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

 

Conclusions to Part 1

 

 

The assertion that ‘A specific patient, who has been diagnosed as PVS, cannot feel pain’ can be defended on the grounds that:

*           consciousness is lacking and that this is so either:

(i)   as a theoretical consequence of being diagnosed as PVS; or

(ii)  as has been experimentally verified in the instant case.

*           the ability to experience pain is lacking and that this is so either:

(iii) as a theoretical consequence of being diagnosed as PVS; or

(iv) as has been experimentally verified in the instant case.

Each of these grounds has been examined in the preceding chapters and found wanting: Chapter 1 considered the experimental grounds for judging that consciousness was absent and found that the only conclusion (assuming the complete identification of ‘brain processes’ and ‘mental processes’) that was justified was that consciousness was absent if all brain activity had ceased.[i]  Because of its importance, a particular form of this argument was considered separately in Chapter 2: i.e. the argument that the manifestation of only reflex actions justifies the conclusion that consciousness is absent.  The theoretical underpinnings of the distinction between ‘reflex’ and ‘non-reflex’ actions, were found on examination, to be dependent on the adoption of a Cartesian perspective.  Both the distinction itself, and the implication to be drawn from the absence of ‘non-reflex’ behaviour, were found to be open to challenge and it was concluded that even if a patient manifested only reflex behaviour, it was still possible that consciousness might persist.  Hence ground (ii) was undermined.

Chapter 3 examined whether it is possible to demonstrate conclusively that an individual is not experiencing pain.  It was found that no definitive test exists for establishing the presence, or absence, of pain and that there are grounds for suggesting that such tests cannot - even theoretically - exist .  Furthermore, it was found that the concept of ‘pain’ is not a purely scientific concept but is intimately bound up with questions of value and attitude.  These conclusions undermined ground (iv).

Chapter 4 considered the definition of PVS and found that different academic studies had used definitions of PVS which were not equivalent; the confusion caused by this was exacerbated by the use of inappropriate terminology which - in certain instances - could even be described as being inimical to honest debate.  This chapter also considered studies on the misdiagnosis of PVS and found that the level of misdiagnosis of PVS was so great as to be comparable to that to be expected in a purely random process such as the toss of a coin.  Chapter 4 also considered the justification for the inferences that a patient, diagnosed as PVS, was not conscious or could not experience pain; it concluded that such inferences were open to doubt; a doubt which, in view of the studies on misdiagnosis, is substantial.  These conclusions undermined grounds (i) and (iii).

Thus, none of the four arguments listed above (i) - (iv) is conclusive; in each case the conclusion that the patient cannot experience pain is accompanied by a penumbra of doubt.

Chapter 5 considered how, in the making of medical judgements, the existence of such doubt could best be incorporated.  It concluded that decision procedures based on choosing that which was most likely, were deeply flawed; it proposed that, in cases of doubt, one should -

“... act so that the unwished-for consequences that flow from a (then unknowably) incorrect choice are minimised.” [ii]

This decision procedure was then applied to the problem of whether PVS patients should be treated as being conscious and able to experience pain; the conclusion was drawn that:

Conclusion 5 -5 : All patients diagnosed as PVS, should be treated as if [iii] they are conscious and can experience pain.

This conclusion was based simply on the extent of misdiagnosis of PVS which had been uncovered and was without reference to doubts that have been found to exist in relation to the other grounds (i) - (iv); these doubts are cumulative and add further weight to this conclusion, which is the main proposal of Part 1 of this thesis.

____________

 

The use of ambiguous terminology appears to be a constant and discomforting feature of the debate on PVS.[iv]  The terms ‘consciousness’, ‘reflex’, ‘pain’, ‘recovery’, ‘misdiagnosis’  have all been used in the academic literature with two or more meanings.  In the presence of such ambiguity it is no wonder that PVS has been described as ‘an area fraught with confusion’.[v]  Perhaps, the single greatest cause of such confusion is the role played by the concept of ‘consciousness’.  I have argued that ‘consciousness’ plays a symbolic role and acts as a surrogate for the concept of personhood, and that, in the interests of clarity, it is imperative that questions of personhood be explicitly addressed.  However, a matter of even greater importance in bringing order to the debate on PVS, is the need for the definition of PVS - and that of the locked-in syndrome - to be clarified.  I have argued that ‘the ability to communicate’ and not ‘consciousness’ is the key to unravelling both the concept of personhood,[vi] and the definitions of PVS and locked-in syndrome.  The following definitions were proposed:

Conclusion 4 -16 :  The Locked-In Syndrome is distinguishable from PVS in that a patient with locked-in syndrome is able to communicate by using the blinking of an eye, or some equally primitive bodily movement.[vii]

Conclusion 4 -17 : The persistent vegetative state is characterised by seeming wakefulness in the absence of an ability to communicate.

