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Not dead, not dying? Ethical categories and persistent vegetative state.

Not Dead, Not Dying? Ethical Categories and Persistent Vegetative State

How shall we regard those in persistent vegetative state? They are periodically awake, and their bodies breathe and digest on their own. These traits bespeak life. Yet they are not conscious and never will be: subjectively, this is death. Similarly, they may be, except neurologically and psychologically, quite healthy, capable of remaining in their condition for many years with only minimal care. Yet in considering treatment options we class them with the dying, perplexed over the permissibility of withholding care and letting patients die with dignity.

Given these uncertainties, should patients in persistent vegetative state be maintained? A growing societal consensus answers in the negative. I support this conclusion, but puzzle over the rationale for it. The kind of reasoning that has been used in deciding-to-die cases of the past two decades has, I believe, begun to fail us. New kinds of cases are being discussed in an old, increasingly obsolete vocabulary.

Persistent vegetative state, I further believe, is a case in point. Indeed, our consideration of persistent vegetative state permits two distinct views of its place in this evolution. In one aspect, it represents a relatively new kind of problem, the disposition of patients whose lives are stable but not worth living. But persistent vegetative state can also be seen as the last stage of another development: the changing definition of death. Likewise, persistent vegetative state can be conceived either as the lowest-functioning phase of life, or as the highest-functioning phase of death; the ethics of treatment can be discussed under either rubric. These two ways of construing the problem point to somewhat different laws and clinical practices, and the choice between them will affect our treatment not only of patients in persistent vegetative state but also of those in less debilitated conditions.

The Changing Context of Decisions About Dying

Moral problems concerning the treatment of patients in persistent vegetative state are almost always discussed in the context of debates over the disposition of the dying. But for both obvious and subtle reasons, these issues are different in character, and concepts that facilitate deliberation in one area may have less application to the other.

Nevertheless, our dilemma in deciding on treatment of vegetative patients benefits by taking into account the recent history of medical decisionmaking about dying. Though the numerous court cases and celebrated examples do not arrange themselves in any neat pattern, their character has gradually evolved. In particular, there have been important changes in the kinds of conditions considered for nontreatment, in the means considered to bring about death, and in the nature of the particular rights asserted by or on behalf of the patient. In each case, the trend is toward less specifically medical circumstances, measures, and roles. This, I contend, is a significant source of uncertainty in our reasoning about the ethics of withdrawing care from patients in persistent vegetative state as well as those with coma and dementia.

Conditions Not Treated: With the passage of time, elective nontreatment is being considered for patients with less serious and less terminal ailments. The earliest clinical cases concerned those in the most debilitated condition of all, death of the entire brain. The perceived need to justify nontreatment of the brain dead seems to have been a key factor in the redefinition of death, [1] a step that, in effect, licensed the withdrawal of care from these patients at the moment of diagnosis.

In the years since the new definition was proposed and enacted by most states, nontreatment has been judicially approved for patients in less dire circumstances. The Quinlan case involved what was diagnosed as persistent vegetative state, though at the time Karen Quinlan was thought to be dependent on a respirator. She lived another decade, however, which indicates that persistent vegetative state is not necessarily "terminal." In subsequent cases given wide publicity, such as Conroy, [2] the patient had not reached the last stage of dementia.

We have arrived, then, at a point where patients who are both stable and conscious are candidates for nontreatment. The current emphasis on the patient's own expressed or imputed wishes makes the question of whether a condition warrants nontreatment depend on a purely subjective criterion, that is, how much the patient values (or would value) continued existence under those conditions. Medical judgments, concerning either diagnosis or desirability of treatment, play only a secondary role. The focus of debate has thus changed from the circumstances of dying--for death may not be at all imminent--to the kind of life the patient wishes to live or not live.

