Abstract
An adaptation of Pascal’s Wager argument has been considered useful in deciding about the provision of life-sustaining treatment for patients in persistent vegetative state. In this article, I assess whether people making such decisions should resort to the application of Pascal’s idea. I argue that there is no sufficient reason to give it an important role in making the decisions.
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Notes
For the problems of Pascal’s Wager see, e.g., [18]. Below criticisms directed against Pascal’s Wager are put aside and the PVS Wager is assessed on its own merits.
How likely it is that a patient recovers consciousness after 12 months in posttraumatic PVS and after 3 months in non-traumatic PVS is controversial [see, e.g., 4: 85–86]. I return to the relevant likelihoods and complications related to determining and making use of them in connection with applying the PVS Wager below.
The acronym PVS is sometimes used of permanent vegetative state. Here it refers to persistent vegetative state only.
When the question is not about advance directives—on which Stone focuses—and a patient is already in PVS, she is incapable of choosing whether or not to have life-sustaining treatment. However, for the sake of brevity, I speak of what it is reasonable for the patient to do. That is also the viewpoint that the surrogate decision-makers deciding on behalf of the incompetent patient (arguably) ought to adopt (see, e.g., [19]).
Stone holds an intermediate position. He maintains that considering the PVS Wager is necessary for making a reasoned and informed decision which may, however, also be against life-saving treatment [4: 87].
Cruzan et ux. v. Director, Missouri Department of Health (88-1503), 497 U.S. 261 (1990). Due to damages she suffered in a car accident in 1983, Nancy Cruzan fell into PVS. After coming to the conclusion that there is no hope that she would recover, her family petitioned in courts to have her feeding tube removed. On December 15, 1990, the tube was removed and she died 12 days later.
As Stone presents the views he puts forward in this connection as his personal views [see 4: 88], his aim is plausibly merely that of drawing attention to what he considers as problems with the position he criticizes, not that of providing conclusive arguments against it. Correspondingly, what I write below can also be taken as considerations relevant to assessing whether the kind of views Stone puts forward suffice to show that there are significant problems with the position he criticizes.
Of course, as human dignity is not the only possible grounding for moral status, accepting such a view does not commit one to the morally repugnant position that PVS patients do not have any moral rights or any value.
Taking the concept of perfectionist dignity to be applicable to PVS patients does not entail that PVS patients ought to be blamed for not exemplifying perfectionist virtue.
A suffering patient who is misdiagnosed as in PVS could, but would not necessarily, be in a minimally conscious state (MCS). According to Stone, the idea of MCS is altogether confused. If it is a state in which a person cannot make judgments or understand what is going on, he asks, why would being in it be worse than being in PVS. If being in MCS is compatible with understanding what is going on, Stone continues, the question cannot be about a state in which a person is minimally conscious [4: 91]. MCS is defined in such wide terms that it allows some MCS patients to be almost like PVS patients and others to be, at least intermittently, almost like normally conscious patients [cf., e.g., 20, 15]. Accordingly, as has been suggested before [17], ‘minimally conscious state’ may not be the best possible appellation for this diagnostic category. If PVS patients cannot suffer and MCS patients can, MCS is therefore quite clearly relevantly different from PVS even if all suffering MCS patients were not able to understand what is going on or to make judgments. If it were impossible to be in MCS for a significant period [cf. 4: 92] that would be a good reason for ignoring the possibility that a patient diagnosed as in PVS is in fact in a MCS. Yet it would appear to be possible that MCS patients can remain in that state for long periods [20].
It might be taken that the problem the suffering PVS patient poses for the PVS Wager can be easily avoided; a proponent of the PVS Wager could just maintain that the PVS Wager ought to be applied only when it is known that a PVS patient is not suffering (to any significant degree). Yet that line of response would not help with the other costs of being in PVS discussed above and below. It also involves epistemological problems that will be discussed later in this article. If it is maintained that we should just sum all the costs that being in PVS involves, weigh them against the possible benefits that could ensue from treating a PVS patient, and then decide about the treatment of a PVS patient on that basis, the PVS Wager would seem to become otiose. What we would then have is the kind of cost-benefit analysis already commonly used in making this kind of treatment choices.
That would also accord with Pascal’s idea. Pascal’s Wager does not entail that believing in God can be reasonable only if it does not have costs. According to Pascal, the benefit possibly gained by believing in God is “an infinity of an infinitely happy life.” [25: 67] Considering that the potential gain is immeasurably great, the costs of believing in God can be deemed inconsequential. Therefore, the best bet is to believe that God exists—or that at least is what Pascal’s Wager aims to show. Yet, to be sure, the main issue now is not that the method by which decisions about PVS patients’ treatment are made accord with Pascal’s writings as closely as possible, but that the method used is plausible and useful.
