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Exile and PVS.

Why do we match the persistent vegetative state with what we frankly should call the persistent medicative state-a relentless use of artificial nourishment and other treatments to perpetuate unconscious existence? Given a patient's prior request, physicians are ethically free-and in most states legally bound-to end support for this form of life. Even in the absence of prior directions there is authoritative medical consensus to do so. Yet an estimated five to ten thousand patients in PVS are maintained in health care facilities.

This reluctance to terminate life support may represent nothing more than financial self interest or fear of litigation; but we cannot ignore a more morally supportable reason, namely the concern that social value judgments might decay into egregious public policy killings. Is there an argument sufficiently compelling to override this slippery slope objection?

One possible line of reasoning is exemplified by considering the patient in intractable pain from advanced metastatic cancer. To abolish the pain a physician might find it necessary to employ large doses of morphine--which could shorten the patient's life. Today there is general medical agreement that--barring patient preferences to the contrary--it is a greater act of beneficence, therefore the physician's duty, to alleviate suffering, even if the patient's life is shortened. Can this rationale be applied to the patient in PVS? Ironically, this argument is confounded by the very authorities, such as the AMA and the American Academy of Neurology, who while advocating treatment withdrawal, assert that: "Persistent vegetative state patients do not have the capacity to experience pain or suffering."

How then can we justify ending a life which is incapable of suffering? We cannot know of course that PVS patients do not suffer. We can only surmise this based on observations we make of external manifestations that correspond to inner states (so we are told) in conscious people. The patient does not smile or frown in response to the sounds of voices or music--therefore, we assume the patient is deriving no meaning or satisfaction from these stimuli. We observe none of the customary signs of awareness or recognition or emotions or thoughts. But even if this lack of awareness is not suffering, can we nonetheless conclude that the patient exists in a state so undesirable that it is perhaps worse than death? If so then we would have the moral warrant to end that state.

What do we know about the patient who is permanently unconscious? Only that he or she is isolated from any form of communication-as though exiled or banished from society, a condition once regarded as punishment equal to if not worse than death, because it is, in effect, dehumanizing.

From the earliest known time human beings have functioned as organic components within a community, connected to family, friends, work, rituals, customs, duties, and entertainments. In ancient societies, including Greece and Rome, death or banishment were the retributions for capital crimes. Early Christian society retained exile despite the rising status it accorded the individual person. Indeed, banishment served along with burning at the stake as punishment for heresy-thus apparently being deemed equivalent to the most painful death.

Through the Middle Ages and beyond, legends of the Wandering Jew and the Flying Dutchman, men condemned to an eternity of exile, testify to the enduring fear of isolation from society, a condition Shakespeare has the banished Mowbrey describe to Richard II (and to the Elizabethan audience) as "speechless death" and "solemn shades of endless night"-- descriptions surely fitting PVS.

And what of modem attitudes? Wars and social upheavals continue to uproot masses of refugees from their homelands and societies. Primo Levi, in The Drowned and the Saved, recalls the concentration camp prisoner's loss of "that most precious communication, contact with their country of origin and their families: whoever has experienced exile, in any of its many forms, knows how much one suffers when this nerve is severed."

I submit that in deliberately prescribing treatments that prolong the lives of patients in a vegetative state, we are causing the persistent vegetative state; thus we are unwittingly yet cruelly resurrecting the archaic practice of banishment. Under the name of beneficence, we are ironically condemning them to an existence long recognized by society as equal to if not worse than death. Does it matter that the patient is unaware of this harmful state? In other circumstances we recognize that a harm is done even if the victim is unaware. An elderly woman being drained of her life savings by an unscrupulous lawyer is the victim of a harmful act whether or not she recognizes it. Although modern neurology dismisses the possibility of suffering in permanently unconscious patients, they exist in a worst possible, dehumanizing condition-enslaved to perpetual inertness, emotionless, helplessness, unlike any other form of human existence, isolated from every human connection and communication-an exile, whether perceived or not, that is an even more terrible punishment, since it is void of context. If physicians find this view persuasive, then withdrawing life-supporting treatment from the patient in PVS becomes not merely ethically permissible, but an obligatory act of beneficence. Lawrence J. Schneiderman is director of the program in Medical Ethics and the Humanities, University of California, San Diego.
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Title Annotation:persistent vegetative state
Author:Schneiderman, Lawrence J.
Publication:The Hastings Center Report
Date:May 1, 1990
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