Means of Death: Patients dependent on medical machinery could be allowed to die simply by removing the life supports. A temporarily stable brain-dead patient was certain to suffer cardiopulmonary death if the respirator and other aids were withdrawn. Patients not dependent on life supports could still die from nontreatment if the need for treatment arose from other causes, such as pneumonia or cardiac arrest, and omitting these therapies--rationalized as "omitting extraordinary care"--has become one common mode of patient management. [3]

These methods do not suffice, however, for the patient who remains stable, as Karen Quinlan did for so many years. The one feature in common between patients in persistent vegetative state and "terminal" patients is their dependence on a medical measure: they can be fed only by conduits installed and maintained by doctors or nurses. Omitting this medical "therapy," then, has become the next step in the evolution of means of ending patients' lives.

It is plain that the road continues past our present resting point. Though cessation of feeding by mouth seems a big jump from forgoing antibiotics, it is a smaller step from cessation of feeding by tube. If causing death by halting the feeding of a patient such as Ms. Conroy now seems justifiable in light of the undesirability (to her, as well as to others) of continued life, similar considerations might support an argument for cessation of all feeding for a debilitated patient still capable of being fed, or even to feed, in the ordinary way.

When this line is crossed, the measures used to end life cease to be medical in character. Respirators can be withdrawn, with the desired effect, only from patients who are seriously ill, but illness is no precondition of starvation. That mode of ending life may be a nonmedical means of ending life for nonmedical reasons. It is not a long way to the end of this road, which is, of course, active euthanasia--a kind of intervention that would be preferred by many patients prospectively contemplating the manner of their demise in the event of stable, but debilitating, illness.

Demedicalization of the Right to Die: The third long-term trend involved in decisions to die concerns the character of the right invoked by or on behalf of the patient. Overtreatment was a central issue in the early days of the contemporary debate over euthanasia. The "villains" in the piece were doctors who tried too hard to keep hopeless cases alive. An important source of their treatment imperative was their sense of the canons of professional integrity: Medical ethics required, in their opinion, that doctors do all that they could to save patients. This sense of duty was bolstered by a number of other factors, including fear of legal liability, financial incentive, overconfidence in their ability to bring about cure, and personal investment in not "losing" patients.

All of these concerns were of greater significance to the physicians than to their patients, and the goal of the patients' rights movement was to restore the patient's own interests and values as the dominant consideration in treatment decisions. The "right to die" was, in that context, a right against doctors and other caregivers.

With the passage of time, however, the cast of characters is changing. The power of patients has been firmly supported in court rulings, hospital regulations, and declarations of professional groups; even financial incentives now pull in the opposite direction. Consequently, the "right to die" is increasingly asserted not in opposition to doctors but as a personal privilege against society generally. Whether a life expires in a medical setting or not, individuals seek to choose the circumstances and manner of their deaths as they have the conduct of their lives. In this demedicalized context, physicians are as likely to be allies as foes, assisting the patient in making the last days comfortable and even advising patients on means of bringing the end closer. The controversy in The Netherlands, where some physicians even provide the means of death, pits patient and physician alike in a common battle for individual autonomy in the face of considerable societal disapproval.

In sum, decisions about dying are being made by and for patients less acutely ill, involving less specifically "medical" means, in asserting a right that transcends medical concerns. It is necessary to ask, then, whether the kind of moral reasoning that has guided us since the earliest cases can be applied successfully to persistent vegetative state and to other, even less "medical," conditions.

Effects of Context on Reasoning About Dying

The developing moral and legal consensus on decisions to die has rested on two major propositions: first, that the decision to die should reflect the patient's preferences; and second, that a decision to "allow" a patient to die does not violate the moral rule against taking innocent life. The validity of these premises seems more secure in this original context than it does in regard to persistent vegetative state.

Patient Autonomy: The premise concerning patient autonomy would seem to have straightforward application to persistent vegetative state. Those with sufficient foresight to voice their wishes concerning treatment desired under a variety of contingencies could cover that state as well as any other; any wish to be maintained in that hopeless, nonsentient condition seems to defy common sense.

