Oxford Uehiro Prize in Practical Ethics: If Doctors Could Administer a Treatment That Would Move a Patient From a Vegetative State to a Minimally Conscious One, Should They Do So?

This essay was the runner up in the graduate category of the 6th Annual Oxford Uehiro Prize in Practical Ethics.

Written by University of Oxford student Matthew Minehan.

INTRODUCTION
Sally is a healthy young woman who suffers catastrophic brain trauma. Over many months, her doctors subject her to functional Magnetic Resonance Imagining (fMRI) scans and other assessments that leave them in no doubt that she is in a vegetative state. While she shows sleeping and waking activity patterns, her body is operating on ‘automatic’ and she has no consciousness. She is “incognizant, incapacitated and insensate” (Fenwick 1998, p.86).

Sally’s doctors are aware of a new treatment that, if administered, would move her from the vegetative state to a minimally conscious one. This new state would involve fractured consciousness, a lack of awareness of her condition, an inability to direct her own life and an incapacity for complex thought. Because Sally has no known next of kin and issued no advance directive, the decision on her treatment is left to her medical team.

Should the doctors in this hypothetical scenario administer the treatment to Sally?

While contingent issues such as limited resources and opportunity costs may count against administering the treatment, this paper will argue that, all else being equal, the world would be a better place if the doctors did administer it.

For the sake of clarity, the arguments presented below are made with the following assumptions: (i) Sally has been correctly diagnosed, (ii) Sally’s vegetative state shows every sign of being permanent, (iii) there are no alternative treatments that might return Sally to a higher level of consciousness, and (iv) there is no reason for thinking that moving Sally to the minimally conscious state will start a healing process whereby she will later achieve a higher level of consciousness.

CONSCIOUSNESS AND MORALITY
It is often thought that entities obtain their worth through consciousness, perhaps because consciousness has intrinsic value or perhaps because it “confers value on those who possess it” (Levy 2014, p.127). Utilitarians value the conscious experience of pleasure (Mill 1871), while deontologists are typically concerned with moral agents and moral patients (Alexander & Moore 2016), who are generally conscious beings. However, consciousness also plays a central role in disvalue – it is because of the conscious experience of life that some lives are manifestly not worth living.

There are many unknowns about the minimally conscious life, and it is easy to paint a dire picture. Kahane and Savulescu (2009, p.18) liken minimal consciousness to dementia, and several authors suggest that, due to the potential for pain and suffering, life in this state risks being much worse than life in a vegetative state (Wilkinson et al. 2009; Johnson 2011; Kahane & Savulescu 2009). What the current paper seeks to highlight, however, is that the minimally conscious life may also be considerably better than the vegetative one. Indeed, this would not be a difference of degree but of kind. As Wade (2001, p.353) notes of a vegetative patient, “If the patient is truly unaware then it is presumably difficult to do either harm or good. The patient truly has “no interests” …” The minimally conscious state, in contrast, can plainly be good or bad for the patient in that state.

Nevertheless, the identity of our minimally conscious patient is in doubt, with Sally being “a temporally extended psychological entity that may no longer exist” (Kahane & Savulescu 2009, p.19). Neither vegetative Sally nor minimally conscious Sally are likely to share Sally’s memories, nor will there be any meaningful similarity in the way they reason or perceive the world. Furthermore, the transition between each ‘Sally phase’ is abrupt, and very unlike the gradual change that normally accompanies the transition from infancy to old age.

If the patient in the minimally conscious state is not Sally, then who is it? To avoid confusion, we will call her post-Sally.

THE VALUE OF POST-SALLY’S LIFE
There are two ways of assessing the value of an individual life: Firstly, whether the life is good for that person, and, secondly, whether the life has value per se (Crisp 2017). We shall consider both.

Is Post-Sally’s Life Good for Post-Sally?

While post-Sally’s life might not be as valuable as Sally’s was, a positive valuation may be made on each of the three main accounts of well-being: Hedonism, objective list and desire fulfilment (Parfit 1984, p.493).

Hedonism

For hedonists, the question becomes: Does any experienced pleasure outweigh any pain? It is plausible to think that it might. Graham (2018, p.129) highlights how, if minimally conscious patients resemble other severely disabled individuals, then they will likely adjust to their situation and may even obtain “positive hedonic experiences” through the likes of music. Furthermore, if the treatment discussed in this paper existed, then surely supplying regular doses of morphine, antidepressants, mood enhancing drugs or deep brain stimulation (Fitzgerald 2016) would also be feasible.

