PVS, MCS and Shifting PVS, MCS and Shifting Standards of Death and Standards of Death and

PersonhoodPersonhood

ISD II – NeurologyISD II – NeurologyEthics/Humanities/Health LawEthics/Humanities/Health Law

Andrew LatusAndrew Latus

A Continuum of ConditionsA Continuum of Conditions

ComaComa– Brain activity, but no consciousness or Brain activity, but no consciousness or

wakefulness.wakefulness. Persistent Vegetative State (PVS)Persistent Vegetative State (PVS)

– Wakefulness, but no awareness Wakefulness, but no awareness Minimally Conscious State (MCS)Minimally Conscious State (MCS)

– Wakefulness and minimal awarenessWakefulness and minimal awareness Quite Different: Locked-in SyndromeQuite Different: Locked-in Syndrome

– Full consciousness, but extreme paralysisFull consciousness, but extreme paralysis

Karen QuinlanKaren Quinlan

In April, 1975, Karen Quinlan suffers In April, 1975, Karen Quinlan suffers anoxia to the brain, probably as a result of anoxia to the brain, probably as a result of taking a combination of barbitutates, taking a combination of barbitutates, benzodiazapines and alcoholbenzodiazapines and alcohol

Enters a Persistent Vegetative State (PVS)Enters a Persistent Vegetative State (PVS) Kept alive via feeding tubes and a Kept alive via feeding tubes and a

respiratorrespirator– Note effect of technologyNote effect of technology

Karen QuinlanKaren Quinlan

Late 1975, parents go to court to Late 1975, parents go to court to disconnect her respirator (not her feeding disconnect her respirator (not her feeding tube)tube)

January 1976, New Jersey Supreme Court January 1976, New Jersey Supreme Court ruled that the ‘right to privacy’ allowed the ruled that the ‘right to privacy’ allowed the family of an incompetent patient to decide family of an incompetent patient to decide to disconnect life supportto disconnect life support

Quinlan’s doctors ‘weaned’ her from the Quinlan’s doctors ‘weaned’ her from the respirator. respirator.

Died June 13, 1986Died June 13, 1986

Nancy CruzanNancy Cruzan

June 11, 1983 - Cruzan, 24, suffers June 11, 1983 - Cruzan, 24, suffers anoxia (about 15 minutes) as a anoxia (about 15 minutes) as a result of a car crashresult of a car crash

Enters a persistent vegetative state. Enters a persistent vegetative state. Kept alive by a feeding tube (not a Kept alive by a feeding tube (not a

respirator) respirator) After 7 years, parents sought After 7 years, parents sought

permission to disconnect their permission to disconnect their daughter's feeding tubedaughter's feeding tube

Nancy CruzanNancy Cruzan

June, 1990 - U.S. Supreme Court rules that in the June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of absence of 'clear and compelling' evidence of what N.C. would have wanted, she may not be what N.C. would have wanted, she may not be disconnected.disconnected.

Publicity brings new witnesses (who knew her as Publicity brings new witnesses (who knew her as Nancy Davis, her married name). Nancy Davis, her married name).

In a new trial, a lower court rules the 'clear and In a new trial, a lower court rules the 'clear and compelling' standard has now been met. compelling' standard has now been met.

Dec. 14, 1990 - N.C. is disconnected & Dec. 14, 1990 - N.C. is disconnected & subsequently diessubsequently dies

Robert WendlandRobert Wendland

Suffered brain damage in a car accident in Suffered brain damage in a car accident in 19931993

Wendland was supposedly in a permanent Wendland was supposedly in a permanent Minimally Conscious State (MCS)Minimally Conscious State (MCS)

Could respond to simple commands.Could respond to simple commands. Wife and children claim he never Wife and children claim he never

recognized themrecognized them Mother claimed he would cry and kiss her Mother claimed he would cry and kiss her

hand during visits hand during visits

Minimally Conscious StateMinimally Conscious State

““a condition of severely altered consciousness in a condition of severely altered consciousness in which minimal, but definite, behavioral evidence which minimal, but definite, behavioral evidence of self or environmental awareness is of self or environmental awareness is demonstrated.”demonstrated.”