Nevertheless, patient autonomy assumes a different character in this connection. As indicated above, patient autonomy concerns rights held by people in the patient role against people (especially physicians) in the caregiver role. But persistent vegetative state does not conform to this model. In this circumstances, the central question is not the right to decide one's medical treatment, but the general right to end one's life. Perhaps an argument can be made to support that right, but stripped of its medical trappings, it falls into the category of suicide, an act from which many advocates of the right to refuse life-sustaining treatment tend to distance themselves as much as possible. Moreover, in view of the inability of those affected to bring about their own death, termination of care for those in persistent vegetative state becomes, more or less by definition, assisted suicide.

Yet our educated moral sense does not accept these affinities. While filing a living will is today's ethical medicine, few have such positive attitudes toward "suicide" and assisting suicide. When the patients under discussion were the catastrophically ill and dying, the sharp difference between refusal of treatment and suicide was easier to maintain in moral evaluation. In connection with persistent vegetative state and even less acute conditions, however, this distinction is strained.

Letting Die: The medical professions are dedicated to restoring health and forestalling death, and their members are bound like all of us by the general taboo on killing. The debate of the last two decades over the ethics of death and dying has been concerned largely with dispelling the belief that anything other than zealous treatment to the very end is morally forbidden.

The central argument, addressing both the positive duty to help and the negative duty not to kill, is by now quite familiar. The special, positive duty of the health professions is said to be limited to care that benefits the patient, which continued life support does not always do, and to acquiesce in the will of the patient. Admittedly, uncertainties do arise in defining the patient's best interests, and in assessing the patienths competence to define them.

Nevertheless, the second part of the argument, addressing the proscription against taking life, is more problematic. The patient's right of autonomy, for example, is not sufficient here. Presently, physicians are not required to respond to a patient's request for death, where these involve "active" means; indeed, physicians so inclined are not permitted to furnish the requisite means. Given the continued effort to uphold the taboo on killing, the success of the argument depends crucially on the ability to establish the claim that the cessation of life-sustaining therapy is not an instance of taking life.

When the right to die is invoked on behalf of a patient whose death is unavoidable and imminent, the phrase "letting die" has a clear meaning. Death will occur soon whether or not the physicians try to stop it, and the underlying condition qualifies uncontroversially as the cause of death. But patients in persistent vegetative state may be quite stable. When death can be forestalled for decades, life-sustaining care is postponing the "inevitable" only in the sense in which we are all mortal. Thus the withdrawal of care (i.e., nutrition and hydration) reverses what would otherwise happen. The removal of life support, rather than the patienths underlying illness, appears to cause the patient's death. [4]

Must we conclude, then, that discontinuing care for patients in persistent vegetative state violates the proscription against taking life? Two circumstances permit this act to be labeled otherwise. Cessation of nutrition seems to be an omission rather than an act, and thereby not a taking of life. In addition, the conditions that bring food and water to patients can be viewed as invasive and "medical," and thus the sort of intervention that patients may refuse on the basis of their rights.

For some, these factors will suffice to justify the withdrawal of custodial care from vegetative patients. Neither conclusion, however, is particularly well-grounded. The first suggests, wrongly, that it makes no sense to speak of killing by omission. The second makes a fetish out of the details of the method of feeding, which otherwise would be regarded as relatively inconsequential.

The historical development of the death-and-dying controversy illuminates the error in overemphasizing the medical character of artificial feeding devices. This history, we have seen, reveals acceptance of the death of less and less acutely ill patients, and a demedicalizing tendency that supports a general reevaluation of the need to value quantity over quality of life. Consideration of those in persistent vegetative state is but a stage in this development. The next cases may concern patients more like Elizabeth Bouvia who are not quite so fully demented or debilitated, including some who can be fed by "natural" means, such as eating utensils.

