Ethics and the vegetative state

Abstract

Before discussing ethical issues to do with patients in permanent (or persistent) vegetative state (PVS) it is necessary to address the foundational issue of whether PVS as a concept is able to provide a robust link to situations in the real world. The high reported rates of misdiagnosis and recovery in patients diagnosed as being in PVS casts doubt upon the applicability of ethicists’ thought experiments on Platonic forms to actual decision making in clinical situations. We should abandon the illusion that we can have access to logical certainty through diagnostic definition, and should instead frame our opinions and our procedures in ways that can accommodate a high element of uncertainty, and should in the light of recent studies give considerable weight to the possibility that patients, at present unable to express opinions on their care, will later become able to do so, if given proper treatment and adequate evaluation.

Notes

The nomenclature in this area is confused. Most neurologists now adopt the usage of the Royal College of Physicians (RCP) (1996) and refer only to the “vegetative state”, the “continuing vegetative state”, and the “permanent vegetative state”. Nonetheless, almost everybody else—the press, the law, much medical literature, Hollywood, many clinicians, and the public in general— continue to use the older term “persistent vegetative state” as if it meant “permanent vegetative state”. The term “post-coma unawareness”, suggested by the Australian National Health and Medical Research Council (2003), would be an improvement (although in the light of Andrews’ et al. (1996) findings a more accurate term might simply be “locked-in syndrome”).

“Of the 40 patients diagnosed as being in the vegetative state, 10 (25%) remained vegetative, 13 (33%) slowly emerged from the vegetative state during the rehabilitation programme, and 17 (43%) were considered to have been misdiagnosed as vegetative.”