Falling into a persistent vegetative state (PVS) is another situation that might be complex for a patient, caregivers, and close people. It involves ethical and medical issues, the living will of a client, his/her prior recommendations and decisions, and advance care planning. PVS can trigger vigorous debates about future care, its necessity, and the possibility of improving the patient’s state. At the same time, the ideas of the caregivers or families might be contradictory or disregard the living will of a patient. Under these conditions, PVS and the treatment withdrawn might raise numerous ethical concerns that should be considered when making a final decision. It is vital to consider all existing perspectives, the legal framework and guarantee that the interests of the patient are observed. In some cases, it becomes a complex task because of multiple parties and their visions.
The PVS means that a patient does not have brain death, and he/she is in a specific state called a coma. He/she remains alive; however, because of the peculiarities of the condition, he/she cannot move, respond to the environment, or interact with other people. It also means that the patient cannot make decisions and approve specific actions or treatment plans (Munson & Lague, 2016). For this reason, caregivers and close people become responsible for the further provision of care. Another problem linked to PVS is that it is not recognized as death by the legal system. For instance, the U.S. court demands credible evidence and expertise proving that there is no chance of recovering cognitive functions to allow the termination of life (Kestigian & London, 2016). Vagueness and complexity in the definition of the patient’s state make other parties, such as health workers and family members, more important when making the final decision about future actions.
Usually, in the healthcare setting, patients’ preferences should prevail. They can accept the proposed treatment plans or reject them regarding their own visions and ideas about possible outcomes. The patient’s right to decision-making is one of the pillars of the healthcare system, which influences all parties and used strategies (Munson & Lague, 2016). It is embodied in the principle of autonomy, stating that all competent adults can make informed decisions about their medical care (Shapiro, 2015). However, in PVS, this principle becomes violated because the patient does participate in his/her treatment anymore. Instead, his/her previous visions and preferences should be viewed as the factors impacting the treatment process. Unfortunately, in numerous situations, family members do not know the patient’s preferences regarding such scenarios. The problem might also be compacted by the absence of the living will with the clearly outlined actions that should be performed in such cases. For this reason, there is a sophisticated ethical dilemma that demands resolution.
Family and patients’ close people are another party that becomes critically important when deciding on future care. In some cases, especially if the client’s will is unknown and there is no advance care plan, the family does not treatment withdrawn as it presupposes the inevitability of death (Sviri et al., 2009). For this reason, same as in the proposed scenario, close people insist on the continuation of treatment, hoping for improvement. On the one hand, this decision seems ethical as it focuses on the preservation of the patient’s life and attempts to help him/her to survive. However, the given decision might contradict to health workers’ recommendations and the patient’s will, which results in the violation of the autonomy principle and deprives a patient of a chance to control his/her own life, even if he/she is in PVS.
Specialists responsible for the provision of care and controlling the client’s state belong to another party influencing the final decision. In the proposed case, the idea of the ineffectiveness of the continued treatment comes from them. Usually, they use the results of recent examinations, investigations, and overall experience to start discussing treatment withdrawal with family members (Vogelstein, 2016). It is a common practice for patients with PVS who cannot make decisions on their own. Possessing all needed information, doctors might offer families this solution insisting on the impossibility of attaining recovery (Vogelstein, 2016). However, the problem is that, in most cases, this party adheres to already existing data science-driving algorithms applied to all situations (Mast, 2020). This standardization means that the same solutions without opportunities for choice are employed regarding all patients, regardless of their visions or individualized care plans (Mast, 2020). This approach also introduces the ethical dilemma as it violates the principle of autonomy and might result in undesired outcomes.
Living Will and Advance Care Planning
In such cases, living will might become a critically important document relieving caregivers and families of the burden to make a choice and decide. It is a legal document providing preferences for medical care if a person becomes unable to make decisions on his/her own (Mast, 2020). Such advance directives can guide specialists if they work with patients in PVS and should determine the future treatment (Mast, 2020). If a patient has a living will, caregivers might not need the approval of the family, as close people cannot override the document and deprive a patient of the authority to make his/her decisions and care plans. Under these conditions, the ethical dilemma can be resolved by using the living will as the central document regulating all actions if the client cannot do it. Unfortunately, there are some cases when patients do not have such directives or not all conditions are described in detail (Kuehlmeyer et al., 2012). In such scenarios, families have to accept the burden to make the final decision.
Advance care planning is another important step that can be made by a patient to ensure his/her interests are considered and respected. It can be described as the process of planning health care with all possible complications and hard decisions (Kastbom et al., 2020). It will ensure that close people and caregivers possess the correct understanding of the client’s preferences and that they are respected. This concept is applicable to PVS as the condition presupposes that a patient becomes critically dependent on decisions made by other people and cannot refuse the proposed course of actions or treatment. Under these conditions, advance care planning might help to resolve the ethical dilemma and guarantee that the principle of autonomy is respected and there is no place for ethical dilemmas (Fagerlin & Schneider, 2004). At the same time, the absence of such plans might complicate the case and increase the role of families in making the final decision about treatment withdrawal.
In such a way, every case of PVS presupposes an ethical dilemma, especially if the patient does not have a living will or a clear advance care plan. If the family insists on the continuation of treatment, it might mean additional suffering for a client, even if the motifs presuppose the possible recovery and improvement of the state. At the same time, caregivers who are responsible for the provision of recommendations also acquire additional challenges (Preston & Kelly, 2006). First, they have to correctly evaluate the case and step away from the standardized approach as it might result in the emergence of ethical issues. Second, they should be ready to interact with families and persuade them in the necessity to follow the recommended course of action, which might also demand additional responsibility and competence. Under these conditions, the final solution and its ethicality become a debatable issue.
It is possible to state that the patient’s preferences should always prevail as every person is guaranteed the right to control his/her body. In cases with PVS, the family members or attorneys should decide following the patient’s desires and demands to the provision of care in case he/she cannot control the further actions. The family’s refusal from treatment withdrawal should rest on the client’s visions of treatment and his/her will. If there is no such information, living will, or advance care plans, the close people can act regarding their knowledge of the patient as they possess the best knowledge linked to the case. At the same time, it is vital to consider caregivers’ recommendations as they correctly realize the given situation and can offer their recommendations.
At the same time, the best ethical decision should also rest on the idea of balance. The respect for moral principles should be combined with the analysis or resources that might be needed to support the patient. The fact is that other clients might demand equipment and medicines used to care for a person in PVS (Sviri et al., 2009). For this reason, the accepted decision must not harm other people, especially if the available resources are limited and might be critical for different cases. Following the principle of autonomy and the idea that other individuals should not suffer from the decisions made by the medical staff or family members, the desire to continue the provision of care should rest on the correct understanding of the patient’s will. Otherwise, it will result in the emergence of ethical issues and the violation of the fundamentals of care.
Altogether, the healthcare sector might offer multiple challenges and ethical issues. The principle of autonomy remains the major pillar meaning that all patients can select treatments and make decisions independently. However, when the client cannot state his/her recommendations, such as in cases associated with PVS, a contradictory situation might emerge. The living will and the advance care plan might help to resolve the problem by outlining the course of actions and interventions a person wants, and all decision-makers should adhere to this legal document. However, in some scenarios, these recommendations are absent, meaning that close people and caregivers should accept the responsibility and act on their own. Following the ethical principles, they should respect the client’s will and make decisions resting on his/her preferences. The treatment withdrawal or the refusal from this step should come from the knowledge of the person. Otherwise, their actions will contradict the code of ethics and result in additional suffering for the patient and other individuals.
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