In the last century, with the advent of plastic tubing, new ethical issues have been raised regarding nutrition and hydration of patients in comatose, or that of persistent vegetative states. By performing fairly simple procedures, artificial nutrition and hydration (AN&H) may be provided to almost all patients, including those unable to swallow.2 Therefore, patients who would otherwise imminently die may sometimes be kept alive for months or years. A Controversial issue that C.Pallis describes in his commentary on whole brain death is that of patients who are in persistent vegetative state (PVS). PVS, patients are not capable of voluntary action or behavior. They are not aware of their environment and do not have the capacity to experience pain or suffering.1 It is sometimes described as when a person is technically alive, but his/her brain is dead. However, that description is not completely accurate. In persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact.4 Spontaneous movements may occur and the eyes may open in response to external stimuli, but the patient does not speak or obey commands.1 However, these patients are not terminally ill and may survive for years if AN&H are provided. In such cases, the fundamental question is do physicians and families have an obligation to continue supplementation indefinitely, despite the fact they will never regain consciousness?

Although, in regard to patients who are at closer stages of dying and for whom AN&H will provide absolutely no benefit, few would agree that we have an ethical obligation to supplement these patients.2 There are other patients, for whom the burdens clearly outweigh the benefits, and for whom continuation can be predetermined with no debate. If the case is that the PVS patient is in effect never going to regain consciousness, would it not be more 'humane' to allow these individuals to be rid of any further suffering? Below are ethicists arguments for withholding AN&H from the PVS patient:

1. If PVS patients cannot experience pain, to withdrawal AN&H will not cause any further discomfort or pain. 2. To supplement PVS patients is costly and burdensome in many ways, and after a period of several months the likelihood that the patient will return to sentient functioning becomes decreasing unlikely. 3. With so many pressing sensible needs around the world, (such as hunger in third world countries) is it altruistic to spend large sums of money on patients who will almost certainly never recover, rather than on people who have a greater chance? 4. Since the provision of AN&H is a medical treatment, withholding them no more changes the basic medical cause of death than does withholding a respirator. Patients die not from starvation or dehydration, but from their underlying disease processes. 5 Withholding AN&H is not a painful process as long as the patient's lips, eyes, and mouth are kept moist. 2

On the other side of spectrum however, there are those who firmly believe that it is wrong to withdrawal AN&H from the PVS patients. For some godly believers feel that since all humankind is made in the image of God, and since even the PVS patient remains in that image, we never have the right to terminate nutritional support3. One of their concerns is that since God continues to perform miracles, and since we cannot know the future, we cannot know when a situation is truly ineffective.3 For these believers, there would never be a time when nutrition should be discontinued.

Ethicists who stand opposed to withdrawal of AN&H frequently believe:

1) AN&H are necessary to preserve patient dignity. 2) Nutrition and hydration is ordinary humane treatment and should be provided to every patient. The argument between artificial versus ordinary is pointless since such supplementation can be provided at small cost and with little difficulty. 3) Withdrawal of AN&H amounts to starving the patient to death. Dehydration and starvation would be the proximate cause of death, not the underlying illness. 4) If we begin withholding such care from the dying, we are denying their humanity. This may represent the beginning of the slippery slope toward active euthanasia.2

Consequently, the first point of debate would be whether there is ever a time that AN&H can ethically be withdrawn. For those that emphasize God's 'miraculous interventions' and our inability to predict the future, possibly the answer would be "No." We should remain true to our moral convictions and act accordingly when it comes to patients with PVS and loved ones. These ethicists have not determined the issue of when the patient is considered clinically dead in the sense of higher or whole brain functioning. Should there be a definition of death in place? The constant debate over whether the PVS patient in loss of higher brain death, should in fact be let off AN&H is a struggle that Philosophers and Doctors continue to debate. If I were to be in the PVS position, the answer would be to let me live until 'natural' forces take my life, for the hopeful fact remains that regaining spontaneous consciousness perhaps could prevail. Can the medical profession or Harvard ad hoc committee hold the upper hand in making such definitions in light of such speculation as to whether there is a definition for such a finite state?

Footnotes

1. "Coma and persistent vegetative state" Http://healthlink.mcw.edu/article1921394859.html. Medical

College of Wisconsin Physicians and Clinics.

2. Scott B. Rae, "Moral choices; An introduction to ethics" Grand Rapids, MI: Vandervan Publishing 1995.

3 John F. Kilner, et al. "Dignity and Dying: A Christian Appraisal" Grand Rapids MI: William B Eardman's Website: Http://www.cbhd.org

3. Pallis C. "Whole brain death reconsidered- physiological facts and philosophy" From Journal of medical Ethics, Vol. 9, P. 34 Society for the study of medical ethics, 1983