Part 1: Introduction

Introduction	Part 2	Part 3	Appendices
Part 1	Introduction to Part 2	Introduction to Part 3	Appendix A
Introduction to Part 1	Chapter 6	Chapter 9	Appendix B
Chapter 1	Chapter 7	Chapter 10	Appendix C
Chapter 2	Chapter 8	Chapter 11	Appendix D
Chapter 3	Conclusions to Part 2	Thesis Conclusions	Appendix E
Chapter 4			Appendix F
Chapter 5			Bibliography
Conclusions to Part 1			Books and Articles
			Legal Cases

“No cry of torment can be greater than the cry of one man.

Or again, no torment can be greater than what a single human being may suffer. ...

The whole planet can suffer no greater torment than a single soul.”

Wittgenstein [i]

Part 1 of this thesis is essentially concerned with subjecting three aspects of the medical conceptual scheme to scrutiny.

The first aspect is the assertion that PVS patients have no consciousness; this will be discussed in Chapter 1. The judgement that PVS patients lack consciousness - and consequently cannot experience pain - is crucial to much of the current ethical discussion concerning PVS patient care. One of the methods traditionally used to establish such lack of awareness is the ‘reflex test’. This test consists in subjecting a patient to repeated stimuli - such as loud noises or pin pricks on the skin - and examining the nature of the patient’s responses to such stimuli. The determination that all of a patient’s responses are ‘reflex actions’ is considered to be both a necessary, and a sufficient condition, for making the judgement that a patient lacks consciousness. Chapter 2 is concerned with uncovering the theoretical grounds offered in support of the ‘reflex test’ and subjecting these to a critical examination.

The second aspect to be examined is the claim that PVS patients are unable to feel pain. In one sense this is an obvious corollary to the proposition that PVS patients have no consciousness; however, it can also be examined as an assertion in its own right and in a context wider than that of PVS patients. Chapter 3 will consider the justifications offered for, and the reliability of, judgements that certain patients cannot experience pain.

The third aspect to be investigated is the definition of PVS and the features which, it is asserted, distinguish PVS from ‘Locked-In Syndrome’.[ii] In particular, consciousness is assumed to be absent in the former but present in the latter; the presence of consciousness in the Locked-In Syndrome being shown by the existence of some non-reflex actions. These non-reflex actions - such as the intentional flicker of an eyelid - are so minimal that they can be effectively masked by the presence of muscle ‘twitches’. This possibility has been used by Chris Borthwick[iii] to argue that PVS is not a well defined condition because, in certain cases, it is indistinguishable from the ‘Locked-In Syndrome’, and that in these cases there is no test - and in particular no brain scan - which can differentiate between the conditions. Chapter 4 examines problematic aspects of the definition of PVS and will utilise aspects of Borthwick’s arguments. His arguments, which are summarised and examined in Appendix B, would - if valid - undermine the assertion that PVS patients necessarily lack consciousness.

The argument being advanced in this thesis is not that patients diagnosed as PVS are, in all cases, conscious and able to experience pain, but rather that a reasonable doubt exists as to both propositions. Of considerable relevance to this question are a number of studies which have sought to ascertain the extent of misdiagnosis of PVS; these studies are summarised in Appendix A. If it is accepted that doubt exists as to the consciousness of PVS patients, it then becomes necessary to attempt to quantify this doubt and then to show how this doubt, once quantified, can be incorporated into good medical practice. This is the focus of Chapter 5.