By Dave Andrusko
Time has gotten away from me, so I will only start to comment on another ghastly article, this time written by Dr. Catherine Constable, of New York University School of Medicine, that ran in the journal “Bioethics.” It appears under the quaint—okay, bizarre—title, “Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack.”
“Tack” is a nautical term, but we commonly use the phrase “changing tack” to suggest a change in direction or approach. For Dr. Constable that change is (in the absence of knowing a patient’s wishes) to toss overboard the presumption that people in a PVS ought to be fed and hydrated.
To be sure this “default position,” Dr. Constable says, “would seem to be consistent with a strong national emphasis on autonomy and patient-centered healthcare.” But, she argues, it “should be reversed.” Why? Monday we’ll talk about it in detail, but her abstract gives us the guts of her argument:
“I will argue that among patients in PVS, there is not a compelling interest in being kept alive; that in general, we commit a worse violation of autonomy by continuing ANH when the patient’s wishes are unknown; and that more likely than not, the maintenance of ANH as a bridge to a theoretical future time of recovery goes against the best interests of the patient.”
Constable, who studied bioethics at the Ethox Centre at Oxford University, drinks from the same fountain as bioethicist Peter Singer. Whether the person in a PVS is alive is irrelevant. Absent consciousness (which, by the way, can no longer be assumed), the patient has no “interest” that must be respected. She writes,
“Excluding any known wishes of the patient or family to the contrary, a decision to preserve the life of a patient in a state of permanent unconsciousness based on respect for life itself is morally no more sound than a decision to take that life.”
Constable at least concedes the possibility of recovery. (Or misdiagnosis. Up to 43% of patients diagnosed to be in a PVS were discovered not to be when assessed by experienced teams.) But that is no reason, in her opinion, to override the presumption NOT to feed and hydrate because the recovery would still leave them in “some state of middle consciousness; a life, quite possibly, worse than non-existence.”
As I say, more on Monday. But it is a very short distance between, on the one hand, starving someone to death (because they have no “interests” to be respected) and, on the other hand, starving them to death even though they HAVE given prior indication they would want this minimal care.
Constable does smuggle in the “costs” to “society” of caring for PVS patients and turns autonomy on its head (they really would want to be starved to death and by not doing so you are thwarting their autonomy). And bear in mind that she has already slighted those in “some state of middle consciousness.” How long before they are next?
See you Monday.
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