1. society
2. crime
3. personal offense
4. homicide

HER MAJESTY’S CORONER
For the County of West Yorkshire
(Western District)
Mr. C. P. Dorries,
H. M. Coroner,
Office of H. M. Coroner,
Medico-Legal Centre,
Watery Street,
SHEFFIELD.
S3 7ET
Dear
City Courts
The Tyrls
BRADFORD BD1 1LA
Tel: 0 2 7 4 -3 9 1 3 6 2
My ref: JAT/AP/11K
2 December 1993
,
Re: Anthony David Bland, deceased
I think I mentioned this to you when we met last Saturday, but now I am writing as a matter
of courtesy formally to tell you that I am resuming the inquest into the death of Tony Bland
on Tuesday, 21st December. I am expecting it to be fairly low key and to last about a day.
Kind regards,
Yours sincerely,
J. A. Turnbull
H. M. CORONER
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24th
August
89.
SLP/JT.
2Xi% J. Howe,
Airdale Hospital,
Bkroion Hoad,
Steeton SD20 6P3).
\
Bear Br. Howe,
1 refer to my conversations with you about Mr. Bland who I
understand from you is in & vegetative state but not brain
dead.
You indidated to me that in ycrur view and that of consultant
colleagues, there was no hope of recovery for this younft man
and it was felt in the circumstances efforts to prolong life
should be abandoned and that he should be allowed to pass
away peacefully• I understood t x m you that his family
are aware of your pevposed management.
In this connection, you mentioned that it was proposed to
discontinue medical treatment and also to withdraw food and
water which I presume is in fact being supplied by nasogastric
tube or possibly intravenously.
You contacted me in order to obtain ay views on your proposed
action. You had already spoken to Jfe. Turnbull, who had
suggested you speak to me.
I explained to you that I as coroner had no jurisdiction over
any living person, and that my jurisdiction would (assuming
that the ease were transferred to me) arise only when the young
man was dead.
I did however say that in my view your proposed course of conduct
was one which I could not approve and indeed I felt that you were
exposing yourself to a very serious risk of criminal liability.
I suggested that before you undertook any steps, you should obtain
clear legal advice, and that in any case X neither could condone
or approve your suggested course of conduct.
In a later conversation with you yesterday, you confirmed that you
would not take m y of the steps mentioned except that it was
your intention not to administer antibiotic therapy.
I have since had. an opportunity to consider the raaiief ftt-^hc-r
and discuss it with senior members of the West Midlands Police
who are engaged in the Hillsborough disaster enquiry.
In the light of these discussions X am now writing to you to
confirm that strictly, I as coroner am not involved in this matter
until the death has been repotted to me. However, as it has been
raised with me and X consider that it has serous implications
both ethically and legally, X must again make it clear that
X cannot countenance, condone, approve or give consent to any
cont*d
2^th Av.gu.st
i
89.
.
action or inaction which co\ild be or could be construed as
Leirif’
'
;designed or intended to shorten or terminate the life
of tbi.ri young man. This particularly applies to the witholding
of tlie necessities of life, stash as food and drink* slothing
and vanath and, on reflection, this includes medical care,
including antibiotic cover where necessary*
1 would be grateful if you could please reply by return and
confirm that this is understood, and that no such activity or
inactivity will be undertaken in relation to this patient.
I am aware that there are occasions vfhen fpople are terminally
ill, as,y froia cancer, that a clinical decision nay be taken not
to seek to prolong life by heroic aedioal intervention, and
this aay include the withholding of say antibiotic drugs.
problem in this case is that although this young nan may
bs severely brain damaged, it is clear from what you said that
he is not brain dead in accordance with the published criteria.
In fact, X am very concerned whether it is possible, in the
light of the information you have given me, to even considers
this patient as terminally ill.
I am in some difficulty, as I have never seen this patient and
m not responsible for his clinical management, and in any case
hare no jurisdiction, as he is not dead. However, it must be
apparent that there most be a difference if he dies as a result
of say hypoxic brain damage or if he dies as a result of some
"new act or omission” implemented because it is thought that
his prognosis and quality of life are such he might be better
dead than alive.
You will also appreciate that any clinical decisions which you
may take are of course your sole i-esponsibility, and you have
always to be in a position to defend them and to show that they
comply with the law of this land. X have no doubt that your
legal advisors will be able to guide you further in this matter.
X think that X might just mention that if you feel that you need
clarification of the legal position with regard to any or all of your
proposed actions, then&t mi$ht be worth asking your legal advisors
whether it would be possible to make an application to the High
Court for directions and guidance.
Please note that a copy of this letter is being sent to Mr. Turnbull,
Her Majesty's Coroner for West Yorkshire, the Solicitor to the
Regional Health Authority, the Secretary of the Medical Protection
SAoiety (who X understand axe your Defence tfnion) and the West
Midlands Police®
cont*d.
!>
%t
Jt
24th August
89.
i w W J i L
Finally, I -would like to say two thingss~
a.
If this yotaag saaa were at scons point to dif the
death asust be reported to Mr* Turnbull viu> is
the coroner for your district. He will then
liase with me if he thinks that is appropriate.
b.
1 «©uld like to say that I feel for the lad,
the fsadly and the medical and nursing
teams in this terrible tragedy which has
befallen this young man,
Tours sincerely,
S.L.Bspper,
MSsSms^*.
c.c. Mr. T.A. Turnbull, H.M.C. Bradford.
R.H.A. Solicitor, Mr. Chapman, Yorkshire Regional H.A. Windsor Hse, Cornwall Rd
Medical Protection Society, 50 Hallam St, London.WiN 6DE
HarrogateHGl 2PW.
Mr. M, Jones, W/Midlands Police.
HER MAJESTY’S CORONER
For the County of West Yorkshire
(Western District)
Mr. C. P. Dorries,
H. M. Coroner,
Office of H. M. Coroner,
Medico-Legal Centre,
Watery Street,
SHEFFIELD.
S3 7ET
CITY COURTS
THE TYRLS
BRADFORD BD1 1LA
Tel: 0274-391362
My ref: JAT/AP
4 September 1992
Dear Mr. Dorries,
Re: Tony Bland - Hillsborough Disaster
Thank you for your letter of yesterday’s date. I entirely agree with the course which we
discussed on the telephone. I have in fact sent a message through my officer to Tony
Bland’s parents that I would welcome a meeting, even at this stage, to discuss the present
position and they seem to have welcomed this. I will let you know the outcome.
I will certainly make it plain in due course that your involvement was peripheral but that,
in order to be absolutely correct, you have felt, and I have agreed, that it would be
inappropriate for you to conduct the inquest.
I look forward to contact after your holiday and the planned lunch.
Kind regards.
Yours sincerely,
J. A. Turnbull
H.-M. CORONER
CPD/PMS
3 September 1992
Mr James Turnbull
H M Coroner for West Yorkshire
The City Courts
BRADFORD
West Yorkshire
Dear Mr Turnbull
HILLSBOROUGH DISASTER
TONY BLAND____________
I refer to our telephone conversation on Friday morning and am writing to
thank you for agreeing to deal with the Inquest which will have to follow the
death of this young man.
As I indicated to you over the telephone I had some involvement on the day of
the disaster (primarily the care of relatives) through my work for a
voluntary agency.
I was subsequently involved in both Lord Justice Taylor's
enquiry and the Inquest giving advice to a Medical Defence Union.
Although
my role was fairly peripheral, I am sure it should still be regarded as a bar
to me hearing any further Inquest relating to the disaster.
I must confess that even dealing with the requests from relatives for copies
of statements gave me pause for thought, but I took the view that there was a
considerable difference in the administrative matter of dealing with
paperwork (which has to be in my possession) and any form of normal judicial
function such as an Inquest.
I have even discussed this with Gillian
Harrison at the Home Office who agreed that there would be no conflict of
interest provided I was not making decisions about statements of former
clients.
Nonetheless, I am a little cautious about the choice of wording that might be
used in any explanation given publicly as one is aware that certain people
are very ready to take things out of context.
It may well be that everyone
will regard it as perfectly natural that you deal with the case but if an
explanation is requested I would be grateful if you could make it quite plain
that my previous involvement at Hillsborough was purely peripheral.
Very many thanks for your assistance.
When I return from holiday at the end
of September I will telephone you with a view to lunch one day.
Yours sincerely
C P Dorries
H M Coroner
FILE NOTE
21.10.91
TELEPHONE CONVERSATION WITH MR. ROGER HARRABIN B.B.C.
Tel: 061 200 2113.
RADIO
He rang to say he wanted to speak to be about my interpretation of the
law relating to Anthony Bland.
He rang while I was out, I called him back.
I explained that I was
not in a position to discuss the law because it was outside my province,
that I dealt with people when they had died and not while they were
still alive.
I pointed out to him that what he was really asking me
was to give him a explanation of the law on euthanasia and that his
own legal experts should be able to do that.
He asked again whether I would be willing to give him my understanding
of the legal position and I said that I didn't think that would be
appropriate.
He said that there were some Lawyers who seemed to indicate
that if the feeding tube were removed this would be alright whilst others
took the view that it would n o t . I said it was precisely because of
this problem that I wasn't willing to give him a comment.
I also pointed out to him that the issue as to whether or not a crime
had been committed would not be one primerily for me but for the D.P.P.
He asked me whether if the feeding tube was removed and the case was then
refered
to me
having died whether I would refer
it to the D.P.P?
I said I would though I qualified the reply by saying that this was based
on some assumptions and of course it all depended on the circumstances.
I then pointed out to him that I could not go any further than that.
He asked me why it was that I had got involved at all with Anthony Bland
and why I had been consulted in the first place.
I explained to him
that Anthony was not in my jurisdiction, that if he now died another
Coroner would have to deal with the case, the only reason why I had
come involved was because at the time when this issue was raised Iwas in
the middle of the Hillsborough Inquests and if Anthony had died then no
doubt the other coroner would have asked me to take the case over and
deal with it as part and parcel of the whole proceeding.
The situation
of course has now completely changed.
He asked me whether I thought that other Coroners would take the same
view as I did with regard to referral and I said I could not possibly
answer that.
He wanted to know if I was a Chief
Coronor in Sheffield
I explained to him that each district had
one Coroner though there
were deputies and assistants, that the country was divided into
districts and that all Coroners within their own districts were of
equal status.
/€
a.
FILE NOTE DATED 1.9.91.
Mr. Limb from the Yorkshire Post phoned me in the previous week, I think
on Wednesday.
He wanted to talk to me about Anthony Bland.
He assured
me that there wereKt publishing any articles about the matter because
the Blands didnt want it nor was he seeking to obtain an interview, but
merely trying to get some background information.£?n the strict
understanding that anything that I said would not be published.
I agreed to talk to him for a few minutes.
He asked me whether the
Blands had been in touch with me about Euthanasia for Anthony.
I said as far as I could recollect, I had not had any direct contact
with the Blands (I said I would have to check the files to be absolutely
sure) but I had been in correspondence with a doctor who was looking
after him on this issue.
I made it clear to the reporter that at the time when this was raised
which was quite a few months ago, I had indicated that no way could I
possibly countenance^iny^action which would constitute a criminal
offence.
Furthermore I had no jurisdiction in the matter because I
d i d n ’t deal with cases until after a person had died and in any case,
the case was outside my jurisdiction now.
Indeed it was then, but I did not
correspond about it because I was in the middle of the Hillsborough
inquests.
The situation is of course now different.
I did recollect j-n erenvcro-a-t-i'on w rth- h-±m that I made a reference to
Anthony Bland at the Interim Inquests on the 4th of May 1991 and that
one of my officers I think contacted the family to check that they would
not object to him being mentioned.
Again I said I would have to double
check the files.
I made it quite clear that I was not in a position to
give legal advice either to him or to anybody else on what could or
could not be done in certain circumstances.
That it was a matter for
the clinicians to be satisfied that they were doing the right thing and
they were complying with the law and that they should contact their own
legal advisors if they wanted to.
He asked me what I thought about
witholding antibiotics if a chest infection occurred or witholding food.
I repeated what I had said about legal advice and the clinicians getting
their own legal advice from their own lawyers.
I said that it was not
unknown that terminally ill patients were not aggressively treated.
That each case had to be decided as appropriate.
In any case I could
see a very substantial difference between witholding food and not
treating somebody with antibiotics for say p n e u m o n i a
. that person
being in a terminal state.