May these less debilitated patients insist, by advance directive or through proxies, that this kind of feeding be withheld or withdrawn? An affirmative answer would require a significant step from what is permitted today, but whether we choose to take that step or not, there is clearly no substantial conceptual break involved in such a policy. A patient requiring a nasogastric tube rather than feeding by mouth is clearly the more debilitated, but it is the debilitation rather than the feeding mechanism that should influence our medical decisionmaking. Consider, by way of analogy, a less-debilitated, conscious patient who has undergone surgery on the mouth and requires intravenous feeding. If this patient insists, for reasons of his own, on dying, deliberation about the ethics of our response should not put any major emphasis on the manner in which he is fed.

The installation of the conduit, it is true, entails bodily invasion requiring medical intervention, and in this respect the right that permits refusal may be the right to refuse treatment rather than a general right to die. But this consideration does not in itself resolve what is really at issue with the patient in persistent vegetative state. The patient, in being insensate, is not bothered by the invasion or by the discomfort of the feeding tube. In any case, it is sometimes possible (if inconvenient) to feed patients in persistent vegetative state with a spoon since their swallowing reflex persists. [5] Yet the fact that the central moral dilemma remains even in such a case shows that the invasiveness of the feeding mechanism is not really what is at issue. Ending the life of a patient in persistent vegetative state, then, is difficult to justify by the line of reasoning used in debates over more acutely ill patients. It is a question less about "patients" than about people, people who might live on indefinitely but only in circumstances we understand them to have rejected. The absence of a life-threatening condition requires us to consider more "active" means for ending their lives, and in so doing to join a larger debate over the rightness of choosing the circumstances of dying, including the desirability of continuing to pay lip service to the taboos on suicide and active euthanasia. A resolution of the ethical issues involved in treatment of patients in persistent vegetative state awaits a societal moral reevaluation even broader and more extensive than the dramatic shift that has occurred in medical practices regarding the very ill.

The Definition of Death and

Persistent Vegetative State

There is an alternative approach, however, that could resolve the treatment dilemmas regarding persistent vegetative state, short of requiring an outcome to these much larger debates: The definition of death could be changed to include permanent loss of sentience. Under such a definition, further treatment of vegetative patients would not be required of any facility or provider of health care, and except in unusual circumstances all "life" supports, including nutrition and hydration, would be withdrawn. If the revised statute followed the pattern of existing definitions of death, cessation of treatment would not even require an invocation of the patient's wishes.

There is a strategic advantage in this approach. The definition of death is a problem that has been resolved, and if it can be expanded to include persistent vegetative state, the latter might be removed from the arena of controversy. The law, however, should not rely solely on strategic considerations in defining death. A statute determines only the patient's legal status, but life and death are more than legal concepts. People are either alive or dead--or perhaps in-between--on ice floes and space ships far from the reach of any laws. Any law that made patients legally dead whom we would otherwise, for good reasons, deem alive would smack of expediency over principle.

But what kinds of grounds suffice to define death? One proposal is that they should be moral ones: the boundary from life to death is crossed at that time at which treatment should be discontinued. This claim, however, confuses the definition of death with its moral implications. Once death has occurred, treatment may cease, but these are distinct matters.

The definition of death, then, needs to be settled on ground independent of legal and moral purposes. It is akin to a question of fact--is the patient still among us?--rather than one of action. Indeed, classifying those in persistent vegetative state as dead can serve as a justification for ending treatment, which it could not do, on paion of circularity, were the classification itself merely a treatment decision.

This methodological point needs emphasis, I believe, because any proposal to expand the definition of death to include persistent vegetative state will look like definitional gerrymandering to many people. To avoid the appearance of playing with words to avoid difficult moral choices, the argument for classifying vegetative patients as dead must be made convincing independently of the uses to which it would be put. [6]

While I believe that this case can be made, it will not be easy to present it to the public in a convincing way. It requires a substantial adjustment in our thinking about death, one that changes the focus from biological to psychological processes. Under both the traditional, cardiopulmonary definition and the newer whole-brain definition, death is identified as the moment of cessation of biological processes. The definitions differ over which biological processes constitute the organism's life: breathing and circulation, on the older definition, neural regulation of these processes according to the new. An expanded brain-death definition, meanwhile, would focus on those brain processes that sponsor consciousness and feeling. Once these brain functions have permanently ceased, the individual is dead.

