21
Steinbock
B.
Recovery
from
persistent
vegetative
state?
The
case
of
Carrie
Coons.
Hastings
Cent
Rep
1989;19:14-5.
22
Najenson
T,
Sazbon
L,
Fiselzon
J,
Becker
E,
Schechter
I.
Recovery
of
communicative
functions
after
prolonged
traumatic
coma.
Scand
J
Rehabil
Med
1978;1O:15-21.
23
Haig
AJ,
Reuss
JM.
Recovery
from
vegetative
state
of
six
months'
duration
associated
with
Sinemet
(levodopa/carbidopa).
Arch
Phys
Med
Rehabil
1990;71:1081-3.
24
May
PG,
Kaelbling
R.
Coma
of
a
year's
duration
with
favourable
outcome.
Dis
Nerv
Syst
1968;29:837-40.
25
Levin
HS,
Saydjari
C,
Eisenberg
HM,
Foulkes
M,
Marshall
LF,
Ruff
RM,
et
al.
Vegetative
state
after
closed
head
injury:
a
traumatic
Data
Bank
report.
Arch
Aeurol
199
1;48:580-5.
26
Higashi
K,
Hatano
M,
Abiko
S,
Ihara
K,
Katayama
S,
Wakuta
Y,
et
al.
Five
year
follow
up
study
of
patients
with
persistent
vegetative
state.
J
Neurol
Neurosurg
Psychiatry
1981;41:552-4.
27
Rosenberg
GA,
Johnson
SF,
Brenner
RP.
Recovery
of
cognition
after
prolonged
vegetative
state.
Ann
Neurol
1977;2:167-8.
28
Arts
WFM,
Van
Dongen
HR,
Duin
JVH-V,
Lammens
E.
Unexpected
improvement
after
prolonged
posttraumatic
vegetative
state.
J
Neurol
NeurosurgPsychiatry
1985;48:1300-3.
29
Tanheco
J,
Kaplan
PE.
Physical
and
surgical
rehabilitation
of
patient
after
6
year
coma.
Arch
Phys
Med
Rehabil
1982;63:36-8.
30
4
out
of
10
doctors
back
euthanasia
law
change
(news).
BMA
News
Review
1993;19:9.
(April
1993.)
(Accepted
27April
1993)
Patients
in
the
persistent
vegetative
state:
problems
in
their
long
term
management
Keith
Andrews
Royal
Hospital
and
Home,
Putney,
London
SW15
3SW
Keith
Andrews,
director
of
medical
and
research
services
BMJ
1993;306:
1600-2
Physicians
responsible
for
the
long
term
manage-
ment
of
patients
in
the
persistent
vegetative
state
face
several
problems.
These
include
deciding
whether
tube
feeding
is
treatment
or
nutritional
care,
whether
withdrawal
of
tube
feeding
is
an
appropriate
form
of
management,
what
clinical
advantage
there
is
in
active
treatment;
at
what
level
of
awareness
can
a
patient
be
said
to
have
a
quality
of
life;
and
who
should
determine
a
patient's
right
to
die.
These
problems
are
determined
more
by
social,
legal,
emotional,
cultural,
religious,
and
economic
forces
than
by
clinical
facts.
Patients
in
the
persistent
vegetative
state
have
no
obvious
cognitive
function
and
are
generally
thought
to
have
a
very
poor
prognosis.
These
factors
have
led
to
several
inferences
being
drawn
about
such
patients
which
have
implications
for
their
management:
that
they
have
no
quality
of
life;
that
there
is
no
advantage
in
keeping
them
alive;
that
they
cannot
feel
distress
if,
say,
their
food
is
withdrawn;
and
that
others
must
make
decisions
on
their
behalf.
The
recent
case
when
the
High
Court
was
asked
to
agree
to
the
removal
of
feeding
from
a
young
man
in
the
persistent
vegetative
state
has
highlighted
these
issues.
In
this
paper
I
address
some
of
the
problems
faced
by
physicians
responsible
for
the
long
term
management
of
people
with
severe
or
profound
disabilities.
The
case
of
Anthony
Bland
Anthony
Bland
was
aged
18
when
he
suffered
severe
anoxic
brain
damage
during
the
disaster
at
Hills-
borough
football
ground
three
years
ago.
