Reflections on Ethics 38
The Living Dead: Ethical Considerations
The Terri Shiavo case leads us to consider those trapped somewhere between life and death; bodies kept alive by medical intervention with the status of the personality who inhabited that body questionable.
We can consider that these cases fall into three categories, though the boundaries between them may be blurred. There are those who are "brain dead;" those in a "persistent vegetative state;" and those in a "coma."
When someone is considered brain dead; the parts of the brain that are involved in high level thinking and those parts that control automatic functions such as breathing and heartbeat are severely damaged or destroyed. The functions of the body can be maintained by life support equipment; but if the equipment is turned off ("pulling the plug" is the popular term,) the body dies within minutes.
While a person can appear brain dead for a few brief minutes and recover, anything beyond that time is considered irrevocable.
Some still raise ethical problems with brain dead people in that their bodies may be kept functioning on life support solely to keep organs fresh for transplant operations. Others raise ethical problems with simply pulling the plug to let the body expire. Medical ethicists have determined that there is no problem. The person is indeed dead even though the body functions are being maintained by machine.
At the other end of the spectrum is coma. Brain damage may be severe; it may be minor. The individual is unconscious, unable to speak, apparently unable to wake up, the eyes usually closed. There are pain responses, and the gag reflex works. Brain scans show activity in the cerebral cortex with looks after our high level functioning and in the more primitive areas which look after automatic functions. Life support, other than a feeding tube, is not usually required.
People in a coma can regain consciousness though not all do. Even after a number of years in a coma, some patients do wake up.
Those in a coma generally do not present an ethical problem. Given there is brain activity, patients in a coma are considered to remain amongst the living. Given there is a reasonable possibility of recovery, it is not standard practice to allow these people to die.
In between coma and brain dead is persistent vegetative state. In this case, the cerebral cortex is damaged or destroyed and shows no activity on a brain scan. Yet the more primitive areas continue to function. The patient breathes and the heart beats. The normal sleep and wake cycle continues. Their eyes open. They show many reflex actions such as blinking, smiling, moving, responding to a touch. Yet the part of the brain that looks after higher level activity is not involved in this.
With no cerebral cortex, the very essence of the person is gone; personality, thinking, sense of self, memory, ability to create new memories, emotions - they are all destroyed.
Given that the automatic functions are still in operation, a person in a persistent vegetative state does not usually need life support other than a feeding tube.
It is usually stated that no-one has ever come out of a persistent vegetative state. This is not quite correct. According to the LA Times, there has been one "recovery," and that after 20 months. The individual in question then survived another 5 1/2 years, paralyzed, and able to communicate only through nods, and spelling out words on an alphabet board. He is reported to be happy he was kept alive.
Given that, at any given time, there are about 35,000 people in a persistent vegetative state in the United States and that most such patients, if they continue to receive care and feeding, die within five years, the odds are very strongly against recovery.
Neurologists are in general agreement that there is no possibility of recovery, and that the person as we understand it is essentially dead. Medical ethicists, in considering patients in a persistent vegetative state, consider it is appropriate to permit them to die by withdrawing their feeding tubes, leading to starving the body to death. This is considered preferable to keeping the body alive unnecessarily until it inevitably dies due to one of infections, general systemic failure, respiratory failure or strokes.
Polls show, by a two to one margin, that the termination option is what most people would want for themselves if they were in this state. And when given the option, after seeing loved ones in a persistent vegetative state for an extended period, next-of-kin, more often than not, choose it.
Where this issue has gone to courts, judgements have supported medical opinion and next-of-kin wishes.
The general consensus about what is considered right is apparent.
It is what I would want for myself.
But the Shiavo case demonstrates that a dissenting voice with connections can create difficulties.
Make your own decision while you are able. Document that decision. Make all those who might end up exercising responsibility for you are aware of what you want.
- If you want an extremely simplistic approach to understanding these terms:
- Brain dead - Lights out; nobody home
- Persistent vegetative state - Lights on; nobody home
- Coma - Lights out; somebody home.
- Not my first preference - I would prefer a quick drug cocktail to end things rather than having people watch me starve to death for up to two weeks; but euthanasia is another issue.