杏吧原创

It鈥檚 Monday and, with your mind elsewhere, you head across the road. You鈥檝e
just set foot on the tarmac when the car hits you. When you wake, it鈥檚 a changed
world. You can鈥檛 move. You can鈥檛 speak. You can鈥檛 eat unaided鈥攊n fact you
are fed by a tube.

It鈥檚 everyone鈥檚 nightmare; an accident causing brain damage so severe that it
leaves you completely dependent on others, yet unable to communicate with them.
And you鈥檙e likely to live like this, without recovery, for another 10 to 15
years.

Stop and think. What would you choose? Would you want to be allowed to die,
or to continue living? The question is perhaps even more difficult if it is your
spouse, parent or child who is incapacitated. Then, having chosen, just how
certain could you be that you had made the right decision. And who do you think
should ultimately decide: you, your family, medical professionals or the courts?
Perhaps it would have been easier if you鈥檇 made a 鈥渓iving will鈥�. These documents
are written while the maker is sound in body and mind to indicate their wishes
in the case of catastrophic accident or illness.

Few of us make wills about how to dispose of our estate, and fewer still
write 鈥渓iving wills鈥�. But it is known that many of us say we would want to die
if severely injured after an accident. For example, surveys of health
professionals in the US and Britain show that around 90 per cent think that
survival in a vegetative state would be 鈥渨orse than death鈥�. And more than 40 per
cent of them believe that survival with severe disability would be worse than
ending up in a vegetative state.

It鈥檚 tempting to think that living wills are the answer. But, in reality,
they have their own complications. The wording is crucial. In many cases there
is likely to be legal argument if the victim鈥檚 disability does not quite match
that covered by the will or if the prognosis is uncertain. Secondly, how do you
know the person hasn鈥檛 changed their mind after the accident?

Three years ago, I came across such a case. I was asked to assess Ms X. She
had been hit by a car two years earlier, and suffered severe brain damage. She
was left unable to move voluntarily except with one arm and hand. She could not
speak. A number of experts saw her independently and thought she was not in a
persistent vegetative state, but was close to being so, with only fleeting
consciousness. The likelihood of further recovery was believed remote. It was
thought that she might live like this for another two decades.

Her close family and the doctor responsible for her care judged that her
quality of life must be low, that her life was pointless and that tube feeding
should be withdrawn. They believed their case was strengthened by the fact that
long before the accident, Ms X had told her family several times that she would
not wish to continue living if ever severely injured. The hospital applied to
the courts for feeding to be withdrawn.

I was asked jointly by the hospital and the Official Solicitor, who
represents the interests of people such as Ms X, to carry out a
neuropsychological assessment on her soon before the court hearing. It was clear
that the brain injury had severely limited her mental functions. But she was
conscious and able to answer questions by pressing a buzzer to indicate yes or
no. What is more, she no longer held the views she had expressed before the
accident, and now wanted to continue living.

A second opinion was called for, confirming these findings, and soon after
the application to the courts was withdrawn. A recent follow-up carried out
three years later found that while Ms X remains totally dependent on care, she
has unexpectedly recovered in a number of significant ways. She now speaks, and
communicates her wishes by talking. She is now fed by mouth, not by tube. And
despite having greater insight into her condition, reporting pain at times and
low moods, she still wants to live.

Ms X is not alone. We know from other case reports and clinical experience
that some able-bodied people who sustain horrific physical and brain injuries
persist in wishing to live, even if they have become totally dependent on
others, suffer pain and occasionally feel suicidal. What is more, they may feel
like this even if they had strong views to the contrary before they were
injured.

Who decides?

So, given the vagaries noted above, with whom does the decision to keep
severely injured people alive finally rest? Some bodies, such as the British
Medical Association, have recommended that the doctor responsible for treatment
should make the final decision, following discussion with the rest of the
healthcare team and the family. In Scotland, legislation is being proposed to
allow an individual to delegate the decision, while still in a sound state, to a
named person or 鈥済uardian鈥�.

In most countries, national healthcare systems are short of funds. In
Britain, able-bodied people often have to wait months for important operations.
Someone who is in a persistent vegetative state or in a 鈥渓ow awareness鈥� state
requires expensive 24-hour nursing care. Given these competing pressures, it is
unfair to expect the physician responsible for the patient鈥檚 care to make an
objective decision.

Indeed, in the case of Ms X, artificial feeding would have been withdrawn had
her doctor, a guardian acting on the basis of a living will, or her family had
the power to decide. Arguably, it was the experience of the Official Solicitor
in dealing with these cases that led to a specialist neuropsychological
assessment being sought鈥攚hich in this case was vital.

Decisions about the removal of artificial feeding should take into account
the views of the doctor, family, guardian, any living will and expert opinion.
But essentially, the life or death decision is moral rather than clinical, and
is best placed in the objective hands of the courts as representatives of public
opinion.