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Responding to Patients in the Persistent Vegetative State

Donal P. O'Mathuna, Ph.D.

     {This article was published in Philosophia Christi 19.2 (Fall 1996): 55-83. This journal is a publication of the Evangelical Philosophical Society.}

     Modern medicine has provided people with many great benefits, but it has also forced people to make difficult ethical decisions. One of the hardest of these is to let a loved one die when medical technology could keep him or her alive. People must now decide if and when they would want certain treatments withheld or withdrawn from themselves or others. The ethical issues involved raise questions about autonomy, quality of life, appropriate use of resources, the wishes of family members, professional responsibilities, and many more.

     The withdrawing of food and fluids from patients in persistent vegetative state (PVS) is one of these tragic situations. This term was first coined in 1972, and the condition has since been the subject of much ethical and legal debate.[1]  The tragic cases of Karen Ann Quinlan and Nancy Cruzan brought this debate into full public view.[2]  These patients do not seem to be conscious, nor capable of communication. They seem to be unaware of both their environment and themselves. They depend on others to provide for all their needs, which brings in financial concerns. Some will live for years in this condition, provided they are given adequate nutrition and hydration.

     Many find it agonizing to watch anyone, particularly a loved one, languish in this condition with little hope for recovery. For this reason, allowing PVS patients to die can seem very merciful. So, the ethical question arises: should we withdraw artificially administered food and fluids from these patients and allow them die?

     Many issues are raised by this difficult question.[3]  For some, autonomy is the central issue. If we can show that this particular patient would not want to live in such a condition, food and fluids should be withdrawn and the patient allowed to die. For others, the issue is whether artificially administered food and fluids should be considered ordinary care or extraordinary care. Ordinary care is generally viewed as obligatory. Some view food and fluids, even those artificially administered, as ordinary because they are basic to survival, and symbolic of care and comfort. Others view artificially administered food and fluids as extraordinary because they are medical technologies and, in PVS, do not heal or lead to improvement in the patient's status.

     Others view these patients' quality of life as so poor, they see no obligation to continue feeding and hydration. Some view sustaining these patients lives as unethical because of its expense. Still others center the debate on whether or not PVS patients are persons. If not, they see no obligation to continue providing food and fluids. Others propose resolving this dilemma by creating new criteria for determining when death occurs.[4]  If PVS patients are actually dead, there should be little argument over withholding or withdrawing their food and fluids.

     Obviously, the variety of issues and perspectives involved lead to different conclusions. Christian authors have not given widespread attention to this issue. However, some evangelical writers have supported one distinctively Christian position. They claim that PVS patients no longer bear the image of God and therefore need not be fed or hydrated.[5]  Our paper will examine and critique this argument that PVS patients are "theologically" dead. In contrast, we will argue that the "image of God" concept should lead us to continue providing PVS patients with artificially administered food and fluids.

     This paper will address only the withdrawal of food and fluids from PVS patients without other complicating conditions. Patients in PVS are susceptible to other conditions like pneumonia, heart failure, or cancer. Care-givers and family must make tough decisions every time a medical intervention is considered. Similar decisions must be made concerning the most appropriate medical treatment for any profoundly ill patient. However, these complicating conditions bring new factors into the discussion which we will not directly consider here. However, our conclusions will have strong implications for how we respond to these other situations.

     The answer to this more limited question has profound implications beyond PVS. The end stages of diseases like Alzheimer's, Huntington's, and Parkinson's sometimes leave patients in PVS. If we need not feed or hydrate them when they reach that stage, will this influence how we care for them earlier? How will people know when to start treating them as PVS patients? If we do not feed or hydrate these patients, who would otherwise continue to live, will this affect our attitudes toward other profoundly disabled persons?

     Another group of patients in PVS are anencephalic newborns.[6]  In a recent reversal of its policy, the American Medical Association now views as ethical the removal of organs from these newborns before they die.[7]  If these living newborns are appropriate organ donors simply because they are in (what are called "permanent") PVS, then some other living humans in PVS are also appropriate organ donors simply because they too are in (permanent) PVS.

Before examining the ethical issues, we must first look at some of the relevant medical aspects of PVS.

Medical Issues

     A review of the medical information concerning PVS was published in 1994 by the Multi-Society Task Force on PVS (MSTF).[8]  They estimated that 10,000 to 25,000 adults and 4,000 to 10,000 children live in PVS in the United States.[9]  PVS can be caused by acute brain injury (e.g. car accidents or lack of oxygen from a heart attack or near-drowning), chronic degenerative disease (e.g. Alzheimer's disease, Parkinson's disease), or developmental malformations (e.g. anencephaly).[10]  The injury or disease often results in profound damage to, if not complete death of, the cerebral cortex--that region of the brain believed by many to be responsible for all higher, cognitive functioning.[11] 

     According to the MSTF, patients in PVS show no evidence of awareness or thinking, and do not communicate.[12]  None of their actions appear purposeful, learned or voluntary. However, the brain stem often functions normally in PVS, allowing a much greater range of activities than seen in related syndromes. Most patients in PVS continue to breathe on their own, circulate blood normally, have periods of waking and sleeping, may move their limbs, smile, shed tears and respond to external stimuli. Some may grunt, groan or scream.

     Most patients in PVS cannot chew or swallow food, though some can.[13]  Thus arises the ethical dilemma. Some means of artificially administering food and fluids is usually required. Most often a liquid diet is given via a gastrostomy tube which is inserted directly into the stomach. Insertion of this tube requires surgery, but is a relatively low-risk procedure with almost guaranteed effectiveness. "Indeed, feeding tubes may be unique among all medical technologies in that they almost exceptionlessly deliver on their claims."[14] 

     A patient's prognosis must be considered when choosing medical therapies. According to the MSTF, there is no effective treatment available to reverse PVS.[15]  The chances of spontaneous recovery depend on the cause of PVS and the age of the patient.[16]  There is currently no hope for recovery from degenerative diseases (like Alzeimher's) or developmental abnormalities (like anencephaly). However, when PVS in adults was caused by a traumatic injury (e.g. traffic accident), one year later, 33% had died, 15% remained in PVS and 52% recovered consciousness. Of those who recovered consciousness, 54% had severe disability, 33% had moderate disability and 13% had a good recovery.[17]  Among children in PVS dues to traumatic injuries, 62% recovered, 18% of those with a good recovery. When PVS resulted from a nontraumatic injury (e.g. cardiorespiratory arrest), only 15% of adults recovered consciousness, with severe disability being more common. Recovery among children was similar.

