Should Dehydration Be the
Default Decision for PVS?
Bioethics exploded into the headlines over the last few weeks after the Journal of Medical Ethics published an article promoting "after-birth abortion," that is, the right of parents to have infants killed if the child's presence in life did not serve their (or society's) interests.
But hidden by the sturm und drang over infanticide, Bioethics published another radical proposal that received virtually no attention—but which, if adopted, could result in thousands of persistent vegetative state (PVS) patients being dehydrated to death.
The question concerns whether or not to provide such patients with food and water. Tube-supplied sustenance—called artificial nutrition and hydration (ANH)—is considered a form of medical treatment that can be withdrawn or withheld like any other medical care, such as antibiotics, chemotherapy, and indeed, aspirin. Of course, unlike withdrawing other treatments, ceasing to provide ANH results in the patient's death in every case—usually over a 10-14 day period.
(Withdrawing such medically efficacious sustenance should not be confused with situations in which a patient's body is actively shutting down during the dying process and the body can't assimilate food or water. In such cases, ANH is medically inappropriate. The patient dies of their disease, not dehydration.)
Currently, in the absence of an advance directive to the contrary, benefit is given to life in PVS and other catastrophic brain injury cases—with surrogate decision makers able to order that such treatment cease if they think it is in the patient's best interests. But that would change if Catherine Constable, the author of the Bioethics article, gets her way.
She argues for a policy in which ANH must be withdrawn once a patient is diagnosed to be permanently unconscious unless the family orders otherwise. In other words, dehydration would become the default position for patients diagnosed in PVS.
How does she justify such a harsh measure? First, she denies PVS patients have an "interest" in living because (quoting Princeton bioethicist Peter Singer) "life cannot benefit them." That being so, money rules:
We need not label these patients as already 'dead' or claim that withdrawing care is not the same as 'taking life' in order to find that it is difficult to apply any sort of 'right to life' argument to a patient who would not now or ever choose to exercise that right. In view of this conclusion, other considerations, such as the cost to the health care system . . . would seem poised to be deciding factors. Of course, such an argument could also be voiced in support of killing these helpless patients by harvesting their organs. Indeed, it already is—as I have discussed previously. But what about the people who unexpectedly wake up? Constable says most of these weren't truly PVS—even though some had been so diagnosed. (In fact, studies show that PVS is misdiagnosed about 40% of the time.)
But that doesn't matter because "the new life gained" by the "miracle patient" is "far less likely to resemble what he lost than to be some state of middle consciousness;" a life "quite possibly, worse than non-existence." Moreover, the potential benefit of living to be a miracle patient "is not sufficient to trump the public interest in allocating resources to patients more likely to benefit."
In typical bioethics style, Constable then puts in a hedge, allowing that families of PVS patients should "be given the last word." That would still put at immediate risk of dehydration the thousands of existing PVS patients without families.
But even Constable's bow to family intimacy seems political and hollow. Thus even though she states that families "should be encouraged to consider whatever factors they deem useful," families would be made to believe that dehydration is right:
We should discontinue the practice of putting families in the position of having to justify a decision to withdraw ANH by making assertions about what the patient would have wanted . . . To put the onus on a family to justify the decision to withdraw ANH is to effectively treat them as would-be executioners who need to be checked . . . In the case of PVS, when in doubt as to a patient's wishes, it is better to discontinue life-sustaining treatment.
But if it is true that families now have to justify choosing to dehydrate, this radical shift would put families in the position of having to justify the continuance of food and fluids in the face of potentially hostile doctors, bioethicists, and the public policy of society.
Families often already face too many such pressures. Creating a "default for death" policy would not only make matters worse, it would establish the foundation for a veritable duty to die.