He again tried to press me on this and I
refused to get involved in any legal argument-!* I did say that I was
very very sorry for the Blands.
That it was a dreadful situation for
them to be in, but that it was clear that as Anthony was not on a
ventilator but was breathing spontaneously, he obviously did not fulfil
the brain stem criteria of death.
Mr. Limb then wanted to know whether
I could perhaps help him with anybody who might be able to give him some
legal advice on the ins and outs of the problems associated with
Anthony.
I said that I couldn ’t though Dr. Howard might be able to
help.
An alternative would be to get in touch with the Law Society and
ask them if they knew of any experts w h o m he could approach.
We finished the conversation by me saying how very sorry I was for this
family and how in some many ways I would have liked to have seen them
but it was a difficult problem in all the circumstances for me to do.
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m
AIREDALE HEALTH AUTHORITY
TELEPHONE: STEETON 652511
Your Ref:
FAX: STEETON 655129
Telephone enquiries on this
matter should be made to
Our Ref:
Airedale General Hospital
Skipton Road
J G H /J P S
Mrs J Stafford
Ext.
Steeton
Keighley
West Yorkshire
BD20 6TD
2743
Dr S L Popper
H M Coroner
Medico-Legal Centre
Watery Street
SHEFFIELD
S3 7ET
24 January 1991
Dear Dr Popper
ANTHONY DAVID BLAND - DOB 21.09.70
IN-PATIENT ON WARD 3, AIREDALE GENERAL HOSPITAL
I am sure you will be saddened to know that there has been no change in poor
Anthony Bland's condition. He
remains in a persistent vegetative state. His
sister and mother only visit intermittently but his father still comes and sits
by his body twice a week. From time to time, he becomes distressed and
disturbed by his son's condition.
I see him for a I
about once a month and I know he goes to see his general practitioner about
once a month as well.
I hope you find the enclosed viewpoint from the Lancet of interest.
If you
have already seen it and read it, please forgive me for troubling you with a
photocopy.
Kind regards
Yours sincerely
J G HOWE
Consultant Physician
Copy to Dr J P Barker, Medical Protection Society
Mr W J M Lovel, Regional Solicitor, YRHA
West Midlands Police Headquarters
VOL 337: JAN 12, 1991
THE LANCET
96
•V
15. lia te S . N iche n w k e ts hold key w m lc s bourn. Campaign I'N O M arcfi lb:
31.
16. D avies K M - C u rren t tren ds in cigarette advertising «n<J m arketing.
N & t f / J A W 1987; H i ; 725-31.
17. Kuyal College o f 1‘hysicians o f L o ndo n. H ealth or sm oking? London:
Pitm an (“ublishing L td , (983.
IB. OUice o f P opulation C ensuses and Survey*. D eath by cause |9U8
K egiitration D H 298/2- London: H M Stationery O llicc: I9tt9.
IV. W * n icr K , G o ld cn h ar L , M cL a u g h lin C 'Che econom ics o f cigarcuc
advertising: im pacts on m agiuines' revenues and editorial practice
regarding coverage o f sm oking an d health. 1‘rucccdings o f the 7th
W oi Id Conference oil Tobacuo a nd H ealth , P erth , A ustralia (in press).
20. W o ild H a i t i ) O rganisation U urope Regional O llice. Sinuke-frce
Uurope— a 5 year action plan- C openhagen: W H O , 19MB.
21. W orld H ealth O rganisation It can he done: a smoke free E u ro p e . Geneva:
W H O Regiunal Publication, IV90.
7. M edia E x p enditu re Analysis L td , M edia E xpen diture Ajwlysts. London:
M E A L , 19H9.
t). Joint Indu stry C om m ittee N ational A udicnce Research Survey. N ational
Readership S urvey, July W bU toJu ne 19BV L o ndo n: J 1C N A H S , IVtiV.
9. D ep artm en t o f H ealth and Social S ecurity, T o b a c c o A dvisory Council.
V oluntary A greem ent on T o b a cco P rod ucts A dvertising a n d I Ic-Uvh
W arnings. l~ o n d o n :T A C , 19B6.
10. D ep artm en t o f H ealth an d Social Security. G o v ern m e n t announce new
restrictions un cigarette advertising. I’rcis release U6 /U6 . M arch 2-):
I9b6.
11. A m os A. W o m en 's m a g u in e s an d tobacco: the prelim inary findings o f <|
survey un d ie tobacco policies o f the lop w om en's magazines in Europe.
1‘toceedings o f the 7ih W orld Conference un T o b a cco and H ealth,
P e n h , A ustralia (in prcis).
12. D c p aru n cn i o f H ealth and Social S ecurity. F irst R ep o n o f the C om m ittee
lo r M onito ring A greem ents o n T o b a cco A dvertising an d S ponsorship.
L ond on: l l t y , Stationery O llice, 1989.
13. P e p a m n e n t o f H ealth. S ix u n d R ep o rt o f the C o m m ittee for M onitoring
A greem ents un T o b a c u ) A dvertising (Uiwl Sponsorship. L o ndo n: H M
Stationery O lU ce, I9b9.
14. D ouglas T . S m okin g o u t extra ad revenue. M u r t u iu ig W u k |98fl A pril
22: 15.
22. T o x ic S ubstances Uoard- H ealth o r T o bacco . W ellington: N e w Zealand
D e p a rtm e n t o f H ealth , 191)9.
4
23. C om m issio n o f (he E uropean C o m m unity . Proposal for a Council
D irectiv e o n the advertising o f tobacco prod ucts in the p te ss a n d by
m eans o f bills and posters. (C Q M (8 9 163 fm al/2— D o c.C 3-76/M9).
Withdrawal of life-support from patients in a
persistent vegetative state
In s
t it u t e o f
M
e d ic a l et h ic s
Pr o l o n g in g L
W
o r k in g
if e a n d
W e recently argu ed that d octo rs m a y so m e tim e s bs
eth ically justified in a ssistin g the d eath ° f a patient w ith
c o n tin u e d pain or d istress ca u se d by an in curable illness and
w h o has exp ressed a clear and co n siste n t w ish lor this
o u tc o m e .' W e b elieve that su ch a p olicy w o u ld b e u n likely to
lead to the u n req u ested e n d in g o f the lives o f patients w h o
are u n co n scio u s o r severely d e m e n te d . B u t co u ld there be
g ro u n d s for w ith d raw al o f life -su p p o rtin g m edical
treatm en t in s u c h p atien ts w h o s e c o n d itio n has b een
d ia g n o sed w ith certain ty as p erm a n en t, i f they have
p rev io u sly e x p ressed a sim ilar w ish? S u c h g ro u n d s m ay
ex is t in the case o f p a tients left in a p ersisten t vegetativ e state
after su rv iv in g a n acu te brain in su lt b eca u se o f m o d e m
resuscitation and life -su sta in in g treatm ent.
Causes a n d frequency
P atien ts in a p ersisten t v egeta tive state h ave p erm an en tly
lost the fu n ction o f th e cerebral cortex . A b o u t 4 0 % h a ve had
sev ere h ead in ju ry, w ith w id esp re a d severa n ce o f w h ite
m atter fibres to a n d from th e cerebral co rtex. A n o th e r 4 0 %
h av e su ffered m a ssiv e loss o f cortical cells b ecau se o f
h y p o x ia , usually after cardiorespiratory arrest d u e to
d isea se, trau m a, or m ed ical accid en t. T h e others m ay liave
h ad various acu tc cerebral in su lts, in clu d in g h y p o g ly ca em ia ,
p o iso n in g , or o n e o f several acu te brain d iseases.
E xtrap olation s fro m su rv e y s in Jap an ,1 th e N e th e r la n d s,1
A
Par
s s is t in g
ty o n t h e
D
eath
Et h
ic s oe
*
,;md th e U S A 4 in d ica te a likely annual in cid en ce o f ov er 6 0 0
n ew ly veg eta tiv e p a r e n ts from acute ca u ses in th e U K , w ith
a p rev alen ce o f about 1500. S u c h estim ates rpay be tripled if
ch ro n ic d isea ses are taken into accou n t: p a tie n ts w ith
c h ro n ic derner.tiiig brain d isord ers m ay even tu a lly b ea > m e
veg eta tiv e , and so m e ch ild ren w ith severe d ev elo p m en ta l
ab n orm a lities n ev er surpass a veg etative suite— b u t [hesc
cases are e x c lu d e d from this report.
C linical state
S u c h p a tien ts m ay h a v e lo n g p eriod s o f “ w ak efu ln ess"
w ith o p e n e y e s that alternate w ith "sleep " . Jen n ett a n d P lu m
therefore h eld that it w as inappropriate to regard these
p atients as in com a and su g g ested the te n n p ersisten t
veg eta tive state.* W h e n aw ake the ey es m ay briefly fo llo w a
m o v in g o b je ct b y reflex, or b e attracted in the d irection o f
lou d so u n d s. All four lim b s are sp astic b u t can w ith d ra w
from p a in fu l stirnuli, an d the h a n iis sJw w reflex gro p in g an d
*C hiun nan: M r Geoffrey D rain . M em bers; M iss Sheila A dam . IV o ri'h o m a s
Ariei S ir Jo h n U atten, M iss Irene U loom fidd, D r Colin lirew er, P ro f Alex
C am p bell, D f D o n ald l i v u u , P rof Charles Fletcher* D r G illian l 7ord> P ro f
Roger H iggs, P ro f Bryan Jeruicu , D r Elliot Shineboum e* die V ery R evd
E d w ard S h o u e r, P rof J u n e s W ilham son, and M rs L y n n e Young. Secretary.
D r K eu n cih Boyd. H o n research assistant: M iss U rsula G allagher. T h i s
discussion p ap e r represents ih c views o f the working p u n y , b u t n o t
necessarily those o f oilier m em b ers o f the Institute o f M edical F.iiucs.
graspin g. T h e face can g rim a ce, sm all a m o u n ts o f food or
fluid p u t in th e m ou th m ay be sw a llo w e d , an d groan s and
cries o c c u r hu t n o w o rd s are uttered. A lth o u g h
in exp erien ced ob servers m a y interpret reflex m o v e m e n ts as
voluntary r e sp o n ses, an d vocal so u n d s as w o r d s , careful
ob serv atio n indicates n o p sych olog ica lly m ean in gfu l
resp onse to th e en v ir o n m e n t. B r eath in g is sp o n ta n eo u s and
the p atient d o e s n o i d e p e n d o n artificial ventilation.
N o available laboratory d ia g n o stic test can in d icate liiat a
p aiiem is p erm an en tly veg etativ e. R esearch in vestig atio n o f
s o m e vegetativ e patients h a s s h o w n a cerebral m eta b o lic rate
e q u iv a len t to that in d e e p an aesth esia.4 C o m p u te d
to m o g ra p h y an d m a g n e tic reso n a n c e im a gin g o n ly sh o w
e v id e n c e o f >evere brain d a m a g e , n ot that th e cortex as a
w h o le is o u t o f actio n , a n d electro en cep h alo gra p h y is
u n h elp fu l. T l i e d ia gn osis th erefo re d e p e n d s o n careful
clinical o b ser v a tio n ov er several w eek s. U s u a lly a co n fid e n t
d ia g n o sis can b e m a d e 3 m o n th s after th e acu te in su lt,6 bu t in
y o u n g c h ild r e n th e brain se e m s to b e m o re resistant to
h y p o x ic isch aem ia and o th e r in su lts, and the ex ten t and
tim esca lc o f reco very is less p red icta b le .7
A b o u t 5 0 % o f patients left v eg eta tiv e after an acu te brain
in su lt d ie w ith in the first year. H o w e v e r , if th e y su rvive the
first 3 m o n t h s m a n y su ch p a tien ts stabilise a n d m a y then live
for years; th ere are m a n y rep orts o f survival for 5 years, and
so m e for u p to 30 years.6 P r o lo n g e d survival requires
c o n tin u e d artificial feed in g , eith er by nasogastric tube or
g a str o s to m y , bu t d o es n ot d e p e n d o n an acute hospital; so m e
patients m a y b e look ed after at h o m e .
S u rv iv a l at w h a t cost?
