对植物状态生存的理性思考

分析植物状态生存的判定和分类,从人的本质分析植物状态的生存价值,从生物学、社会学角度分析植物状态生存与死亡的区别与联系,认为植物人仅仅是生物学上的不完全生命状态,在社会学意义上,他是死亡个体。对我国卫生费用的现状进行评估,从医学、社会学和经济学角度对植物状态生存者维持或放弃治疗进行了理性分析。     

Tube feedings and persistent vegetative state patients: ordinary or extraordinary means?

This article looks at the late John Paul II's allocution on artificial nutrition and hydration (ANH) and the implications his statement will have on the ordinary-extraordinary care distinction. The purpose of this article is threefold: first, to examine the medical condition of a persistent vegetative state (PVS); second, to examine and analyze the Catholic Church's tradition on the ordinary-extraordinary means distinction; and third, to analyze the ethics behind the pope's recent allocution in regards to PVS patients as a matter of conscience. Rather than providing clarification, I argue that the papal allocution has raised many difficult questions. People in situations where decisions must be made about withdrawal or continued ANH are in need of guidance. Moreover, additional analysis is needed to determine whether the papal allocution is in conflict with the traditional Catholic medical ethics understanding of the ordinary-extraordinary care distinction.     

Care versus treatment at the end of life for profoundly disabled persons

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population.     

More dead than dead: perceptions of persons in the persistent vegetative state

Patients in persistent vegetative state (PVS) may be biologically alive, but these experiments indicate that people see PVS as a state curiously more dead than dead. Experiment 1 found that PVS patients were perceived to have less mental capacity than the dead. Experiment 2 explained this effect as an outgrowth of afterlife beliefs, and the tendency to focus on the bodies of PVS patients at the expense of their minds. Experiment 3 found that PVS is also perceived as “worse” than death: people deem early death better than being in PVS. These studies suggest that people perceive the minds of PVS patients as less valuable than those of the dead – ironically, this effect is especially robust for those high in religiosity.     

Abandon the dead donor rule or change the definition of death?

Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law--such as authorizing procuring surgeons to end the lives of patients by means of organ procurement--and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those who would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.     

Does any aspect of mind survive brain damage that typically leads to a persistent vegetative state? Ethical considerations

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness.     

Persistent Vegetative State: A Presumption to Treat

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation.     

Withdrawing life-sustaining medical treatment--a physician's personal reflection

The decision to withhold or withdraw artificially provided hydration and nutrition is one which evolves over time and must be made jointly by the medical team and the patient's family. Although withholding nutrition can be argued to be ethical and appropriate for certain clinical scenarios, it is still a decision which can be difficult to make and, because of different social and legal issues, can be difficult to carry out. This is the story of one physician's journey as he worked with the mother and father of a young child who suffered a severe neurological injury and was left in a persistent vegetative state.     

植物人研究中的一些神经心理学问题

自从Ｊｅｎｎｅｔｔ等提出＂持久的植物状态＂概念之后,有关植物人的问题已经引起中国医疗卫生界的广泛重视,并且在临床治疗方面取得了一定的成绩。该文对国内及国际植物人研究状况作了简要的评述．作者认为统一关于植物人定义的认识,研究植物人的病理生理机制以及确定临床观察的心理学定量指标乃是中国科学工作者当务之急。     

Persistent vegetative state, prospective thinking, and advance directives

This article begins with a discussion of persistent vegetative state (PVS), focusing on concerns related to both diagnosis and prognosis and paying special attention to the 1994 Multi-Society Task Force report on the medical aspects of PVS. The article explores the impact of diagnostic and prognostic uncertainties on prospective thinking regarding the possibility of PVS and considers the closely related question of how prospective thinkers might craft advance directives in order to deal most effectively with this possibility.     

A Fate Worse Than Death? The Well-Being of Patients Diagnosed as Vegetative With Covert Awareness

Patients in the vegetative state are wholly unaware of themselves, or their surroundings. However, a minority of patients diagnosed as vegetative are actually aware. What is the well-being of these patients? How are their lives going, for them? It has been argued that on a reasonable conception of well-being, these patients are faring so poorly that it may be in their best interests not to continue existing. I argue against this claim. Standard conceptions of well-being do not clearly support the conclusion that these patients would be better off having life-sustaining treatment withdrawn, and in fact, it may be possible for these patients to retain a passable level of well-being. I suggest that further research into the subjective experiences of these patients will allow us to better promote their well-being.     

