Download Consciousness and Personhood

PVS, MCS and Shifting
Standards of Death and
Personhood
ISD II – Neurology
Ethics/Humanities/Health Law
Andrew Latus
A Continuum of Conditions

Coma
– Brain activity, but no consciousness or
wakefulness.

Persistent Vegetative State (PVS)
– Wakefulness, but no awareness

Minimally Conscious State (MCS)
– Wakefulness and minimal awareness

Quite Different: Locked-in Syndrome
– Full consciousness, but extreme paralysis
Karen Quinlan
In April, 1975, Karen Quinlan suffers
anoxia to the brain, probably as a result of
taking a combination of barbitutates,
benzodiazapines and alcohol
 Enters a Persistent Vegetative State (PVS)
 Kept alive via feeding tubes and a
respirator

– Note effect of technology
Karen Quinlan
Late 1975, parents go to court to
disconnect her respirator (not her feeding
tube)
 January 1976, New Jersey Supreme Court
ruled that the ‘right to privacy’ allowed the
family of an incompetent patient to decide
to disconnect life support
 Quinlan’s doctors ‘weaned’ her from the
respirator.
 Died June 13, 1986

Nancy Cruzan
 June 11, 1983 - Cruzan, 24, suffers
anoxia (about 15 minutes) as a
result of a car crash
 Enters a persistent vegetative state.
 Kept alive by a feeding tube (not a
respirator)
 After 7 years, parents sought
permission to disconnect their
daughter's feeding tube
Nancy Cruzan




June, 1990 - U.S. Supreme Court rules that in
the absence of 'clear and compelling' evidence of
what N.C. would have wanted, she may not be
disconnected.
Publicity brings new witnesses (who knew her as
Nancy Davis, her married name).
In a new trial, a lower court rules the 'clear and
compelling' standard has now been met.
Dec. 14, 1990 - N.C. is disconnected &
subsequently dies
Robert Wendland
Suffered brain damage in a car accident in
1993
 Wendland was supposedly in a permanent
Minimally Conscious State (MCS)
 Could respond to simple commands.
 Wife and children claim he never
recognized them
 Mother claimed he would cry and kiss her
hand during visits

Minimally Conscious State



“a condition of severely altered consciousness in
which minimal, but definite, behavioral evidence
of self or environmental awareness is
demonstrated.”
May be temporary or permanent
Criteria (at least one of):
–
–
–
–
following simple commands
gives yes or no responses, verbally or with gestures
verbalizes intelligibly
demonstrates other purposeful behavior …. in direct
relationship to relevant environmental stimuli
Minimally Conscious State
Unlike PVS, those in a MCS can feel pain,
etc.
 “meaningful, good recovery after 1 year in
an MCS is unlikely”
 “being nonfunctioning and aware to some
degree is worse than being nonfunctioning
and unaware”

– Ronald Cranford

“MCS is not a diagnosis; it is a value
judgment.”
– Diane Coleman, president, Not Dead Yet
Robert Wendland
 Florence,
his mother, opposed the
attempt by his wife, Rose, to have
Wendland’s feeding and hydration
tube removed
 Wendland died in July 2001 of
pneumonia before California
Supreme Court could rule
 California Supreme Court eventually
ruled against Rose
Two Quite Different Issues

Definition of Death
– E.g., Is someone in a permanent PVS or MCS dead?
– Raises the issue of ‘personhood’



We need to know what a person is, in order to decide
whether the person is gone
Generally conceded that ‘person’ does not equal ‘human’
Substituted Judgment
– Allowing someone to serve as proxy decision maker
– If taken seriously, death is irrelevant

Discussions of cases like the preceding tend to
mix the two issues
Definitions 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 Death

Define “death by neurological criteria”

Standard Account: Harvard Criteria
– Devised by a committee at Harvard Medical
School in 1968 (just after first heart
transplant)
– Requires a loss of virtually all brain activity
(including brain stem)
Brain Death: Alternative Accounts

Cognitive Criterion
– “Higher person” criterion
– Lack of core conscious properties such as
reason, memory, self-awareness

Irreversibility Standard
– Less conservative than Harvard, more
conservative than cognitive criterion
– Death occurs when unconsciousness is
irreversible
 How

do we know?
Worth noting that the possibility of organ
transplantation has influenced the debate
Revising the Definition of Death
Again?
 Harvard
standard of brain death has
become quite standard
 Should it be revised again?
 Consider the implications for the
conditions discussed today