It is d ifficu lt to see h o w p r o lo n g e d survival in this
n o n -s c n tie n t and u n d ig n ified state can be in th e best
interests o f th e patient. It is p ecu liarly d istressin g for the
p atient's relatives and frien d s to h a v e to w a ich for years d ie
u n resp o n siv e sh ell o f a lo v e d o n e. T h e e c o n o m ic and social
c o n se q u e n c e s o f in d efin ite treatm en t o f vegetativ e patients
m ay a lso m e a n that th e# m ed ica l an d n u rsin g care and
reso u rces that they receiv e, w ith n o p rosp ect o f recovery, are
d en ied to oth er patients w h o c o u ld benefit.
But w h ile co n tin u ed survival m ay n ot b e in th e best
interests o f p atien t, fam ily, or so c ie ty , the reaso n s c o m m o n ly
a d v a n ced for assisting d eath d o n o t ap p ly. V eg etative
p atients are n o t su fferin g , b eca u se the m ec h a n ism s for
su fferin g h a v e b een d estro yed . N o r are they term in ally ill,
b ecau se su rvival for m a n y years is p ossib le. M o r e o v e r , they
are u n a b le to request the w ith d raw al o f life -su p p o rtin g
treatm en t. H o w can this d ile m m a b e resolved?
Trends in th e U S A
T h e r e is a g row in g c o n se n s u s in the U S A that it m ay be
a p p rop riate to w ith h old life -su sta in in g m ed ica l treatm ent
from v e g e ta tiv e patients. T h i s attitu de reflects increasing
co n cern to resp ect patients' a u to n o m y , in c lu d in g their right
to refu se life-sa vin g and life -su sta in in g treatm en t, an d also
to p r o te c t m en ta lly in co m p e ten t p a tien ts from inap propriate
m cd ical p ro lo n g a tio n o f life.* In 19 7 6 , “ d o n o t resuscitate
ord ers” e m e r g e d , and m a n y h o sp ita ls an d n u rsin g h o m e s
n o w h a v e form al a rran gem en ts to lim it life -sa v in g and
life -su sta in in g treatm ents for b o th m en tally c o m p e te n t an d
in c o m p e te n t patients. I n d e e d , su ch a g reem en ts arc
b e c o m in g req u ired b y law , a n d m o r e than 4 0 states have
Natural D e a t h A cts that legally reco g n ise ad van ce
d irectiv es— in th e fo rm o f livin g w ills o r durable
p ow ers o f attorney— w h ich e n a b le p e o p le to anticip ate the
need for d ecisio n s to b e m ad e a b o u t their m ed ica l care w h en
Ltiey can n o lon ger exp ress their w ish e s . D ecla ration s o n
withdraw al o f life-su p p o rt, in c lu d in g referen ce to vegetative
patients, have b een m a d e b y a P r e sid e n t’s C o m m is sio n ,14
the A m erica n M ed ica l A s so c ia tio n ,41" th e O ffice o f
T e c h n o lo g y A s s e s s m e n t,11 a n d an in tern ation al c o n se n s u s.1*
M a n y U S cou rts h av e a p p r o v e d req u ests to w ithdraw
life-su p p o rt fro m vegetativ e p a tients— u su ally w h en
hospitals liave in sisted o n a cou rt o rd er b efo re agreeing to
the req u ests o f fam ilies— b u t several h a v e recently
c o m m e n te d that d octors an d fam ilies o u g h t n o w to d ecid e
and act w ith o u t reference to th e c o u r ts, ex c e p t w h e n there is
serious d isagreem en t. T h e U S S u p r e m e C o u rt recently
agreed w ith the p rin cip le o f w ith h o ld in g life su p p ort from
vegetative p atients, bu t by 5 v o tes to 4 d cc id e d ^ h a t a State
co u ld require c o n v in c in g e v id e n c e that th e patient had
p reviou sly ex p ressed a w ish n ° t tP
Kept alive in a
vegetative sta te.1^ 1*
W hat treatments m a y be w ith d raw n?
D o c to r s w h o look after veg eta tiv e p a tients frequently
agree w ith fam ilies a n d n u rsin g sta ff to w ith h o ld antibiotics
and card iop u lm on ary resu scitation . B u t cardiorespiratory
arrest se ld o m o ccu rs an d , ev en w ith o u t a n tib io tics, repeated
in fection s are o fte n su rv ived . M a y there b e eth ical grou n d s
for artificial feed in g to be w ithh eld ?
T h e first q u e stio n to b e a d d r e ss e d is w h eth er artificial
feed in g is u form o f m ed ical treatm en t. T h e co n se n su s in the
U S A , su p p o rted b y p rofessional a n d legul au th ority , is that
feed in g by nasogastric or g a stro sto m y t y b e is m edical
treatm ent; w e agree w ith this v iew .
S e c o n d ly , will w ithdraw al o f f o o d an d water cause the
patient to suffer th e u npleasant p h y sical sensation s usually
associated w ith starvation an d d eh yd ra tion ? W e agree w ith
the A m erica n v iew that there is n o rem ain ing neurological
meciuuii&ivi to n ia^e pain o r su fferin g p o s s i b l e / and that
g o o d oral h y g ie n e can be m ain tain ed b y appropriate nursing
care alter food a n d fluid s h a ve b e e n w ith d ra w n .
i ' i m l l y , giv in g fo o d an d w ater to th e sick h as sym b o lic
sig n ilican ce as a m ark o f c o n tin u in g care and an expression
o f h u m a n ity . B u t th e sy m b o lic sig n ifica n ce o f an act cannot
be d ivo rced from its p u rp ose an d co n tex t. In vegetative
patients the n orm al p u rp o se o f su sta in in g life a n d easing the
ravages o f h u n ger a n d thirst do
not b en efit the patient.
not a p p ly , a n d
feed in g d oes
Conclusion
T h e m ajority v ie w o f the I M E w o rk in g party is that it can
be m orally justified to w ith d ra w artificial n u tritio n an d
h yd ration from p a tien ts in a p ersisten t veg eta tive state. T h e
d iagn osis an d p ro g n o sis m u s t b e b e y o n d d o u b t, an d sh ou ld
be agreed b y m o re than o n e ex p e r ie n c e d d octor. In such
circu m stan ces w ithd raw al o f life -su sta in in g treatm en t cou ld
be agreed by t h e m , b y oth e r carers, an d b y th e relatives or
friends o f the p atien t. S o m e relatives m a y b e reluctant,
because they b eliev e that life m u s t b e p reserved in all
circu m stan ces, or b eca u se o f u n fo u n d e d o p tim ism d erived
from certain m a n ifesta tion s o f th e vegetativ e state— a view
w h ich m a y be en co u ra g ed b y so m e carers. W h ilst the w ish es
o f relatives sh ou ld b e resp ected , th e w ork in g party b eliev es it
is unfair and u n k in d to a llo w u n realistic o p tim ism to be
sustained. In su ch circu m sta n ces m a n y relatives m a y w ish
die patient to d ie at h o m e , and occa sio n a lly a d ecision m ay be
r i tii l a n c e t
VOL 337; JAN 12, 1991
•V
with a persistent vegeuiive siaie. J Neurol Neurosurf I'lychiuiry 1977;
40:876-85.
decision to w ithdraw o r w ithhold life support- J A M A 1990, 2 6 ):
426-30.
5- Jenneti U, P l u n F. Pcrsistcni vegetative state after brain damage. A
sy ndrom e in search o f a twunc. L u n c rl 1472; i: 7 34-37.
6. Jcn n ett U. Vegetative state; causcs, m an ag em en t, ethical dilem m as. C u r r
A ’U e ufi 1990 (in press).
7. C am pbell A G M . C hildren in a persistent vegetative (late. U r M e d J 1984,
2K»: 1022-23.
b M ackay R D . T erm in a tin g life-sustaining tre a tm e n t— recent U S
development*. J M e d tU hici 1988; 14i 135-39.
9 . P resident's Com m ission for th e S tudy o f Ethical P ro b lem s in M edicinc
an d Uiomedical and U eluvioral Research. D ecidin g to lorego hiesustaining trcaunent: ethical, m edical an d legal issues in treatm ent
decisions. W ashington, D C ; U S G o v ern m e n t P rin tin g OlVice, 1983.
10. A M A C ouncil on Ethical and Judicial A tta in . W ith holding o r
w ithdraw ing lile-prolonging medical Ireaintent. J A M A 1986; 236*
471.
11. U S C ongress Office u f T echno lo gy A ssessment- In stitu tio n a l protocols
for decisions about life-sustaining tru iim c m s. W ash in g to n , D C U S
G o v ern m en t P rim ing O llicc, 1988 (< jl'A -U A -389).
12. Stanley J M . T h e A pplctun consensus; s uggested in tern atio n al guidelines
for decision; p fprego m fdic»| irc au ncnt. J A l ( d E ll\ ic t 1989, IS;
129-36.
13. A ngell M . P risoners o f technology; the ease o f N an cy C n u ^ a N h i # I J
M e J 1990; 322: 1226-28.
H - L o U, Rouse F , D o n ib ra n d L . Fam ily decision m aking o n trial; w hu
dccidcs for incom petent patients? N E i y l ] M e J 1990; 322: 1228-32.
15. A n nas G J , A rnold U, A roskar M , c | al. Uiocthieists' s tatem e n t on the U S
S uprem e C o u rt’s C r u i w i decision. N E n g tJ M e J 1990,323; 686-ti7.
16. W illiam s B T . Life-sustaining technology: m aking th e decisions in
learning from A m cnca. H r M e d J 1989; 29B: 978.
17. H iggs R . Living wills an d ire aim cn t refusal. H r M e J J 1987; 2VS:
3. M m d erh o u d J M , U raakm an K. H c t vcgeterende bcstaan. N e d I'tjA c h r
GeneetkJ 19M5; 129: 2 J85-ti8.
4 . A M A C ouncil o il Scientific AlVairt. P ersistent vegetative siaic and the
|8 . (Jillon K . Living wills, pow ers uf attorney an d m edical practice. J M e J
l i i h i d 1988; 1 4 :59-<>0.
m a d e to w ith d ra w life -su sta in in g treatm en t from a patient
w h o is already at h o m e . H o w e v e r , relatives sh o u ld not m ake
su ch a d ecisio n o n their o w n , w ith o u t m ed ical ad vice and
su p p o rt, b eca u se o f p o ss ib le legal rep ercussion s.
T h e w ork in g party reco g n ises that the legal p o sition o f
su c h d ecisio n s, e v e n w ith full m e d ic a l su p p o rt, is u n d ear in
th e U K — w h ere there h as b een m u c h less p u b lic d iscu ssiu n
o f th e se issues than in th e U S A , 16 a n d w h ere living wills are
n ot form ally reco g n ised . 1,,‘* F o r this reason it urges
p rofessional b o d ies to r eco g n ise p u b lic ly that w ithdraw al o f
artificial n u trition an d h y d ra tio n m a y b e an appropriate way
to m an age vegetative p atien ts. T h e availability o f such
declarations by p ro fessio n a l b o d ie s w o u ld en ab le individual
' d o cto rs to r a iu this p o ssib ility se n sitiv e ly w ith relatives, and
w o u ld p ro m o te d isc u s sio n o f th is difficu lt su b ject b etw een
p rofessional carers a n d w ith the p u b lic .
Correspondence to D r K . M - Boyd! I D o u n e T e rrace, E d inb urgh E H )
6D Y, UK.
REFERENCES
1. Insiitutc o f M edical E th ic t W orking P arty. A ssisted death. l. a u u i 1WO;
336s 610-13.
2. Higushi K , Sakata Y ,H a ta n o M ,e t a l Epidcm iological studies on patients
Occupational Medicine
Edited by Joseph La D ou . East Norwalk, Conn: Appleton &
Lange/London: Prentice Hall. 1990. Pp 594- £30.7G(1H3.15.
ISBN 0-838572103.