Nothing in this definition (variously called "personal," "mental," or "cortical") implies that the patient's body dies when the higher brain functions cease. In this view, the body of the patient in persistent vegetative state is still alive, and could remain so, but the patient is not. This view admittedly has an air of paradox: we are our bodies, so how could we be dead while our bodies remained alive? Yet, this kind of thinking is not wholly unfamiliar. Tumor cells cultured in the laboratory are living remains of patients who have died of cancer; in the same way, the entire functioning body of the patient in persistent vegetative state is his living remains. Moreover, the traditional definitions of death also make a distinction between the patient's demise and his body's: the patient ceases to exist at the time of death, but his body does not. The new definition adds only that the patient's body not only exists but lives.

It may be intuitively difficult to accept that the entity in persistent vegetative state, still a living body, is not the patient. Or, even more to the point, that the body, in so many respects healthy, is dead in any but a metaphorical sense. Yet we have crossed this hurdle before: Patients who are "whole-brain-dead," qualifying under brain-death statutes adopted by most states, also breathe, circulate blood, digest, and carry out other life functions. To be sure, "cortically" dead patients are more intact, needing no respirators or constant attention, but what they do is not so different. The reeducation necessary to accept them as dead is not as great as that required under the redefinition we have already adopted.

In one respect, expanding the definition of death to include persistent vegetative state would be easier to absorb than the original brain-death dormulation. Some, perhaps most, of the acceptance of whole-brain-death can be explained by the widespread belief that it meant permanent cessation of consciousness and the loss of qualities that make life worth living? An expanded definition, then would catch up with the public's reason for accepting the old one.

Scholars will be less interested, however, in the chance for public acceptance than in whether an expanded definition is, in the appropriate sense, valid or correct--whether, that is, patients in persistent vegetative state really are dead. This is a complex philosophical issue that cannot be fully addressed here. [8] An argument can be made, however, that such a definition comports with educated common sense. Consider this though experiment: a man is decapitated, and physicians are able to keep both the head and the body functioning more or less as normal. They cannot, however, reconnect them. Which is the patient?

The answer cannot be, "Both," for body and head may be widely separated in location. Nearly everyone able to choose one or the other will, I believe, choose the head. After decapitation, the head is the patient, and the conditions of its health and death are those of the patient as a whole. Losing a body through decapitation is considerably more distressing, in this story, than losing a limb, but it is not more threatening to one's identity. The body, meanwhile, continues to live. It is not the patient, and may survive the patient if the latter cannot be kept alive.

This is, very roughly, what happens in persistent vegetative state. [9] Though brain and body remain physically intact, they are functionally severed. Those parts of the brain that make consciousness and feeling possible are irreversibly lost, and the continued functioning of the body has no more significance in the patient's life than would, say, a kidney removed from his body and prospering for decades to come in the body of another. That the whole body (except for relevant parts of the brain) is involved rather than one organ is not a difference that makes a difference.

What bearing does such an outlandish thought experiment have on the real-world clinical and legal issue of brain death? It does not show that the expanded definition would be practical, or even desirable. But it does show that it is conceptually sound, and given the mental leap required to view as dead a patient whose body is fairly healthy, this is an essential accomplishment. [10]

Even so, a definition of death that included persistent vegetative state faces objections on several levels. It may be politically difficult, if only because the public may not yet have digested the recent expansion of the definition to include whole-brain-death. Moreover, no national movement exists to expand the definition, and key professional groups not only have abstained from calling for the change but show no sign having been convinced of its value or appropriateness. The President's Commission, whose report endorsing a whole-brain definition prompted a slew of state statutes, acted only after acceptance of the idea by the medical profession and progressive judicial and legal opinion.