He
remained
in
a
vegetative
state
for
three
years
and
died
when
his
nasogastric
feeding
was
withdrawn.
All
of
the
expert
witnesses
in
the
court
case
agreed
that
there
was
no
hope
of
any
recovery,
and
the
local
health
authority,
supported
by
Anthony's
parents,
sought
the
court's
permnission
to
stop
feeding
by
nasogastric
tube
to
allow
Anthony
to
die.
This
was
the
first
case
to
come
to
the
courts
in
England,
although
the
principle
has
been
accepted
in
some
American
states,
Canada,
and
some
other
countries.
IS
FEEDING
A
TREATMENT?
The
main
basis
of
the
argument
for
the
withdrawal
of
feeding
was
that
feeding
was
a
treatment
and
that
it
was
acceptable
for
doctors
not
to
treat
someone
with
no
hope
of
recovery.
At
the
trial
I
suggested
that
treat-
ment,
by
its
very
nature,
was
given
to
treat
an
abnormality
and
said
that
I
could
not
understand
what
abnormality
the
food
was
supposed
to
be
treating-its
purpose
being
to
supply
normal
nutrition
to
an
otherwise
healthy
body.
The
arguments
depended
on
the
fact
that
the
feeding
required
technology
(the
gastrostomy
tube),
special
food,
supervision
by
a
dietitian,
and
insertion
of
the
tube
by
a
trained
nurse.
Although
it
is
standard
practice
to
provide
prescribed
preparations
of
food
for
nasogastric
tubes,
there
is
no
reason,
apart
from
the
time
needed
for
its
preparation,
why
liquidised
"normal"
food
should
not
be
used.
Similarly
a
dietitian's
advice
is
desirable
but
not
essential-few
of
us
need
a
dietitian
to
advise
us
on
our
nutritional
intake
unless
we
require
a
special
diet
for
a
metabolic
or
primary
nutritional
disorder.
It
is,
how-
ever,
accepted
that
the
tube
is
an
abnormal
or,
more
accurately,
a
technical
method
of
feeding
a
patient.
The
tube
is
a
method
of
overcoming
a
physical
block
to
allow
the
provision
of
normal
food
to
an
otherwise
healthy
body.
The
tube
is
therefore
the
treatment,
the
food
is
not.
Neither
can
be
effective
without
the
other,
however,
and
the
package,
of
tube
and
food,
must
therefore
be
the
treatment.
DEATH
BY
NATURAL
CAUSES?
Leaving
aside
these
niceties,
the
purpose
of
with-
drawing
the
nasogastric
tube,
and
therefore
the
food,
would
be
to
end
the
life
of
the
patient.
In
the
trial
much
emphasis
was
placed
on
the
opinion
of
most
of
the
expert
witnesses
that
if
the
tube
was
removed
the
cause
of
the
death
would
not
be
the
doctor
but
the
original
brain
damage.
Another
point
of
view,
however,
is
that
the
act
of
removing
the
tube
would
result
in
starvation,
death
being
due
to
damage
to
previously
healthy
tissues
secondary
to
the
patient
not
being
able
to
gain
access
to
food.
The
same
situation
would
arise
in
the
"locked-in"
syndrome,
in
which
a
patient
is
cognitively
intact
but
totally
paralysed
because
of
a
lesion
in
the
pons,
or
in
a
case
of
fracture
of
all
four
limbs,
as
in
a
skiing
accident.
In
such
cases
a
patient
would
starve
to
death
if
food
was
not
provided,
but
would
the
death
be
thought
to
be
due
to
natural
causes-brain
damage
or
fractured
limbs-or
due
to
the
withholding
offood?
A
patient
who
has
no
quality
of
life?
Quality
of
life
is
difficult
to
define,
especially
for
someone
unable
to
express
any
views.
This
is
relevant
because
a
person's
quality
of
life
is
something
which
only
that
individual
can
decide-it
depends
on
concepts
of
handicap
rather
than
disability.
Whatever
our
opinion
of
someone's
quality
of
life,
if
that
person
disagrees
then
we
must
be
wrong.