M ed ica l stu d e n ts a n d jun ior d o cto rs have o n ly lim ited
o p p ortu n ities to learn a b o u t o ccu p a tio n a l m ed icin e , a
specialty in w h ic h m o s t career o p p ortu n ities w ere to be
fou n d in in d u stry u n til co n su lta n t p o sts and trainees
recently began to e m erg e in th e N H S . E veryd ay m edical
practice o ften b rin gs to ligh t p r o b le m s in w h ich occu p ation
has a stron g b earin g o n the ca u se o f an illness o r the
su ccessfu l m a n a g e m e n t o f a p a tie n t, b u t sou rces o f h elp for
the n o n -sp ecia list arc; n o t ea sy to fin d . T h e in cid en ce o f
occu p ational d isea ses h a s d e c lin e d strikingly in m any
d ev elo p ed co u n tr ies, tha n k s to th e su ccess o f control
m easures w h ic h n o w e x is t in m a jo r industries. But m ost
w orkers are e m p lo y e d in sm a ll b u sin e s se s w h ere, despite
legislation , co n d itio n s ca n b e q u ite different and health
h azards m ay b e en c o u n te r e d freq u en tly . T h i s failing, and
the fact that n e w tech n o lo g ie s o fte n p o s e novel health risks,
co n tin u es to m ake the early rec o g n itio n o f occupational
disord ers by clin ician s an im p o r ta n t part o f m edical practice.
O ccu p atio n a l p h y sicia n s h a v e b e c o m e prim arily in volved
w ith the p rev en tio n o f w ork -rela ted disord ers rather
than their trea tm en t, a n d m a y therefore c o m e from
various b a ck grou n d s. T h i s t e x tb o o k ’s ed itor, for exam p le,
is a clinical ep id e m io lo g is t b y train in g, bu t m any other
skills m ay b e req u ired to m a ster the causes and
1 1 2 1 -2 2 .
c o n tro l o f d iseases in th e w orkplace: o c c u p a tio n a l h y g ie n e ,
t o x ico lo g y , law , industrial relations, a n d e r g o n o m ic s all have
a role— h e n c e the in stitu tio n o f o ccu p ation al h ealth team s.
S u c h d iversity m ay deter the n on -sp ecia list. T h e ed ito r’s
a ch iev em en t is to p resen t occu p a tion al m e d ic in e in a w ay
that b rin gs the su b ject to light a lo n g sid e o t h e r m ed ical
sp ecialties w ith o u t these other a sp ects b e in g to o o b tr u siv e,
yet at t|te sam e tim e sh o w in g the scop e o f o ccu p a tio n a l
h ealth a s a sp ecialty, in clu d in g its interface w ith
e n v iro n m en ta l con cern s. T h e m u lti-a u th o r text b rin g s
tog eth er d escrip tion s o f o ccu p ation al d ise a s e s, and their
p rev en tio n an d treatm en t, in a clear an d s u c c in c t m a n n er
w ith m a n y usefu l referen ces for furth er rea d in g. It s h o u ld
h a v e particular appeal to th o se stu d y in g for specialist
p ostg rad u ate q ualifications— in c lu d in g M R C I 1 ca n d id a tes,
n o w that q u estio n s o n o ccu p ational m e d ic in e are in clu d ed in
that cu rricu lu m - D e s p it e a n in evitab le N o r t h A m erican bias
in so m e Of its moment th e b ook Reserves to b e w id ely read as
an in tro d u ctory text.
Depanmenl ol Community Medicjn#.
Giesham Road.
Cambridge CHI 2ES. UK
P
etek
J.
Ba
x ter
Protection of thq 3rain Frqm Ischemia
Edited by P. R. Weinstein and A. I. Faden. Baltimore/London:
Williams & Wilkins. 1990. Pp 307. £74. IS B N 0-683089080.
T h e 1990s o p e n w ith a sc e n t o f th e ra p eu tic o p tim is m in
stroke m ed icin e- W e h a ve learnt that cerebral isch aem ia is a
p ro cess, n o t an even t. W h ilst so m e o f the b rain d ie s qu ick ly
after an isch a em ic in su lt it is likely that a su b sta n tia l part o f a
p a tie n t’s final d isab ility is related to m o re gradual p r o c e s se s
o f isc h a e m ic d am a ge, so m e o f w h ic h m ay b e a m en a b le to
therapy. T h e m ain p a th op h ysio lo gical c o n c e p ts o n w h ich
*
,rman o f the Jewish
Agency, Simha Dinitz, yes­
terday said that Arab objec­
tions to Soviet Jews settling in
the occupied territories were a
“cover” for their real ob­
jection to immigration to
Israel as such.
.in
23
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ided a
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M irosta Stepan, the fonner
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culties, which have spin me
country on ethnic and pol­
itical lines.
Mr Milosevic said Serbia s
proposed new constitution
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two o f its provinces, Voj-
Supreme Court rules against ‘right to die
F ro m M artin F letcher
• A fuel
base in
i cleaned
environemment
U tU v .
THE US Supreme Court, in an
historic ruling yesterday, said states
can insist on comatose patients being
kept alive indefinitely in the absence
o f “clear and convincing evidence
that they would want to die.
In its first decision on a “right to
die” case, the court said no such
evidence existed in the case o f Nancy
Cruzan, a 32-year-old girl who has
been brain-dead since a car crash
seven years ago and whose parents
have fought to remove the feeding
tube which is keeping her alive.
The state o f Missouri has refused to
allow her life to be terminated even
though nobody has ever recovered
from such a persistent vegetative
state, and the girl’s doctors say she
could live for another 30 years. It
costs $130,000 (£75,000) a year to
keep her alive. The 5-4 ruling does not
bar states from allowing comatose
patients to die. It also acknowledges
the right o f “competent” people to
make ‘living wills’ to refuse lifesupporting treatment
The highly emotive case, pressed by
the American Civil Liberties Union,
had divided the medical and legal
professions, and the court’s ruling will
have far-reaching implications. More
than 10,000 Americans are being kept
alive in vegetative states at a cost o f at
least $ 1 billion a year and, as in other
developed nations, the numbers are
increasing as medical technology
advances. Lower courts have handed
out a series o f conflicting rulings in
similar cases.
Giving the court’s opinion, Chief
Justice William Rehnquist argued
that the constitution “does M t re­
quire a state to accept the substituted
judgement o f close family members in
the absence o f substantial proof that
their views reflect the patient’s”.
He noted that “not all incompetent
patients will have loved ones avail­
able to «;rve as surrogate decision­
before
operation,
*
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d hours
MM
;thethe
.op
erate provided
p
n
.™
makers.
A,A
state
is e
entitled
toog
guard
against potential abuses in such
situations.” In the dissenting opinion,
Justice William Brennan referred to
the fact that before the accident Miss
Cruzan had once said that, if she was
sick or injured; she would not want to
continue living unless she could live
half-way normally.
The court and the state o f Missouri
“have discarded evidence o f her will,
o f the right to a decision as closely
approximating her own choice as
humanly possible. Nancy Cruzan is
entitled to die with dignity,” he said.
In two other important rulings
yesterday, the Supreme Court made it
significantly harder for girls under 18
to obtain abortions.
By five votes to four it upheld an
Ohio law requiring that one parent be
notified before a girl under 18 can
have an abortion. By the same margin
it approved a Minnesota law requiring
notification o f both parent* * least 48
girls had the alternative o f seeking a
judge’s approval.
The rulings are the court’s first on
the subject since it started a national
debate on abortion last summer by
permitting
ues to impose restric­
tions. It did not address the fun­
damental question o f whether a
woman has a constitutional right to
abortion, but gave some indication o f
nor might go if the court is eventually
forced to rule on that.
With the other eight justices evenly
split on the issue, her vote is crucial.
In yesterday’s rulings she upheld the
Ohio law and voted against the
Minnesota law, supporting it only
when the judicial by-pass option was
included.
About 12 per cent o f the 1.5 million
abortions performed in America each
year are on minors. Nearly half all
pregnant teenage girls in the United
States have abortions.
tion, ther
reconciliat
peninsula
outbreak o
South K
anniversary
mallyaccep
proposal to
tions betwet
from each >
sides have
date for the
Few obsen
this get-tog<
round o f
meetings in
will bring th
to a break
deadlock.
In most v
and South 1
in contrast:
apart. The
ingly prosp
and politica
political f
North faces
In a sig
growing sell
mally agree<
yesterday t<
military he
Seoul by 1
Korean gov
for the mo
more than
million).
There are
„ o r ................... . .
oil, particularly
1 analogue o f the
The long plug
. The plumber I
1, yes, well removetcetera, we could
ig at the wrong end
here, and after the
J ebbed, I said is
•native, and he said
i rubber one on a
;o wrong there, I’ve
e van.
e I was lying in the
i necessitated by
m d under the first
y twisting my new
1 my toe, that the
;nly came to me.
invented in the
If man had always
nkages, would the
not be seen as an
i breakthrough?
>ion been invented
We not bless the
ubsequently came
radio? Is a threef matches not the
il who mourn lost
e lighters, or the
le wondrous boon
have replaced the
;or?
it my theory not
he world an incalr place, if only the
lad a word for it?
win be sold
next month to an overseas buyer.
The huge collection, comprising
thousands o f letters exchanged
between many o f the 20th centu­
ry’s most famous writers and the
publishing house, is to be auc­
tioned at Sotheby’s on July 19,
and is expected to fetch at least
£200,000. Macmillan is selling the
material — enough to fill a
furniture lorry — to release muchneeded storage space and to pay
for the maintenance o f the
remaining records.
Covering the years 1905 to
1969, the archive includes a
literary treasure trove o f 20,000
confidential readers’ reports on
manuscripts submitted for pub­
lication. Amor I the budding au­
thors who attracted scathing
criticism were H.G. Wells, A.A.
Milne (“not a grain o f wit or
humour”), Vera Brittain and
Osbert Sitwell, who was described
by the Macmillan expert as “un­
comfortable and clumsy in verse”.
American literary lion Norman
Mailer suffered the indignity o f
having his masterpiece The Naked
and the Dead described as 300
pages too long and with no appeal
to women, though the assessor
added: “The author is potentially
a good, if not great writer.” The
archive also includes some racy
correspondence from Enid Blyton
complaining that a one-shilling
price increase for her books de­
prived readers o f four ice-creams.
antis
earlie* m d u >^ w »wni(,
*■
1867-1905 is housed. But Sarah
Tyacke, the library’s director of
special collections, says that al­
though keen to have it, the library
has
ju st
b ough t
the
G.K. Chesterton archive and has
no funds available. “We are not
indifferent to this collection but
we have exhausted for the mo­
ment the goodwill o f our outside
benefactors. Sometimes we have
to bite on a nasty bullet. It is a very
sad occasion.” Even sadder for
Britain if the archive ends up in
Texas or Tokyo.
t»)e o a I i }
like H\e
Mf
A
The
3l\d H'C
G 6D
M ay Days’ SOS
fter the fanfare at the
launch o f the Royal Court’s
brave production o f M ay
Days, a series o f 15 half-hour plays
on political issues, comes the
reality: the idea is a flop. Most
nights they are attracting houses o f
les“ ;ian 25 per cent, leaving 300
A
PIARY
or so empty seats. The Court’s
artistic director, Max StaffordClark, attributes the low atten­
dance for the plays —written by an
assortment o f journalists, drama­
tists and thinkers including the
Bishop o f Durham and Julie
Burchill — to the publicity, which
sold them as provocative and
difficult (“a season o f political and
social dialogue”) rather than bland
and entertaining. At least the bartakings are holding up well. An
evening’s ticket is for three plays.
Many see one and sit out the other
two in the bar.
• Plans by the American publish­
ers Little Brown to announce
details o f Nelson M andela's m em ­
oirs during his visit to New York
last week have been delayed by
protracted "paperwork and nego­
tiations". Meanwhile, reports that
the South African novelist Nadine
Gordimer has been asked to
collaborate on the book have been
fuelled by the news that, after
almost h a lf a century o f political
activity, she has at last joined a
political party. Last month
Gordimer, who is currently on
holiday in France, became one o f
the fe w white members o f the
African National Congress, o f
which Mandela is vice-president.
,„ v ..« ..- a a o tits
Channel 4 screening tomorrow.
Tory MP and veteran anti-Euro
campaigner Teddy Taylor says:
“This programme is great news for
democracy — providing the
power-mad Eurocrats don’t try to
introduce new laws banning it.”
There is at least a scandal a week
coming out o f Brussels, insists
Taylor, who cites as the current
example the simultaneous run­
ning o f an expensive EC anti­
smoking campaign with the
dumping on eastern Europe and
third world markets, at a cost o f
£300 million, o f its excess produc­
tion o f high-tar tobacco. “I can
provide Bradbury with material to
make as many more series as he
wants,” says Taylor.
