The Persisting Problem of Precedent Autonomy Among Persons in a Minimally Conscious State: The Limitations of Philosophical Analysis and Clinical Assessment

Abstract

Determining whether it is ethical to withdraw life-sustaining treatments (WOLST) from a patient in the minimally conscious state (MCS) recalls recurring debates in bioethics, including the applicability of precedent autonomy and the usefulness of quality-of-life assessments. This article reviews the new clinical understanding of MCS and the complexities involved in detecting covert awareness in patients. Given the diagnostic and prognostic uncertainty surrounding most MCS determinations, we review the ongoing debates concerning precedent autonomy as they apply to making WOLST determinations for patients in MCS. We also consider the moral obligations clinicians might have to understand an MCS patient’s advance directives, current preferences, and quality of life. We argue that an optimal approach for making WOLST determinations requires weighing patients’ previous wishes against their current circumstances but that even here, factual as well as ethical vagaries and disagreements will be relatively commonplace.

Keywords:

• brain imaging
• decision making
• imaging techniques
• minimal consciousness
• neuroethics

Notes

1 In the Cruzan case, the U.S. Supreme Court ruled that the Due Process Clause of the constitution insures that people are allowed to reject medical treatment (including ANH). Cruzan v. Dir., Mo Dep’t of Health, 497 U.S. at 287 (1990).

2 Although MCS patients likely have experiential interests, it is unlikely, or least difficult to determine whether they maintain critical interests, which Dworkin (1993) identifies as the hopes and aims that give our lives coherence.

Additional information

Funding

Preparation of this article was generously supported, in part, by the Moody Endowment. ▪