Disability versus futility in rationing health care services: defining medical futility based on permanent unconsciousness--PVS,coma, and anencephaly

All societies must ration health care services in the face of unlimited demand. The concept of medical futility may appear to be an uncontroversial means by which to ration services. Depending upon how it is applied, however, limiting services based on alleged medical futility may violate prohibitions against disability-based discrimination. In particular, use of medical futility to require removal of life-sustaining interventions has been held to violate the Americans with Disabilities Act. The ADA protects both people with disabilities who are conscious and people in unconscious states, such as permanent vegetative state (PVS), coma, and anencephaly. Ultimately, as the number of people in permanently unconscious states increases, our society will have to recognize that consciousness is an essential characteristic defining human beings and determining whether a legal right to unlimited life-sustaining intervention should apply. This article proposes to define medical futility to preclude life-sustaining interventions after a stated period of permanent unconsciousness and to redefine the end of life consistently as neocortical death.     

The burdens-benefits ratio consideration for medical administration of nutrition and hydration to persons in the persistent vegetative state.

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life of a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome.     

Consciousness: a neurological perspective

Consciousness is a state so essentially entwined with human experience, yet so difficult to conceptually define and measure. In this article, we explore how a bidimensional model of consciousness involving both level of arousal and subjective awareness of the contents of consciousness can be used to differentiate a range of healthy and altered conscious states. These include the different sleep stages of healthy individuals and the altered states of consciousness associated with neurological conditions such as epilepsy, vegetative state and coma. In particular, we discuss how arousal and awareness are positively correlated in normal physiological states with the exception of REM sleep, while a disturbance in this relationship is characteristic of vegetative state, minimally conscious state, complex partial seizures and sleepwalking.     

An ethics of suffering: does it solve the problems we want to solve?: commentary

Erich H. Loewy proposes to elevate the moral obligation to prevent and relieve suffering to the level of a prima facie moral duty by delineating which beings are of primary moral worth and which are of secondary moral worth. Sentient beings have a capacity to suffer and are therefore of primary moral worth. Beings that are insentient cannot suffer; therefore such beings are only of secondary moral worth. Objects of secondary moral worth include patients in a persistent vegetative state (PVS) and brain-dead patients. This proposal, he says, would solve a number of problems in clinical bioethics. First, it would help to clarify our moral duties at the bedside. And secondly, by creating a hierarchy of moral values, it helps to differentiate which patients are owed our primary allegiance and resources. Despite his extensive and painstaking proof, I believe several questions remain about the use of the "capacity of sentient beings to suffer" as a basis for a universal grounding in ethics.     

Adolescent autonomy and minors' legal rights: contraception and abortion

During adolescence, dependent children grow into independent and autonomous adults, and it is necessary to make difficult policy judgements about children's rights. Questions that arise include: shoudl minors have the right to work, to marry, to make legal contracts, and to obtain medical care without parental consent; or should parental consent be required by the state in order to protect minors and to preserve parental authority. This discussion focuses upon the area of family planning, a topic of special interest to policymakers because they now face many questions about minor's contraceptive and abortion rights in Congress, in state legislatures, and in the courts. comprehensive response to policy questions about family planning rights for minors would require information about adolescent development, maturity, and autonomy; about teenagers' sexual and contraceptive attitudes and behavior; about the nature of parent-child communication regarding sexual and contraceptive questions; and about politics and values. Many from the legal system want help in answering questions about minors' rights. As little research has been conducted, policymakers can obtain only limited guidance from social scientists. As the policy issue is fundamentally tied to developmental issues, the better the knowledge about the development of cognitive competence, social competence, and autonomy, the easier it will be to make the difficult legal and policy judgements about minor's rights. Regarding minors' access to contraceptives, the situation is somewhat cloudy. There is only 1 state statute that requires parental consent for access to contraceptive medical services, passed in Utah in 1981, and pertaining to services provided with public funds. Yet, common law requires parental consent for any medical treatment (with exceptions for emancipated or mature minors) and "physicians often hesitate to serve young people without first obtaining parental consent because they fear civil liability." The situation is even more cloudy in the case of abortion. The Supreme Court's present position seems to grant emancipated and mature minors access to abortion without a requirement for parental consent or notification, but states may place some requirements for parental involvement upon other minors, as long as these minors have an alternative route to abortion. A thorough search of the literature on adolescent development reveals that the policy questions loom larger than the alternatives. 2 policy alternatives are: to single out a reasonable age below which minors require either parental consent or some form of adult involvement; or treat family planning and fertility control as basic rights which cannot be abridged because of age.     

Faith-to-faith at the bedside: theological and ethical issues in ecumenical clinical chaplaincy.