Treating a PVS patient as being conscious and able to experience pain, has no implications for their ‘personhood’.  In Chapter 10 it will be argued that ability to communicate is a necessary condition for the ascription of personhood and the adoption of such a criterion, in conjunction with the definition of PVS proposed, would imply an obligation on medical staff to work diligently to establish patient communication.  This is precisely what is found at present in the best medical practice in relation to the treatment of PVS patients; however, the proposals being made here enable such practice to be put on a more secure theoretical footing.[viii]  Furthermore, treating PVS patients as being conscious and able to experience pain removes the urgency and much of the ethical necessity for distinguishing between the ‘PVS’, ‘near-PVS’ and the ‘locked-in syndrome’.[ix]  All such patients are to be treated as conscious and as having the ability to experience pain.  The ethical obligation on carers is identical for all three conditions - it is to attempt to devise methods of communication with the patient to a level where their views as to their treatment, can be ascertained. 

If such attempts are successful, then, as a corollary, the ‘personhood’ of the patient is also established.

If they are not successful and the ability to communicate is considered to be permanently lost, then the ‘personhood’ of the patient has ceased.  The patient has died ‘as a person’.  The implications that follow from such judgements are considered in Part 3.



[i] In cases of PVS some brain activity persists.

[ii] Conclusion 5 -2 : Acting on the basis that those circumstances which are most probably true, are true, does not ensure that the unwished for consequences that flow from a (then unknowably) incorrect choice are minimised.  In such cases an index should be compiled of the probabilities of various eventualities, weighted in proportion to the magnitude of their respective unwanted consequences, and the eventuality be chosen which corresponds to the minimum index.  In short, the decision procedure to be adopted in such cases of incomplete knowledge, is that one should act so that the unwished-for consequences that flow from a (then unknowably) incorrect choice are minimised.

[iii] The phrase ‘as if‘ is used not in the sense of suggesting a pretence, but rather in the sense of suggesting that in the face of incomplete knowledge as to which PVS patients are conscious - and some undoubtedly are - all should be treated as if they were conscious. 

[iv] See: Conclusion 4 -13 : The reasons suggested by the studies on misdiagnosis of PVS for its occurrence are inappropriate  terminology, imprecise definition of PVS and overly primitive procedures for determining awareness.

[v] Childs op.cit. p.1465.

[vi] This question is considered in Chapter 10.

[vii] It was necessary to introduce the proviso ‘... or some equally primitive bodily movement’ because there are patients who are open-eyed, apparently unresponsive and who display primitive postural movements but who it is subsequently found can communicate by some primitive bodily movement other than eye movement; for example, patient B of the Andrews (1996) study was such that:

“Only when he was satisfactorily seated was it identified that he had a slight shoulder shrug which could be used for communication purposes.” [Andrews (1996) p.15]

[viii] The proposal is, in essence, to bring the definition of PVS into harmony with best clinical practice which, I suggest, implicitly uses just such a definition; see, for example:

a)Conclusion 4 -14 : The Andrews 1996 study on misdiagnosis used ‘ability to communicate’ as a surrogate for ‘possession of awareness’.

b) A new test devised by the Royal Hospital for Neurodisability in London for examining PVS patients - though described in media reports as a testing for ‘returning awareness - appears to be essentially concerned with developing communication:

“The technique, known as Smart (Sensory Modality Assessment and Rehabilitation Tool) involves systematically stimulating each of seven modalities - sight, hearing, touch, smell, taste, movement and communication - whilst looking for signs of returning awareness.” [The Independent 17.12.1997.]

[ix] indeed, the term ‘near-PVS’ becomes redundant.