     These statistics show that a significant number of people recover from PVS within a year after injury. However, the chances of recovery are much lower after longer periods in PVS. Therefore, the MSTF concluded that PVS should be considered permanent 12 months after a traumatic injury, or three months after a nontraumatic injury. However, a few cases of dramatic recovery after extended periods are well documented. One patient recovered after three years in PVS, to the point of being alert and well-oriented.[18] 

     For those who remain in PVS, the average life-expectancy is two to five years.[19]  It is unusual for someone to survive more than 10 years, although two patients have survived for 37 and 41 years. However, the MSTF report did not take into account how different types of care affected patients' survival. In fact, there have been no formal studies on how the level of care impacts PVS patients' life expectancy. More aggressive and more caring treatment would probably lengthen survival times.[20] 

     There are some related conditions which must, where possible, be clearly differentiated from PVS.[21]  In whole-brain death all brain function has ceased. There are no sleep-wake cycles, and no spontaneous respiration. Today, brain death is synonymous with death. Hence, statements like "She is brain dead. Why do they not let her die?" are misleading and reflect a misunderstanding of the terminology. In spite of efforts to change the definition of death, currently someone in PVS is neither dead nor brain dead.

     The locked-in syndrome has some similarities to PVS since the person is almost completely paralyzed. However, locked-in patients can often move their eyes purposefully, showing they are conscious and aware of their environment. They can communicate with those around them. Tragically, they are otherwise unable to move.

     The MSTF also distinguished patients in coma from those in PVS. Within two to four weeks, a patient in a coma usually either recovers consciousness, enters PVS, or dies. PVS differs because a patient in a coma does not have sleep-wake cycles, respiration is usually depressed and the duration of coma is much shorter. However, others treat coma and PVS as examples of the same kind of clinical entity because of their prominent similarities, namely apparent lack of consciousness and unarousability by ordinary means.[22] 

Are PVS Patients Unconscious?

     It is commonly assumed that PVS patients are unconscious and therefore unaware of themselves and/or their environments. This belief is central to many arguments favoring withholding or withdrawing food and fluids from PVS patients, including those by Christian authors. The MSTF reiterated this position: "Patients in a coma are unconscious because they lack both wakefulness and awareness. Patients in a vegetative state are unconscious because, although they are wakeful, they lack awareness."[23] 

     But how is this determined? A central problem in the MSTF argument is that it equates the lack of behavioral evidence for consciousness with the absence of consciousness. But consciousness is completely compatible with a lack of evidence for it. However, even when evidence would suggest consciousness, the MSTF quickly disregarded it. There are strongly held beliefs underlying these discussions and evaluations. Unfortunately, they are often not clearly expressed.

     For example, after listing the many functions performed by PVS patients, the MSTF concluded: "These motor activities may misleadingly suggest purposeful movements, yet these responses have been observed in patients in whom careful study has disclosed no evidence of psychological awareness or the capacity to engage in learned behavior."[24]  For such a fundamentally important conclusion, it is curious that the MSTF did not reference any of these studies. Regardless, their conclusion actually begs the question. As A. A. Howsepian, MD notes in critically reviewing the MSTF report: "Of course, if these movements are purposeful, then there is evidence of psychological awareness in some of these patients." [25] 

A recent review of consciousness research presents a very different picture of our current ability to determine the presence or absence of consciousness in patients.

     Even if it is in principle possible to invent a 'consciousness monitor', a device that would 'detect' the physical signs of the presence of consciousness in a patient, no such technology is anywhere in sight, as it is not even known what exactly is to be measured. The root of the problem lies deeper than the inadequacy of the technology, or the lack of sufficient data, however. What seems to be critically lacking is also a solid theoretical framework to ground and facilitate the experimental research. For example, there is really no established consensus, even in the medical field, as to what should count as the criteria of consciousness, to demarcate the domain of the conscious from that of the unconscious or the nonconscious[26]  (second and third emphases added).

     The MSTF moved well beyond its stated goal of addressing only "the medical facts" about PVS.[27]  As Howsepian states: "One cannot help but be engaged in a philosophical activity when dealing reflectively with such matters as consciousness, evidence, purposiveness, awareness, irreversibility, and the self."[28]  Even Veatch, in promoting the view that PVS patients are dead, recognizes that "measuring irreversible loss of capacity for a brain function such as consciousness involves fundamentally nonscientific value judgments."[29] 

     Yet there is also medical evidence to dispute the belief that PVS patients are unconscious. Many studies show that patients in induced comas do retain some sort of consciousness.[30]  These studies

     . . . provide us with a broad range of empirical evidence which is robustly compatible with the thesis that some comatose patients have a conscious mental life of some sort--maybe even a mental life which is richer than that of some sleeping persons; or maybe a mental life which has a quality unlike any with which we are presently acquainted.[31] 

     This at least invalidates the MSTF's claim that those under deep general anesthesia (i.e. induced coma) are people "whom all would agree are unaware and insensate"[32]  (emphasis added).

     The extent of cerebral cortex damage leads the MSTF to confidently assert that PVS patients are "noncognitive, nonsentient, and incapable of conscious experience."[33]  Yet the physical location of our 'seat of consciousness' "remains a hotly debated issue."[34]  There is mounting evidence that the cerebral cortex is not the only area of the brain involved in cognition. Recent studies on the brain of Karen Ann Quinlan revealed some unexpected results.[35]  Her cerebral cortex showed little damage, with most damage being in her thalamus, an area of the brain distinct from the cerebral cortex. These studies support the critical role of the thalamus in cognition and awareness. Other studies suggest that another part of the brain, the cerebellum, is also involved in cognition.[36]  Some respected researchers in this field even hold that in some sense consciousness resides in the whole brain.[37]  Howsepian, in contrast to the MSTF, concludes that "our understanding of the biological underpinnings of consciousness is relatively primitive."[38] 

     Howsepian reveals many philosophical and clinical problems with the MSTF report. The clinical uncertainty in this field should be clear by now. In spite of the "common practice in medicine to have a more or less circumscribed set of behavioral and physiological criteria to determine the occurrent presence or absence of consciousness in patients. . . . the issue is not so straightforward"[39]  (emphasis original). The confident assertion that PVS patients are unconscious and unaware of themselves and their environment is based on ambiguous clinical data. Rather, we must admit that we cannot reliably determine if PVS patients are unconscious. In fact, there is significant evidence that they retain some form of consciousness.

Do PVS Patients Suffer?

     Another disputed issue is whether or not PVS patients experience pain and suffering. Paul Schotsmans, a Dutch medical ethicist, notes that if PVS patients do experience pain this "would fundamentally change the discussion of the withdrawal or withholding of nutrition and hydration."[40]  He cites a book by "French neurologists, reanimation specialists, nurses and ethicists" which documents that medical opinion is clearly divided on this issue.[41]  Yet this same author concludes that the pain of being in PVS would be "more burdensome and more prolonged" than any pain experienced while dying after the withdrawal of food and fluids.[42]  In spite of his earlier claim, the possibility of PVS patients experiencing pain did not change Schotsmans' view.[43] 

     While Schotsmans at least acknowledged the medical controversy in this area, the MSTF did not: "The perceptions of pain and suffering are conscious experiences; unconsciousness, by definition, precludes these experiences."[44]  Since it has concluded that PVS patients are unconscious, they also "cannot experience pain and suffering."[45]  However, the MSTF did note that the pain response in newborns does not involve the cerebral cortex, which it took to be the primary locus of damage in PVS.[46]  It logically follows that PVS patients have the same potential to experience pain and suffering as newborns. The MSTF argument also implies that brute animals cannot experience pain since they are not self-conscious. Howsepian finds this to be "at best counterintuitive and at worst patently false."[47] 

     The confident assertion that PVS patients cannot suffer or experience pain is premature. Replying to a letter noting this, the MSTF admitted that "a minority" of neurologists believe some PVS patients could be conscious, and "an even smaller minority" maintain PVS patients experience pain and suffering.[48]  Regardless of the size of this minority, medical opinion is divided, an important fact the MSTF report failed to mention. If PVS patients do experience pain, this is significant evidence against their being unconscious. We should at least seriously consider the potential our responses have for affecting their levels of pain and suffering of all types.

