Because futility cannot be invoked, some experts argue that PVS represents such a dismal quality of life that LST cannot be consistent with a patient’s best interests. While society generally errs on the side of prolonging the lives of incapacitated patients whose preferences are unknown, some ethicists argue that it should be presumed patients in PVS would not desire LST unless they have expressly stated preferences to the contrary. Public opinion polls support this notion, because the majority of people surveyed would not want LST if they were in PVS (5). This flexible position respects the divergent beliefs of the minority, permitting previously competent patients to continue LST when they choose.
Physicians who invoke this line of reasoning to override a surrogate’s decision explore relatively uncharted legal terrain. In the 1991 case of Helga Wanglie, an 87-year-old woman in a vegetative state, her husband wished to continue LST. Objecting to ongoing LST, her treating physicians attempted to remove the husband as legal guardian, but were rebuked (6). Without addressing the presumed desires of adults in PVS, the courts uphold the legal standing of surrogate decision-makers as long as they are acting in the patient’s best interests. On the other hand, a Massachusetts jury found that physicians were not guilty of malpractice when they entered a do-not-resuscitate order for a 71-year-old comatose woman without surrogate permission (5).
Do patients in PVS meet the minimal criteria for human existence?
A third ethical argument for withdrawing and withholding treatment in vegetative patients is unique to PVS. This line of reasoning challenges our assumptions about “patient interests” and resurrects the philosophical debate over the essence of human life. By virtue of being in PVS without hope for recovery, these patients have lost the minimal requirements of being human and have no hope of regaining them. In this view, prolonging mere biologic life is pointless because essential human qualities cannot be restored. This applies to patients in PVS for such duration that the probability of regaining consciousness is exceptionally rare (i.e., 12 months after trauma, or 3 months after nontraumatic injury). In such cases because no patient interests can be served and no medical goals are obtainable, no duty exists to provide life-sustaining treatment (7).
Physicians who choose to invoke this last argument should be aware of its uncertain legal and moral acceptance. Legally, the ethical argument that patients in PVS have no interests to advance has not been challenged directly in the courts. Groups rejecting the notion that patients in PVS lack minimal requirements for human life were galvanized by Terri Schiavo’s plight. Although public opinion polls determined that a clear majority would want their guardian to remove the feeding tube if they were in Terri’s predicament, a vocal minority was opposed (5). Politicians such as Congressman Tom DeLay entered the fray, declaring the removal of Terri’s feeding tube an “act of medical terrorism.” This right-to-life movement found an ally in the Roman Catholic Church when Pope John Paul II avowed that patients in PVS do, in fact, meet minimal criteria for human life and as such deserve nutrition and hydration (8). His opinion has yet to be adopted as doctrine, and political and moral consensus have not been achieved.
click for large version
click for large version
Conclusions
PVS is diagnosed 1 month after a patient enters a state of wakefulness without awareness. Movements are common in these patients, but they are not purposeful or reproducible in response to stimuli. Once PVS has exceeded durations of 3 months following nontraumatic injury or 12 months following trauma, the probability of meaningful recovery is exceptionally rare.