Legal consequences and ethical dilemmas of pain perception in persistent vegetative states

"Persistent vegetative state" (PVS) describes brain-damaged patients who survive their injuries in a sleeplike, insensible state, with periodic awakenings. Due to technological advances, such individuals can sustain biological existence for prolonged periods of time. Their existence results in a dichotomy between the legal and medical interpretations of persistent vegetative states, giving rise to ethical conflicts. The author reviews the limitations in our understanding of what PVS signifies for the afflicted individual, and explores the conflicts arising from such limitations that may impact an individual's right to live or die. The author concludes that the medical community has yet to adopt consistent clinical criteria to diagnose PVS and that a universal standard for PVS is needed to avoid the abuse of vegetative individuals' rights.     

Recent advances in medically assisted conception: legal, ethical and social issues.

A review of reports, bills and legislation from around the world, during the period from 1987 to 1991, reveals certain areas of consensus on the possible or actual, ethical and legal regulation of medically assisted conception. Other areas remain controversial, due not only to cultural and religious differences but also to the social significance of the very implementation of these new technologies. Irrespective of these differences, the reformulation of certain shared international principles of human rights permits a greater specificity both in their translation and in their application to medically assisted conception. Areas discussed include the dignity of the person, the security of human genetic material, the quality of services, the inviolability of the person and the inalienability of the person.     

Advance directives and the persistent vegetative state in Victoria: a human rights perspective

With advances in medical technology, it is now possible to sustain the life of a person in a persistent vegetative state (PVS) until a decision is made to withhold or withdraw life-sustaining treatment. Who makes that decision? Under the Medical Treatment Act 1988 (Vic) there is no legally enforceable right for a person to choose, in advance, what intervention that person will and will not accept if he or she ends up in a PVS. The best that can be achieved is that a person can appoint an agent who is empowered to refuse medical treatment on the person's behalf in the event of incompetence. It is suggested that this mechanism ignores two fundamental human rights: self-determination and the inherent right to dignity. This article proposes the development of an advance directive mechanism that provides for a person to refuse, in advance, specified intervention, thereby respecting fundamental human rights and alleviating the existing need for an agent to second-guess a person's desires and best interests.     

胸背部外伤致持续性植物状态案例分析

在现有的法医学文献中,多将持续性植物状态（persistent vegetative state,PVS）作为颅脑损伤的并发症进行介绍。但在法医学鉴定实践中,非颅脑损伤所致的PVS并非少见。另一方面,目前通用的法医学鉴定标准中,只有《道路交通事故受伤人员评定》将PVS明确列为评残条文,并归入“颅脑、脊髓及周围神经损伤致”项内。由于上述两方面原因,PVS、特别是非颅脑损伤所致PVS的损伤程度、伤残等级的评定均成为鉴定难点。在实际检案中．可以结合PVS的病因和病理机制、临床表现及法医学检查特点加以综合分析,进而作出损伤程度、伤残等级的评定。     

Withdrawal of artificial nutrition in the persistent vegetative state: a continuous controversy

The withdrawal of life support from patients in persistent vegetative state (PVS) is a controversial issue, as highlighted by a continuous public debate and recent judicial decisions. In Germany, a topic of particular interest is the abatement of artificial nutrition. First, doubts have come up whether every kind of technically delivered nutrition should be rated identically or whether a distinction between feeding tubes/gastrotomies and intravenous administration should be made. Second, the question is left open whether artificial nutrition is part of basic care and as a consequence may never be discontinued, or if it has to be regarded as life-sustaining treatment which can be refused by surrogates on behalf of the nonautonomous patient. Most recently, controversial judicial decisions have dealt with the question if substituted judgement concerning abatement of artificial nutrition by surrogates or legal guardians is permitted or if the approval of a court is necessary. Forensic evidence is provided which indicates that the withdrawal of artificial nutrition in patients in the persistent vegetative state may become a contributing causative factor or even the immediate cause of death. The legal implications with regard to the above-mentioned issues of controversy are discussed.     

The 14/2006 law on human assisted reproduction techniques: scientific and ethical considerations]

The new Spanish Law on Artificial Human Reproduction Techniques is analyzed from the scientific, ethical and legal points of view, paying special attention to the preimplantational diagnosis and the experimental utilization of gametes and preembryos. Other items are also analyzed.     

The 14/2007 Law on Biomedical Research: comments on ethical and scientific aspects]

The Spanish Law on biomedical investigation is analyzed from the scientific and ethical points of view. In the author's opinion, some terms used in the text in order to avoid ethical and legal conflicts are not right from the biological point of view.     

Terri Schiavo: the assessment of the persistent vegetative state in accordance with German law

The case of Terri Schiavo in the USA served to intensify the debate in Germany which itself had in part already been characterised by fundamentalism. Now that some time has elapsed and the political debate has quietened, this case is to be taken up again in discussing the permissibility and the prerequisites of passive euthanasia for patients in a persistent vegetative state. A short reconstruction of the facts of the case (II) is to be followed by a survey of the case law of the Criminal Panels (III) which is essential to understand the present legal policy debate to be discussed at a later stage (IV).     

Withdrawing life support from patients in a persistent vegetative state: the law in the Netherlands

This article sets out how a case like that of ms. Schiavo is likely to be decided in a Dutch court and compares that with the law in the United States. In the Netherlands there is one case with striking similarities: the decision of the Arnhem Court of Appeal of 1989. After describing that case (which to a large extent still reflects the legal state of the art), comments are given on several aspects of the issue, such as the labelling of artifical feeding as a medical intervention, the role of the physician, the position of the proxy or surrogate, the ways to resolve dispute in case of conflict, and the significance of advance directives. The analysis will show that, although there is more consensus on the issue now than there was 16 years ago, there are still several questions that need to be addressed in the future.