Consider, say, the case in which treating a PVS patient would not entail that patients with better prospects of recovery are left without treatment and the only significant cost of treating the PVS patient would be a monetary one that her enormously rich relative could easily pay. See also [4: 88].
Advance directives are meant to express a person’s view of what she considers to be the best thing to do in the situation for which the directive is issued. The person need not choose what she considers as the morally best way of proceeding; she may make a totally self-interested choice. Thus, in the context of advance directives, the relevance of the above considerations as regards others’ interests is limited accordingly. Also, as already suggested, Stone allows that a reasonable person resorting to the PVS Wager may also decide that the costs of life-sustaining treatment outweigh its benefits.
Stone objects to the view that the most common post-PVS state is one of severe disability by rejecting the position that patients who recover from PVS would typically be in permanent MCS. As explained above, Stone finds the diagnostic category of MCS confused. He also maintains that there is no evidence that recovering PVS patients would ever be in permanent MCS [4: 89ff.]. Yet even if Stone were right here, that would not show that the most common post-PVS state is not one of severe disability of the kind described above. As I am not aware of research that would disprove the view reported by the Multi-Society Task Force on PVS [4] I there refer to, I now rely on that view.
This is not to say that happiness must consist either of sensory pleasure or living in accordance with one’s rational nature understood in very demanding perfectionist terms. The most plausible interpretation of happiness is arguably to be found between these two extremes. Perhaps happiness is best understood in terms of being virtuous in the (modest) sense of being kindly and fair, coming to terms with the human condition, and not taking oneself too seriously [4: 89]. This possibility is considered below.
In many respects, the situation here can be similar to those faced by discharged psychiatric patients and released prisoners. According to empirical studies, at least for a period after discharge, the suicide rates for these two groups of persons are significantly higher than that of people in general (see, e.g. [21]).
If the PVS patient is, say, (at least) a (decent) parent of a small child or the person most likely to invent a cure for cancer, the benefits accruing to others if she woke up with the required abilities would arguably be a relevant consideration here too. However, as acknowledging them would not appear to (significantly) affect the main argument of this article, I now put such benefits to others aside.
Predicting what kind of medical advances will be forthcoming can be difficult. Therefore, basing the expectation that a PVS patient will wake up on the anticipation that she can be cured with the help of new medical inventions can make assessing the probability that a PVS patient awakens even harder than it otherwise is.
As the main argument of this article does not presuppose solving the problem of what would be a sufficient probability of awakening I now put that question aside. Answering it is rather the job of the proponents of the PVS Wager.
Percentages can also be found for recovery within 3 and 6 months after injury, at least. However, focusing on the above figures suffices for the main argument of this article.
Or after the first 11 months after succumbing to PVS. As said above, PVS is defined as VS present 1 month after acute traumatic or non-traumatic brain injury, or lasting for at least 1 month in patients with degenerative or metabolic disorders or developmental malformations.
Stone [4: 89] also objects to the idea of not choosing for life-sustaining treatment in PVS by asking whether we should craft advance directives declining antibiotics in case we came down with pneumonia when we want to die because we have lost our families in a car accident. If the prospect of recovery from pneumonia were quite small, or impossible to assess, and being a pneumonia patient could require years of treatment similar to that needed in PVS, one might reasonably want to issue such an advance directive even if one had not lost one’s family. On the significance of mental suffering of the kind Stone refers to in connection with end-of-life decisions see, e.g., [22, 23].
Having statistics of how many patients in a given age-group, with a particular kind of damage to brain, etc. recover could be helpful for surrogate decision-makers, but usually not to persons issuing an advance directive. In real world cases, the latter do not know the age at which they would fall into PVS, the magnitude and nature of the damage to their brain that would involve, etc.
For the sake of argument, I now put aside the possibility that a patient would consider being in PVS so undignified that she would never want to be kept alive in that condition. If she has issued an advance directive to that effect, the surrogate decision-makers (arguably) ought not to consider whether she should be given life-sustaining treatment.
It is worth pointing out here that some critics of advance directives have argued such knowledge to be unobtainable in principle (see, e.g. [24]).
As already suggested above, the above conclusion does not entail that the PVS Wager can never help a person to acknowledge considerations relevant to making an informed choice. Furthermore, a person issuing an advance directive could, of course, want to wager that the PVS Wager applies in his case. Yet, for the kind of reasons discussed above, the risks of such wagering can be quite high. Therefore, it is also arguable that surrogate decision-makers should not engage in such wagering.
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Acknowledgments
I thank Juha Räikkä and two anonymous reviewers for helpful comments on an earlier version of this article. The writing of this article was financially supported by the Academy of Finland for which thanks are also due.
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Varelius, J. Pascal’s Wager and Deciding About the Life-Sustaining Treatment of Patients in Persistent Vegetative State. Neuroethics 6, 277–285 (2013). https://doi.org/10.1007/s12152-011-9113-9
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DOI: https://doi.org/10.1007/s12152-011-9113-9