March 28, 2006

Changing notions of death-2: Persistent vegetative state

The next stage in the evolution of when death occurs (see part 1 on this topic) came with the tragic case of Nancy Cruzan.

In 1983, 25-year old Nancy Cruzan careened off the road, flipped over and was thrown from her car into a ditch. Nancy hadn’t breathed for at least 15 minutes before paramedics found and revived her - a triumph of modern medicine launching her family’s seven-year crusade to free Nancy from a persistent vegetative state.

Nancy Cruzan's sad fate launched a fresh examination of death, centering around whether a person in a particular kind of coma, known as a persistent vegetative state, could be considered to be 'effectively dead' even if they did not meet the legal conditions of being heart dead or brain dead.

A persistent vegetative state is related to a coma in the following way:

A coma is a profound or deep state of unconsciousness. The affected individual is alive but is not able to react or respond to life around him/her. Coma may occur as an expected progression or complication of an underlying illness, or as a result of an event such as head trauma.

A persistent vegetative state, which sometimes follows a coma, refers to a condition in which individuals have lost cognitive neurological function and awareness of the environment but retain noncognitive function and a perserved [sic] sleep-wake cycle.

It is sometimes described as when a person is technically alive, but his/her brain is dead. However, that description is not completely accurate. In persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact. Spontaneous movements may occur and the eyes may open in response to external stimuli, but the patient does not speak or obey commands. Patients in a vegetative state may appear somewhat normal. They may occasionally grimace, cry, or laugh. (my italics)

So a person in a persistent vegetative state does not meet the legal definition of being brain dead. Nancy Cruzan's parents were faced with the difficult question of what to do.

After her accident, they worked tirelessly to help bring her back to consciousness, without success. After five years, the family finally accepted that Nancy's condition would never improve. Already worn out from losing the fight to bring Nancy back to life, the Cruzans began a painful, and very public, legal battle to have the state hospital remove her feeding tube and let her die.

But their attempts at removal were opposed at that time by the state of Missouri, which argued that life support should not be removed since Nancy Cruzan was not legally dead. It was only in 1990, after even losing in the US Supreme Court, that the family won in state court and was allowed to remove her life support systems. She then became legally dead.

Singer argued that this was another significant shift in our understanding of death, because Cruzan was neither brain dead nor heart dead. What she had lost was the sense of personhood, a sense of awareness of herself and of her past and her possible future, her 'higher cerebral powers of the brain.' In other words, she had ceased to exist as the person whom her family and friends had known, and had become instead just a living organism, one which was neither brain dead nor heart dead. Her tombstone marker says: "Born July 20, 1957 / Departed January 11, 1983/ At Peace December 26, 1990" suggesting the idea that she ceased to exist as a person in 1983, although she continued to exist as an organism until 1990.

Singer points out that the idea that someone like Cruzan who is in a persistent vegetative state could be 'allowed to die' by withdrawing life support systems raises serious ethical questions, because it lowers the bar on what we consider to be death, and puts us in the realm of making judgments about whether someone should live or die based on whether or not they have higher cognitive functions such as an awareness of self. In other words, we have to make a decision as to whether someone has died as a 'person' even though they may be legally alive. This raises the question of who is competent to make such a decision in such situations and it seems like society has decided that it should be the family and their doctors.

But even that did not end the question, as the recent case of Terry Schiavo illustrates. She was in a persistent vegetative state but different members of the family had different wishes as to whether life support should be removed, and this resulted in the legal and media and political circus as to who had the right to make that decision. The courts had to finally step in and rule that the husband had the legal rights of guardianship and could make the decision, and life support was removed. A new poll this week finds that 64% of Americans support that decision to remove the feeding tube, with 27% dissenting.

Interestingly, Singer argues that he does not see much of a major ethical distinction between withdrawing life support and actively causing death by, say, giving a lethal injection. He thinks that the argument that when we remove life support we are 'letting nature take its course' is a way of rationalizing our actions to make it palatable to us, but does not resolve the ethical dilemma. He said that hospitals and intensive care units are designed precisely to prevent nature taking its course, and to withdraw that service from some people is no different from euthanasia.

So it seems as if society, not legally but in an indirect way, has shifted the definition of death so that people in a persistent vegetative state are already considered to be effectively dead, at least as 'persons', and thus withdrawing life support so that they become legally dead, is acceptable.

To be continued. . .

POST SCRIPT: Religious beliefs and torture

In a series of earlier posts (see part 1, part 2, and part 3), I argued for the complete ban on torture. A new survey finds that secular people are more likely than Christians to oppose the use of torture. Among Christians, Catholics are the most likely to support torture.


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I agree with Singer that, ethically, there is little difference in pulling a feeding tube and lethal injection. In fact, in a persistent vegetative state situation, I would say that actively bringing about death is more moral than removing a feeding tube. And almost every person, even the most fundamental theist, would agree with me, were it a dog instead of a person. We all recognize that pets should be euthanized when injured beyond repair, to prevent suffering. But because a person is more "valuable", in some sense, than a dog, some people dither.

Posted by Graeme on March 28, 2006 05:56 PM

taking someone in a vegetative state off life support is the same as committing murder! you're killing someone who isn't legally dead yet.

Posted by geniepye on January 31, 2008 06:33 PM