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Should patients in a persistent vegetative state be allowed to die? Guidelines for a new standard of care in Australian hospitals

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Abstract

In this article we will be arguing in favour of legislating to protect doctors who bring about the deaths of PVS patients, regardless of whether the death is through passive means (e.g. the discontinuation of artificial feeding and respiration) or active means (e.g. through the administration of pharmaceuticals known to hasten death in end-of-life care). We will first discuss the ethical dilemmas doctors and lawmakers faced in the more famous PVS cases arising in the US and UK, before exploring what the law should be regarding such patients, particularly in Australia. We will continue by arguing in favour of allowing euthanasia in the interests of PVS patients, their families, and finally the wider community, before concluding with some suggestions for how these ethical arguments could be transformed into a set of guidelines for medical practice in this area.

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Notes

  1. Jennett and Plum (1972, p. 734).

  2. Jennett (1993, p. 40).

  3. Ibid.

  4. Cranford (2006, p. 67).

  5. NHMRC (2008, p. 5).

  6. Stender et al. (2014, p. 519).

  7. R. D. Truog notes that in some cases life-sustaining support such as tubal feeding is provided as a “matter of convenience” as hospitals do not have the time or resources to keep patients nourished through oral feeding (Truog 2008, p. 47).

  8. Jennett (1976, p. 595; 1993, p. 43). A recent case demonstrating this is that of Jahi McMath, a teenager deemed to be brain-dead in December 2013 by staff at a Children’s Hospital in Oakland, California and whose life support was considered an inappropriate use of medical resources (Fieldstadt 2013).

  9. Stender et al. (2014, p. 514).

  10. Cruzan by Cruzan v. Harmon, 760 S.W.2d 408 (1988); Singer (1994, pp. 61–62).

  11. Ibid., p. 63.

  12. Cranford (2006, p. 105); Order, In Re: The Guardianship of Theresa Marie Schiavo, Incapacitated, File No. 90-2908GD-0003.

  13. Cruzan; in Quinlan it was described as “the right to a natural death.”

  14. Schloendorff v. Society of New York Hospital, 211N. Y. 125, 129–130, 105N. E. 92, 93 (1914).

  15. N.J. Const. (1947), Art. I, par. 1.

  16. Constitution of the United States, Amendment 14.1.

  17. Cruzan.

  18. Schiavo; see also Harvey v. Harvey, 949 F.2d 1127, 1133-34 (11th Cir.1992): “Use of the courts by private parties does not constitute an act under color of state law.”

  19. Ibid.

  20. Airedale NHS Trust v. Bland, [1993] 1 All ER 821.

  21. Ibid.

  22. Singer (1994, p. 59).

  23. Mitchell et al. (1993, p. 75).

  24. NHMRC (2008, p. 59).

  25. Geraghty (2002, p. 185).

  26. Northridge v. Central Sydney Area Health Service [2000] NSWLR 1241.

  27. Messiha v. South East Health [2004] NSWSC 1061.

  28. Faunce and Stewart (2005, p. 261).

  29. Saxton (2013, pp. 205–206).

  30. Willmott et al. (2014, pp. 545–547).

  31. Slaveski v. Austin Health [2010] VSC 493.

  32. Such an argument is also suggested by Catherine Constable in reference to the situation in the US in “Withdrawal of Artificial Nutrition and Hydration for Patients in a Permanent Vegetative State: Changing Tack” (2012, p. 157).

  33. From a distributive justice perspective there would need to be limitations placed on what treatments such patients could reasonably demand. Truog recounts the case of Catherine Gilgunn, an elderly woman who slipped into a coma following uncontrollable seizures. Her daughter refused to sign a Do Not Resuscitate order due to a belief Gilgunn would have “wanted everything possible to save her life regardless of cost.” After requesting an ethics consult, physicians stood by a decision that resuscitation would be “inhumane and unethical” and did not attempt to resuscitate Gilgunn when she later arrested. Gilgunn’s daughter sued and while the jury agreed that the patient probably would have desired resuscitation, as such an act would have been medically futile, it was decided the physicians were not obliged to provide it (Truog 2008, p. 46).

  34. Jennett (1993, p. 41).

  35. Demertzi et al. (2011, p. 1060).

  36. Ibid., p. 1061.

  37. Gipson et al. (2014, p. 5).

  38. Ibid., p. 6.

  39. Pamela Bone, “Foreword,” in Syme (2008, p. v).

  40. Kass (2002, p. 245).

  41. Stanley (1989, p. 131).

  42. Ibid.

  43. Fisher (1999, p. 475).

  44. Gray et al. (2011, p. 278).

  45. NHMRC (2008, p. 3).

  46. Wilkinson et al. (2009, p. 509).

  47. Ibid.

  48. Ibid.

  49. Andrews (1991, p. 121).

  50. Jackson (2013, p. 962) and McCullagh (2004, p. 243).

  51. Glover (1977).

  52. Gipson et al. (2014, p. 5).

  53. Health Experience Research Group, Oxford University’s Department of Primary Care and Health Sciences “Media Representations of Coma: Reality versus Fiction.” Available at: http://www.healthtalk.org/content/media-representations-coma-reality-versus-fiction.

  54. Fine (2005, p. 307).

  55. Kuehlmeyer et al. (2012, p. 335).

  56. Ibid.

  57. Gardner (2007, p. 166). It is not possible to speculate what the reaction might have been to the use of pharmaceuticals as an alternative method.

  58. Truog (2008, p. 47).

  59. Syme (2008, p. 274).

  60. Willmott et al. (2011, pp. 523–544).

  61. Stanley (1989, p. 130).

  62. S5. Medical Treatment Act (VIC) 1988.

  63. VCAT 121 (28 February 2003); While this decision only applied to Victorian Law, bioethicist Loane Skene noted in 2004 that it was likely to be adopted in other states (Skene 2004). Other commentators also wrote in the same year that this decision should become policy Australia-wide (Mendelson and Ashby 2004, p. 286).

  64. R v. Klinkermann [2013] VSC 65.

  65. R v. Shirley Justins [2008] NSWSC 1194.

  66. McGee (2014, p. 26).

  67. McGee (2004, p. 46).

  68. Medew (2014).

  69. Andrews (1991, p. 121).

  70. Bernat (2010, p. S36).

  71. Wanzer and Glenmullen (2007, p. 16).

  72. Cranford (2006, p. 69) and NHMRC (2003, p. vii).

  73. Wilkinson and Savulescu (2012).

  74. Mitchell et al. (1993, p. 72).

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Kendal, E., Maher, LJ. Should patients in a persistent vegetative state be allowed to die? Guidelines for a new standard of care in Australian hospitals. Monash Bioeth. Rev. 33, 148–166 (2015). https://doi.org/10.1007/s40592-015-0039-6

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