A Christian Argument for Withholding Food and Fluids

     Many medical organizations support the removal of food and fluids from patients in PVS.[49]  This reflects society's opinion on this issue. In three separate surveys, over 80% of the American public said they would want food and fluids removed if they were in PVS.[50]  Numerous medical ethicists support this decision for a variety of reasons, some of which were given at the beginning of this paper.

     Should Christians lend their support to this growing consensus in our society? Peter Emmett, a Christian physician, comprehensively surveyed the arguments for and against withholding or withdrawing food and fluids from PVS patients. He concluded that a satisfactory answer would appear only if humans were seen as made in the image of God.[51]  He stated that the image of God is present in all humans who have the capacity to image God, seen as some level of relational and rational abilities. In a subsequent article, he claimed that a patient in PVS "is no longer the image of God because physiological life, permanently devoid of relationality and cognition, is not adequate to be imago Dei."[52] 

     Robert V. Rakestraw developed this argument further. For him, to be an image of God "presupposes some capacity, either actual or at least potential, for self-awareness and self-direction, for relationships and for the exercise of authority over creation."[53]  He concluded, "A body without neocortical functioning cannot image God . . . Neocortical destruction is both a necessary and sufficient condition for declaring an individual dead theologically."[54] 

     John Jefferson Davis comes to this same conclusion. He has claimed that a patient with no potential for life, relationships or consciousness should be viewed as "biblically dead."[55]  He supported his view by noting that the soul can live without a physical body in the Intermediate State (2 Cor 5:1-8). Based on this, he concluded that in PVS it is plausible that the patient's body lives on without his or her soul.

     Evangelicals are not alone in developing this type of theological argument. Schotsmans, a Roman Catholic scholar, put it this way: "The PVS patient has lost his personality, become totally dependant, cannot organize his own life. He is no longer a free human being. . . . He is socially dead . . ."[56]  The Jesuit ethicist, Kevin Wildes, wrote that with the extent of brain damage in PVS ". . . it seems impossible to argue that a substantial union of body and soul remains or that an obligation to sustain life remains."[57] 

     All of these arguments are based on the assumption that a patient in PVS is unconscious and has no potential for cognition or awareness. However, we have shown how precarious this assumption is. Even if a patient shows no evidence of consciousness, there may still be some form of consciousness present. Even if the cerebral cortex is destroyed, medical evidence shows that other areas of the brain are involved in cognition and awareness. Even if there is no consciousness present now, that does not imply there is no potential for consciousness.

     Under Rakestraw's own definition, current medical knowledge suggests that he reaches the wrong conclusion. PVS patients do remain images of God. He distinguishes PVS patients from the severely handicapped because "some capacity and potential--however slight--for imaging God is present in these [latter] cases."[58]  For him, to be an image of God one only needs some potential for these abilities, which some medical experts believe PVS patients have.

     The underlying problem is with the attempt to categorize all PVS patients as completely unconscious. In contrast, others propose that PVS include a continuum of levels of consciousness.[59]  This more accurately reflects the clinical difficulty in diagnosing a complete lack of consciousness. The awakening of Gary Dockery after 71/2 years has dramatically revealed this difficulty. Various medical experts involved with the case were reported as describing his condition as PVS, locked in syndrome, or some coma-like state.[60]  Dockery's condition seems to have fluctuated along a continuum of consciousness, and does not fit neatly into any one syndrome.

     This continuum was acknowledged by the original describers of PVS, who then asserted "it seems wise to make an absolute distinction" between those who show evidence of consciousness and those who don't.[61]  Once this is done, people can view PVS patients as distinctly different from other patients, which justifies treating them differently. First classifying patients is assumed to clarify our moral obligations to them.

     The Christian authors similarly categorize PVS patients, after first figuring out what it means to be an image of God. Certain rational, spiritual, moral, or relational capacities are proposed as integral to being an image of God. Any human who does not have these capacities (or the potential to develop them) is not an image of God. We no longer have any obligation to keep these humans alive, while we do with humans who are images of God.[62]  Once again, the assumption is that if we first categorize patients as images of God, or not, the right treatment will be apparent.[63] 

Determining Who Is A Person

     The argument over who is an image of God resembles the argument over who is a person. Joseph Fletcher developed a list of 20 characteristics required for someone to be regarded as a person.[64]  He later reduced these to four, concluding that "neocortical function is the key to humanness, the essential trait, the human sine qua non."[65]  Rakestraw claims "that the essence of humanness is being an image and representative of God and that neocortical function is necessary to being that image."[66]  He claims his argument differs from Fletcher's, but the similarities are more apparent.

     Stanley Hauerwas addresses this issue in an aptly titled chapter, "Must a Patient Be a Person to Be a Patient? Or, My Uncle Charlie Is Not Much of a Person But He Is Still My Uncle Charlie."[67]  He notes that trying to determine whether or not someone is a person is an abstract and artificial way to resolve ethical dilemmas. When asked to identify ourselves, we do not first classify ourselves as persons and proceed from there. Rather, we think of ourselves in terms of our relationships with one another: I am a father, teacher, son, etc. When we think about caring for the dying, we do not care for them because they are persons. "We care or do not care for them because they are Uncle Charlie, or my father, or a good friend."[68] 

     So why do authors keep returning to the question of personhood? Our society has no moral consensus on how we ought to care for our dying parents or friends. But we still want guidelines to help make decisions at these times. In a pluralistic society, abstract, generic terms seem most appropriate in formulating these guidelines. We also shift to discussing issues in terms of our rights. In medical ethics, the dominant view of rights is that grounded in respect for persons. Hence, we pursue some calculus to determine who is a person and who is not.[69]  Having figured this out, we assume it will be clear who should get which treatment.

     But the controversy is not so readily resolved. Current literature on PVS contains well-reasoned arguments viewing PVS patients as persons, and others viewing them as non-persons. Food and fluids can reasonably be defended as ordinary or extraordinary. The hope that abstract philosophy would yield logical answers that all reasonable people would accept, has never been realized.

     Given this uncertainty, it seems that any decision may be ethical. The focus then shifts to competency, debating who has the right to make these decisions.[70]  Referring to decisions about PVS patients, one writer applauds this: ". . . it is crucial, I believe, that we keep our focus clearly on the question of who should have the right to make the decision, rather than on the decision itself"[71]  (emphasis original). But the morality of these decisions, and the fundamental issues underlying them, is what must concern us.

