Faculty of Law, University of Oxford, Oxford, UK.
Green Templeton College, University of Oxford, Oxford, UK.
J Med Ethics. 2019 Apr;45(4):265-270. doi: 10.1136/medethics-2018-105250. Epub 2019 Feb 14.
In English law there is a strong (though rebuttable) presumption that life should be maintained. This article contends that this presumption means that it is always unlawful to withdraw life-sustaining treatment from patients in permanent vegetative state (PVS) and minimally conscious state (MCS), and that the reasons for this being the correct legal analysis mean also that such withdrawal will always be ethically unacceptable. There are two reasons for this conclusion. First, the medical uncertainties inherent in the definition and diagnosis of PVS/MCS are such that, as a matter of medical fact, it can never be established, with the degree of certainty necessary to rebut the presumption, that it is not in the patient's best interest to remain alive. And second (and more controversially and repercussively), that even if permanent unconsciousness can be unequivocally demonstrated, the presumption is not rebutted. This is because there is plainly more to human existence than consciousness (or consciousness the markers of which can ever be demonstrated by medical investigations). It can never be said that the identity of the patient whose best interests are at stake evaporates (so eliminating the legal or ethical subject) when that person ceases to be conscious. Nor can it be said that the best interests of an unconscious person do not mandate continued biological existence. We simply cannot know. That uncertainty is legally conclusive, and (subject to resource allocation questions and views about the relevance of family wishes and the previously expressed wishes of the patient) should be ethically conclusive.
在英国法律中，存在着一种强有力的（尽管可以反驳）的假设，即生命应该得到维持。本文认为，这种假设意味着，从永久性植物人状态（PVS）和最小意识状态（MCS）的患者身上撤回维持生命的治疗措施始终是非法的，这种假设之所以是正确的法律分析，意味着这种撤回在伦理上也是不可接受的。得出这一结论有两个原因。首先，PVS/MCS 的定义和诊断中固有的医学不确定性使得，作为一个医学事实，永远无法以反驳假设所需的确切程度来确定，让患者继续活着不符合其最佳利益。其次（更具争议性和反响性），即使可以明确证明永久性无意识，也无法反驳这一假设。这是因为，人类的存在显然不仅仅是意识（或者可以通过医学调查证明的意识标志）。当一个人的意识消失时，不能说涉及到的患者的身份（从而消除法律或伦理主体）就消失了。也不能说无意识者的最佳利益不要求继续保持生物存在。我们根本无法知道。这种不确定性在法律上具有决定性，并且（在资源分配问题以及关于家庭意愿的相关性和患者之前表达的意愿的观点的基础上）在伦理上也具有决定性。
