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PVS, MCS and Shifting Standards of Death and Personhood

PVS, MCS and Shifting Standards of Death and Personhood. ISD II – Neurology Ethics/Humanities/Health Law Andrew Latus. A Continuum of Conditions. Coma Brain activity, but no consciousness or wakefulness. Persistent Vegetative State (PVS) Wakefulness, but no awareness

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PVS, MCS and Shifting Standards of Death and Personhood

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  1. PVS, MCS and Shifting Standards of Death and Personhood ISD II – Neurology Ethics/Humanities/Health Law Andrew Latus

  2. A Continuum of Conditions • Coma • Brain activity, but no consciousness or wakefulness. • Persistent Vegetative State (PVS) • Wakefulness, but no awareness • Minimally Conscious State (MCS) • Wakefulness and minimal awareness • Quite Different: Locked-in Syndrome • Full consciousness, but extreme paralysis

  3. Karen Quinlan • In April, 1975, Karen Quinlan suffers anoxia to the brain, probably as a result of taking a combination of barbitutates, benzodiazapines and alcohol • Enters a Persistent Vegetative State (PVS) • Kept alive via feeding tubes and a respirator • Note effect of technology

  4. Karen Quinlan • Late 1975, parents go to court to disconnect her respirator (not her feeding tube) • January 1976, New Jersey Supreme Court ruled that the ‘right to privacy’ allowed the family of an incompetent patient to decide to disconnect life support • Quinlan’s doctors ‘weaned’ her from the respirator. • Died June 13, 1986

  5. Nancy Cruzan • June 11, 1983 - Cruzan, 24, suffers anoxia (about 15 minutes) as a result of a car crash • Enters a persistent vegetative state. • Kept alive by a feeding tube (not a respirator) • After 7 years, parents sought permission to disconnect their daughter's feeding tube

  6. Nancy Cruzan • June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of what N.C. would have wanted, she may not be disconnected. • Publicity brings new witnesses (who knew her as Nancy Davis, her married name).  • In a new trial, a lower court rules the 'clear and compelling' standard has now been met. • Dec. 14, 1990 - N.C. is disconnected & subsequently dies

  7. Robert Wendland • Suffered brain damage in a car accident in 1993 • Wendland was supposedly in a permanent Minimally Conscious State (MCS) • Could respond to simple commands. • Wife and children claim he never recognized them • Mother claimed he would cry and kiss her hand during visits

  8. Minimally Conscious State • “a condition of severely altered consciousness in which minimal, but definite, behavioral evidence of self or environmental awareness is demonstrated.” • May be temporary or permanent • Criteria (at least one of): • following simple commands • gives yes or no responses, verbally or with gestures • verbalizes intelligibly • demonstrates other purposeful behavior …. in direct relationship to relevant environmental stimuli

  9. Minimally Conscious State • Unlike PVS, those in a MCS can feel pain, etc. • “meaningful, good recovery after 1 year in an MCS is unlikely” • “being nonfunctioning and aware to some degree is worse than being nonfunctioning and unaware” • Ronald Cranford • “MCS is not a diagnosis; it is a value judgment.” • Diane Coleman, president, Not Dead Yet

  10. Robert Wendland • Florence, his mother, opposed the attempt by his wife, Rose, to have Wendland’s feeding and hydration tube removed • Wendland died in July 2001 of pneumonia before California Supreme Court could rule • California Supreme Court eventually ruled against Rose

  11. Two Quite Different Issues • Definition of Death • E.g., Is someone in a permanent PVS or MCS dead? • Raises the issue of ‘personhood’ • We need to know what a person is, in order to decide whether the person is gone • Generally conceded that ‘person’ does not equal ‘human’ • Substituted Judgment • Allowing someone to serve as proxy decision maker • If taken seriously, death is irrelevant • Discussions of cases like the preceding tend to mix the two issues

  12. Definitions of Death • Whole-body Standard: until quite recently death was thought as requiring the permanent cessation of heartbeat and breathing • Artificial respiration, etc. made this standard outmoded

  13. Brain Death • Define “death by neurological criteria” • Standard Account: Harvard Criteria • Devised by a committee at Harvard Medical School in 1968 (just after first heart transplant) • Requires a loss of virtually all brain activity (including brain stem)

  14. Brain Death: Alternative Accounts • Cognitive Criterion • “Higher person” criterion • Lack of core conscious properties such as reason, memory, self-awareness • Irreversibility Standard • Less conservative than Harvard, more conservative than cognitive criterion • Death occurs when unconsciousness is irreversible • How do we know? • Worth noting that the possibility of organ transplantation has influenced the debate

  15. Revising the Definition of Death Again? • Harvard standard of brain death has become quite standard • Should it be revised again? • Consider the implications for the conditions discussed today

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