The Puzzle of the Permanently Unconscious

Abstract

The Laws of Ireland The Republic of Ireland has been the last country in the European Community legally to prohibit abortion, specifying no permissible exceptions. An amendment to the Irish Constitution, passed by national referendum in 1983, recognized a right to life of the unborn "with due regard to the equal right to life of the mother." But on 5 March 1992 the Supreme Court held that abortion is legal in Ireland in limited cases. The Supreme Court judgment followed after the Attorney General enjoined a fourteen-year-old rape victim from leaving Ireland to get an abortion in England. Her intention became known to the police because the girl's family asked them the official procedure for procuring DNA samples from fetal cell tissue for use as evidence against the alleged rapist. Once they knew of the girl's intention to get an abortion, and given the 1983 amendment for protection of fetal life, the police felt obliged to inform the Director of Public Prosecution, who in turn notified the Attorney General's office. A high court judgment upheld the Attorney General's injunction: the right to life of the fetus was granted priority over the girl's right of freedom to travel for legal abortion services elsewhere. The Supreme Court judgment, however, overturned the high court by a vote of 4 to 1, interpreting the 1983 amendment with reference to the girl's age and the evidence that there was a "substantial risk of suicide" following her rape, coupled with severe depression brought on by the injunction preventing her from traveling outside Ireland for an abortion. The Court's judgment has placed an onerous responsibility on legislators to specify more precisely the conditions under which abortion may be permitted in Ireland. Doctors and hospitals are already contemplating the ethical implications and practical consequences for health care institutions that might result from any forth-coming abortion legislation. The abortion debate in Ireland has now entered a new era, in which its terms have changed radically. There is considerable uncertainty about legislative outcome.--Dolores Dooley, University College, Cork, Ireland. Are treatment decisions for the permanently unconscious patient a central issue or a peculiar obsession in bio-ethics? Are the permanently unconscious "severely disabled" under the terms of the Americans with Disabilities Act? Can the courts pronounce permanently unconscious patients dead, thereby making their organs available for transplant? Ought legislatures to redefine death so that the permanently unconscious are included under neurological criteria for death? Ought legislatures to redefine "terminal illness" to include permanent unconsciousness? Do physicians--or hospitals--have to provide ICU care for permanently unconscious patients if they believe that doing so is professionally wrong? Not in the best interests of the patient? Not in the best interests of the health care system or the institution from a financial perspective? Is providing treatment for a permanently unconscious patients even if their advance directives say they want treatment no matter how dire their condition? Are permanently unconscious patients 'persons' in a philosophical sense? What do we know about these patients and their condition? If continued treatment is a problem, how big a problem is it? Customary (and unreferenced) estimates are that there are 5,000-10,000 permanently unconscious patients in the U.S. The American Medical Association estimated, in 1990, that there were 15,000-25,000 patients in persistent vegetative state (PVS) in the U.S.A. 1992 research study found 3 percent of the 1,611 patients in four Milwaukee nursing homes in persistent vegetative state. Three percent of the 1.3 million nursing home residents in the U.S. translates to 39,000 patients in PVS. Why are these 5,000 to 39,000 patients who are permanently unconscious continuing to receive treatment? …