But Stephen Woodard, assistant
director o f the European Move­
ment, counters: “It is bound to be
an unfair portrayal. There are
abuses which affect all govern­
ments — regional, national or
European — but those in the
European system are no greater
than in any other.” European
commissioners need large ex­
penses to cope with foreign travel,
he says. So the image o f bloated
fat-cats gorging on fo ie gras is
mistaken? “They work very
hard,” says an aggrieved Wood­
ard, “and there are comparatively
few bureaucrats compared to the
English civil service.” Either way,
the programme should provide a
welcome European version o f Yes
M inister.
sC V
c<5> i ' c ,
*v: * ' J N
lO'X^- tiKe
appealing
dressers wf
pads to sem
J im in
N
i
othii
Sffi
whip Jim W
create a goc
students frc
Shetland co
elled to Wes
on a day in 1
the momeni
the student:
outside the <J
started to gc
immediately
keys. But the
shut behind t
measure, the <
double lockt
raised at W'e
W allace's ,
Culey, i l c c :
and what she
“barmy” tel
Jim Wallacc
The caller w
hour after \
ing for helj
locked doo;
request for
Liberal De
dents’ day
bated brec
4
&
7th September
SEP/JS!*
JGE/JPS/
He. J.G* Sow©,
Consultant physician,
AirdaXe Health Authority,
Airdale General Hospital*.*
Skipton Iload,
bteeton,
Seighley*
Vest Yorkshire HD20 6TB. .
B e a r 2a?. H owe,
S^krox..M?II) M B . . . .
Shank you very much for your letters of the 23rd and 31st
of ^August. I have particularly nefcad the second paragraph
of your letter of the 31st of August.
/
:
We discussed this matter again on the 1st of September
whan X spoke to you regarding our concern that the parents
of Anthony felt that the police were in some way to blame
for the management of this young man.
You. very kindly fflade it clear.that you have explained to
the Blands that this was not the case and that you would
make it clear to them again*
As you had raised the pacoblea of i^turedinanagement with
me it -was essential that I should point out that this was
outside ay jurisdiction and that clinical decisions and
jaaaagement must he for you hut that they have to be reached
or taken -within the tenas and provisions of English Law
both civil and criadjaal* Shis of course is not only in your
interests hut also in the interests of Tony’s family.
I m obliged to you for the copy papex*s which you have sent.
Although I would like to comment on these, I think in all
the circumstances surrounding this matter it would be
inappropriate for m to do so at the present time and I
hope that you will understand the reason for this.
Yours sincerely,
S. L. POPPER
H. M. GOROmm
89«
C' L '
5th September
SLP/JT.
JAT/AG.
Mr. J. INwribull,
H.M.Coroner,
Coroner*s Court,
The City Courts,
Bradford. i m XU.
Dear Jim,
Thank you for your note regarding Anthony Hand, I did discuss
the circulation with Dr. Howe before I undertook it, and he
was in fact perfectly content with it.
Yours sincerely,
S.L.Popper,
H.M»Coroner
HER MAJESTY'S CORONER
For the County of West Yorkshire
(Western District)
C IT Y COURTS
THE T Y R L S
B R A DFO R D BD1 1 LA
Tel: (0274) 391362
Your ref: SLP/JT
Cur ref: JAT/AG
Dr. S. L. Popper.
H.M.Coroner.
Coroner's Office,
Medico-Legal Centre,
Watery Street
SHEFFIELD S3 7ET
30th August 1989
Thank you for your courtesy in letting me have
a copy of your letter to Dr. Howe of the 24th August.
Of course I agree entirely with your assessment of
the legal position. I do not know whether you told
Dr. Howe that you were sending copies of the letter
elsewhere before you did so. If I may say so I think
that I would have refrained from doing this at this
stage.
Yours sincerely,
J. A.-JfrrfnSuTl.
AIREDALE HEALTH AUTHORITY
TELEPHONE: STEETON 52511
Your Ref:
Airedale General Hospital
Skipton Road
Telephone enquiries on this
matter should be made to
Our Ref:
JGH/JPS/
Steeton
Keighley
Mrs J Stafford
West Yorkshire
BD20 6TD
Ext.
460
Dr S L Popper
HM Coroner
Medico-Legal Centre
Watery Street
SHEFFIELD
S3 7ES
31 August 1989
Dear Dr Popper
ANTHONY DAVID BLAND - DOB 21.09.70
AT PRESENT ON WARD 3, AIREDALE GENERAL HOSPITAL
Thank you for your letter of 24 August 1989 about
morning.
Mr Bland, which arrived this
This is just a short note to let you know that this young man's medical and
nursing care continues unchanged from the course it has followed over the last
four months. He remains unconscious and is being fed by nasogastric tube. He
has recently had a course of antibiotic for a chest infection.
I would be interested to hear your personal comments on the American
Neurologists' statement on persistent vegetative state which I sent to you. It
seems to me that there is an important principle to be tested in this and
similar cases, but I do not think I am the man to test it. I will ask the
Editor of the Journal of Medical Ethics if he would like to commission some
articles on this subject in the hope of stimulating some discussion in the
profession. The BMA Ethics Committee might also like to look into this matter
or perhaps a committee of one of the royal colleges.
Patients like this have
been kept alive in a vegetative state for periods in excess of ten years, at
great personal cost to their families
and the care staff. They also consume
resources which could be used for people who have a chance of recovery, or at
least relief of their suffering, for there can be no doubt that someone who is
unconscious can not suffer. It may be that, in time, the way to deal with this
distressing condition will become clear but, for the moment, Mr Bland's family
and the nursing staff at Airedale General Hospital will continue to suffer and
are likely to do so for many years since the rest of his body systems are
undamaged.
Finally, can I say how much I appreciate your clear, sympathetic and helpful
advice.
Kind regards
Yours sincerely
J G HOWE
Consultant Physician
q£
'L '/
c A -^
■
AIREDALE HEALTH AUTHORITY
TELEPHONE: STEETON 52511
Your Ref:
Telephone enquiries on this
matter should be made to
Our Ref:
JGH/JPS
Airedale General Hospital
Skipton Road
Steeton
Keighley
.Mrs. .J..Stafford
West Yorkshire
BD20 6TD
Ext
460
Dr S L Popper
HM Coroner
Medical Legal Centre
Watery Street
SHEFFIELD
S3 7ES
23 August 1989
Dear Dr Popper
ANTHONY DAVID BLAND - DOB 21.09.70
AT PRESENT ON WARD 3, AIREDALE GENERAL HOSPITAL
Thank you for your very full and frank conversation today.
In view of what you told me about the police attitude, we have not withdrawn
artificial feeding in the unfortunate patient we discussed.
Please find enclosed photocopies of two articles about persistent vegetative
state after brain damage. The article from the Lancet in 1972 was the first
thorough description of the syndrome and a proposal for a satisfactory name,
which is now widely used. The second article is a statement of the American
Academy of Neurology's attitude to the care and management of patients with
persistent vegetative state and it is an attitude which I, myself, would want
for me or my family or any patients with whom I am in contact.
Our patient's family were satisfied that there had been no sign of improvement
and feel very strongly that prolonging this boy's life by artificial feeding is
no longer justifiable. They do not, however, want to see me get into trouble
over it and so they are prepared to continue seeing him being fed but do not
wish us to treat any infections, should they arise.
I would be interested to hear your comments on the American Neurologists'
statement and would also be interested to hear what the local police think
about it as well. This is an important and distressing subject and it would be
helpful if there were clear guidelines to help doctors and relatives deal with
the problem.
I look forward to hearing from you in the near future.
Thank you once again.
Kind regards
Yours sincerely
J G HOWE
Consultant Physician
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34.
Veasy L G . W iedmeier SE. O nm ond G S. et al. Resurgence of acute rheu­
m atic fever in the intermountain area o f the United States. N Engl J Med
1987: 316:421-7.
M ichael J G . Ma&sctl B F . Perkins R E. E ffect o f sublcihal conccotralkoos o f
35.
H osier D M . Craeneti JM . T csk e D W . W hotter U . R esurgence o f acuu
penicillin oo the virulence aod antigenic composition of group A strepto­
cocci. J Bacteriol 1963: 85:1280-7.
36.
25. Rothbard S . Watson RF. Variation occurring in group A sirepcococci during
human infection: progressive loss o f M substaoce correlated with increasing
susceptibility to bacteriostusis. J Exp Med 1948; 87:521-33.
26.
Feb. 4, 1988
T H E NEW ENGLAND JOU RNA L O F MEDI
286
27. Poyoion FI. Paine A. Researches on iteum altsm . London: J & A Churchill.
1913:394-5.
28. Clover JA. Incidence o f rheumatic diseases. 1. The incidence o f acute rheu­
matism. Lancet 1930; 1:499-505.
29. Paul JR. The epidemiology o f rheumatic fever- 3rd ed. New York: Ameri­
can Heart Association. 1957:108-24.
30. Baumol WJ. A m erica's productivity "crisis." New Y ork Tim es. February
15,
!987:Section 3:2.
31. Quinn RW. Epidemiology o f group A streptococcal infections — their
changing frequency and severity. Y ale J Bk>i M ed 1982; 55:265*70.
32. Stollerman G H. Nephritogenic aod rheumatogenic G roup A streptococci.
J Infect Dis 1969; 120:258-63.
33. Bisno AL. T he concept o f iheumatogenk: and nomheumalogemc group A
streptococci- In: Read SE . Zabriskie JB, eds. Streptococcal diseases and the
response. New York: A cadem e Press. 1980:789-803.
rheumatic fever. Am J Dis Child 1987; 141:730-3.
Wald ER. Dashefsky B . Fetdt C . Chiponis D . Byers C . Acute rheumatic
fever in western Pennsylvania and the Instate area. Pediatrics 1987; 80:
371-4.
37. Rizzo C , Congent J , Congent B. Kaplan E. Factors associated with the
resurgence of rheumatic fever in Ohio. In: Abstracts of the 27th Interscience
Conference on Antimicrobial Agents and Chemotherapy. O ctober 4-7 ,
1987. W ashington, D ,C .: American Society g f Microbiology. 1987:114.
abstract.
38. Marcon M J, Hribar MM, Hosier DM , et al- Appearance and antimi­
crobial susceptibility o f mucoidal Group A streptococci in a central
Ohio pediatric population. In*. Abstracts o f the 27th Interscience Confer­
ence on Antimicrobial Agents and Chemotherapy, October 4 - 7 , 1987.
W ashington. D .C .: American Society o f M icrobiology. 1987:227. ab­
stract.
39. GLIM W orking Party. The generalized linear interactive modeling system.
Release 3.77. Oxford: Algorithms Group, 1984.
S P E C IA L A R T IC L E
ARI^FICIAL FEEDING — SOLID GROUND, NOT A SLIPPERY SLOPE
R o b e r t S te in b ro o k ,
M .D .,
an d B e rn a rd
L o , M ,D ,
Abstract
Decisions about artificial feeding arouse more
controversy than those involving any other life-sustaining
treatment. Because food and water are generally consid'
ered basic elements of humane care, representing love
and concern for the helpless, it is often thought that they
must always be provided. In a landmark decision, the Supreme Judicial Court of Massachusetts ruled that a feeding
could be removed from a patient in a persistent
vegetative state if this was consistent with his previously
expressed wishes. The case of Paul E. Brophy, Sr., is part
of an emerging medical and legal consensus on the withholding of artificial feeding from adult patients. The wewis
growing that tube and intravenous feeding should be Itkened to other medical interventions and not to the routine
provision of nursing care or comfort. Competent patients
have the right to refuse such feeding. Feeding can also be
stopped in incompetent patients who have earlier stated
such a wish. (N Engl J Med 1988; 318:286-90.)