Objective List
Assessing post-Sally’s well-being on an objective list account is complicated by the plethora of possible lists. Regardless, she may well experience qualifying mental states, and the chosen list should be one that would be applied to any mentally comparable beings in nature, and not merely to fully functioning human adults.

Desire Fulfilment
Things are even more complicated on desire fulfilment accounts, both due to a possible clash between the desires of Sally and post-Sally and because post-Sally may be deemed incapable of producing qualifying desires. Kahane and Savulescu (2009, p.13), for instance, suggest that “[a] being cannot have desires, and thus desiderative interests, without a sufficient degree of cognitive capacity”, and, when applying this rule to a scenario like post-Sally’s, they explain that “her desiderative interests (assuming she has any) would not be generated by any present desires but by her past ones” (Kahane & Savulescu 2009, p.18). In other words, these interests would be Sally’s rather than post-Sally’s.

It is unclear precisely what Kahane and Savulescu think qualifies as a desire, although perhaps they think that desires must be propositional in nature (akin to ‘lingualist’ approaches that ground desires and other intentional states in language; Glock 2013, p.213) or, at least, ‘proto-propositional’, in the sense that they require the mind to engage in some form of sensory representation (Glock 2013, p.222). However, while post-Sally clearly has no mental states with propositional content (she cannot form the view ‘I want a cupcake’) and probably has no mental representations, neither of these seems to capture what is essential about desires. It might be thought, for instance, that the very experience of phenomenal pain entails a wish for it to be relieved (one would not require reflection on the pain in addition to the pain itself) (Stephens & Graham 1987). Likewise, the fact that something registers as a phenomenal pleasure may entail a desire for it to continue.

Post-Sally’s non-propositional desires may include those to feed and relieve her bladder, which would both be objectively satisfied by life-support machinery. Indeed, while her desires may be limited, post-Sally may be one of the few beings who routinely have all their desires fulfilled. As for any possible conflict between post-Sally’s current desiderative interests and Sally’s previous ones, it could be suggested that what post-Sally gets up to is actually none of Sally’s business.

Is Post-Sally’s Life Good for the World?
While consciousness is valuable, it might be suggested that post-Sally has too little consciousness to matter or an insufficiently integrated mental world for any mental experiences truly to be hers. Regardless, it would not follow that these experiences have no value in themselves. Consider the following thought experiment:

Imagine a possible world in which there are no conscious entities and no mental events, with one exception: A simple mollusc that exists in a minimally conscious state. Though simple, the experiences of this minimally conscious mollusc are nevertheless positive. We will leave open the sense in which they are positive, although perhaps they are pleasurable (on a hedonistic account) or fulfilling of simple desires (on a desire fulfilment account). Would the possible world inhabited by this mollusc be better than a world in which there was no consciousness? Given that consciousness is what is valuable, it seems evident that it would be. Likewise, it should follow that, all else remaining equal, our own world would be improved by the addition of this minimally conscious mollusc.

Granting still that consciousness is what is valuable, the fact that the minimally conscious organism comes in the form of a mollusc is surely not relevant: If the organism’s experiences are net-positive, the implication of an improved world through the addition of a somewhat conscious being would still obtain, regardless of its physical form. If this is right, then judging post-Sally against the standard of a typical human being (rather than against the standard applied to the mollusc) would be as mistaken as judging a pumpkin as if it were human, simply because the pumpkin was shaped like a human face. Consequently, we may sharpen the thought experiment by qualifying that the conscious experiences of the mollusc are essentially identical to those of a minimally conscious human patient without changing the implications. This suggests, in short, that if post-Sally is a minimally conscious being with net-positive experiences, then it is better for both her and the world to have her around.

This certainly contrasts with Plato’s intuitions about shelled sea creatures (Plato 1975, 21C-D), who, even if they experienced pleasure, “lacked thought, memory, knowledge, and true opinion” and thus led undesirable lives. Perhaps this is because Plato was interested in comparing these simple life-forms with the ordinary human experience. There seems little doubt that the richness of ordinary human consciousness – bound up as it is with understanding, goals and discernment of value – out-weighs a minimally conscious life. But consider the following: If there was a contented minimally conscious mollusc or other sea creature, would we have a reason to euthanise it because its existence was worse than non-existence? Likewise, given the choice between eating a minimally conscious mollusc and a non-conscious one, does the former’s mental life provide a reason for consuming it over the latter? So long as the mollusc has positive experiences, to suggest so seems absurd.