The Image of God

     When biblical concepts are treated in an abstract fashion, we are left with the same ambiguity. Similar debates occur over who is, or is not, an image of God. As discussed elsewhere, the controversy over what it means to be an image of God has raged for centuries.[72]  Various attributes have been proposed as the essential features of being an image of God. But the Bible doesn't give us a list of these attributes. Nowhere does it tell us when a human life becomes an image of God or ceases being an image of God.

     A question like "Who is no longer an image of God?" is an abstract question which Scripture was not primarily written to answer.[73]  The image of God passages were not written to show which humans are images and which are not. They state that humans are images of God because God created us as such (Gen 1:26-27).

     Being an image of God brings with it some privileges: likeness to God (Gen 1:26), dominion over the earth (Gen 1:26, 28-30), and protection from others (Gen 9:6; Jas 3:9). Because we are images of God, we have some unique attributes, including rational, relational, moral and spiritual capacities. We are not images of God because we have these capacities. All humans are images of God, and because of this, these types of activities are part of what it means to be human.

     Although we long for answers to all our questions about life, Scripture reminds us that human knowledge is limited (Eccl 3:11; 8:17; 11:2-6). We have seen the need to admit this concerning consciousness and suffering. We must sometimes do likewise in theological areas. Eccl 11:5 states: "Just as you do not know how the spirit enters the bones in the womb of the pregnant woman, so you do not know the activity of God who makes all things."[74]  We lack the knowledge to make confident assertions that some living humans do not have the potential to be images of God or persons. Instead we should accept that all living humans are images of God.

     Using an analogy from agriculture, this passage encourages us to continue scattering our seed even though we can't know which will grow (Eccl 11:6). We must continue to act in the face of uncertainty, basing our hope and security on God's grace.[75]  Similarly, we have no idea if feeding those in PVS will "succeed." Yet we must at least give the body the opportunity to show us the amazing power of God. It is the very tenacity of the human body to go on living which seems frustrating with PVS patients. But by refusing to feed them, we are placing our hope in death, not in God's grace. As attractive and merciful as death may seem, it remains our enemy (1 Cor 15:26).

Acting as Images of God

     Being an image of God is not just a title bestowed on humans. It brings with it certain responsibilities. In the Ancient Near East the term "image" was used to describe a statue left by a conquering king as a reminder of his presence, even though he might be physically absent.[76]  Seeing the image, people were forced to remember whose land they occupied, and act in an appropriate manner. Thus the image was seen as the representative or ambassador of the ruler.

     This explains why such an important phrase occurs so infrequently in the Bible. The focus is not on who is an image of God, but on how we can live as true images of God. Much of the Bible explains how we can be his faithful representatives. God gave Adam and Eve dominion over the earth, but he also gave them directions on how to be good stewards of the land (Gen 1:28-30). If they had properly imaged God to the rest of creation, they would have maintained the harmony and goodness in which it was created. This is part of the value and responsibility of being an image of God. As the Jewish scholar Abraham Heschel commented, "No image of the Supreme may be fashioned, save one: our own life as an image of His will. Man, formed in His likeness, was made to imitate His ways of mercy. He has delegated to man the power to act in His stead. We represent Him in relieving affliction, in granting joy. Striving for integrity, helping our fellow men."[77] 

     As images of God we are given the amazing capacity to form a personal relationship with the God of the universe. But as a result of the Fall, we are no longer born into this relationship (John 1:12-13; 3:5-7). Many people live their lives alienated from God and thus cannot act as true images of God. As Carl Henry put it, each person is now a "shattered image."[78] 

     Christ is the only true image of God (2 Cor 4:4; Col 1:15). By establishing a relationship with Christ we can begin to restore our shattered image (Rom 8:29). Christians are called to actively participate in this process of sanctification (Col 3:10). As we seek to live our lives by the power of the Holy Spirit, according to the example of Christ, we will have the character of God formed in us and thus become truer images of God.

     While all of us fall short of being true images of God (Rom 3:23), by the grace of God, we all remain images of God (Gen 9:6; Jas 3:9). These two passages apply to all humans, even those missing the most basic ingredient needed to act as a true image: a relationship with God. These humans retain the privilege and value of being an image of God, even though their capacity for moral and spiritual vitality is severely compromised (John 15:4-5; Eph 2:1-5). We should be very slow to think that some are no longer images of God because they seem to have little capacity for rational or emotional vitality.

     Scripture describes us as images of God to encourage us to act as his true representatives. This concept does give guidance in moral issues. However, in responding to patients in PVS, we should not focus on determining which living humans are images of God. Rather we should focus on how we as images of God should act towards other living human beings, including those in PVS.

     Jesus encountered a similar issue when a lawyer asked him: "Who is my neighbor?" (Luke 10:29). The lawyer believed that once he knew which people were his neighbors he would treat them accordingly. He obviously thought that one type of action was required towards neighbors, and something different towards non-neighbors. He just needed some help figuring out which was which.

     Jesus' reply in the Parable of the Good Samaritan rejects this whole question (Luke 10:30-37). This story clearly shows that all humans should be treated as neighbors. We should be concerned about acting as good neighbors, not trying to figure out who is, or is not, my neighbor. Often we learn that someone is our neighbor after an interaction in which he or she is treated as a neighbor by being cared for, interacted with and protected.[79]  The status of "neighbor" is something we should acknowledge in all strangers, not something we confer upon some after abstract speculation (Deut 10:19).

Practical Problems with Abstract Concepts

     The attempt to determine how we ought to treat others by first classifying them (as persons, images of God, or neighbors) is more compatible with a rationalistic world view than a biblical one. Yet the very objectivity this method seeks to provide becomes a fatal weakness when it distances us from the people we are trying to help.

     We need to detach ourselves to some extent from some situations to avoid purely emotional decisions and to ensure sound principles are followed. However, abstract ideas sometimes disengage us too much from uncomfortable situations. Classifying strangers as non-neighbors is an easy way to rationalize not stepping out in faith to meet their needs. The priest and the Levite did not view the injured man as a neighbor, and left him dying on the road. Too much aloofness can foster inhumane decisions. This aloofness can be fostered by the types of questions asked in ethical dilemmas, as the following case study reveals.[80] 

     Michael is a 21-year-old resident at White Oaks, a long-term care facility. He has the physical size of a 7-year-old and the mental age of a 2- to 21/2-year-old. He is not in PVS, but his situation raises similar issues. When admitted to a hospital for an appendectomy, some of the staff wondered about how aggressively to treat him. The ethics consultant recalls what they were saying.

     There's so little there; so little quality of life; so little human life. He is not ambulatory; he doesn't have any intellectual life; he has no companionship and seems incapable of it; his parents never visit him at White Oaks and they've never visited him here. He's just one of our White Oaks patients, like so many others, and each time we get him better, he just goes back to White Oaks, and that's no life (p. 279-80).