E C IS IO N S about artificial feeding are more controversial than decisions about other life-sustainmg treatm ents. M any physicians consider that basic,
hum ane care requires that patients always be given
food and water, because they represent love and concem for the helpless.1 In a landm ark decision, the
Suprem e Jud icial C ourt o f M assachusetts ruled in
1986 th a t a feeding tube could be removed from a 49year-old m an in a persistent vegetative state, in accordance with his wish not to live as a “vegetable.” 2
T he case of Paul E. Brophy, Sr., is p art of an emerging
medical, ethical, and legal consensus on w ithholding
tube or intravenous feeding from adult patients. T he
Brophy case is particularly noteworthy because neither the facts nor the patient’s wishes were in dispute,
and the decision focused solely on the feeding issue.
for a ruptured basilar-artery aneurysm .2'3 In June,
Brophy was transferred to a convalescent hospital in
a persistent vegetative state. In August, after he
contracted pneumonia, his physicians and Patricia
Brophy, his wife and legal guardian, agreed that he
n o t be r e s u s c i t a t e d in the event of a cardiac arrest. In
December 1983, Mrs. Brophy consented to the surgical insertion of a feeding tube into his stomach,
Long before his illness, Brophy had repeatedly told
family members to “pull the plug” if he should ever
end u p in a coma. Years earlier, he had expressed this
view to his wife in discussing the case of K a ^ n Ann
Q uinlan, the comatose New Jersey woman whose removal from a respirator required a court order. In the
late 1970s, Brophy was commended for bravery for
pulling a man from a burning truck. O n learning that
the m an had suffered greatly before dying m onths later? Brophy threw his commendation into the trash. He
told his wife, “ I should have been five minutes later. It
would have been all over for him.’ H e told his brother,
“ If I ’m ever like that, ju st shoot me, pull the plug.
And ju s t before his own neurosurgery, Brophy told
one o f his daughters, If I can t sit up to kiss one of
m y beautiful daughters, I may as well be SIX teet
„ 2 Brophv never specifically discussed artificial
D
C a s e S u m m a ry
Paul E. Brophy, Sr.,*^was a form er firefighter and
emergency medical technician’ who never regained
consciousness after unsuccessful surgery in April 1983
From the Division o f General Internal Medicine. University o f California, San
Francisco, and die Los Angeles Times. Los Angeles. Address reprint requests to
Dr. Lo at Box 0320. R m . A-405. University o f California. 400 Parnassus A ve.,
Sao Francisco. CA 94143-0320.
Supported ia pact by a grant from th e Commonwealth Fuad.
u
feeding, however.
Vol. 318
(EW ENGLAND JO U R N A L O F MEDICINE
No. 5
Mrs. Brophy, a devout Catholic a n d a nurse,
worked p art time with the mentally retarded. When
her husband’s condition remained unchanged through
1984, Mrs. Brophy concluded that his active life was
over. In view of his previously expressed wishes, she
began to question the provision of artificial feeding.
After consultation with clergy, ethicists, and a lawyer,
she requested that the feeding be stopped. T he cou­
ple’s five children and other family members support­
ed her decision unanim ously, b u t her husband’s phy­
sicians and the hospital adm inistration were opposed.
In February 1985, M rs, Brophy asked a probate court
to allow her husband’s tube feeding to be discontin­
ued. In December, the probate judge found th at
Brophy would rather be dead than have his life pro­
longed in a persistent vegetative state.5 H e specifically
concluded th a t if Brophy were competent, he would
decline artificial feeding. Nevertheless, the judge ruled
that the feeding m ust continue,
Mrs, Brophy appealed. In September 1986, the
Massachusetts Supreme Judicial C ourt held in a 4-to3 decision th a t B rophy’s feeding tube could be re­
moved, Three U,S, Supreme C ourt justices declined
to review the decision.
The next m onth, Brophy was transferred to a near­
by hospital, in the care of a neurologist who had testi­
fied th at Brophy was in a persistent vegetative state.
This physician held meetings with hospital staff mem­
bers to explain the controversial case,. M any volun­
teered to help care for Brophy. Plans for supportive
care, including anticonvulsants and antacids, w ere co­
ordinated with M rs. Brophy.
O n O ctober 23, eight days after the tube feeding
was discontinued, Brophy died o f pneum onia a t the
age of 49.6 H is wife, who had remained at the hospital
around the clock, their children, and a grandchild
were a t the bedside. T he attending physician de­
scribed Brophy’s death as an “amazing peaceful, quiet
time.” 6
T h e L e g a l D e c is io n
T he Suprem e Jud icial C ourt ruled that Brophy’s
tube feeding could be discontinued as he would have
wished.2 It based the decision on common law and the
constitutional right of patients to refuse medical treat­
ment, regardless o f w hether others consider such a
refusal unwise. Rejecting the argum ent that artificial
feeding should be continued because it represented
ordinary rather than extraordinary care, the majority
decision stated that “to be m aintained by such artifi­
cial m eans over an extended period is not only intru­
sive b u t extraordinary.” 2 T he decision also rejected
a distinction between w ithholding and withdrawing
treatments already initiated, including artificial feed­
ing. It said that if w ithdraw ing treatm ent is seen as
more difficult than w ithholding it, this distinction
could discourage attem pts a t certain types of care and
lead to prem ature decisions to allow patients to die.
T he court said that Brophy’s right to refuse medical
treatments, including artificial feeding, outweighed
three state interests that might favor continuing treat­
287
ment: the preservation of life, the prevention of
suicide, and the ethical integrity o f the medical pro­
fession.
W ith respect to the preservation o f life, the court
reasoned that the state had no duty to preserve life
when the patient would feel th at the means of doing so
dem eaned his or her hum anity. O nly Brophy could
make decisions about the quality of his life — not
physicians or third parties, including the court. The
court acknowledged that Brophy “may live in a per­
sistent vegetative state for several years,” Even though
he was not terminally ill, he had a right to refuse lifesustaining treatm ents, including artificial feeding.
As to the prevention o f suicide, the discontinuation
of Brophy’s feeding would not represent suicide or
direct killing, the court ruled, nor would it subject him
to a painful death by starvation. Instead, it would
merely allow the underlying disease to take its natural
course.
Finally, the majority decision concluded th at the
ethical integrity o f the medical profession would not
be violated as long as health care providers were not
compelled to discontinue feedings against their w ill
The court acknowledged that “there is substantial dis­
agreem ent in the medical community over the appro­
priate medical action” in such cases, Brophy’s physi­
cians and the hospital could not be forced to withhold
artificial feedings from him , it ruled, if such action ran
contrary to their “view o f their ethical duty toward
their patients.” Instead, it ordered the hospital to as­
sist M rs. Brophy in transferring her husband to an­
other site where his wishes could be carried out.
Three judges dissented> O ne objected th a t the
state’s interest in the preservation o f life “ had not been
given appropriate weight.” A nother said th at the deci­
sion sanctioned the person’s right to commit suipide
and th a t of others to participate. T he third, while not
citing any legal precedents, rejected the view th a t giv­
ing food and liquids is medical treatm ent as “outra­
geously erroneous,” adding, “I can think of nothing
more degrading to the hum an person than the balance
which the court struck today in favor of death and
against life.” 2
O t h e r D evelopm en ts
T h e Brophy decision is especially im portant in light
of developments elsewhere. T h e M assachusetts ruling
is in accord with legal precedents in other states, in­
cluding the Conroy case in New Jersey7 and the Barr
ber case in California,8 as well as several more recent
decisions.
In April 1986, the California Second District Court
of A ppeals ordered physicians to remove a nasogastric
tube from Elizabeth Bouvia, a 28-year-old quadri­
plegic woman with severe cerebral palsy who required
m orphine injections for arthritic pain.9 In 1983, a low­
er court had rejected Bouvia’s request to be allowed to
starve to death while hospitalized.10 A t the time, Bou­
via could take adequate nutrition orally with assist­
ance. By 1986, however, her condition had worsened.
T he appellate court ruled that her refusal of treatm ent
288
TH E NEW ENGLAND JOU RNA L O F MEI
was not a form of suicide, thereby rejecting the argu­
ments of hospital officials that removing the feeding
tube would make them party to a suicide. According
to the court, a patient need not be comatose or term i­
nally ill to refuse treatm ent, even when the treatm ent
may be life-saving and even when its absence may lead
to an earlier death. T he court added that the right to
refuse medical treatm ent was virtually absolute and
the patient’s motives were not a m atter for debate or
decision by others.
Also in A pril 1986, Florida’s Second D istrict C ourt
of Appeals allowed the removal o f a nasogastric tube
from Helen C orbett, a 75-year-old woman in a persist­
ent vegetative state.11 After her death, the court ruled
that such patients have the right to forgo life-sustain­
ing measures, including artificial feeding. C orbett’s
constitutional rigljt to decline treatm ent took prece­
dence over Florida’s 1984 Life-Prolonging Procedures
Act, the court also ruled. This law specifically ex­
cluded the “ provision o f sustenance” from its defini­
tion o f life-sustaining procedures that patients can de­
cline.11T h e Florida Suprem e C ourt declined to review
the decision.
*
In J u n e 1987, the Suprem e Court of New Jersey
ruled on two artificial-feeding cases. O n e involved
H ilda Peter, a 65-year-old nursing home patient in a
persistent vegetative state.12 T h e court, reiterating a
conclusion it had reached in the 1985 Conroy case,7
said there was no distinction between artificial feeding
and other forms o f life-sustaining treatment. O n the
basis o f “clear and convincing” evidence that Ms. Pe­
ter would, if competent, choose to withdraw her naso­
gastric tube, it ordered the state om budsm an to recon­
sider his decision blocking this action. T he second
case involved Nancy Jobes, a 31-year-old woman who
had been in a persistent vegetative state for seven
years after a severe automobile accident.13 T he court
upheld a lower-court decision authorizing the pa­
tient’s husband to seek the removal o f her jejunostomy
feeding tube.
These court decisions cited a widely publicized
statem ent adopted in 1986 by the Council on Ethical
and Judicial Affairs of the American Medical Associ­
ation.14 T h e council stated th at “it is not unethical to
discontinue all means of life-prolonging medical treat­
m ent” for patients in irreversible comas. T h e state­
ment specifically included nutrition and hydration on
a list of life-prolonging medical treatments. Similar
views have been set forth by many physicians and
ethicists.,’,s*22
T h e E m e r g in g C o n s e n s u s
Taken together, tfa^ge developments suggest an
emerging medical, ethical, and legal consensus on the
situations in which artificial feeding can be with­
draw n. T h e focus of discussion should be the patient’s
wishes, not the type o f treatm ent o r the patient’s
prognosis. Artificial feeding can be viewed on a level
with other medical interventions — cardiopulmonary
resuscitation, mechanical ventilation, dialysis, anti­
biotic therapy. It should not be considered a p a rt of
Feb. 4, 1988
‘'ordinary care” or the routine provision o f nursing
care and comfort. C om petent patients have the right
to refuse this treatm ent after assessing for themselves
the benefits and burdens. This right is not limited
to comatose or terminally ill patients. For incompe­
tent patients, feeding, like other treatm ents, can be
stopped in accordance with the patient’s previously
expressed wishes.
S u g g e s t io n s f o r C a r e G iv e r s
A few practical suggestions may help care givers
decide about artificial feeding and other life-sustaining
treatments. First, physicians should encourage com­
petent patients to discuss their preferences about care,
including artificial feeding, in clinical situations likely
to develop. They should check to see that patients
understand the benefits and burdens o f tube and in­
travenous feedings. These discussions may need to be
repeated, since patients may need time to decide or
may change their minds. W hen patients use am bigu­
ous terms, such as “life support” or “heroic meas­
ures,” the care giver should prom pt them to say what
they m ean more specifically.
Such discussions are particularly im portant for eld­
erly patients and those with chronic life-threatening
illnesses, who may become incompetent and unable to
participate in decisions. Empirical evidence shows
that most patients welcome such discussions.23,24 The
literature is growing on how to conduct them within
the context o f supportive medical care.25
Second, physicians should encourage patients to
provide advance directives, preferably the durable
power o f attorney for health care coupled with an ex­
plicit statem ent o f preferences.26-28 Physicians should
also docum ent in their medical notes the patient’s
wishes about artificial feeding as well as other lifesustaining treatm ents. C lear docum entation may pre­
vent later controversy, with allegations o f elder abuse,
and it will provide assurance that the patient’s prefer­
ences will be respected.29
T hird, attending physicians should discuss recent
developments in artificial feeding with nurses and
house staff. T h e argum ent that feeding must be given
because it represents basic, hum ane care should
be addressed directly. Instead of using artificial feed­
ing to show caring, plans can be made for supportive
care — pain control, skin care, and perifcnal hy­
giene.22 Even when artificial feeding is not used to
treat m alnutrition and dehydration, the symptoms of
hunger and thirst can be relieved by moistening the
p atient’s m outh with ice chips or, when possible, with
oral food and fluids.19 Nurses and house staff who do
not wish to care for such patients should indicate their
preference in advance, so that patient care will not be
disrupted. It may be possible to find volunteers to take
their place.
