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.     

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.     

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.