An
extreme
point
of
view
could
be
that
patients
in
the
persistent
vegetative
state
have
a
good
quality
of
life,
since
they
are
fed,
watered,
warm,
safe,
and
without
worries.
Another
view
is
that
if
they
are
unable
to
appreciate
anything,
1600
BMJ
VOLUME
306
12
JUNE
1993
then
they
cannot
have
a
good
or
a
bad
quality
of
life.
What
we
really
mean
is
that
we
interpret
their
quality
of
life
as
being
poor
it
is
our
quality
of
life
which
is
affected.
No
advantage
in
keeping
a
patient
alive?
If
a
patient
has
no
awareness,
what
advantage
is
there
in
the
patient
continuing
to
live
and
our
con-
tinuing
to
provide
food?
The
term
advantage
is
diffi-
cult
to
define,
although
possibly
most
people
think
they
know
what
it
means.
In
the
case
of
Anthony
Bland
the
term
used
was
"clinical
advantage."
When
I
said
that
I
was
not
sure
what
this
meant,
the
judge
made
it
clear
that
he
interpreted
this
as
recovery.
Under
this
definition
there
is
no
doubt
that
the
continuing
feeding
of
most
patients
in
the
persistent
vegetative
state
has
no
clinical
advantage
since
there
can
be
no
recovery.
This
has
serious
implications
for
many
other
disabled
people.
In
rehabilitation
there
are
three
goals:
to
aid
recovery,
to
maintain
existing
levels
of
ability,
and
to
slow
down
rates
of
deterioration
in
degenerative
disorders.
There
is,
therefore,
no
clinical
advantage
in
much
of
the
rehabilitation
for
patients
with
disabling
disorders
since
there
is
no
recovery.
Millions
of
disabled
people
will
probably
disagree,
and
the
implication
of
clinical
advantage-if
based
on
recovery
-must
be
of
concem
to
those
with
multiple
sclerosis,
stroke,
Huntington's
disease,
cancer,
rheumatoid
arthritis,
and
so
on.
What
is
a
worthwhile
level
of
recovery?
I
am
often
challenged
about
what
I
and
my
colleagues
hope
to
achieve
in
our
care
of
patients
in
the
persistent
vegetative
state.
If
I
am
honest
there
are
times
when
I
wonder
myself.
My
official
answer
is
to
prevent
distressing
complications
(contractures,
pressure
sores,
urinary
tract
calculi,
and
undemutrition),
to
aim
for
some
recovery
(that
word
again),
and
to
provide
an
optimal
quality
of
life
in
the
limits
of
a
patient's
ability.
Few
patients
remain
totally
unresponsive
after
under-
going
a
rehabilitation
programme,
but
many
will
still
be
severely
disabled.
This
raises
questions
about
whether
such
efforts
should
be
made
to
achieve
some
level
of
response
and
whether
severe
disability
is
a
worthwhile
achievement.
The
difficulty
for
the
rehabilitation
specialist
is
no
different
from
that
of
the
neurosurgeon
or
intensive
care
specialist-we
do
not
know
the
outcome
of
a
treatment
until
after
we
have
tried
it.
Our
introduction
of
a
rehabilitation
pro-
gramme
to
patients
in
the
persistent
vegetative
state
has
recently
resulted
in
some
successes
which
were
previously
not
believed
possible.'
On
the
other
hand,
what
do
we
make
of
the
young
man
who
remains
totally
dependent
on
others
for
all
his
needs
but
smiles
all
day
and
apparently
enjoys
watching
simple
activities
and
being
part
of
a
group?
What
do
we
make
of
the
young
man
with
anoxic
brain
damage
who
was
in
the
persis-
tent
vegetative
state
for
three
years,
but
who
has
recently
started
smiling
on
request,
laughing
appro-
priately
at
television
cartoons,
and
showing
pleasure
in
his
surroundings?
Is
there
no
clinical
advantage
in
continuing
to
feed
these
patients?
No
distress
if
food
is
withheld?
In
all
of
the
above
examples
there
was
some
awareness
and
therefore
the
possibility
of
appreciating
pain:
the
patients
would
no
doubt
demonstrate
some
distress
if
food
was
withdrawn.