This leads us to conclude that:

All else being equal, a world in which post-Sally exists in a minimally conscious state and in which her experiences are net-positive is better (i.e. more valuable) than a world in which post-Sally exists in a vegetative state or does not exist at all. It is also good for post-Sally.

Of course, all else will rarely be equal, and it is doubtful that bringing about post-Sally’s existence would be the most optimific option available to her doctors. Patients with more promising prognoses could be treated instead, and, given post-Sally’s low level of consciousness, perhaps even a donation to the local animal shelter would be more beneficent. Nevertheless, these concerns are contingent on modern medical capabilities. Perhaps life support will be inexpensive in the future, which may tip the balance back in favour of creating post-Sally. Regardless, if the doctors wished to create post-Sally and if they could adequately fund both the initial treatment and her ongoing care, then they should not be prevented from doing so. They would not be harming post-Sally.

CONCLUSION
Unless post-Sally suffered from pain or anguish that could not readily be overcome by painkillers or anti-depressants, it seems evident that, all else being equal, a world in which she existed in a minimally conscious state would be better than a world in which she existed in a vegetative state or not at all. It would also be good for post-Sally. Whether it is appropriate to bring her about, however, is a more complex matter, and depends on contingent issues such as opportunity costs. On most calculations we would normally not give post-Sally a run as the resources involved would be extensive and her mental life not rich enough compared with likely alternatives. Once created, however, post-Sally’s existence would in no sense be a bad thing. After all, and all else being equal, a world in which we have post-Sally is more valuable than a world without her.

REFERENCES
Alexander, L. and Moore, M. (2016) ‘Deontological Ethics’, The Stanford Encyclopedia of Philosophy (Winter 2016 Edition), Edward N. Zalta (ed.). https://plato.stanford.edu/archives/win2016/entries/ethics-deontological/

Crisp, R. (2017) ‘Well-Being’, The Stanford Encyclopedia of Philosophy (Fall 2017 Edition), Edward N. Zalta (ed.). https://plato.stanford.edu/archives/fall2017/entries/well-being/

Fenwick, A. J. (1998), ‘Applying best interests to persistent vegetative state – a principled distortion?’, Journal of Medical Ethics, 24(2), 86-92.

Fitzgerald, P. B. (2016) ‘Deep brain stimulation in depression’, Australian & New Zealand Journal of Psychiatry, 50(1), 94-95.

Glock, H. (2013) ‘Animal minds: A non-representationalist approach’, American Philosophical Quarterly, 50(3), 213-232.

Graham, M. (2018) ‘Domains of well-being in minimally conscious patients: Illuminating a persistent problem’, AJOB Neuroscience, 9(2), 128-130.

Johnson, L. S. M. (2011) ‘The right to die in the minimally conscious state’, Journal of Medical Ethics, 37(3), 175-178.

Kahane, G. and Savulescu, J. (2009) ‘Brain damage and the moral significance of consciousness’, Journal of Medicine and Philosophy, 34, 6-26.

Levy, N. (2014) ‘The value of consciousness’, Journal of Consciousness Studies, 37(3), 175-178.

Mill, J. S. (1871) Utilitarianism (4th Ed.), London: Longmans, Green, Reader, and Dyer.

Parfit, D. (1984) Reasons and Persons, Oxford: Clarendon Press.

Plato (1975) Philebus, Translated with Notes and Commentary by J. C. B. Gosling, Oxford: Clarendon Press.

Stephens, G. L. and Graham, G. (1987) ‘Minding your P’s and Q’s: Pain and Sensible Qualities’, Noûs, 21(3), 395-405.

Wade, D. T. (2001) ‘Ethical issues in diagnosis and management of patients in the permanent vegetative state’, British Medical Journal, 322(7282), 252-354.

Wilkinson, D. J., Kahane, G., Horne, M. and Savulescu, J. (2009) ‘Functional neuroimaging and withdrawal of life-sustaining treatment from vegetative patients’, Journal of Medical Ethics, 35, 508-511.

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