ON THE ISSUES
Two essays look at ethical issues arising from new neuroimaging research suggesting that a small minority of patients with severe brain injury might be able to communicate.
Title: Severe Brain Injury and the Subjective Life
Authors: J. Andrew Billings, Larry R. Churchill, and Richard Payne
Summary: Does brain activity necessarily equate to consciousness or a meaningful existence? The authors contend that "modern neuroscience provides many findings about the complexity of brain function that should discourage us from jumping from evidence of local brain reactivity to conclusions about consciousness." They conclude , "Given the extreme likelihood of unacceptably poor outcomes, most of these patients [in a persistent vegetative state]as judged by their advanced directives or through substituted judgmentshould have life support discontinued."
Title: In the Blink of the Mind's Eye
Authors: Joseph J. Fins and Nicholas D. Schiff
Summary: Can a signal on an MRI scan help guide end-of-life decisions? The authors conclude, "Certainly, this is not yet the case, nor will it be anytime soon." While neuroimaging holds promise for helping reclassify some conscious patients thought to vegetative, it "should never become a routine arbiter of whether life-sustaining therapy should be withdrawn."
Title: Are DCD [Donation after Cardiac Death] Donors Dead?
Author: Don Marquis
Summary: Donation after cardiac death protocols are subject to two constraints. The first is that organ removal must occur as soon as possible after cardiac arrest. The second is that it must not occur so soon that the donor is not yet dead. Can both be satisfied at once? If hearts can be transplanted successfully, then is their loss of circulatory function reversible? DCD protocols are widely accepted, so arguments for them have apparently been persuasive. But this does not mean they are sound, and the author argues that DCD donors are not dead at the moment of donation because their cardiac function is reversible. In a related commentary, James L. Bernat argues against Marquis, writing, "Once a donor has been without circulation long enough that autoresuscitation cannot occur, and since DCD donors have do-not-resuscitate orders and medical resuscitation will not occur, the permanent cessation of circulation inevitably and rapidly evolves into irreversible cessation. Given these conditions, permanent cessation of circulation is a valid surrogate indicator for irreversible cessation."
Title: When Information Can Save Lives: The Duty to Warn Relatives about Sudden Cardiac Death and Environmental Risks
Authors: Bernice Elger, Katarzyna Michaud, and Patrice Mangin
Summary: In certain cases of sudden death, forensic experts may discover that family members of the deceased are at risk of harm. What duty do forensic pathologists, many of whom normally have no contact with relatives of victims, have to warn those relatives about their risk for sudden cardiac death or for exposure to life-threatening environmental risks? Looking at similar duties of physicians and researchers to warn third parties of risk suggests that forensic experts have the same responsibility.
Title: Rethinking Guidelines for the Use of Palliative Sedation
Author: Jeffrey T. Berger
Summary: Current guidelines consider palliative sedation to unconsciousness (PSU) an effective medical treatment for some terminally ill patients who have no other means of relief from severe symptoms, and yet questions persist. Chief among them is whether PSU can be distinguished from active euthanasia, since sedated patients are unable to drink and are not usually given intravenous hydration. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction, such as assuring that expected time to death from disease is less than or equal to time to death from PSU-induced dehydration.
Policy and Politics: Multiple Embryo Transfers: Time for Policy
Author: David Orentlicher
Summary: Since professional guidelines have not been effective at reducing multiple-embryo transfers, which pose risks to babies and mothers, the author argues that it is time for the United States to enact policy that will limit the number of embryos transferred to a woman, and proposes some guidelines.
At Law: Suicide Attempts and Treatment Refusals
Author: Rebecca Dresser
Summary: What should happen when a patient refuses treatment after a suicide attempt, either directly or through an advance directive? This essay considers whether legal officials should consider the treatment refusal part of the suicide attempt and authorize clinicians to intervene, or classify the refusal as an independent choice that clinicians must respect.
Case Study: Sexuality and a Severely Brain-Injured Spouse
Commentaries by Kristi L. Kirchner, Rebecca Brashler, Rebecca Dresser, and Carole Levine
Summary: The commentators examine a case in which a man who is a caretaker for his wife with severe brain injury is accused of sexual abuse after she becomes pregnant and is engaged in a legal battle over her custody.
Perspective: Assisted Suicide in the U.K.: From Crime to Right?
Author: Aidan O'Neill
Summary: A Scottish human rights lawyer examines a 2009 British ruling about deciding whether to bring, or consent to, a prosecution for assisted suicide.
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The Hastings Center