March 1989 X/7
STATEMENT OF THE AMERICAN ACADEMY OF NEUROLOGY
The diagnosis, prognosis, and care of patients who are permanently unconscious, that is, in an irreversible coma or in a persistent vegetative state (p.v.s.). has been the issue underlying much ethical and legal controversy. The decision of the Massachusetts Supreme Court in the Brophy Case, and the decision of the Missouri Supreme Court in the Cruzan case, were diametrically opposed. Yet both Courts sought to base their decisions on the medical care suitable for the patients in question. Ethicists when considering the care for patients who are permanently unconscious are also divided. Some maintain that patients who are permanently unconscious should receive artificial hydration and nutrition because they will benefit from such treatment. Others maintain that such treatment is optional for patients who are permanently unconscious because even though artificial hydration and nutrition circumvents a fatal pathology and extends life, it does not offer an overall benefit to the patient. In this essay, we shall present briefly the recent statement of the American Academy of Neurology in regard to permanently unconscious patients (Neurology. January 1989. 39) and offer some ethical observations.
Principles
The statement may be divided into three main sections: the medical description of a person permanently unconscious: the nature of artificial hydration and nutrition; and the use of artificial nutrition and hydration for a permanently unconscious patient.
1. The medical description. The patient who is permanently unconscious, as a result of a functioning brain stem and a total loss of cerebral cortical functioning. is able to breathe spontaneously, but has no self awareness, is unable to perform voluntary actions and does not experience pain, The diagnosis of such a condition can be made with a high degree of medical certainty after a period of one to three months. Patients in a persistent vegetative state may continue to survive for a prolonged period of time as long as artificial provision of nutrition and fluids is continued. Thus, because life support has been utilized, patients in this condition are not "terminally ill." But the condition described above is permanent because of the trauma and total loss of function in the cerebral cortex.
2. The nature of artificial hydration and nutrition. The artificial provision of hydration and nutrition is a medical treatment, rather then a nursing procedure, and is analogous to other forms of life-sustaining treatment, such as a respirator. When a patient is unconscious, both a respirator and an artificial feeding device serve to support or replace normal bodily functions that are compromised as a result of the patient's illness.
3. The use of artificial hydration and nutrition for patients in p.v.s. It is good medical practice to initiate hydration and nutrition when the patient's prognosis is uncertain, but to allow for termination if the patient's condition is hopeless, the family having been informed and consent to the withdrawal. Artificial hydration and nutrition may be discontinued in accordance with the principles and practices governing the withholding and withdrawing of the forms of medical treatment i.e,, based on a careful evaluation of the patient's diagnosis and prognosis, the prospective benefits and burdens of the treatment, and the stated preferences of the patient and family. When medical treatment fails to promote a patient's well-being, there is no longer any ethical obligation to provide it. Medical treatment, including the medical provision of artificial nutrition and hydration, provides no benefit to patients in p.v.s. once the diagnosis has been established to a high degree of medical certainty.
Discussion
Several points are relevant from an ethical perspective.
1. This is an ethical statement by physicians concerning an important and difficult issue in medical care. For this reason alone it is worthy of note. For too long judges, lawyers. theologians, and ethicists have analyzed contentious issues in medicine and many scientists and physicians have acted as though their profession were "value free." While not denying the contribution of ethics and law to the solution of issues arising from medical care, the voice of medicine must be heard also if a well-balanced and clinical view of these human problems is to develop. Hopefully, physicians' groups will apply themselves to other ethical issues associated with medicine. such as the access to health care.
2, The statement and proof that artificial hydration and nutrition is a medical treatment similar to the use of a respirator is welcome because it offers a model for decision making that most people can understand. The great contribution of the A.A.N.. statement though is the simple syllogism: Medical treatment attempts to promote the well-being of the patient. But artificial hydration and nutrition does not promote the well-being of the permanently unconscious patient. Therefore, artificial hydration and nutrition may be withheld from a patient who is permanently unconscious.
3. There is no hint of approval of euthanasia, neither active nor passive, in this statement. The reason for withdrawing treatment from a patient permanently unconscious is not a quality of life argument. Rather, treatment is withdrawn by analyzing the quality of the means insofar as the condition of the patient is concerned. When the artificial hydration and nutrition are withdrawn, the family and physicians do not cause death. Rather death is caused by the underlying pathology; the inability to chew and swallow. The intention of the family and physician is to avoid doing something which would be useless or which would impose an excessive burden on the patient.
4. Grasping the distinction between avoiding harm to the patient (a good act) and causing the patient's death (an evil act) is difficult for many when artificial hydration and nutrition are in question. The main reason for this difficulty seems to be that death occurs inevitably when the artificial hydration and nutrition is removed, no matter what the motive underlying the removal might be. But human actions receive their designation as good or evil from the proximate intention of the person performing or withholding an action, not from the accidental effects of the intended action. Hence, if the proximate motive of removing the hydration and nutrition is to avoid harming the patient, then the ensuing death, because it is not intended, is extraneous to the moral evaluation of the act. One way to help people make a good ethical decision about removing life-support is to ask: "Would you remove this life-support even if it would not result in the patient's death?"
Conclusion
For many reasons, the statement of the A.A.N. is welcome and enlightening. But the statement alone will not lead to consensus. Rather, we need more discussion and common understanding of such terms as the quality of life, the nature of a moral act, what constitutes the well-being of a patient and causing death as distinguished from allowing death to occur naturally when there is no moral imperative to prolong life.
Kevin O'Rourke, OP
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