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The persistent problem of PVS.

The Persistent Problem of PVS

The persistent vegetative state remains a puzzle. The Karen Ann Quinlan case concerned a PVS patient. Yet more than a decade later we are steill confused about what PVS is, still debating what principles should govern treatment decisions for these patients--indeed, some worry about whether these patients should be considered alive at all.

Concern over the puzzle of PVS has become greater of late. Considerable consensus now exists on much of the ethics of terminating life-sustaining treatment, yet the PVS cases seem to strain the generally applicable framework. It is widely accepted that life-sustaining treatment may be withdrawn when the burdens to be patient outweigh the benefits. PVS patients, however, push our commitment to this patient-centered standard to the limit. The PVS patient experiences nothing; the benefits and burdens of continued treatment fall mainly on others. These patients tether their families to the hospital bed to keep vigil for years and consume resources that could otherwise go to conscious patients.

PVS also tests, for some, the tradtional boundary between withdrawing life-sustaining treatment and assisted suicide or active euthanasia. Withdrawing treatment from PVS patients may appear extremely close to active killing. The PVS patient can survive for years; when life supports are withdrawn, the cause of death may seem to be not an underlying disease process but the act of withdrawal. This problem is all the more vexing because the usual treatment issue in the case of a PVS patient is whether to stop artificial nutrition and hydration--still the most controversial form of treatment withdrawal, in part because some find it indistiguishable from actively causing death.

Concern over PVS patients has grown for economic reasons as well. There are thousands of PVS patients occupying beds in health care institutions and consuming financial resources. In a search for items to cut from the budget, years of support for the permanently unconscious may seem to some a tempting place to start. The need for ethical analysis and appropriate restraint is a cute.

As these concerns show, PVS is a tough case. But it cannot be left for last, to be considered only after the easier cases have been resolved and the principles devised--the case that may strain but should not break the rule. The category of PVS raises challenges that go to the heart of the rule itself--the rule on who should be considered dead and who alive, the rule governing treatment decisions, the rule, in short, on what we owe those lingering on the very edge of life.

This collection of articles takes PVS as its central focus, in an effort to reconceptualize the problem and then rethink the broader rules. Ronald Cranford begins at the beginning, with the medical facts. Even among health care professionals, confusion remains about what PVS is and the difference between PVS and other neurological conditions, particularly coma.

Baruch Brody then offers a provocative analysis of a clinical case: a young woman unconscious for several years, whose parents wish to continue her life-sustaining treatment--a feeding tube and antibiotics. Pursuing a method he calls "pluralistic casuistry," Brody ultimately argues that antibiotics coudl be withdrawn despite objection by the parents.

Following Brody's discussion of the issues in the clinic, Paul Armstrong and B.D. Colen address the issues in the courtroom. They deplore what they see as unnecessary recourse to the courts in case after case on the termination of treatment. They trace it to myths and misinformation about the law in the minds of treating physicians.

Finally, Daniel Wikler offers a controversial analysis exploring alternative ways to support the conclusion that PVS patients should not be maintained. He finds the usual ethical justification for withdrawing treatment inadequate. Instead, he suggests, we could after the definition of death to include permanent loss of consciousness; treatment of PVS patients could then case.

From Cranford's discussion of the terminological problems, through an exploration of the issues in the clinic and courtroom, to Wikler's examination of how past conceptualizations may have failed us and his argument for a new approach, this collection faces the complexities of PVS. By focusing on its unique characteristics and special analytic challenges these articles not only offer solutions to the PVS puzzle. They also suggest wasy to fit that puzzle into the broader pattern of principles for deciding between life and death.
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Title Annotation:persistent vegetative state
Author:Wolf, Susan M.
Publication:The Hastings Center Report
Date:Feb 1, 1988
Previous Article:She's going to die: the case of Angela C.
Next Article:The persistent vegetative state: the medical reality (getting the facts straight).

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