Some fundamental questions about human life: Ethical comments of Japanese physicians in terms of the appropriate care of patients in persistent vegetative state
- Atsushi Asai, MD, Mbioeth., DMsc.
Department of Biomedical Ethics, School of Public Health,
Kyoto University Graduate School of Medicine
Konoe-cho, Yoshida, Sakyo-ku, Kyoto 606-8501 Japan
Eubios Journal of Asian and International Bioethics 11 (2001), 66-67.
This paper is based partially on my presentation at the TRT5 at Tsukuba on November 20, 1999.
There are many controversial ethical problems in the management of patients in persistent vegetative state (PVS patients). Some of them are so fundamental that few, including physicians and ethicists, can agree with each other in this regard. Almost all ethical issues with regard to the care of incompetent patients are involved in this category including sanctity of life, quality of life, medical futility, personhood, advance directives, and resource allocation. In this paper, I would like to refer to some ethical issues concerning PVS patients by analyzing attitudes of Japanese physicians toward the care of PVS patients. They will include the questions about human dignity, value of life, and the goals of medicine. I will present some typical comments that Japanese physicians wrote in a survey conducted in 1997 in Japan. The survey was done on 317 representative members of the Japan Society of Apoplexy and the quantitative results of the study and detailed research methods were published elsewhere (1). Then, basic questions raised by the comments will be brought forward. My arguments and questioning are preliminary and fragmentary. The main aim of this short paper is to ask some ethical questions abut human life. A PVS patient is defined as one who is permanently unconscious and this category of the patients do not include mentally disabled persons or demented patients.
2 Some Typical Comments That Japanes Physicians Provided About The Care Of Pvs Patients
I would like all of audience of EJAIB to think through the following comments and to judge whether or not these comments are ethically plausible. The comments will be itemized in the following. My brief comments will be added in the end of each category.
2-1 Dignity as a human being
"A PVS patient is a severely disabled person and deserves respect and care as much as any other patient".
"The dignity of a PVS patient is not offended at all and, therefore, medical professionals should treat and care for them with respect".
"Dignity as a human being of a PVS patient is preserved better than that of a brain-dead patient".
"Respecting human dignity constitutes sustaining a patient' life as long as possible".
I agree that a PVS patient is one of severely and literally disabled human beings. However, whether or not these comments are ethically plausible depends on what human dignity really is and who should determine it. And, there seems no direct connection between respecting human dignity and life-prolongation. This is because prolonging undignified life cannot mean respecting human dignity and prolongation of life is about quantity and dignity is about quality. I am also not sure how to claim the difference in dignity between a PVS patient and brain dead patient. Even if it is postulated that brain dead persons are not dead, what makes ethically different in terms of human dignity between the two? More basically, can we evaluate other person's dignity?
2-2 The goals of medical care and medical education
"Physicians ought to sustain the life of a patient in any condition. I had been taught that prolonging the patient' life is our obligation and I have been educating young physicians and students in the same way".
"I cannot directly shorten a patient' life because of my professional obligation".
"Whenever possible, I will have everything done to maintain a patient' life".
Is unlimited and unconditional life prolongation the overriding goal of medical care? Are physicians really obliged to sustain the life of their patients in any conditions? It seems that some physicians have accepted what they were taught unconditionally without critical consideration. These comments urge us to think who should set the goals of medicine, especially when a patient is persistently unconscious. This is because the goals of medicine determine ethical and professional obligations physicians have to follow.
2-3 Patient' preferences, family' wishes, and advance directives
"Patient' preference is by far the most important in deciding what ought to be done for him or her. The patient' advance directives should be respected".
"I usually intend to prioritize family' wishes over dignity of a patient who is irreversibly unconscious when I decide management plan".
"It is very important for us to respect the family' wishes about the care of patients in a mere biological state, but it does not follow that we have a duty to defer to whatever they want".
Advance directives are considered, by many physicians, a useful tool to respect and materialize patient autonomy when the patient becomes incompetent. However, what does autonomy of a permanently unconscious patient actually mean? Can we automatically expand the power of autonomy to incompetent patients? It is suspected that an attitude expressed in the second comment is shared by considerable number of physicians in Japan where patient's family have a strong influence in medical decision-making. In fact, it deserves to ask ourselves which is more important, incompetent patient' previous wishes or current family wishes. My conclusion is undermined. When there is no hope of recovery from persistent unconscious state, whose benefits should be prioritized in medical decision-making? Can a PVS patient really benefit from anything such as life-sustaining treatments or high quality care" Again, I am not sure.
2-4 Distinction between extraordinary medical care and ordinary care
"Minimal treatments should in principle be given. But, I would not use mechanical ventilation".
"Even if a patient's advance directives and/or his or her family required us to discontinue life-prolongation, we could not accept all they want. This is because there is a certain treatment that a physician is professionally obliged to do".
"I would never stop giving artificial nutrition and hydration to a PVS patient".
"Despite patient' advance directives, artificial nutrition and hydration cannot be withdrawn".
"It is inhumane not to give water to those who are alive. However, it is uncertain that we should provide a PVS patient with hyperalimentation (high calorie nutrition)".