Finally, attending physicians who object to with­
holding artificial feeding should notify patients or fam­
ilies of their views at the time o f admission or before a
crisis occurs. Such disclosures are especially im por­
tant in nursing homes and hospitals .for the chronically
Vol. 318
No. 5
NEW ENGLAND JO U R N A L O F M EDICINE
ill. Allowing patients or their surrogates time to choose
another physician or facility that will honor their deci­
sions is far preferable to waiting until the patient's
condition deteriorates before attem pting a transfer.
When no transfer is possible, the patient’s wishes
should take priority over the objections o f care givers.
Respect for the p atient’s autonomy should prevent
physicians from imposing artificial feeding against pa­
tients’ wishes. Jn the Bartling case,30 the California
Second District C ourt of Appeals ruled that a compe­
tent patient’s request to discontinue his mechanical
ventilation should have been honored after efforts to
transfer him failed. Weighing testimony that in a
Christian hospital devotecj to the preservation o f life it
would be unethical for physicians to discontinue
support systems for patients “viewed as having the
potential for cognitive, sapient life,” the court re­
sponded that the patient’s right to determ ine his own
medical treatm ent m ust be “ param ount” over such
objections if this right “is to have any m eaning at all.”
W hen transfer is possible, physicians in some states
may have the legal right to send patients to another
hospital, as the M assachusetts Suprem e Judicial
Court ruled in the Brophy case. Such transfers place a
considerable burden on patients and their families,
however, and for that reason their use has been cur­
tailed in certain jurisdictions. New Jersey courts have
rejected them on both legal and ethical grounds, for
example. In 1986, a superior court judge held that
Beverly R equena, a 5^-year-old woman dying o f amy­
otrophic lateral sclerosis, could not be transferred
against her wishes after she decided to refuse artificial
feeding, even though a nearby hospital was willing to
accept her as a patient and honor her refusal.31 T he
decision, which was upheld on appeal,32 gave consid­
erable weight to the patient’s emotional attachm ent to
the first hospital, where she had received care for 17
months. T h e judge concluded, “ It is fairer to ask [the
hospital staff] to give than it is to ask Beverly Requena
to give.” 31 T h e Suprem e C ourt of New Jersey reached
a similar conclusion in the Jobes case, rejecting a nurs­
ing home’s request to discharge M rs. Jobes if her fam­
ily did not consent to continued artificial feeding. Such
use of authority, the court said, would “essentially
frustrate M rs. Jo b es’ right of self-determination.” 12
P o l i c y I m p l ic a t i o n s
T he Brophy case and the recent New Jersey Su­
preme C ourt rulings illustrate some o f the difficulties
that can arise when courts are asked to settle disputes
about life-sustaining treatm ents. T o begin with, the
legal process may be protracted. Even with an expe­
dited appeals process/the final decision in the Brophy
case was handed down 19 m onths after Patricia
Brophy’s original petition.
Also, adversarial courtroom proceedings often are
not the best way to establish medical facts and ju d g ­
ments accurately. An im portant issue in the Brophy
case was w h eth er'p atien ts in persistent vegetative
states suffer from hunger or thirst if tube feedings are
withheld. Because doctors testified on both sides of
289
this question, the issue became controversial. There
is consensus in the medical literature, however, that
patients in persistent vegetative states do not feel
pain, as the A m erica^ Academy of Neurology pointed
put in an amicus curiae brief. When such errors of
fact go uncorrected throughout the appeals process,
the resulting court decisions will be based on in­
correct medical judgm ents and may cause confusion
and cynicism.
T he courts play their greatest p art in resolving in­
tractable disagreements or concerns about improper
motives or possible m alpractice.12 T he courts can
check whether appropriate decision-making proce­
dures have been followed, but they generally should
not m ake the actual decisions about withholding treat­
ments. Likewise, doctors cannot expect the courts to
provide specific guidance in every clinical instance of
artificial feeding. Legal uncertainty should not deter
physicians from making decisions th at follow sound
medical practice and ethical principles. As the New
Jersey Suprem e C ourt noted, “Courts are not the
proper place to resolve the agonizing personal prob­
lems that underlie these cases. Q u r legal system can­
not replace the more intim ate struggle that m ust be
borne by the patient, those caring for t|ie patient, and
those who care about the patient.” 12
In recent years, many state legislatures have ex­
panded the rights of patients to; refuse life-sustaining
treatm ents. They have enacted laws that legitimize
the preparation o f advance directives about medical
care, such as living wills and durable powers of attor­
ney for health care. Typically, these laws grant care
givers immunity from civil and criminal liability when
they carry out the docum ented wishes of incompetent
patients. Such jaws may help physicians and families
or surrogates to reach decisions about life-sustaining
treatm ents without the courts.
C ertain state laws conflict with the developments
discussed here, however. For example, 24 o f 39 livingwili laws enacted through m id -1987 refer specifically
to artificial feeding. Seven o f them clearly exclude
such feeding from the'life-sustaining treatm ents that
can be w ithdraw n from terminally ill patients. An ad­
ditional 13 associate artificial feeding with necessary,
care involving the patient’s com fort.,Four allow the;
w ithdraw al of feeding not needed for the patient’s \_
comfort.33 T he C orbett ruling11 affirmed th at a pa­
tient’s constitutional right to decline treatm ent takes
precedence over the provisions of a Florida law pro­
hibiting the refusal o f artificial feeding- State legisla­
tures may wish to consider am ending existing livingwili laws and drafting future statutes to reflect current
medical and legal developments.
These developments also show how physicians and
medical organizations can shape public debate about
life-sustaining treatm ents. T h e American Medical As­
sociation’s policy statem ent on artificial feeding influ­
enced the Brophy, Bouvia, Corbett, Jobes, and Peter
cases. M oreover, professional organizations can try to
correct m isunderstandings about medical facts, as the
A m erican Academy o f Neurology did in the Brophy
TH E NEW ENGLAND JOU RNA L O F MEDIO
case. Specialty societies can develop and publish con­
sensus statem ents on areas of life-sustaining treatm ent
that fall w ithin their expertise. Physicians and medical
2. Brophy v. New England Sinai Hospital. In c .. 497 N .E. 2d 626 (Mass.
1986).
3. Steinbrook R . Feeding o f the comatose: a medical, legal frontier. Los An*
geles Tim es. February 17. 1986:1.
o rg an izatio n s c a n p ro v id e g u id a n c e to h o sp ita l a n d
4.
I n r e Q u in la n . 3 55 A . 2 d 6 4 7 ( N .I . 1976).
5.
Brophy v. New England Sinai Hospital. Inc . Mass. Probate County C t..
Norfolk Division. O ctober 2 |, 1985. (No. 85E0009-G1.)
English B . Brophy dies 8 days after feedings are halted. Boston Globe.
October 24, 1986:1.
In re Conroy, 486 A. 2d 1209 (N .J. . 1985).
Barber v. Superior Court, 195 Cal. Rptr. 484 (Cal. App. 2d D ist., 1983).
Bouvia v. Superior Court. 225 Cal. Rptr. 297 (Cal. App. 2d D ist., I9g6).
Steinbrook R , Lo B. The case o f Elizabeth Bouvia: Starvation, suicide, or
problem patient? Arch Intern Med 1986: 146:1^1-4.
Corbett v. D 'A lessandro. 498 So. 2d 368 (Fla. App. 2d D ist., 1986).
M atter o f Peter by Johanning. 529 A. 2d 419 (N .J. 1987).
M atter o f Jobes. 529 A. 2d 434 (N .J. 1987).
Current Opinions of the Council on Ethical and Judicial Affairs o f the
American M edical Association — 1986. W ithholding o r withdrawing life
prolonging medical treatment. Chicago: American Medical Association.
1986.
President's Commission for the Study o f Ethical Problems in Medicine and
Biomedical and Behavioral Research. Deciding to forego life-sustaining
treatment: a report cm the ethical, medical and legal issues in treatment
decisions. W ashington, D .C .: Government Printing Office. 1983.
Resolution o f the M assachusetts Medical Socicty. July 17. 1985.
California Medical Association Council. W ithholding o r withdrawing life*
sustaining treatment: ethical guidelines for decision making in long-term
care facilities. January 17. 1986.
Joint Committee on Medical Ethics o f the Los Angeles County M edical and
Bar Associations. Principles and guidelines concerning the foregoing o f life*
sustaining treatments. D ecember 1985.
Guidelines cm the termination o f life-sustaining treatment: a report by the
Hastings Center. Briarcliff M anor. N .Y .: The Hastings C enter, 1987.
W anzer SH. Adelstein SJ. Cranford RE. ct al. The physician’s responsibil­
ity toward hopelessly ill patients. N Engl J Med 1984; 310:955-9.
Terminal dehydration. Lancet 1986: 1:306.
Lo B . Dombrand L. Guiding the hand that feeds: caring for the demented
elderly. N Engl J Med 1984; 311:402-4.
Lo B . McLeod G A . Saika G . Patient attitudes to discussing life-sustaining
treatm ent. Arch Intern M ed 1986; 146:1613.5.
Steinbrook R . Lo B, Moulton J. Saika G , Hollander H, Volberding PA.
Preferences o f homosexual men with AIDS for life-sustaining treatment.
N Engl J M ed 1986; 314:457.60.
M iller A , L o B . How do physicians discuss do-not-resuscitate orders? West
J M ed 1985: 143:256-8.
Steinbrook R , Lo B. Decision making for incompetent patients by designat­
ed proxy: California's new law. N Engl J M ed 1984; 310:1598-601.
Schneidermao U . Arras JD . Counseling patients to counsel physicians cm
future care in the event o f patient incompetence. Ann Intern M ed 1985;
102:693-8.
Annas G J. Glantz LH. The right o f elderly patients to refuse life-sustaining
treatment. M ilbankQ 1986; 64:Suppl 2:95-162.
California Department o f Health Services. Guidelines regarding withdraw­
ing o r withholding o f life-sustaining procedure(s) in long-term care facili­
ties. August 7, 1987.
Bartling v. Superior Court. 209 Cal. Rptr. 220 (Cal. App. 2d D ist.. 1984).
In re Requena. N .J. Super. Ct. C h. D iv., Septem ber24, 1986. (No. P-32686E.)
In re Requena. N .J. Super. Ct. App. D iv.. O ctober6 . 1986. (No. A-44286T5.)
Socicty for the Right to Die. Handbook o f living will laws. New York:
Society for the Right to D ie. 1987.
Superintendent o f Belchertown State School v. Saikewicz. 370 N .E . 2d 417
(M ass. 1977).
Buchanan A. Brock DW . Deciding for others. Milbank Q 191f9t 64:Suppl
2:17.94.
Siegler M , W cisbard AJ. Against the em erging stream; Should fluids and
nutritional support be discontinued? Arch Intern M ed 1985; 145:129*31.
Lo B. Dombrand L. The case o f Claire Conroy; W ill administrative review
safeguard incompetent patients? Ann Intern Med 1986; 104:869-73.
nursing home adm inistrators and to state and local
governments.
U n r e so l v e d I ssu es
H ow should decisions about artificial feeding be
m ade for patients whose wishes are not known? Will
abuses occur when it is permissible for feeding to be
withdraw n or withheld? These im portant issues about
artificial feeding are unresolved.
T h e emerging consensus does not address situations
in which an incompetent patient’s wishes are not
known. It has been suggested th at physicians make
joint decisions \yith family m embers or surrogates, in
accordance with th® p atient’s best interests.12,15' 19'20
A dditional safeguards have been proposed, such as
the involvement o f ethics committees,4 legally ap ­
pointed guardians,34 or om budsm en.7 M aking deci­
sions about any aspect of life-sustaining treatm ent for
such patients is difficult, and the entire process needs
to be better defined In the years ahead.35
T here is also concern th at recent developments may
be m isinterpreted-and lead to instances in which feed­
ing will be withheld inappropriately, particularly from
nursing home residents.36,37 Some fear that there is a
greater potential for abuse in forgoing artificial feeding
than in forgoing other life-sustaining treatm ents. Al­
though the potential for abuse m ust be recognized, it
seems unreasonable to subject patients for this reason
to treatm ents they do not want.