Chaplains who serve in a clinical context often minister to patients representing a wide variety of faiths. In order to offer the best pastoral care possible, the chaplain should first possess a set of personal theological convictions as a foundation for ministry. Second, he or she needs to be sensitive to the beliefs and practices of the patients. Third, it is vital to develop a relationship of acceptance and trust not only with patients under their care, but also with family members and caregivers as well. At times, situations will arise that are purely religious or theological. In a clinical setting, however, the questions and problems that arise more often are both theological and ethical. It is beneficial for the chaplain to be involved in an ethics committee, where the specifics of each case can be discussed, and staff can offer counsel to patients and their families. This study examines issues that chaplains face at the bedside, such as terminal care, life-prolonging treatments, dementia, persistent vegetative state, and euthanasia-assisted suicide. We will discover that those who are involved in clinical pastoral ministry will be called upon to be a comforter, mediator, educator, ethicist, and counselor.     

Can CORE assessment data identify those clients less likely to benefit from brief counselling in primary care?

Studies show that counsellors in primary care see many clients with difficulties of a severity similar to those found in secondary care services. Evidence from both RCTs and studies of routinely collected data indicates that many of these ‘clinical’ clients benefit from brief counselling intervention. However, little is known about why some benefit while others fail to do so despite completing their counselling contract. This paper considers client characteristics recorded at assessment and aims, using logistic regression analysis, to identify those characteristics predictive of a poor outcome. Results indicate that a number of characteristics are associated with poor outcome; the most important predictors are economic inactivity and aspects of the patient's condition, particularly continuous/recurrent depression, with some differences between genders. However, the models produced were not acceptable in their predictive power. This may be partly due to data quality issues or important characteristics not being available in the data. The paper concludes that being unemployed or on state benefits may be a proxy measure of severity that has an important impact on outcome for all patients, and particularly for males. Some reasons are suggested and areas of future research are identified.     

OPEN DIALOGUE IN PSYCHOSIS II: A COMPARISON OF GOOD AND POOR OUTCOME CASES

As an approach to treatment of psychosis, Open Dialogue aims to begin treatment within 24 hours of first contact between the health system and the patient or family, and in accordance with social constructionist principles, it includes the family and the social network in open discussion of all issues throughout treatment. As one step toward evaluating the impact of this novel model of care, statistical and qualitative analyses of 78 consecutive first-episode psychotic cases was undertaken, discriminating good from poor outcome cases on the basis of functional and symptomatic criteria. Results suggested differences in the diagnosis and duration of prodromal and psychotic symptoms, as well as in treatment processes in the two groups. Avoiding hospitalization and using anxiolytics instead of neuroleptics were associated with a good outcome. Overall, data bearing on the effectiveness of OD were encouraging, as only 22% poor outcome patients emerged. However, if the possibility for starting a dialogical process is minimal, the treatment may lead to poor outcome, even where this is not predicted by premorbid social and psychological factors.     

Death and organ procurement: public beliefs and attitudes

Although "brain death" and the dead donor rule--i.e., patients must not be killed by organ retrieval--have been clinically and legally accepted in the U.S. as prerequisites to organ removal, there is little data about public attitudes and beliefs concerning these matters. To examine the public attitudes and beliefs about the determination of death and its relationship to organ transplantation, 1351 Ohio residents >18 years were randomly selected and surveyed using random digit dialing (RDD) sample frames. The RDD telephone survey was conducted using computer-assisted telephone interviews. The survey instrument was developed from information provided by 12 focus groups and a pilot study of the questionnaire. Three scenarios based on hypothetical patients were presented: "brain dead," in a coma, or in a persistent vegetative state (PVS). Respondents provided personal assessments of whether the patient in each scenario was dead and their willingness to donate that patient's organs in these circumstances. More than 98 percent of respondents had heard of the term "brain death," but only one-third (33.7%) believed that someone who was "brain dead" was legally dead. The majority of respondents (86.2%) identified the "brain dead" patient in the first scenario as dead, 57.2 percent identified the patient in a coma as dead (Scenario 2), and 34.1 percent identified the patient in a PVS as dead (Scenario 3). Nearly one-third (33.5%) were willing to donate the organs of patients they classified as alive for at least one scenario, in seeming violation of the dead donor rule. Most respondents were not willing to violate the dead donor rule, although a substantial minority was. However, the majority of respondents were unaware, misinformed, or held beliefs there were not congruent with current definitions of "brain death." This study highlights the need for more public dialogue and education about "brain death" and organ donation.