Clinical uncertainties present on equally important objection. A key factor in expanding the definition of death to include whole-brain-death was the certainty of diagnosis. An infallible procedure for diagnosing persistent vegetative state has yet to be produced. Near-total certainty of prognosis must be achieved before a higher-brain death statute can be considered. In this respect, the resolution of the moral dilemma awaits further development of medical technique.

Even were reliable tests available, the public would need reassurances. The widespread fascination with stories of people reviving after many years in "coma," often in the face of flat predictions to the contrary by physicians, proved troublesome even to the whole-brain definition of death. After several members of the President's Commission explained the whole-brain definition to the public on Nightline, the usually informed host segued to a story of a patient who had returned to consciousness from a prolonged vegetative period. That case clearly did not meet the conditions of the proposed brain-death criterion, and so had nothing to do with the Commission's proposal, but nevertheless was presented as an apparent counterexample.

The problems of redefining deth to include persistent vegetative state, however, depend in the end upon the public's willingness to accept it. Since the public may not have a precise understanding of the last revision in the definition of death, widespread acceptance of a new definition is difficult to predict. Much depends on how the new definition is understood. One clue would come at the bedside, in the reactions of family members to being told that their apparently healthy loved one is to be pronounced dead: here the precedent is favorable. Family members encountering whole-brain-dead loved ones who breathe and maintain normal blood pressure and temperature, have come to accept their doctor's assurances that the patient is already dead.

Patients in persistent vegetative state, however, present more of a problem. The main reason is their relative independent from life-sustaining machinery: the signs of life, such as breathing, cannot be explained away as effects of life supports. Perhaps the most problematic aspect, however, is that a withdrawal of life supports cannot be relied upon to produce an immediate cessation of remaining life functions. After death would be pronounced, a living body remains, and its disposal is bound to raise questions.

In this respect, then, the two "strategies" I have examined for dealing with persistent vegetative state converge. A definition of death that included persistent vegetative state would not avoid the problem of killing and letting die; it would reintroduce it at a new level. The living body of the patient pronounced dead will go on breathing unless it is killed or allowed to die. We must do one or the other, since burying a breathing body is unthinkable. How, then, would a re-redefinition of death be of any use in addressing the dilemmas associated with persistent vegetative state?

This question, like the problem of accurate diagnosis, was a source of confusion in the previous movement to redefine death. The relationship between (whole) brain death and the cessation of principal vital functions such as breathing and circulation (i.e., death traditionally defined) remains a source of uneasiness if not contradiction. Many doctors, and some authorities, would in unguarded moments speak of pronouncing death on a brain-dead patient, so that life supports could be removed and the patient "allowed to die." To some, the fact that brain-dead patients could not be kept "alive" for more than a few weeks even with intensive care was sufficient reason for accepting the new definition. Careful retraining of speech habits has been necessary to avoid this kind of phraseology.

Again, however, important precedents have been established by the first redefinition of death. If patients in persistent vegetative state are dead, then nothing that happens to them causes their death. Just as the public accepts the idea that brain-dead patients may have their vital organs removed--an action that could not possibly be maneuvered into the "letting die" category--so may they come to accept the administration of an agent that causes cardiac arrest to patients in persistent vegetative state. In both cases, the logic of redefinition of death ensures that the taboo on taking the life of a person does not apply.

In this way, a new revision of the definition of death resolves the dilemma of killing and letting die. It permits us to surmount the present, difficult stage of the evolution of clinical practice in which we hesitate to terminate what life resides in patients in persistent vegetative state but do permit an agonizing period of "dying" of starvation.

Letting Die and Pronouncing Death

How, then, shall we respond to the dilemma of persistent vegetative state, which presents a choice between violating the moral rule against taking life and senselessly prolonging it? Clinical practice, endorsed by judges, increasingly favors measures leading to death. But the conceptual basis for this practice is still being constructed. Each of the strategies discussed here--labeling interventions as "letting die," and redefining death to include persistent vegetative state--has advantages, and the argument thus far permits some relative evaluation.