Very
few
patients
in
the
persistent
vegetative
state
are
so
severely
brain
damaged
that
they
demonstrate
no
response,
and
most
respond
to
pain
either
by
withdrawing
or
grimacing.
Since
the
first
level
of
awareness
of
pain
is
thought
to
be
in
the
thalamus
such
a
response
to
pain
does
not
necessarily
mean
that
a
patient
is
aware
of
the
pain.
If
we
want
to
be
particular
we
could
ask,
"How
do
you
know?"
After
all,
the
only
way
any
of
us
can
communi-
cate
that
we
find
any
stimulation
unpleasant-or
pleasant
for
that
matter-is
by
speech
or
some
physical
gesture.
If
we
are
paralysed
we
can
no
longer
indicate
our
feelings.
In
the
case
of
the
persistent
vegetative
state
we
therefore
have
to
rely
on
our
clinical
experi-
ence
and
our
understanding
of
neurology,
which
is
not
100%
reliable:
when
Carrie
Coons's
feeding
tube
was
removed
on
the
order
of
a
court
she
woke
and
started
feeding;
and
when
Karen
Quinlan's
respirator
was
switched
off
she
continued
to
breathe
spontaneously
for
another
10
years.
These
unsuccessful
attempts
to
end
patients'
lives
were
based
on
the
available
knowledge
of
the
severity
of
their
brain
damage.
Someone
once
said,
"If
the
brain
was
so
simple
we
could
understand
it,
we
would
be
so
simple
that
we
couldn't."
The
question
of
distress
is
obviously
important.
If
we
are
going
to
decide
not
to
keep
a
patient
alive
and
to
withhold
food
and
water,
no
one
would
want
the
patient
to
suffer
distress.
If
there
is
no
cortical
function
then
we
assume
that
the
patient
cannot
be
aware
of
the
distress.
While
recognising
that
a
withdrawal
response
to
pain
is
a
basic
reflex
which
has
a
functional
value
of
removing
the
stimulated
part
from
danger,
it
is
more
difficult
to
see
how
facial
grimacing
in
response
to
pain
stimulation
of
the
leg
can
have
a
useful
reflex
purpose
except
to
alert
other
members
of
the
species
to
the
possibility
of
danger.
Is
it
possible
that
we
have
given
too
little
thought
to
a
patient's
lower
brain
functions
as
part
of
the
person
we
are
caring
for?
I
have
seen
only
one
patient
in
the
persistent
vegetative
state
die
of
starvation
(because
oesophageal
stricture
prevented
reinsertion
of
a
nasogastric
tube).
She
took
three
weeks
to
die
and
became
more
alert,
constantly
awake,
and
agitated
presumably
due
to
the
release
of
brain
stimulating
chemicals
in
response
to
hypoglycaemia.
It
is
one
thing
to
state
that
she
could
not
have
felt
any
distress
because
she
had
a
damaged
cortex,
it
is
another
to
be
fully
convinced
(and
to
convince
her
carers)
that
there
really
was
no
suffering.
Under
such
circumstance
heavy
sedation
would
probably
be
worthwhile,
but
this
would
be
making
a
positive
intervention
in
a
process
that
could
otherwise
be
regarded
as
being
due
to
passive
or
negative
intervention.
Who
decides
if
a
patient
should
die?
Even
if
we
assume
that
it
is
logical
to
assist
the
death
of
a
patient,
who
is
going
to
make
the
decision?
The
physician
in
charge
should
reach
an
agreement
with
the
patient's
family
and
any
other
carers
that
it
would
be
appropriate
to
withdraw
feeding.
Indeed,
the
request
may
come
from
relatives.
What
seems
to
be
clear
is
that
no
decision
should
be
made
without
the
agreement
of
relatives.
There
is,
however,
a
major
problem
if
members
of
a
patient's
family
hold
conflicting
views.
There
is
also
the
question
of
whether
even
a
patient's
family
has
the
right
to
decide
whether
that
patient
lives
or
dies.
Our
main
duty
is,
presumably,
to act
in
the
best
interests
of
the
patient.