May be temporary or permanentMay be temporary or permanent Criteria (at least one of):Criteria (at least one of):

– following simple commands following simple commands – gives yes or no responses, verbally or with gesturesgives yes or no responses, verbally or with gestures– verbalizes intelligiblyverbalizes intelligibly– demonstrates other purposeful behavior …. in direct demonstrates other purposeful behavior …. in direct

relationship to relevant environmental stimulirelationship to relevant environmental stimuli

Minimally Conscious StateMinimally Conscious State

Unlike PVS, those in a MCS can feel pain, Unlike PVS, those in a MCS can feel pain, etc.etc.

““meaningful, good recovery after 1 year in meaningful, good recovery after 1 year in an MCS is unlikely” an MCS is unlikely”

““being nonfunctioning and aware to some being nonfunctioning and aware to some degree is worse than being nonfunctioning degree is worse than being nonfunctioning and unaware”and unaware”– Ronald CranfordRonald Cranford

““MCS is not a diagnosis; it is a value MCS is not a diagnosis; it is a value judgment.” judgment.” – Diane Coleman, president, Not Dead YetDiane Coleman, president, Not Dead Yet

Robert WendlandRobert Wendland

Florence, his mother, opposed the Florence, his mother, opposed the attempt by his wife, Rose, to have attempt by his wife, Rose, to have Wendland’s feeding and hydration Wendland’s feeding and hydration tube removedtube removed

Wendland died in July 2001 of Wendland died in July 2001 of pneumonia before California pneumonia before California Supreme Court could ruleSupreme Court could rule

California Supreme Court eventually California Supreme Court eventually ruled against Roseruled against Rose

Two Quite Different IssuesTwo Quite Different Issues

Definition of DeathDefinition of Death– E.g., Is someone in a permanent PVS or MCS dead?E.g., Is someone in a permanent PVS or MCS dead?– Raises the issue of ‘personhood’Raises the issue of ‘personhood’

We need to know what a person is, in order to decide We need to know what a person is, in order to decide whether the person is gonewhether the person is gone

Generally conceded that ‘person’ does not equal ‘human’Generally conceded that ‘person’ does not equal ‘human’ Substituted JudgmentSubstituted Judgment

– Allowing someone to serve as proxy decision makerAllowing someone to serve as proxy decision maker– If taken seriously, death is irrelevantIf taken seriously, death is irrelevant

Discussions of cases like the preceding tend to Discussions of cases like the preceding tend to mix the two issuesmix the two issues

Definitions of DeathDefinitions 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

Brain DeathBrain Death

Define “death by neurological criteria” Define “death by neurological criteria”

Standard Account: Harvard CriteriaStandard Account: Harvard Criteria – Devised by a committee at Harvard Medical Devised by a committee at Harvard Medical

School in 1968 (just after first heart School in 1968 (just after first heart transplant)transplant)

– Requires a loss of virtually all brain activity Requires a loss of virtually all brain activity (including brain stem) (including brain stem)

Brain Death: Alternative AccountsBrain Death: Alternative Accounts

Cognitive CriterionCognitive Criterion– ““Higher person” criterionHigher person” criterion– Lack of core conscious properties such as Lack of core conscious properties such as

reason, memory, self-awarenessreason, memory, self-awareness Irreversibility StandardIrreversibility Standard

– Less conservative than Harvard, more Less conservative than Harvard, more conservative than cognitive criterionconservative than cognitive criterion

– Death occurs when unconsciousness is Death occurs when unconsciousness is irreversibleirreversible How do we know?How do we know?

Worth noting that the possibility of organ Worth noting that the possibility of organ transplantation has influenced the debatetransplantation has influenced the debate

Revising the Definition of Death Revising the Definition of Death Again?Again?

Harvard standard of brain death has Harvard standard of brain death has become quite standardbecome quite standard

Should it be revised again?Should it be revised again? Consider the implications for the Consider the implications for the

conditions discussed todayconditions discussed today