     They want the consultant to determine what he thinks of "his quality of life and our responsibilities" (p. 279). They want to classify Michael to somehow make future tough decisions easier. However, the consultant turns the case along a different path when he talks to Dr. McDonough, one of the residents.

     "Dr. McDonough, what was this patient like? How did he strike you? What did you think of him?" . . . He said, "Michael is a very strange individual. He shows unusual behavior. I'll never forget him--how he seems to be capable of just three things.

     "First, if you call out his name very loudly he turns to you and bestows on you a wonderful smile. It is the smile of a saint. I've never seen anything like it before--beautiful but eery--and he keeps smiling at you for a while.

     "Second, he has a toy tractor in his bed. He holds it in front of his face and spins the two back wheels for several hours at a time, but with a look of great concentration.

     "The third thing about him I'll never forget: he does what I would call finger ballets. He touches his fingers together, then closes his hands, opens them again as though he were playing 'Here's the church and here's the steeple,' and then, well, he does a kind of ballet with his fingers. Again, he has a look of concentration on his face like Vladimir Horowitz performing on piano."

     "How do you feel about him?" I asked Dr. McDonough.

     ". . . I will confess to feeling fear and a bit of fright when I'm in his presence. I haven't had much experience at this." Then, under his breath, Dr. McDonough added quietly, "He's like an alien to me. I don't know his world" (p. 280).

     There is naturally some alienation between us and those in conditions we do not experience or understand. This is very pronounced with those in PVS. But we can alienate them even more when we classify them abstractly. Even the word "vegetative" in PVS alienates them from us.[81]  God has reached across the alienation between us and him. We are similarly called to reach out to the strangers of the world, even those around whom we feel uncomfortable (2 Cor 5:16-21). As we attempt to image him truthfully, we ought to reach across the barriers to those in PVS. Our concern should be how we can act as neighbors towards these patients who are strangers to us in profound ways.[82]  In doing so, we may be surprised that they respond more like an image of God than our abstract speculation might predict.

     For example, when PVS patients in one nursing home were treated more like persons, they responded accordingly. Often the simplest things made the biggest differences. In most institutions PVS patients continually lie in bed in the same room. As the director of this home stated, "We have found that adequate seating has improved awareness and arousal. . . . Our first object is to get them sitting up. It is amazing the response this produces. Body tone improves, head control appears. They look around and may focus on objects or companions."[83] 

     Another author claims that the idea of these patients being "dead" or "non-persons" is a prejudice.[84]  The problem is not that these patients are no longer persons, but that we do not know how to communicate with them. His assumptions are that if patients in comas are accepted as persons, if the sounds and movements made by them are taken as attempts to communicate, not just meaningless reflexes, and if time is spent replying to them in the language of their signals, contact can be made with them. He reports establishing verbal or non-verbal communication with many people in comas and PVS.[85]  While the New Age assumptions which underlie some of Mindell's views must be examined carefully in light of a biblical world view, the evidence recorded in his book is significant.

     The observations of people working with PVS patients suggest that the notion that they are no longer persons or images of God is wrong. The fact that just one patient regained consciousness after three years in PVS makes it clear that we ought not argue that these people are no longer images of God. It is an arbitrary classification based on a judgment that this form of life is not worth living.[86]  Instead, we ought to treat them as images of God, which would minimally involve physical, relational and spiritual sustenance. This means giving them food and fluids, spending time with them, interacting with them, and praying and reading Scripture with them.

The Importance of Protection

     There is another major problem with attempts to determine who is, and who is not, an image of God. Hauerwas has noted that in medical ethics "person" is usually a protective notion. However, in literature arguing that some humans are not persons it is used primarily "as a permissive notion that takes the moral heat off certain quandaries raised by modern medicine."[87]  In removing this protective aspect, and viewing certain humans as non-persons, or no longer images of God, we condone practices we would otherwise view as wrong.

     Human history is littered with the tragedies of slavery, racism, sexism and Nazism. These witness to what can happen when some people view others as less than fully persons, or unworthy of life.[88]  Many accept abortion because they do not view the unborn as persons. By the same classification, some no longer feel an obligation to feed and hydrate patients who would otherwise remain alive. How broadly will this classification extend? At the time of writing, the United States Supreme Court was considering hearing a case involving the withdrawal of artificially administered food and fluids from an incompetent, but conscious patient.[89]  Some already argue that advanced Alzheimer's patients are former persons and should be allowed to die.[90]  Infanticide is defended by others by claiming that young infants are non-persons.[91] 

     The Bible uses the image of God concept in the context of protection (Gen 5:1-2; 9:6; Jas 3:9). Images of God should be protected. But protection of others should characterize images of God as they strive to act as his faithful representatives. We can mold our character to be more like his by protecting the vulnerable. God declares that pleading the cause of the afflicted and the needy is the essence of what it means to know him (Jer 22:16). Those who are gracious to the needy honor God (Prov 14:31).

     The NT reveals a similar picture of God's concern for the protection of the needy and the outcasts of society. Matthew clearly points to how important this was to Jesus. The first miracles of Jesus narrated in Matthew's gospel were healings done for the outcasts of Jewish society: a leper, a Gentile, a servant and a woman (Matt 8:1-17). Throughout his ministry Jesus went to those seen as being of little benefit to society. This focus was maintained in the NT church (Acts 4:34-35). Those who are images of God should give to the needy as a way to glorify God, but also out of gratitude for how much they have already received from him (2 Cor 9:13-15).

     We are called to protect more than just images of God. Dominion of the earth was not a license to exploit and ruin, but was to lead us to protect creation and help it flourish (Gen 2:15). Laws protected the land (Num 25:2-5) and animals (Exod 23:5, 11-12; Deut 25:4) to ensure they were nourished and rested. An attitude of protection should characterize images of God.

     Those who will inherit the kingdom of God are those who feed the hungry, give drink to the thirsty, clothe the naked, and spend time with the sick and imprisoned (Matt 25:31-46). God knows our most basic needs are for nourishment and protection, and he promises to provide these (Matt 6:25-34). Faithful images of God should promise nourishment and protection to all, including PVS patients, regardless of whether or not they are viewed as images of God.

The Cost Factor

     God gives us use of the earth's resources, but we are to use them wisely (Gen 1:29-30; Luke 16:11; Acts 10:10-16). Could the limited resources of our health care system not be better used if we let PVS patients die? Many do not want to bring financial concerns into health care dilemmas, but that is unrealistic in today's cost-cutting environment. This aspect of the dilemma of PVS patients reveals other deep issues we must all grapple with.

