[5.] Terri Schiavo and the End of Personhood.

 

 

The cases of Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo[1] raise the following ethical and philosophical issues:

 

·         What sort of evidence of a person’s prior wishes should we require when deciding whether to take her off of life support? When there is no such evidence, and there is disagreement among the members of the patient’s immediate family, how should that decision be made?

·         Are all genetic human beings persons, or are some genetic human beings so psychologically diminished that they no longer count as persons?

·         Is death a single, discoverable event? or is it a process with no definite starting point and no definite end point?

 

 

[5.1.] Coma vs. PVS.

 

The National Institutes of Health distinguish between coma and PVS (persistent vegetative state) as follows:

A coma is a profound or deep state of unconsciousness. An individual in a state of coma is alive but unable to move or respond to his or her environment. Coma may occur as a complication of an underlying illness, or as a result of injuries, such as head trauma.

 

As Pence notes, people have emerged from comas after several years, including up to 21 years.

 

A persistent vegetative state (commonly, but incorrectly, referred to as “brain-death”) sometimes follows a coma. Individuals in such a state have lost their thinking abilities and awareness of their surroundings, but retain non-cognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other key functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may even occasionally grimace, cry, or laugh. Although individuals in a persistent vegetative state may appear somewhat normal, they do not speak and they are unable to respond to commands.[2]

 

This definition does not make it explicit whether PVS patients are sentient, i.e., whether they possess

 

sentience (df.): capacity for conscious experience.

 

However, on the assumption that sentience is a “higher brain function,” then this definition implies that they are not conscious and thus not capable of sensing anything, including pleasure or pain.

 

It is very rare for a patient who has been in PVS for more than a year to regain consciousness. Pence cites a study [see note 25, p.N-13] of 434 adults who entered PVS for more than a year; of those patients, only seven recovered. Another study [see note 26, p.N-13] concluded that patients in PVS for more than three years have only a one in 1000 chance of coming out of it. There are no known cases of anyone emerging from PVS after more than four years. (By the end of her life, Terri Schiavo had been in PVS for 15 years.)

 

Patients in PVS can seem to their loved ones to be conscious at times, when in fact they are completely unconscious. As Pence notes, “Patients’ biographies can be over, yet they may have open moving eyes. Families find this fact hard to bear...” (146)

·         Here he is employing the concept of biography used by bioethicist James Rachels; in this sense of the word, a biography is “all the significant mental, personal, social and emotional markers in one’s life.” (143)

 

 

[5.2.] Advance Directives.

 

Terri Schiavo lacked any sort of advance directive. There was only the testimony of her husband and others regarding what she would want for herself were she to become permanently incapacitated.

 

advance directive (df.): a document in which a person states what sort of medical treatment she wishes to have in the event that she becomes incapacitated and can no longer communicate her desires.[3] Types of advance directives include:

·         living will: “informs physicians about conditions under which a person would or would not want medical support continued”[4]

·         Do-Not-Resuscitate (DNR) order: documents a patient’s desire not to be administered CPR if she stops breathing or if her heart stops[5]; this can be part of a person’s living will.

·         durable power of attorney: “assigns to someone else the right to make financial and life-and-death medical decisions if the person becomes incompetent.”[6] This is the most powerful sort of advanced directive where it is available, but not all states recognize this sort of document (they are recognized in Georgia).[7]

 

 

[5.3.] Standards of Death and Brain Death.

 

The traditional standard by which to judge whether someone is dead is

 

the whole-body standard of death (df.): cessation of both breathing and heartbeat.

 

This standard was called into question in the 1960s when

·         ventilators came into use, thus allowing doctors to keep patients breathing artificially when they can no longer breathe on their own; and when

·         the first heart transplant was performed—for a heart to be useful, it must be removed from the donor before the whole-body standard is met.

 

Because of these events, medical professionals began to look for a standard, not of overall death, but of brain death. In the following years, two competing standards of brain death emerged:

 

the Harvard criteria of brain death (df.): “unawareness of external stimuli, lack of bodily movements, no spontaneous breathing, lack of reflexes, and two isoelectric (nearly flat) electroencephalogram (EEG) readings 24 hours apart. These criteria [require] a loss of virtually all brain activity (including the brain stem, and hence breathing).” (144)

·         This is accepted as at least part of the legal standard of death in all fifty states.

·         No one who has met this criterion has ever regained consciousness.

·         Terri Schiavo did not meet this standard.

 

the cognitive criteria of brain death (df.): “These criteria identify a core of properties of persons, assume that beings without such a core are no longer persons, and include reason, memory, agency, and self-awareness.” (144)[8]

·         In the words of bioethicist James Rachels, to use these criteria is to maintain that personhood ends when one’s biography ends.

·         These criteria “have the greatest potential to generate organs for transplantation. So far, however, these criteria have been considered too controversial to be adopted as the legal standard of death in any state, although countless families in fact act on them when they agree to reduce treatment to speed a patient’s death.” (144, emphasis added)

·         But these criteria are also vague, and whether someone meets them “is essentially a matter of judgment.” (151)

·         Terri Schiavo probably met these criteria, although it’s not clear whether her parents would have agreed that she met them.

 

In the State of Georgia, a person is legally dead when he meets either the whole-body standard of death or the Harvard criterion of brain-death:

 

A person may be pronounced dead by a qualified physician, or by a registered professional nurse authorized to make a pronouncement of death under Code Section 31-7-176.1, if it is determined that the individual has sustained either (1) irreversible cessation of circulatory and respiratory function, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.[9]

 

Pence suggests that whether or not a being has died is not a matter to be discovered, but rather a matter to be decided. On his view, dying is not an event that happens all at once. It is more like a process that happens over time, and there is no one moment in that process that counts as the moment of death.

 

Pence acknowledges that many people believe in metaphysical events, like the soul leaving the body, or the soul entering the body at conception or at birth. But he says that the occurrence of such events cannot be proven, and even if they do occur they have no physical manifestation.

 

 

 

 

Stopping point for Wednesday February 4. For next time, finish reading Pence ch.6 (pp.158-70).