Wrestling with the final call
When it comes to end-of-life decisions, taking an ethical path isn't always easy
In the United States over the past 20 years, for better or for worse, something like a consensus--medical, ethical, and legal--has come to inform the handling of patients diagnosed as being in a "persistent vegetative state," or PVS. In hospitals and hospices across the nation, the families and attending physicians of such patients (ranging in various estimates from 10,000 to 35,000) typically confer, sometimes with a panel of ethicists or other physicians, to determine whether these patients should continue to receive treatment and sustenance.
If the patient's wish not to receive such care has been established in a directive or in words spoken to a family member, a decision is usually easily arrived at. Receiving no further medical treatment or tube feeding, the patient slowly dies. Cases in which there are no clear directions are more difficult, though many end with family or guardians concluding, sometimes after a few years, that keeping the patient alive is pointless. (About 85 percent of all adult PVS patients die within five years of incapacitation, though it is not clear how many do so as the result of suspended care.)
In some very few cases, though, the families disagree among themselves about whether support should be suspended. Those disputes typically end up in court. Or, in the case of Terri Schiavo, not just in state and federal courts but in state and national legislatures--and, indeed, on just about every television screen in America. But for all the emotion that it now generates, will the controversy over Schiavo's fate shatter the ethical consensus over the management of patients in a vegetative state?
Answers vary, of course, depending on what kind of expert is asked. Most physicians and bioethicists remain confident in the consensus that began to take shape with the 1976 court ruling on Karen Ann Quinlan, bolstered by subsequent court rulings dealing directly with the removal of feeding tubes. In a recent survey of 900 physicians conducted by HCD Research and the Jewish Theological Seminary's Louis Finkelstein Institute for Religious and Social Studies, 77 percent responded that it was "medically ethical" to remove Schiavo's feeding tube. Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, believes the consensus will survive "because it has basically functioned well."
Divisions. Other ethical thinkers, including many philosophers, religious leaders, and theologians, say that the fissures run far deeper because they result not just from the peculiarities of a difficult case but from questionable assumptions about the status and care of PVS patients in general. At its crux, they say, the question is whether removing a feeding tube is simply part of suspending extraordinary medical measures that keep the patient alive or whether it is withholding basic care in a way that causes death.
To be sure, framing the question that way does not in itself produce instant moral clarity. "As I understand Jewish tradition, there is a murkiness," says Alan Mittleman, director of the Finkelstein Institute. "You are not supposed to do anything to hasten death, but, on the other hand, there is no need to do anything to artificially prolong life." At the very least, in Mittleman's view, that murkiness should give more people, and particularly more physicians, pause. "I would hope that a tragic case like this would make us more mindful of what our God and community expect of us," he says.
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