     The care of PVS patients is expensive. The annual cost of long-term care is estimated between $97,000 and $180,000.[92]  This gives an annual cost of between $1 billion and $7 billion for all PVS patients in the United States! This seems like an exorbitant amount of money when we read of the scarcity of health care resources. Shewmon points out the clear economic implications of viewing PVS patients as dead: "It is improper to assess families, insurance companies, or taxpayers with expensive hospital bills for keeping cadavers warm."[93] 

     Yet speaking in the context of health care, John Kilner claims "that the financial resources exist to eliminate many of today's scarcities."[94]  The problem is how we in the richer countries of the world use our resources. For example, in 1987, the cost of the Medicare endstage renal disease program was less than what Americans spent on potato chips that year.[95]  If all Down's syndrome children born in the United States in 1980 were institutionalized (and many were not, but were cared for at home), the cost would have been one tenth what the nation spent on dog food that year.[96] 

     We will find the money to support what is important to us. We are faced with having to decide if we will use our resources to keep alive those who have no say in the matter. When the Israelites harvested their crops, they were to leave some for the needy and the strangers (Lev 23:22). This is difficult enough when we are being asked to go against our greedy natures. Declaring that PVS patients are not images of God, and that we have no obligations to them, helps us avoid dealing with unbiblical priorities in the use of our resources.

     The financial concerns about keeping PVS patients alive also reveal the extent of utilitarian, materialistic thinking in our society. We want nothing done unless we can reap some tangible benefits. People's value is often based on what they can do, and not on the fact that they 'simply' are human. We think that if we could do nothing for ourselves, our lives would have no meaning or value. PVS patients don't seem to function very much, so we see no value in prolonging their lives. How different this is from the view of life where all humans are valuable because all are made in the image of God.

Ryan's Story

     We may find it hard to see how life in PVS could have meaning, but that does not mean it can't. As Howsepian argues, each PVS patient presents us with a "nidus for virtue"[97] --a little nest in which the seeds of virtue and character formation can be nourished and challenged towards moral maturity. In doing so, the world will see that we are true images of God, reflecting his love (John 13:35). This is exemplified by Ryan's story.

     In May 1992, Ryan, my healthy 4-month old neighbor, stopped breathing. The squad resuscitated him, but over the next few weeks all his cerebral cortex died. To everyone's surprise, he lived when he was taken off his respirator. He continues to live at a long-term care facility where he is fed and hydrated through a gastrostomy tube. He is totally dependant on his care-givers, and his parents, who take him home most weekends.

     Ryan will never do anything for his parents, but they view him the same way they do his twin brother: he is still their son, another image of God. This helps them deal with the tragedy of their situation. His parents praise God for the changes Ryan has brought to their lives. His mother became a Christian after she realized that God did not cause this accident, but wanted to help her with Ryan.

     Ryan's accident was not fair. But as his father says, there is no reason why these things always happen to other people. We cannot shield ourselves from bad things and control our lives completely. He believes God will use this situation somehow, though it's not yet clear how.

     Ryan's parents see many benefits from coping with Ryan's condition. Their priorities in life have changed, for which they are thankful. They are more appreciative of the little things in life, and the things they do have, like their other healthy son. Time with family and other people means much more to them now. Co-workers have told them that Ryan's accident has forced them to re-evaluate how much time they spend with their children. They have been introduced to a whole new world of caring and compassionate people: those who serve the disabled. They are now more sensitive to the needs and concerns of the disabled in general.

     Ryan's parents continue to have to make tough decisions about every medical intervention Ryan needs. But they are clear about one thing: Ryan ought to be given food and fluids. Though they cannot know what Ryan is aware of, they are aware of their duty to let him live. He deserves this much. They have accepted that he could die at any time. But they will feed him until something else causes his death.

     Ryan's parents treat him as the image of God he is. They are acting as images of God in how they respond to their son's tragedy. God has responded to the tragedy of fallen human life by continuing to sustain us in spite of the fact that we often do not respond to his love. He too has gotten frustrated with the lack of responsiveness (Hos 11:5-9; Matt 23:37). He must at times wonder if any trace of his image remains in us when we consistently refuse to act as we ought. Yet he continues to love us (1 John 4:9-10). These parents have chosen to image God through sustaining their son in spite of his lack of responsiveness. This is pure grace, of which our world needs more examples.

Conclusion

     We are faced with tough choices. But declaring some living humans no longer images of God is not the answer. The Bible does not distinguish between humans who are images of God and those who are not. Those making decisions about loved ones in PVS are not helped by being persuaded that the dilemma is illusory because those in PVS are already dead. People have to grapple with the fact that their loved one lives in a tragic condition, and may have little chance of recovery. But he or she is alive. Like all humans, they need food and fluids to remain alive. Like many others, they need help getting their nourishment. The issue is whether or not we will provide the basic essentials. We have to deal with the moral implications of that decision.

     Those of us who believe that artificially administered food and fluids should be given to PVS patients may soon be called to pay for it ourselves. The pro-life movement has realized that responding to abortion must include providing shelter and resources to those who choose to keep their babies. If death is redefined to include PVS, private funding will be needed to care for these patients. This will be the price we will pay for upholding the preciousness of all human life.

     Our God is in the business of protecting and nourishing broken, discarded lives which seem to have little meaning. He can use these tragedies to let his glory shine into a dark and painful world. His images should respond likewise.[98] 

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[1] Bryan Jennett and Fred Plum, "Persistent Vegetative State after Brain Damage: A Syndrome in Search of a Name," Lancet 1 (April 1972): 734-47. Return to Text

[2] See, for example, Marcia Angell, "The Legacy of Karen Ann Quinlan," Trends in Health Care, Law & Ethics 8 (Winter 1993): 17-9; and Bette-Jane Crigger, "The Court and Nancy Cruzan," Hastings Center Report 20 (January-February 1990): 38-50. Return to Text

[3] Frequently cited articles from various perspectives include: Joanne Lynn and James F. Childress, "Must Patients Always Be Given Food and Water?" Hastings Center Report 14 (October 1983): 17-21; Gilbert Meilander, "On Removing Food and Water: Against the Stream," Hastings Center Report 14 (December 1984): 11-3; William E. May et al, "Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons," Issues in Law & Medicine 3 (winter 1987): 203-11; Ronald Cranford, "The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight)," Hastings Center Report 18 (February-March 1988): 27-32. Return to Text

[4] Robert M. Veatch at the Kennedy Institute of Bioethics at Georgetown University, is a prominent proponent of this view. See his "Death, Determination of," The Westminister Dictionary of Christian Ethics, ed. J. F. Childress and J. Macquarrie (Philadelphia: Westminster, 1986), 144-5; and "The Impending Collapse of the Whole-Brain Definition of Death," Hastings Center Report 23 (July-August 1993): 18-24. Return to Text

[5] Robert V. Rakestraw, "The Persistent Vegetative State and the Withdrawal of Nutrition and Hydration," Journal of the Evangelical Theological Society 35 (September 1992): 389-405. Return to Text

[6] Anencephaly is a developmental abnormality that results in newborns missing major portions of their brain, skull and scalp. More than half will die within 24 hours of birth, although one child has lived for two and a half years. American Medical Association, "The Use of Anencephalic Neonates as Organ Donors," Journal of the American Medical Association 273 (May 1995): 1615. Return to Text