The strategy of widening the definition of death might seem to open the door to abuse, an ever-looser criterion that would deliver death sentences by meddling with the dictionary. But in fact this objection points to one of this strategy's strengths. The definition must comport with common usage and common sense, and these provide constraints on further stretching. Persistent vegetative state is not a vague concept; indeed, it could be expanded slightly to read "permanent cessation of consciousness and feeling" without losing precision. This (presumably) final step in redefining death, then, would include the permanently unconscious among those defined as dead, but would not affect the merely unhappy, confused, or disoriented. The mentally disabled were, in times past, victimized by euthanasia, but they cannot be threatened by the definition of death.

This advantage is also a limitation. Though a redefinition of death might resolve some of the problems associated with persistent vegetative state, it will be of no use in addressing the dilemmas of dying for patients in less fully debilitated conditions. It separates the Quinlans from the Conroys and is silent on the latter.

This outcome, however, may be for the best. Persistent vegetative state is not merely an advanced stage of dementia; it is amentia, an absence of everything for which people value existence. Its position as the limiting case on the continuum--the patient from whom all life has ebbed--is what justifies regarding it as death. The same cannot be said of lesser states of decline. We should expect differences in the value attached to these states, and thee exists no consensus on the wider questions of control over dying. Disposition of patients in persistent vegetative state, then, may be a part of the general problem, resolvable through the definition of death, leaving the broader, wider issues for the public debate they deserve.


[1] The motivation for the redefinition is a matter of controversy, as noted below. The importance of treatment decisions is evident in the most widely read early paper, "A Definition of Irreversible Coma," Ad Hoc Committee of the Harvard Medical school to Examine the Definition of Brain Death, 205, JAMA (1968), pp. 337-40.

[2] In re Conroy, 98 N.J. 321, 486 (1985).

[3] Deciding to Forego Life-Sustaining Treatment, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington D.C., 1984, pp. 188-89.

[4] The analytical framework for this discussion of killing and letting die is adapted from Dan Brock's "Forgoing Life Sustaining food and Water: Is it Killing?" in Joanne Lynne, ed., By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water, Bloomington: Indiana University Press, 1986, and his "Taking Human Life," Ethics 95 (1985), pp. 851-65, (1985), though my conclusions are not entirely consonant with his.

[5] Ronald E. Cranford, "The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight)," in this volume.

[6] Much of the literature favorable to the wider definition of death fails, to its detriment, to recognize the importance of this requirement. David R. Smith's otherwise admirable article, "Legal Recognition of Neocortical Death," Cornell Law Review 71 (1986), pp. 850-88, for example, contends that in persistent vegetative state, "rightly viewed, human death has already occurred" (p. 872) but does not say why this is the "right" view.

[7] Unfortunately, I can cite no survey data concerning the public's understanding of the basis of brain-death as the definition of death.

My own unsystematic sampling during the past decade indicates that many doctors, most lawyers and nurses, and nearly all members of the public do not understand the "official" reasoning (i.e., in accord with the rationale given in the President's Commission report) behind the statutes. See Defining Death, President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Washington D.C.: Government Printing Office, 1981.

[8] The issues set out in Michael B. Green and Daniel Wikler, "Brain Death and PErsonal Identity," Philosophy and Public Affairs 9(2): Winter 1980, pp. 105-133; Daniel Wikler, "Conceptual Issues in the Definition of Death," Theoretical Medicine Vol. 5, 1984, 167-80; and Karen Gervais, Redefining Death, New Haven: Yale University Press, 1987.

[9] Except that the brainstem remains intact. No precise analogy is possible because the part of the brain that sponsors consciousness is not anatomically distinct from that which keeps the vegetative body alive.

[10] Those not convined by this brief argument are referred to Green and Wikler, "Brain Death and Personal Identity."

Daniel Wikler is professor of medical ethics at the University of Wisconsin Medical School, Madison, WI.
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Author:Wikler, Daniel
Publication:The Hastings Center Report
Date:Feb 1, 1988
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