In this article, I consider whether the advance directive of a person in minimally conscious state ought to be adhered to when its prescriptions conflict with her current wishes. I argue that an advance directive can have moral significance after its issuer has succumbed to minimally conscious state. I also defend the view that the patient can still have a significant degree of autonomy. Consequently, I conclude that her advance directive ought not to be applied. Then I briefly assess whether considerations pertaining to respecting the patient's autonomy could still require obedience to the desire expressed in her advance directive and arrive at a negative answer.
We aim to improve the medical care and understanding of disorders of consciousness following an acute insult such as coma, vegetative state, minimally conscious state or locked-in syndrome. Coma Science Group Cyclotron Research Center & Neurology Dept University of Liège
Although DJ's condition is in many respects grim, I am not persuaded that treatment would be futile or overly burdensome, or that there is no prospect of recovery. (a) In DJ's case, the treatments in question cannot be said to be futile, based upon the evidence of their effect so far. (b) Nor can they be said to be futile in the sense that they could only return DJ to a quality of life that is not worth living. (c) Although the burdens of treatment are very great indeed, they have to be weighed against the benefits of a continued existence. (d) Nor can it be said that there is no prospect of recovery: recovery does not mean a return to full health, but the resumption of a quality of life that DJ would regard as worthwhile. The references, noted above, to a cure or a return to the former pleasures of life set the standard unduly high.
Respect for patient autonomy and the right of individuals to make their own healthcare decisions where possible lies at the core of the recent Mental Capacity Act 2005. The Act gives statutory authority to “Advance Decisions” (ADs) – enabling people to communicate their healthcare decisions in advance of losing the capacity to do so (e.g. due to coma or dementia). This is increasingly important when new medical technologies mean it is now possible keep people alive for years or for decades in permanent vegetative or minimally conscious states (i.e. with no – or virtually no – awareness of themselves or their environment).
National clinical guidelines on the care of people in a vegetative or minimally conscious state, following severe brain injury These long-awaited guidelines will be a major contribution to clinical and ethical standards of care for this group of patients, not only in the UK but internationally. For England and Wales, they provide much needed clarity on legal decision-making. You can buy a print copy of the guidelines (130 pp, £15) from our online shop, or download a free PDF below. The guidelines were developed by a panel of experts in the field, who have organised complicated and wide-ranging information into six coherent sections: 1 Defining criteria and terminology 2 Assessment, diagnosis and monitoring 3 Acute to longer-term management 4 Ethical and medico-legal issues 5 End-of-life issues 6 Service organisation and commissioning Each section is followed by a set of clear recommendations.