In chapter 7 of Daniel Bor's The Ravenous Brain, he explores disorders of consciousness with regards to brain damage. Many patients who have been in serious accidents and experience massive head trauma are left in a coma. If the unconscious state lasts for more than a year, then the patient is considered to be in a permanent vegetative state, or PVS. For most people, the infamous case of Terri Schiavo comes to mind whenever the topic of PVS comes up. Daniel Bor also references her case as very ethically complicated.
Despite the sophisticated brain imaging techniques available to modern science, it was surprising to learn that the key diagnosis factor is purely based on eye activity. "If a patient is entirely unconscious with eyes persistently closed, then he is in a coma. If he has some form of sleep-wake cycle, and sometimes opens his eyes, but shows no signs of awareness, then he is in a vegetative state"(Bor 225) explains Bor. Patients can be misdiagnosed and if the person is diagnosed as vegetative it can be difficult to tell whether or not the patient is making progress towards a minimally conscious state. It becomes nearly impossible to define movements or utterances as true awareness or as simply random reflexes. Of course it is possible for a patient to recover from PVS, however the longer it persists, the less likely recovery becomes.
In her article Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack Catherine Constable argues that "we commit a worse violation of autonomy by continuing ANH [artificial nutrition and hydration] when the patients wishes are unknown." She believes that unless the patient explicitly expressed their wish to be kept on ANH prior to being unconscious, it should not be assumed that they would wish to be kept in the vegetative state. Although keeping patients on ANH is considered ethical by many current medical and religious standards, she argues that it should actually be the opposite. "More likely than not, the maintenance of ANH as a bridge to a theoretical future time of recover goes against the best interests of the patient. Her argument stands better in the case that future recovery seems grim.
My interest on this issue was truly grabbed by the last few statements of the chapter in which Bor touches on a deeply ethical problem. In the case of patients who are able to recover even partially from PVS, he suggests that "they would be disturbingly reborn...with most of their old memories, skills, and personalities wiped out" (Bor, 234). This statement also challenges the benefits of recovery from PVS. If a patient miraculously recovers, the differences in their personality and abilities are sure to be life altering for themselves and their families. What would a person faced with this reality choose for themselves? Is it right for their families and doctors to decide for them when there are no other options?
References:
Bor, D. (2012). The Ravenous Brain: How the New Science of Consciousness Explains Our Insatiable Search for Meaning. New York: Basin Books, 2012. Print
Constable, C. Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack. Bioethics, 26. 157-163.
I was wondering if eye activity is really the main factor in determining a patient in a coma or a PVS. I would think that maybe actual brain activity or other symptoms would determine the diagnosis. In either case, I liked how you raised the ethical questions of what to do if that patient were to “wake up” or remain in that vegetative state. Just today in my healthcare ethics class we talked about patients and decision-making. If a patient used to be competent and can no longer make decisions for themselves, family members can make those decisions based on what the patient would have wanted/wished. I learned that this is called substituted judgment. In general, I feel as though it would be right for families and doctors to decide for a patient if there were no more options. It highly depends on the individual case and the factors as well. In answering your last question though, if a patient were to “wake up” and their personality was life altering like you said, then I think that families could decide for them in the beginning, while focusing on helping their loved one build his/her personality again. At first the patient may be confused but I think that families and doctors can help the patient understand his/her options by slowly bringing them to reality, instead of completely taking away their autonomy. Whether or not this idea would work is something I do not know but am sure is something we could try.
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