Removing life support from a patient in persistent vegitative state

Bindhu asked:

Interview a hospital administrator to share their philosophy and worldview in relation to the ethical dilemma in Terri Schiavo case and summarize these.

Answer by Craig Skinner

There are no hospital administrators (in Britain) for me to ask. And there is no ethical dilemma.

I’m unclear why a hospital administrator view would be especially helpful. Anyway, since the 1980s, British hospitals have been run by general managers, and the switch from administration to management was a key improvement in the health service. But that’s another story.

As for the Terri Schiavo case, it was the USA equivalent of England’s Tony Bland case, with added razzmatazz, media frenzy, and prolonged duelling by lawyers (14 appeals plus hearings, motions, suits and emergency laws). But, in essence, it was a straightforward Persistent Vegetative State (PVS) case in which useless, invasive medical treatment was finally withdrawn on the grounds that, had the patient been able to say so, she would have declined such treatment.

The facts are as follows:

Mrs S lived with her husband and her parents. Aged 27 years, she developed an eating disorder (bulimia). Bad enough to seriously lower her body potassium and cause cardiac arrest producing severe permanent brain damage and PVS (no cerebral cortex to support consciousness or thought, no prospect of improvement). Able to breathe without a machine, she needed a stomach tube surgically inserted through her skin for food and water.

After 8 years, and every effort, there was no improvement (brain scan showed mostly liquid rather than brain tissue in her head).

Her husband felt that she would not want the invasive feeding tube keeping her alive in her hopeless state. But, rather than he himself suggesting its removal, he asked the court to decide.

The court’s duty here was simply to decide what the patient would wish. A patient (of sound mind) has a right to decline treatment, even if it would be life-preserving. And many do. For example many cancer patients decline another round of chemotherapy, feeling that the small chance of living a bit longer is not worth the inevitable bad side-effects. Mrs S could not say what she wished. Nor did she have a ‘living will’ to give any directive to the court. So the court had to take evidence from family members, doctors and others, and form its best judgment as to what the patient’s view would have been and what was best for her. The verdict was that the tube should be removed, letting her die in peace.

The parents appealed, citing new evidence as to what she would have wanted and new treatment that might help, but the court was unimpressed by the alleged evidence and confirmed its judgment. After further wrangling, the tube was eventually removed allowing her to die.

In essence, then, the court respected the patient’s autonomy (right to choose), although it could only judge her wishes on the basis of evidence presented (as courts do and should do, they can do no other).

Rather similar was the Bland case. Here a young man was crushed in a football stadium disaster, suffered brain damage leading to a PVS, needed a ventilator to breathe for him, and the court ruled that ventilator support should be stopped.

Although there was no dilemma in these cases (in my view), a number of philosophical and ethical issues are relevant to them.

First, what is it that we should be striving to preserve? A person or a human being? By a ‘person’ I mean a self-conscious agent, aware of itself as itself, able to decide things and lead a life (Locke’s famous definition is as good as any). Of course all persons are humans (so far – future computers may be persons; and persons elsewhere in the universe wont be humans), but not all humans are persons. Thus, a newly fertilized egg is human but isn’t even a single human (sometimes it produces twins), let alone a person, and in any case most of us think that early embryos aren’t persons. That’s also how the law sees it (abortion is legal). Similarly I think that if I enter a PVS, I am no longer a person, although still a human being. I agree that personhood is what matters about human life. I am comfortable about abortion and wouldn’t wish to linger in a PVS. Some go further. Singer, for example, thinks an adult chimp has a better claim to personhood than a very young baby.

But note that in the cases we have been discussing the courts looked on the patients as persons, and respected their autonomy (right to decline treatment), rather than simply regarding a human in a PVS as a non-person (although I think such a human is indeed a non-person).

Secondly, is there a moral difference between stopping a treatment that sustains life (passive euthanasia) and giving a lethal injection (active euthanasia)? After all the courts didn’t rule that Mrs S and Mr B get lethal injections, rather that life-sustaining medical support be stopped.

I doubt there is much difference. In either case we know the patient will die. But I suppose it comforts some to think that stopping treatment, rather than actively killing the patient, allows God to take the life (or otherwise, should he feel a miracle is called for). In another famous brain damage case, ventilator support (breathing machine) was withdrawn after a court judgment only for the patient to carry on breathing on her own for many months before dying of an infection, and nobody suggested a lethal injection.

In short, the doctor’s duty to the patient is to offer the best, appropriate treatment, and to respect the patient’s wishes (whether expressed or surmised). An old adage doctors learn is:

First, do no harm, but neither strive
officiously to keep alive.


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