PVS, MCS and Shifting Standards of Death and Personhood

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
• Quinlans 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

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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 Wendlands 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

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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