[7] Ibid., 1614-8. Note: After publication of this paper, the AMA reverted to its original position on this issue. See C.W. Plows, "Reconsideration of AMA Opinion on Anencephalic Neonates as Organ Donors," Journal of the American Medical Association, 275 (1996): 443-4. Return to Text

[8] The Multi-Society Task Force on PVS, "Medical Aspects of the Persistent Vegetative State," parts 1 and 2, New England Journal of Medicine 330 (May 1994): 1499-1508; (June 1994): 1572-1579. Return to Text

[9] MSTF, Part 1, 1503. Return to Text

[10] Ibid., 1503-4. Return to Text

[11] Some writers on PVS refer to this region as the neocortex. While not being anatomically identical, they should be seen as synonymous terms for the purposes of this paper. Return to Text

[12] MSTF, Part 1, 1500-1. Return to Text

[13] Maureen Tudor, "Persistent Vegetative State: Some Clinical Observations," Ethics & Medicine 9 (autumn 1993): 37. Return to Text

[14] Thomas A. Shannon and James J. Walter, "The PVS Patient and the Forgoing/Withdrawing of Medical Nutrition and Hydration," Theological Studies 49 (1988): 637. Return to Text

[15] MSTF, Part 2, 1577. Return to Text

[16] Ibid. 1572-5. Return to Text

[17] According to the Glasgow Outcome Scale, patients with severe disability are partially or totally dependant on others for daily living, those with moderate disability can live independently but are not able to participate in some social or work activities, while those with a good recovery can resume normal occupational and social activities, but with some minor physical or mental deficits or symptoms. Ibid., 1572. Return to Text

[18] K. Higashi et al., "Five-year follow-up Study of Patients with Persistent Vegetative State," Journal of Neurology, Neurosurgery, and Psychiatry 44 (1981): 552-4. Return to Text

[19] MSTF, Part 2, 1575-6. Return to Text

[20] See letters to the editor by Andrew J. Haig, M.D. and John Whyte, M.D., with a reply from the MSTF by Stephen Ashwal, M.D. and Ronald Cranford, M.D., New England Journal of Medicine 331 (November 1994): 1380-1. Return to Text

[21] MSTF, Part 1, 1501-3. Return to Text

[22] A. A. Howsepian, "Philosophical Reflections on Coma," Review of Metaphysics 47 (June 1994): 736 n. 4. Return to Text

[23] MSTF, Part 1, 1501. Return to Text

[24] Ibid. 1500. Return to Text

[25] A. A. Howsepian, "The 1994 Multi-Society Task Force Consensus Statement on the Persistent Vegetative State: A Critical Analysis," Issues in Law and Medicine, in press. Return to Text

[26] Gven Gzeldere, "Consciousness: What It Is, How to Study It, What to Learn From Its History," Journal of Consciousness Studies 2 (1995): 30-1. Part 2 of this article is: "Problems of Consciousness: A Perspective on Contemporary Issues, Current Debates," Journal of Consciousness Studies 2 (1995): 112-43. See also, David J. Chalmers, "The Puzzle of Conscious Experience," Scientific American 273 (December 1995): 80-6. Return to Text

[27] MSTF, Part 1, 1500. Return to Text

[28] Howsepian, "Critical Analysis," in press. Return to Text

[29] Veatch, "Impending Collapse," 23. Return to Text

[30] An example of an induced coma is when patients are given drugs to cause a state like that found in natural comas. This occurs under adequate general anesthesia. Return to Text

[31] Howsepian, "Philosophical Reflections," 745. Howsepian gives an extensive list of these studies, including H. L. Bennett, "Perception and Memory for Events During Adequate General Anesthesia for Surgical Operations," in Hypnosis and Memory, ed. Helen M. Pettinati (New York: Guilford, 1988), 193-231; and R. Trustman, S. Dubovsky, and R. Titley, "Auditory Perception During General Anesthesia--Myth or Fact?" International Journal of Clinical and Experimental Hypnosis 25 (1977): 88-105. Numerous anecdotal reports cite patients accurately recalling events which occurred while they were in natural comas. See Nathan Schnaper, M.D., "The Psychological Implications of Severe Trauma: Emotional Sequelae to Unconsciousness," Journal of Trauma 15 (1975): 94-8. Return to Text

[32] MSTF, Part 1, 1502. Return to Text

[33] Ibid., 1501. Return to Text

[34] Gzeldere, "Problems of Consciousness," 130. Return to Text

[35] Hannah C. Kinney, M.D. et al, "Neuropathological Findings in the Brain of Karen Ann Quinlan," New England Journal of Medicine 330 (1994): 1469-75. Return to Text

[36] F. A. Middleton and P. L. Strick, "Anatomical Evidence for Cerebellar and Basal Ganglia Involvement in Higher Cognitive Function," Science 266 (1994): 458-61. Return to Text

[37] Daniel Dennett and Marcel Kinsbourne, "Time and the Observer," Behavioral and Brain Sciences 15 (1992): 183-247. Return to Text

[38] Howsepian, "Critical Analysis," in press. Return to Text

[39] Gzeldere, "Problems of Consciousness," 130. Return to Text

[40] Paul Schotsmans, "The Patient in a Persistent Vegetative State. An Ethical Re-Appraisal," Bijdragen 54 (1993): 3. Return to Text

[41] F. Tasseau et al, ed. Etats v‚g‚tatifs chroniques. R‚percussions humaines. Aspects m‚dicaux, juridiques et ‚thiques (Rennes: 1991); cited in Schotsmans, "Ethical Re-Appraisal," 3, 14-15. Return to Text

[42] Ibid., 16. Return to Text

[43] His conclusions are the same as those in the work he re-appraised: Paul Schotsmans, "When the Dying Person Looks Me in the Face: An Ethics of Responsibility for Dealing with the Problem of the Patient in a Persistent Vegetative State," in Birth, Suffering and Death: Catholic Perspectives at the Edge of Life, ed. Kevin Wm. Wildes, Francesc Abel, and John C. Harvey (Dordrecht: Kluwer, 1992), 127-43. Return to Text

[44] MSTF, Part 2, 1576. Return to Text

[45] Ibid., 1577. Return to Text

[46] MSTF, Part 1, 1505-6; idem, Part 2, 1577. Return to Text

[47] Howsepian, "Critical Analysis," in press. Return to Text

[48] Ashwal, "Letter," 1381. Return to Text

[49] The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, the Hastings Center, the American Academy of Neurology, the American Medical Association, and the United Kingdom Institute of Medical Ethics Working Party on the Ethics of Prolonging Life and Assisting Death; cited in MSTF, Part 2, 1577. Return to Text

[50] Dena S. Davis, "Shifting the Burden of Proof," Second Opinion 18 (January 1993): 32. Return to Text

[51] Paul A. Emmett, M.D., "A Biblico-Ethical Response to the Question of Withdrawing Fluid and Nutrition from Individuals in the Persistent Vegetative State" (master's thesis, Bethel Theological Seminary, St. Paul, Minn., 1989), 172-215. Return to Text

