Clinical Incoherence about Persons: The Problem of the Persistent Vegetative State

A provocative and disturbing article by Payne and colleagues [1] in this issue reports on the attitudes and beliefs of a panel of neurologists and medical directors of nursing homes about the persistent vegetative state (PVS). The authors chose to survey these physicians because they believed them to be especially knowledgeable. The results are surprising, contradictory, and indicative of confusion about what most of us believe is basic to being a person. A person is a complex being, more of a trajectory through time than an object, that includes a past and a believed-in future combined with society, culture, family, roles, work, relationships (with others, self, and body), a private life, and a transcendent dimension [2].

The PVS is characterized by lack of awareness and preserved sleep-wake cycles; it is physiologically similar to anencephaly. Payne and colleagues [1] point out that physiologic and anatomical studies do not support the capacity for subjective experience in these patients. Yet “substantial minorities” of both neurologists and medical directors believe that these patients “experience pain, thirst, and hunger; are aware of self and environment; and are made more comfortable by intravenous fluids and tube feedings.” Experience is an ambiguous word. In terms of pain, it might mean to undergo, as in receiving a nociceptive stimulus. More often, it implies a cognitive response to a stimulus, by which it is assigned meaning as a specific kind of pain from a specific something. Simple nociceptive responses exist far down the phylogenetic scale and do not seem to be what the surveyed physicians meant. The cognitive function and assignment of meaning usually associated with experience are characteristic of persons and seem to require a generally intact nervous system. Neurologists know these things better than I do, so …