the past, and continue to insist in this hospitalization, that their daughter's infection be managed aggressively. They report no conversations with their daughter about these matters prior to her accident. Those who have to care for Ms. T are frustrated by the situation; they see her care as a waste of their time and a misuse of their abilities. They also feel her parents would benefit from Ms. T's death, as they then could attend to their own lives. Finally, they are worried about the cost to society of continuing to provide care to Ms. T. Since her insurance coverage expired long ago, the entire cost of Ms. T's care now falls upon a public hospital with a limited budget. The staff believes that the provision of care to many other patients is impeded because of the allocation of time and resources to Ms. T. This story is actually a composite of several real cases that I have been following for some years. The account brings together most of the special features of each case that give rise to major ethical issues. Among the most prominent issues raised by Ms. T's case are the following: (1) Regardless of how the current statutes define brain death, is this patient really dead? What are the implications of such a determination? Would that at least mean that all further care could be withdrawn? What if the parents continue to object? (2) Suppose the parents agreed with the staff that their daughter should be allowed to die. What forms of care could be withdrawn? Antibiotics? Food and fluids? (3) If the parents do not change their minds, and Ms. T does not satisfy criteria for determination of death, could care be withdrawn against the parental wishes? Could the parents be requested to find other caregivers to provide the desired level of care? Pluralistic Casuistry In thinking about serious ethical issues raised by real medical cases, it is important to ground the process of reasoning in some basic theoretical structure. The approach that seems most useful is the model of conflicting values. According to this model, there are a number of very distinct but equally legitimate and nonreducible moral appeals that need to be employed in the evaluation of a particular case. …