Persistent vegetative state is a phrase that conjures emotions, hesitancy, and misunderstanding about the prognosis of those with advanced diagnoses. The life, dying and death of Terri Schivo was witnessed by many in the United States and the story surfaced the controversies that surround PVS. By definition, PVS attends to levels of consciousness in human persons. The term was first introduced in the early 1970s when Jennett and Plum attempted to coin a term to define an increasingly frequent level of human existence.34 In those phenomenally progressive years of medical science patients were surviving conditions never before survivable but their level of consciousness was often not restored or brought anywhere near pre-injury levels. Persistent vegetative state describes the condition of patients with severe brain damage who were in a coma and progressed to moments of appearing to be awake but demonstrate no indication of awareness.35 Research with those experiencing PVS led to the American Academy of Neurology issuing a definition and specific guidelines for the vegetative state.
The vegetative state is a clinical condition of completed unawareness of the self and the environment, accompanied by sleep wake cycles with either complete or partial preservation of hypothalamic and brain stem anatomic functions.36
The definition is supported by critical criteria that must be present in persons diagnosed with PVS.37 First, persons cannot demonstrate awareness of themselves or their
surroundings, including an inability to interact with persons or things. Second, there can be no indication of purposeful or voluntary behavioral responses to any type of stimuli. Third, an absence of language comprehension or expression must be present. Fourth, moments of wakefulness as occurs in sleep-wake cycles are present. Fifth, enough hypothalamic and brain stem function to support physical existence needs to be present
and require ongoing medical and nursing care. Sixth, patients exhibit bowel and bladder incontinence. Seventh, cranial and spinal nerve reflexes exist without purposeful
movement.38
The scientific criteria regarding vegetative state, as precise as they are in supporting clinical diagnosis and helping to inform family members about a person's prognosis, still require an even more precise clarification. The use of the adjective "persistent" conjures a condition of past and continuing disability and this leads to the perception that the condition might be reversible. However, the use of the adjective "permanent" is considered more appropriate in describing the irreversible state of physiological being.39 The AAN took on this additional challenge through its research and concludes that there does exist a distinction in the vegetative condition. Persistent vegetative state is a diagnosis appropriate in patients a month after an acute brain injury or those patients with degenerative or metabolic disorders or developmental
malformation.40 Permanent vegetative state is an irreversible state diagnosed by probabilities with a high degree of clinical certainty that the patient will not regain consciousness.41
This extensive discussion of PVS is critical. The effort to clarify for both
clinicians and patients this state of existence continues to cause confusion in clinical and lay communities. One specific reason is that in practice the distinction of persistent and permanent is seldom made. As a result, efforts are currently underway in the United States and Australia to discontinue the use of the term PVS completely. The American Academy of Neurology has suggested a taxonomy that describes two levels of
when the patient has specific temporal and neurological deficits. The minimally responsive or conscious state denotes those patients with some level of cognitive
functioning.42 In practice these newer distinctions, although potentially more precise, are even less evident than the distinction between permanent and persistent. However, when one is attempting to discuss the relative benefit of MANH and set goals of treatment, each of these definitions needs to be clearly articulated within the context of the
individual patient's condition. It is in such personal contexts that discussions of the use of MANH are to be considered.
Ethical principles and sound ethical reasoning are needed when making individual treatment decisions about the use of MANH at the end of life. While discussions about MANH require clarity of prognosis and potential response to treatment, decisions are also influenced by cultural and religious values that shape patients and society. In 2004 the Catholic tradition was given an opportunity to revisit its rich legacy of moral reasoning with regard to end of life care. This opportunity surfaced when John Paul II delivered a papal allocution on the use of artificial nutrition and hydration by persons in a vegetative state.43 His comments complicated and confused many about the use of MANH at the end
of life but they also confused many regarding general end of life care decisions. In summary John Paul II's allocution affirms three specific points.44 One, the life of persons in PVS have the same inherent dignity as the lives of others. Hence, he dismisses the tendency to consider quality of life in the decision making process. Two, PVS is a severe condition of disability rather than a terminal illness. Hence, assistance is to the patient in PVS is morally demanded unlike those in a terminal course where allowing one to die is morally acceptable. Three, artificially provided food and fluids are to be considered
routine care and are to be provided to all persons, including those in PVS. Hence, the burden or benefit analysis is neutralized and seemingly not applicable to those in PVS. A.4 Conclusion
A substantial amount of literature, both secular and religious, has been generated with regard to the use of MANH at the end of life. Some consider artificial nutrition and hydration as another form of life-sustaining treatment whose use is to be tested against a person's benefit-burden assessment. Others consider feeding tubes and what they deliver as a basic form of care and, therefore, morally obligatory. Still others consider the withdrawal of feeding tubes appropriate in persons who are imminently dying but not in persons in PVS. These various positions and the controversies around them influence decision making regarding MANH at the end of life. By adopting an ethics hermeneutic, the intention is to draw on the secular component of agency and the mission related religious theme of sanctity of human person to contextualize the issue of decision making. The hermeneutic helps to consider the ethical significance of the virtuous organization inspired by Catholic mission as it relates to the issue of decision making at the end of life.