If
we
have
two
identical
patients
in
the
persistent
vegetative
state
and
the
family
of
one
wants
the
patient's
feeding
tube
removed
while
the
family
of
the
other
is
strongly
opposed
to
removal
of
the
tube,
should
we
respect
the
wishes
of
both
families?
If
we
do
can
we
truly
be
said
to
be
acting
on
behalf
of
the
patient?
If
so,
which
one?
What
implication
does
this
have
for
other
patients
who
are
not
in
the
persistent
vegetative
state
but
whose
families
think
that
they
would
be
better
off
dead
(such
as
those
who
are
conscious
but
who
have
severe
brain
BMJ
VOLUME
306
12
JUNE
1993
1601
damage,
those
who
are
mentally
handicapped
for
other
reasons,
and
those
with
dementia.
or
other
"incurable"
chronic
disorders)?
We
seem
to
be
progressing
down
the
road
of
accepting
involuntary
euthanasia
before
voluntary
euthanasia
has
been
accepted
legally.
It
is
unlikely
that
starvation
would
be
regarded
as
an
acceptable
way
of
assisting
dying
in
voluntary
euthanasia,
so
should
we
even
consider
this
method
for
involuntary
euthanasia?
Conclusion
I
have
asked
questions
to
which
I
have
no
answers.
The
factors
influencing
them
are
rarely
clinical
but
depend
much
more
on
the
attitude
of
society
to
the
care
of
disabled
people
and
to
social,
legal,
emotional,
political,
cultural,
religious,
and
economic
forces.
Irrespective
of
whether
it
is
legal
to
withhold
food
from
patients
in
the
persistent
vegetative
state,
these
problems
will
continue
to
face
physicians
responsible
for
the
long
term
care
of
such
severely
disabled
people.
Patients
and
their
families
may
now
have
to
be
reassured
that
the
withholding
of
food
will
not
be
automatic.
Before
such
actions
are
considered
it
is
essential
that
a
full
rehabilitation
programme
should
be
offered
to
patients
in
the
early
stages
of
the
persistent
vegetative
state
to
give
them
the
optimal
chance
of
recovery.
And
we
should
be
absolutely
certain
that
our
diagnosis
is
correct.
I
Andrews
K.
Recovery
of
patients
after
four
months
or
more
in
the
persistent
vegetative
state.
BMJ
1993;306:1597-600.
(Accepted
27April
1993)
Patients
in
the
persistent
vegetative
state:
a
response
to
Dr
Andrews
Raanan
Gillon
St
Mary's
Hospital
Medical
School,
Imperial
College
of
Science,
Technology
and
Medicine,
London
SW7
2AZ
Raanan
Gillon,
visiting
professor
of
medical
ethics
BMJ
1993;306:
1602-3
The
central
moral
objective
of
medicine-adhered
to
by
doctors
and
health
care
workers
since
Hippocratic
times-is
to
produce
net
medical
benefit
for
the
patient
with
as
little
harm
as
possible.
Today
we
may
add
to
that
Hippocratic
objective
the
moral
qualifications
that
we
should
pursue
it
in
a
way
that
respects
people's
deliberated
choices
for
themselves
and
that
is
just
or
fair
to
others
(whether
in
the
context
of
distribution
of
scarce
resources,
respect
for
people's
rights,
or
respect
for
morally
acceptable
laws).
This
moral
framework-
a
sort
of
medico-moral
mission
statement-is
consist-
ent
with
the
formal
quartet
of
moral
principles
intro-
duced
to
medical
ethics
by
Beauchamp
and
Childress,'
which
I
discuss
elsewhere,2
and
is
useful
in
analysing
the
various
ethical
questions
posed
by
Andrews
in
his
two
papers
in
this
issue
of
the
BM.3'4
Deciding
what
is
net
medical
benefit
There
are
those
who
believe
that
preservation
of
life-any
sort
of
life-is
a
benefit
and
worth
striving
for.
For
them
even
maintaining
the
life
of
a
patient
in
the
persistent
vegetative
state
(when
the
patient
is
reliably
believed
to
be
in
a
state
of
permanent
uncon-
sciousness)
is
a
medical
benefit
worth
striving
for.
