Ethical dilemmas in health care are often the most difficult to navigate. Quite often the life of a person depends on the decision made when a challenge arises. This is certainly the case regarding patients in a permanent vegetative state. These cases have provoked very strong, opposing opinions throughout the medical community. Generating a definitive answer to how a facility handles these situations is extremely important to ensure appropriate ethical policy is followed throughout the care or termination of medical services for a person in a permanent vegetative state. Four ethical principles assist in guiding the ethical conversation: autonomy, nonmaleficence, beneficence, and justice.
Preserving a patient’s autonomy is a standard ethical policy for health care providers. Examples of how doctors and facilities protect a patient’s right to independence include Advance Directives, the Patient Self-Determination Act, and HIPAA. “The problem is that vegetative patients are not competent to refuse continued treatment, and there is concern about how best to protect them from treatment that they would probably refuse if they could” (Jennett, 2002, p. 356). A patient who has the unforeseen misfortune of entering into the permanent vegetative state may not have the chance to express their stance through an Advance Directive on how he or she wish to proceed medically, therefore stripping him or her of the right to autonomy.
Some patients may have expressed their wishes informally to their family members and loved ones, such as the desire to donate organs when the time comes. If the decision were made to end medical care in a more direct and rapid way, organs would have a better chance of becoming used to help others, which would restore some of the patient’s autonomy (Wade, 2001). Most people would rather donate their organs for the benefit of others, rather than remain in an unconscious state, when given the choice. Unfortunately, these patients are not given a chance to voice that opinion.
Nonmeleficence is the ethical principle to do no harm. It could be argued that a person in a permanent vegetative state feels nothing, and that poses the question regarding whether or not one can do harm to someone who does not feel anything emotionally or physically (Wade, 2001). In addition, continued treatment actually may be doing harm to the patient. “There have been many declarations that survival in a permanent vegetative state is not a benefit to the patient, some regarding it as a fate worse than death” (Jennett, 2002, p. 356).
There are opposing viewpoints that believe patients in a vegetative state actually may be aware of their surroundings. According to Hope (2011) a study confirmed, “patients thought to be in a permanently ‘vegetative’ state may still be able to think and communicate” (para. 1). Although this may sound hopeful for loved ones, for some patients being aware of surroundings but not able to move or communicate is doing more harm to them. Would it be more nonmaleficent to end their suffering if they have poor quality of life?
The philosophical question beneficence raises is will an unknowing patient benefit from an act of good (Wade, 2001)? The patient is not aware of any kind or unkind act done to him or her in an unconscious state. Ongoing treatment could bring about a recovery, but a patient may not view this as beneficent. The state that their body and mind would be in and the quality of life they would have is questionable for whether or not keeping the patient alive was actually doing him or her any good. Beneficence can also relate to the survivors of the patient. In many cases, it is the willingness of the family to keep the patient alive in the hopes of a miracle even if it is against what the doctor’s recommend (Brody, 1988). Is it beneficent to the patient’s family to remain in a state of ongoing grief when there is no improvement in sight?
Justice is the most applied ethical principle for arguing for or against termination of treatment for patients in a permanent vegetative state. One argument that can be raised is whether or not it is fair to continue to allocate resources for a person in this state when it limits the care and resources other patients could be receiving (Wade, 2001). If a person is in a permanent unconscious state and doctors have determined that he or she will not regain consciousness or live a normal life, should the care and services he or she are using be given to a patient who has a greater chance of recovery. In addition, consider the cost to society for paying for the ongoing resources and care these patients will need (Brody, 1988). Is it fair to impose that cost on others? Instead, the funds could be used to save the lives of others. However, if the policy became to end patient’s care once they have reached a permanent vegetative state it could be said that attitudes may change toward other severely disabled people and the ongoing care they receive (Wade, 2001).
Provider’s compassion may begin to be diminished over time through seeing the termination of care on these permanent vegetative patients, and it may desensitize them in a way that would make it difficult for them to provide any ongoing care to disabled people. Terminating an individual’s life whether it is physician-assisted or merely stopping food sources will always pose huge ethical concerns, even if the patient is in a permanent vegetative state and cannot express emotion or feel pain. Forming an opinion on the issue is not easy, and there are many parties who have interest in the outcome such as the patient, their family, the staff providing care, the facility providing care, and society. By applying the four ethical principles of autonomy, nonmaleficence, beneficence, and justice healthcare administrators can begin to form an ethical opinion to shape the way their facility approaches the many challenges permanent vegetative patients cause.
Brody, B. A. (1988). Ethical questions raised by the persistent vegitative patient. The Hastings Center Report, 18(1), 33-37. Hope, J. (2001, November 10). Vegitative patients ‘can still think and respond’. Daily Mail, 0(0), 28. Jennett, B. (2002). The vegitative state. Journal of Neurology, Neurosurgery and Psychiatry, 73(4), 355-357. Wade, D. T. (2001). Ethical issue in diagnosis and management of patients in the permanent vegetative state. BMJ: British Medical Journal, 322(7282), 352-354.