Similar comments have repeatedly appeared in papers and textbooks in the field of bioethics and health care ethics. Ethical distinctions between withdrawing and withholding life-sustaining treatments and between ordinary and extraordinary interventions have been frequently discussed among bioethicists and it seems that many agree that there is no such distinction. However, some physicians in Japan have regarded these acts as different. The fifth comment is particularly interesting and a physician makes very subtle distinction between pure water and calorie-rich water. However, in terms of consequences, a PVS patient would slowly but surely die if the physicians gave nothing but water.
2-5 A matter of consensus?
"We cannot change basic therapeutic strategies for a PVS patient. Nationwide consensus is necessary to determine value of life and ethics of the care of such patients".
Do all of us, say, all of Japanese people need to agree as to how to define a brain death? Is such a question a matter of consensus? Or is it a matter of choice? There is no easy answer about it. But, it should be noted that universal agreement does not necessarily constitute objective rightness. Everyone can make mistakes.
2-6 What makes a life in PVS valuable?
"As long as there exists someone who regards a life in biological life meaningful or valuable, I would continue the patient' life. Even if the patient is living as just a thing, it does not mean that such a patient has been reduced to ashes (a meaningless object) when his or her family wants to maintain his or her life".
A physician who wrote this comment might believe that we should prolong the life of PVS patients, in principle, when the patient_fs family wanted the patient to survive. This comment also might implicitly express the position that when no one wanted to prolong the life of a PVS patient, it could be permissive to discontinue life-prolonging interventions for such patients. I basically agree with his attitude in this regard although I cannot fully argue or defend my position here. My extensive discussion in this regard was described in an essay named "Should a patient in PVS live" published elsewhere (2).
3 Some Questions About Human Life
The comments I just mentioned above inevitably urge us to ask several fundamental inquiries with regard to human life.
"What is human dignity? Who can decide it?"
"Is human life intrinsically valuable or instrumentally valuable?"
"What makes human life valuable?"
"Are ethical problems about life including the value of life in PVS or the definition of death a matter of consensus or a matter of choice?"
"What are the goals of medicine?"
All of the questions are all linked and extremely difficult to resolve. Even well informed thinkers including ethicists and physicians could have sharply different answers for them. However, making significant ethical decisions in clinical settings or deciding social policies, all of us ought to take consistent and clear attitudes towards these problems. Such tasks might be very hard, but essential for those of us who are seriously studying biomedical ethics. In the following, I would like to briefly discuss what human dignity is and what makes our life valuable.
First, what is the dignity of human life? According to a dictionary, the dignity of people, or their lives or activities means that they are valuable, and worthy of respect. It says "Your dignity is the sense that you have of your own importance and value and other people' respect". It is also defined as the quality of character that wins the respect and high opinion of others (3). I would argue that we should define the dignity of life as the sense that an individual has of his or her own importance and value. This is because different people dignify different quality or state of life. Of course, there might exist consensus about what a dignified life or dignified death is like. Many people may agree as to what kind of life is respectable. However, what is the most important is that an individual perceive his or her life important and valuable. For example, suppose that many people regard living with a certain disability as undignified. But it is certainly possible that a person with the disability perceives his or her life important and worthwhile to live. In contrast, some may not tolerate a certain quality of life and feel undignified even if many others think it acceptable. Therefore, it is argued that the dignity of life has to be determined by an individual who lives the life as far as such determination does no harm to others.
If I am right, is it possible for us to discuss whether or not the life of a PVS patient has human dignity? The patient in such a state has no self-consciousness or ability to feel, think, or evaluate the life of his or her own. I have no intention to claim that the human dignity of such patients is low or offended. In my opinion, what is human dignity is just irrelevant to the PVS patients themselves. A problem regarding whether or not a PVS patient is really unconscious is beyond the scope of my discussion here. I just mentioned that I have relied my medical consideration on very reliable medical data (4).
Second, is the value of life intrinsic or instrumental? What makes a life valuable? I believe that what value is should be considered based on what an individual regards as valuable. Value is the worth of something. It is also defined as a relative merit according to the estimated desirability or utility of a thing. If I place a particular value on something, that indicates the importance or usefulness I think it has. Therefore, it seems reasonable to say that what makes X valuable to someone subjectively is the fact that he or she desires X. My point is simply that something cannot be perceived as valuable if no one appreciates it (2, 3). In terms of life in a PVS, the life is valuable as long as someone finds it worthwhile to prolong. It is impossible to say that something is intrinsically valuable despite the fact that no one thinks it valuable. I believe that when people say X is intrinsically valuable, what is really meant is that X is valuable to the people. In the same token, the fact that some regard the life in a certain state as valuable does not follow that the life is intrinsically valuable, but it simply means that it is valuable to those who believe so. In conclusions, my position is that both human dignity and the value of life should be consciously determined by each individual. And when the individual is permanently unconscious, these two concepts could be ethically irrelevant to the individual himself or herself.
1 Asai A. et al.: Survey of Japanese physicians_f attitudes towards the care of adult patients in persistent vegetative state. Journal of Medical Ethics 1999;25:302-308.
2 Asai A.: Should a patient in a persistent vegetative state live? Monash Bioethics Review 1999;18:25-39.
3 Collins Cobuild English Dictionary. The University of Birmingham/Harper Collins Publishers. London. 1997:1854.
4 The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state. NEJM 1994;22:1572-9.
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