In response to a comment on my earlier post on Terri Schiavo and the Law, I tried to amplify my thoughts on the broader ethical issues relating to medical treatment, artificial nutrition and hydration, and PVS. I thought this was worth a separate post.
The philosophical / theological underpinnings of my view are set forth in my two earlier posts (here and here) on this issue. Essentially, I don’t think a monistic view of personhood — that personhood is coequal with the physical body — is Biblical. I’m also not a dualist (personhood consists of two separate components of body and soul). I hold a conditional unity view of personhood. Personhood has different aspects, including body, mind, and soul, and these different aspects are part of a unified whole.
In conjunction with this condition unity view of personhood, I apply the Biblical concept of humans as created in the “image of God.” What is the image of God? Most Biblical scholars agree that it is not a physical image. Rather, it has something to do with our capacity to reason, relate, communicate and create.
Finally, I apply what I believe is a Biblical understanding of death. Death temporarily separates body from the other aspects of personhood, pending the Resurrection — hence the “conditional” aspect of the unity of personhood. The aspects of our person that reflect the image of God continue to exist and one day will be reunited with a body. The current physical aspects of our personhood — the body — is no longer connected to our “person.” We treat physical remains with respect, but we appropriately dispose of them through burial or cremation, knowing that the “person” is no longer present in the body.
If these views of personhood, the image of God, and death are Biblical, and I belive they are, then it is possible, given modern medical technology, that a body could continue to be maintained even though the person has gone on to the intermediate state pending the Resurrection.
As an extreme example, imagine a person whose brain was completely removed from her body, while the heart, lungs and other organs were maintained through artificial respiration, circulation, nutrition and hydration. I think most Christians probably would agree that the “person” in that circumstance has died, and that our technology was merely keeping some parts of the body from decay. If you wouldn’t agree to that, I’d ask how much of the body needs to be maintained before the “person” is gone. For example, if we take the heart from a person who has recently died and transplant it into another person, does the “person” who recently died still exist in this life?
The persistent vegitative state (PVS) is several steps back from my “brainectomy” hypothetical, but the principle is the same. At some point, when there is nothing left of most of the brain but liquid, and there is no remaining capacity or potential for the attributes of communication, relationship, and creativity that reflect the image of God, I believe the “person” has gone on to the intermediate state, and nothing is left but the mortal body.
The commenter to my eariler post asked why, if I hold this view, it would be unethical to terminate a PVS patient through lethal injection or immediate cremation. Here, I believe an ethical distinction remains between actively terminating bodily functions and removing artificial medical support for those functions. A lethal injection or cremation before cessation of all bodily functions would constitute an affirmative act that would betray a lack of respect for the bodily aspect of personhood. Therefore, I would not be comfortable with that kind of action.
However, the removal of artifical medical support is a different matter. In that case, we are allowing the body to take its natural course. I should note here that I don’t see any material distinction between turning off a respirator and removing artificial nutrition and hydration. In either instance, a fundamental requirement for bodily function — air, hydration, or nutrition — is being provided by technological means — a respirator, or tubes inserted by medical professionals into the gatric tract through which nutritional serum and water are metered by a machine. And, in either case, the removal of those technological life supports will result in the cessation of bodily functions. In my view, under these circumstances, turning off a respirator or an artificial nutrition and hydration system is a withdrawal of medical treatment that allows the body to take a natural course. This, in my view, is ethically different than assisted suicide or euthanasia.
As I’ve said before, none of this settles the question whether it was ethical to remove Terri Schiavo’s ANH. If there is a material doubt about whether the patient truly is in a PVS, ANH should not be withdrawn. But, that is exactly the kind of factual determination, I think, that trial courts are best equipped to make. Moreover, I don’t think any medical treatment, including ANH, should be withdrawn if the patient’s wishes were equivocal or to the contrary. But, again, determining what the patient’s wishes were, in the absence of a clear, written advance health care directive (a living will), is, in my judgment, an appropriate function of the trial courts.