Such
people
argued
that
Tony
Bland-an
indisputable
example
of
a
patient
in
the
persistent
vegetative
state,
which
was
reliably
believed
to
be
permanent-should
have
been
kept
alive,
opposing
the
recommendations
of
his
parents
and
of
his
consultant
and
medical
team.
Others-I
suspect
a
large
majority-believe
that
con-
tinuance
of
life
is
a
morally
neutral
means
to
an
end-
good
only
if
the
continuing
life
is
a
"good
life."
For
many
of
us
this
means
a
life
that,
from
the
person's
own
perspective,
is
worth
living.
It
is
important
for
health
care
workers
and
their
patients
and
potential
patients
(and
increasingly
their
potential
purchasers)
to
know
which
view
they
hold.
If
they
are
members
of
the
vitalist
persuasion,
who
favour
prolonging
life
regardless
of
its
quality,
they
should
surely
make
this
clear
so
that
those
who
reject
such
views
may
be
wamed
and
take
appropriate
avoiding
action.
For
my
own
part,
and
to
declare
my
own
bias,
I
detest
the
prospect
of
being
kept
alive
in
any
severely
disabled
state
in
which
I
would
no
longer
be
able
to
make
deliberated
decisions
for
myself
unless
there
was
reason
to
believe
that
I
had
a
good
chance
(preferably
better
than
one
in
two
and
certainly
better
than
one
in
10)
of
recovering
my
ability
to
be
an
autonomous
agent.
This
is
of
course
a
major
dilemma
for
members
of
the
medical
profession
who
are
of
the
vitalist
persuasion-
they
presumably
feel
bad
and
wrong
in
"letting
go"
any
human
life
that
could
be
prolonged.
But
in
trying
to
resolve
their
dilemma
I
believe
that
they
should
use
the
medico-moral
framework
above
and
ask
themselves
whether
a
patient
would,
on
deliberation
have
con-
sidered
the
sort
of
life
that
seems
the
probable
outcome
a
life
worth
living.
A
variety
of
evidence
may
be
relevant
in
answering
the
question,
particularly
any
advance
directives
given
by
the
patient.
If
the
patient's
views
are
unavailable
the
evidence
of
the
patient's
proper
proxies
(usually
close
relatives
or
friends)
about
his
or
her
best
interests
may
be
sought.
However,
even
if
the
proxies
believe
that
preserving
the
life
of
the
patient
in
the
persistent
vegetative
state
is
worthwhile
and
the
patient
had
given
an
advance
directive
to
that
effect
there
remains
the
question
of
justice.
Is
the
allocation
of
resources
to
preserve
a
life
of
absent
or
probably
permanently
severely
impaired
consciousness
fair
or
just
given
that
this
will
deny
those
resources
to
all
other
possible
claimants?
Further
questions
about
the
treatment
of
patients
in
the
persistent
vegetative
state
In
his
first
paper
Dr
Andrews
raises
other
questions,3
which
I
shall
consider
only
briefly-I
have
addressed
some
of
them
more
thoroughly
elsewhere.5
Is
artificial
hydration
and
nutrition
a
medical
treatment?
Yes,
because
it
is
an
intervention
to
prolong
life
that
requires
medical
skills
(imagine
leaving
to
medically
unskilled
people
the
nutrition
and
hydration
of
long
term
unconscious
people
for
whom
there
was
a
reason-
able
prospect
of
good
recovery).
Does
it
matter?
Not
much.
What
matters
is
whether
it
is
care:
care
requires
the intention
and
prospect
of
benefit,
which
takes
us
back
to
the
question
of
whether
the
mere
prolongation
of
life
is
a
benefit,
as
distinct
from
a
life
that
the
patient
considers
worth
living.
Is
the
purpose
of
withdrawing
treatment,
including
hydration
and
nutrition,
to
end
the
life
of
the
patient?
It
depends
on
the
intention
of
the
decision
maker.
There
is
no
requirement
for
such
an
aim
because
it
is
perfectly
possible
that
the
purpose
of
such
a
decision
is
only
the
withdrawal
of
useless,
non-beneficial
treatment-
1602
BMJ
VOLUME
306
12
JUNE
1993
