And especially to Wesley who is going where ever he can and talking about this. He has committed his life to getting the word out to the public about these horrors.
The authors reply:
To the Editor: The mission of the task force was to collect and summarize medical and neurologic facts about the vegetative state, which, in turn, could serve as a basis for future deliberations on the ethical, legal, social, economic, and personal-values considerations. We tried diligently to refrain from making any implicit or explicit value statements in the document. The task force's report essentially agrees with the suspicions of Dr. Haig and Dr. Whyte about the effects of aggressive as compared with limited treatment on the life expectancies of patients in a vegetative state. However, as our report notes, there are no formal studies to assess accurately the impact of these decisions on life expectancy. Perhaps future studies will shed more light on this issue.
More important than life expectancy is the point at which irreversibility (permanency) can be established with a high degree of certainty. After considerable deliberation, the members of the task force concluded that it was necessary to distinguish clearly the permanent vegetative state (in which the chances of recovering consciousness are extremely remote, or as Dr. Zasler and his colleagues say, "rare") from the persistent vegetative state (arbitrarily designated as a vegetative state present one month after the initial traumatic or hypoxic-ischemic event), in which studies demonstrate that full recovery of consciousness and other neurologic functions can occur. We hope that this document will encourage the reporting of more data, either individual case reports or systematic studies of large numbers of patients, that will support or refute the predictive probabilities contained in the report.
The strong consensus among professional specialty societies, health care professionals, case law (including the U.S. Supreme Court's decision in the Cruzan case),1 and statutory laws supports the view that the withdrawal of artificial nutrition and hydration from certain patients with severe brain damage is not "killing" them, as Dr. McQuillen asserts, but rather letting them die by removing a medical treatment. The public and its elected representatives can draw their own conclusions about whether it is appropriate to spend $1 billion to $7 billion yearly for patients in a vegetative state.
The correlation of the vegetative state and unconsciousness rested on the medical view that the cerebral cortex is the primary locus of "conscious awareness." We realize that a minority of neurologic specialists remain unconvinced of this, and an even smaller minority continue to maintain that patients in a vegetative state can experience pain or suffering. Members of the task force were aware of occasional cases of the vegetative state arising from predominantly thalamic damage. Our report notes that relatively selective thalamic necrosis may follow acute global ischemia. The autopsy findings on Karen Ann Quinlan do not refute the basic assumption of the primary locus of consciousness.
Stephen Ashwal, M.D.
Loma Linda University School of Medicine
Loma Linda, CA 92354
Ronald Cranford, M.D.
Hennepin County Medical Center
Minneapolis, MN 55415-1829 for the Multi-Society Task Force on PVS