[52] Paul A. Emmett, M.D., "The Image of God and the Ending of Life," Asbury Theological Journal 47 (spring 1992): 58. Return to Text

[53] Rakestraw, 401. Return to Text

[54] Ibid., 402. Return to Text

[55] John J. Davis, "Feeding, Hydration and the Persistent Vegetative State" (paper presented at the conference "Health Care in Crisis: A Biblical Response," Pittsburgh, 2 May 1992). Return to Text

[56] Schotsmans, "Ethics of Responsibility," 140. Return to Text

[57] Kevin Wm. Wildes, "Life As a Good and Our Obligations to Persistently Vegetative Patients," in Birth, Suffering and Death: Catholic Perspectives at the Edge of Life, 152-3. Return to Text

[58] Rakestraw, 401. Return to Text

[59] Howsepian, "Philosophical Reflections," 751. Gzeldere, in the context of PVS, similarly proposes "degrees of consciousness," noting: "Perhaps it is altogether misleading to think of the presence of consciousness in a binary fashion," i.e. as either there or not ("Consciousness: What It Is," 32 n. 6). Return to Text

[60] Ronald Smothers, "Injured in '88, Officer Awakes in '96: Doctors Call Man's Return From a Vegetative State a Miracle," New York Times 16 February 1996, p. A8. Return to Text

[61] Jennett and Plum, 737. Return to Text

[62] Emmett, "Biblico-Ethical Response," 99-100. Return to Text

[63] Similarly, authors attempt to classify artificially administered food and fluids as extraordinary or ordinary care. "Once classified, the moral question is essentially resolved" (Shannon and Walter, 638). Return to Text

[64] Joseph F. Fletcher, "Indicators of Humanhood: A Tentative Profile of Man," Hastings Center Report 2 (November 1975): 1-4. Return to Text

[65] Joseph F. Fletcher, "Four Indicators of Humanhood - The Enquiry Matures," Hastings Center Report 4 (December 1975): 6. Return to Text

[66] Rakestraw, 402 n. 52. Return to Text

[67] Stanley Hauerwas, Truthfulness and Tragedy: Further Investigations in Christian Ethics (Notre Dame: University of Notre Dame Press, 1977), 127-31. Return to Text

[68] Ibid., 130. Return to Text

[69] For an interesting discussion of these issues in the context of handicapped newborns see Warren T. Reich, "Caring for Life in the First of It: Moral Paradigms for Perinatal and Neonatal Ethics," Seminars in Perinatology 11 (1987): 279-87. Return to Text

[70] Schotsmans, "Ethics of Responsibility," 132. Return to Text

[71] Angell, 18. Return to Text

[72] D¢nal P. O'Math£na, "The Bible and Abortion: What of the 'Image of God'?" in Bioethics and the Future of Medicine: A Christian Appraisal, ed. John F. Kilner, Nigel M. de S. Cameron, and David L. Schiedermayer (Grand Rapids: Eerdmans, 1995), 199-211. Return to Text

[73] Allen Verhey, "Scripture and Medical Ethics: Psalm 51:10A, The Jarvik VII, and Psalm 50:9," in Religious Methods and Resources in Bioethics, ed. P. F. Camenisch (Netherlands: Kluwer, 1994), 261-88. Return to Text

[74] RSV, marginal reading in the NASB and NIV. Return to Text

[75] Kathleen A. Farmer, Who Knows What Is Good? A Commentary on the Books of Proverbs and Ecclesiastes, International Theological Commentary (Grand Rapids: Eerdmans, 1991), 190-1. Return to Text

[76] Claus Westermann, Genesis 1-11 (Minneapolis: Augsburg, 1984), 151-4. Return to Text

[77] Abraham J. Heschel, God in Search of Man: A Philosophy of Judaism, (New York: Farrar, Straus & Giroux, 1955), 290. Return to Text

[78] Carl F. H. Henry, Christian Personal Ethics (Grand Rapids: Eerdmans, 1957), 272. Return to Text

[79] Oliver M. T. O'Donovan, "Again: Who is a Person?" in Abortion and the Sanctity of Life, ed. J. H. Channer (Exeter, England: Paternoster, 1985), 125-6. Return to Text

[80] Reich, 279-87. Return to Text

[81] David F. Forte, "Getting Rid Of the Vegetables," First Things 26 (October 1992): 13-15. Return to Text

[82] Reich, 284-5. Return to Text

[83] Tudor, 39. Return to Text

[84] Arnold Mindell, "Working with Comas," interview by Jeffrey Mishlov, in Approaches to Consciousness (Berkeley, Cal.: Thinking Allowed Productions, n.d.) videocassette. Return to Text

[85] Arnold Mindell, Coma: Key to Awakening (Boston: Shambhala, 1989). Return to Text

[86] Luke Gormally, "Definitions of Personhood: Implications for the Care of PVS Patients," Ethics & Medicine 9 (autumn 1993): 46. Return to Text

[87] Hauerwas, 128. Return to Text

[88] The horrors of Nazi extermination camps did not begin when Adolf Hitler gained power. Many physicians and academics had earlier accepted the notion that some lives are not worth living. The first to be systematically killed were the mentally retarded. See, Fredric Wertham, "The Geranium in the Window: The 'Euthanasia' Murders," A Sign for Cain (New York: Macmillan, 1966), reprinted in Death, Dying, and Euthanasia, ed. Dennis J. Horan and David Mall (Frederick, MD: Aletheia, 1980), 602-41; and Leo Alexander, M.D. "Medical Science Under Dictatorship," New England Journal of Medicine 241 (1949): 39-47. Return to Text

[89] Tamar Lewin, "Bitter Fight to Supreme Court Over the Life of a Man Who Can Only Smile," New York Times, 19 February 1996, p. A6. Return to Text

[90] D. Alan Shewmon, "The Metaphysics of Brain Death, Persistent Vegetative State, and Dementia," The Thomist 49 (1985): 24-80. Shewmon has since reversed his view and argues against his earlier position in "Is "Brain Death" Actually Death? An Autobiographical Conceptual Itinerary," Aletheia, in press. Return to Text

[91] Michael Tooley, "A Defense of Abortion and Infanticide," in The Problem of Abortion, ed. Joel Feinberg (Belmont: Wadsworth, 1973), 51-91. Return to Text

[92] MSTF, Part 2, 1576. Return to Text

[93] Shewmon, "Metaphysics," 80. Return to Text

[94] John F. Kilner, "A Needy World--A Needed World: Scarce Medical Resources and the Christian Story," Asbury Theological Journal 41 (1986): 23. Return to Text

[95] Edmund Pellegrino, M.D., cited in Emmett, "Biblico-Ethical Response," 213. Return to Text

[96] Eugene F. Diamond, "The Deformed Child's Right to Life," in Death, Dying, and Euthanasia, 129. Return to Text

[97] Howsepian, "Philosophical Reflections," 750. Return to Text

[98] Much appreciation is due to A. A. Howsepian for his advice and encouragement, and to Ryan's parents for their openness and example. Return to Text


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