These developments do not change the indications
for w ithholding life-sustaining treatm ent; they merely
include artificial feeding am ong the therapies that
m ay be withheld. T h e best steps to prevent abuse are
more open discussion of artificial feeding, more explic­
it decision-making procedures and docum entation,
and improved monitoring o f the quality of care. Such
actions make it more likely th a t controversial or diffi­
cult decisions will receive careful consideration. In­
stead o f creating a slippery slope, the emerging con­
sensus will place decisions to w ithhold o r withdraw
artificial feeding on even firmer ethical, legal, and
medical ground.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
W e a re indebted to D o n n a A m brogi, J .D ., a n d Steven Becker,
M .D ., for iheir helpful com m ents.
35.
R eferences
36.
1.
Lynn J. Childress JF. Must patients always be given food and water? Has­
tings Cent Rep 1983; 13(5): 17-21.
37.
IEW ENGLAND JO U R N A L O F MEDICINE
Vol. 318 No. 5
291
M E D IC A L P R O G R E S S
BACK PAIN AND SCIATICA
John W> Frymoyer, M.D.
O W back pain is usually a self-limiting symptom,
J but it costs at least $16 billion each year1*2 and
disables 5.4 million A m ericans.3 T he fact th a t a be­
nign physical condition has such an im portant socio­
economic effect can probably be explained by complex
psychological, societal, and legal factors. T his article
emphasizes th a t simple treatm ent is sufficient for most
patients with low back pain and sciatica. Timely surgical intervention for the minority of patients with
sciatica and neurologic claudication who do not re­
spond to conservative care, an d aggressive rehabilita­
tion for those disabled by chronic low back pain, will
favorably influence the outcome in most cases.
I
D e f in it io n s
Low back pain affects the area between the lower
rib cage an d gluteal folds and often radiates into the
thighs. O ne percent of patients with acute low back
pain have sciatica, which is defined as pain in the
distribution of a lum bar nerve root, often accom pa­
nied by neurosensory and motor deficits. Neurologic
claudication is characterized by leg pain th at is less
well localized, sometimes associated with numbness
and weakness, exacerbated by walking, and often re­
lieved by spinal flexion.*,
A n a t o m y o f L o w B a c k P a in
Low back pain can be reproduced by injecting hy­
pertonic saline into supraspinous, intraspinous, and
longitudinal ligaments, ligam enta flava, and facetjoint capsules.5-7 T hese structures and the peripheral
fibers o f the annulus fibrosus are innervated by noci­
ceptive nerve fibers, which are afferent branches of the
posterior prim ary ram i.8 T h e efferent branches of
these nerves uniquely innervate the paraspinal mus­
cles. T h e muscle spasms th a t are often a p art of the
clinical syndrom e are thought to be produced by asyet-undetermined sensory or motor-reflex pathways.
The prim ary role o f muscle injury in the production
of low back pain remains uncertain, even though
strains and sprains o f the lower back are the most
common diagnoses. In severe spinal degeneration,
increased vertebral interosseous pressure is yet an ­
other proposed cause of pain.9
Sciatic pain requires mechanical and inflammatory
stimuli to the anterior prim ary ram i o f lum bar nerve
^7
From the M cClure M usculoskeletal Research Center, the Department o f Orth­
opaedics and Rehabilitation, and the Vermont Rehabilitation Engineering Center
for Low Back Pain. University o f Vermont, Burlinston. Address reprint requests
to Dr. Frymoyer at the Department of Orthopaedics and Rehabilitation, Universi­
ty o f Vermont College o f Medicine. Burlington, VT 05405.
Supported in part by a grant (USOE-G008303001) from the National Institute
of Disability and Rehabilitation Research.
roots.10 It is hypothesized th at in patients with spinal
stenosis, a diminished supply of arterial blood to the
cauda equina is the cause o f neurologic claudication.
Relief o f claudicatory pain is attributed to an increase
in the dimensions of the spinal canal in flexion.
E p id e m io l o g i c C h a r a c t e r i s t i c s o f
L o w B a c k P a in
T h e lifetime prevalence of low back pain ranges
from 60 to 90 percent, and the annual incidence is 5
percent.11’13 M en and women are equally affected, but
women more often report low back symptoms after the
age of 60.13 T h e lifetime prevalence o f sciatica is 40
percent,11,12 but only 1 percent o f patients with acute
back pain have nerve-root symptoms. Sciatica usually
occurs in patients during the fourth and fifth decades
of life; the average age of patients undergoing lum bar
diskectomy is 42 years.14
Epidemiologic studies provide some information
ab out the cause of low back pain and sciatica. Risk
factors include involvement in occupations th a t re­
quire repetitive lifting in the forward ben t-and-twisted
position,15’17 particularly when the lifting require­
ments exceed the worker’s physical capacity18; expo­
sure to vibrations caused by vehicles or industrial ma­
chinery41,19; and cigarette smoking.11' 12,19
Epidemiologic studies also reveal distinct character­
istics in the occupational and psychological profiles of
people disabled by low back pain. Such persons often
view their occupations as boring, repetitious, and,dissatisfying.20,21 Depression, anxiety, hypochondriasis,
and hysteria (as measured by the M innesota M ultiphasic Personality Inventory); alcoholism; increased
divorce rates; and such health problems as headaches
and ulcers are frequently reported.2**"22 W hether these
characteristics represent the causes or results o f the
disability is not known.
Few other factors can be identified as im portant in
the pathogenesis o f low back pain and sciatica. Os- !
teoporosis increases the risk o f spinal compression I
fractures and may account for the fact that elderly ' ^
women report more low back symptoms than do
m e n .13,23 C onvincing genetic antecedents o f low
back pain are isthmic spondylolisthesis, spinal osteo­
chondrosis (Scheuerm ann’s disease), and spinal ste­
nosis associated with achondroplasia. V ariations in
spinal posture (lordosis and scoliosis of less than
60 degrees) do not appear to increase the risk of low
back pain or sciatica.24*25 T h e effects of discrepan­
cies in leg length, height, and weight are contro­
versial.24 T h e association between low back pain
and recreational activities is generally w eak,11 but a
fourfold incidence o f isthmic spondylolisthesis has
. 'V
NEUROLOGY 1989;39:125-l2t>
Position of the
American Academy of Neurology
on certain aspects of the
care and management of the
persistent vegetative state patient
Adopted by the Executive Board, American Academy of Neurology, April 21, I&88, Cincinnati, Ohio.
I.
The persistent vegetative state is a form of eyes-openstudied to date, postmortem examination reveals over­
permanent unconsciousness in which the patient has
whelming bilateral damage to the cerebral hemispheres
periods of wakefulness and physiological sleep/wake
to a degree incompatible with consciousness or the ca­
cycles, but at no time is the patient aware of him- or
pacity to experience pain or suffering.
^herself or the environment. Neurologically, being awake
Third, recent data utilizing positron emission to­
^ H it unaware is the result of a functioning brainstem and
mography indicates that the metabolic rate for glucose
^The total loss of cerebral cortical functioning.
in the cerebral cortex is greatly reduced in persistent
A. No voluntary action or behavior of any kind is
vegetative state patients, to a degree incompat ib!e with
present. Primitive reflexes and vegetative functions
consciousness.
that may be present are either controlled by the brain­
stem or are so elemental that they require no brain
II.
The artificial provision of nutrition and hydra! ion
regulation at all.
is a form of medical treatment and may be discontinued
Although the persistent vegetative state patient is
in accordance with the principles and practices govern­
generally able to breathe spontaneously because of the
ing the withholding and withdrawal of other forms of
jntact brainstem, the capacity to chew and swallow in (»
medical treatment.
horinial manner is lost because these functions are voT-" "'"'"AVThe Academy recognises'that the decision to dis­
untary, requiring intact cerebral hemispheres.
continue the artificial provision of fluid and nutrition
B. Tht primary basis for the diagnosis of persistent
may have special symbolic and emotional significance
vegetative state is the careful arid extended clinical
for the parties involved and for society. Nevertheless,
observation of the patient, supported by laboratory
the decision to discontinue this type of treatment
studies. Persistent vegetative state patients will show
should be made in the same manner as other medical
no behavioral response whatsoever over an extended
decisions, ie, based on a careful evaluation of the pa­
period of time. The diagnosis of permanent uncon­
tient’s diagnosis and prognosis, the prospective benefi ts
sciousness can usually be made with a high degree of
and burdens of the treatment, and the stated prefer­
medical certainty in cases of hypoxic-ischemic enceph­
ences of the patient and family.
alopathy sifter a period of 1 to 3 months.
B, The artificial provision of nutrition and hydration
A C . Patients in a persistent vegetative state may conis analogous to other forms of life-sustaining treatment,
^ffiue to survive for a prolonged period of time (“pro­
such as the use of the respirator. When a patient is
longed survival”) as long as the artificial provision of
unconscious, both a respirator and an artificial feeding
nutrition and fluids is continued. These patients are not
device serve to support or replace normal bodily func­
“terminally ill.”
tions that are compromised as a result of the patient’s
D.
Persistent vegetative state patients do not have illness.
the capacity to experience pain or suffering. Pain and
C. The administration of fluids and nutrition by
suffering are attributes of consciousness requiring cere­
medical means, such as a G-tube, is a medical pro­
bral cortical functioning, and patients who are perma­
cedure, rather than, a nursing procedure, for several
nently and completely unconscious cannot experience
reasons.
these symptoms.
1.
First, the choice of this method of providing fluid
There are several independent bases for the neu­
and nutrients requires a careful medical judgment as to
rological conclusion that persistent vegetative state pa­
the relative advantages and disadvantages of this treat­
tients do not experience pain or suffering.
ment. Second, the use of a G -tube is possible only by the
First, direct clinical experience with these patients
creation of a stoma in the abdominal wall, which is
demonstrates that there is no behavioral indication of
unquestionably a medical or surgical procedure. Third,
any awareness of pain or suffering.
once the G-tube is in place, it must be carefully moni­
Second, in all persistent vegetative state patients
tored by physicians, or other health care personnel
J u u u a r y XOHi) N fiU K O U lC Y .19 12tS
i}'
^ working under the direction of physicians, to insure
decision to withhold all further medical treatment, such
that complications do uot arise. Fourth, a physician’s
as artificial nutrition and hydration, and feels that such
judgment is necessary to monitor the patient’s toler­
a course of action is morally objectionable, the physi­
ance of any response to the nutrients that are provided
cian, under normal circumstances, should not be forced
by means of the G-tube.
to act against his or her conscience or perceived under­
2.
The fact that the placement of nutrients into the standing of prevailing medical standards.
tube is itself a relatively simple process, and that the
In such situations, every attempt to reconcile dif­
feeding does not require sophisticated mechanical
ferences should be made, including adequate communi­
equipment, does not mean that the provision of fluids
cation among all principal parties and referral to an
and nutrition in this manner is a nursing rather than a
ethics committee where applicable.
medical procedure. Indeed, many forms of medical
If no consensus can be reached and there appear to be
treatment, including, for example, chemotherapy or in­
irreconcilable differences, the health care provider has
sulin treatments, involve a simple self-administration
an obligation to bring to the attention of the family the
of prescription drugs by thepatient. Yet such treat­
fact that the patient may be transferred to the care of
ments are clearly medical and their initiation and moni­
another physician in the same facility or to a different
toring require careful medical attention.
facility where treatment may be discontinued.
D.
In caring for hopelessly ill and dying patients, physi­ D.
The Academy encourages health care providers to
cians must often assess the level of medical treatment
establish internal consultative procedures, such as eth­
appropriate to the specific circumstances of each case.
ics committees or other means, to offer guidance in
1. The recognition of a patient’s right to self-deter- • cases of apparent irreconcilable differences. In May
mination is central to the medical, ethical, and legal
1985, the Academy formally endorsed the voluntary
principles relevant to medical treatment decisions.
formation of multidisciplinary institutional ethics
2. In conjunction with respecting a patient’s right to
committees to function as educational, policy-making,
self-determination, a physician must also attempt to
and advisory bodies to address ethical dilemmas arising
promote the patient’s well-being, either by relieving
within health care institutions.
suffering or addressing or reversing a pathological pro­
cess. Where medical treatment fails to promote a pa­
IV.
It is good medical practice to initiate the artificial
tient’s well-being, there is no longer an ethical
provision of fluids and nutrition when the patient’s
obligation to provide it.
prognosis is uncertain, and to allow for the termination
3. Treatments that provide no benefit to the patient
of treatment at a later date when the patient’scondition
or the family qwiy be discontinued. Medical treatment
becomes hopeless.
that offers some hope for recovery should be disA. A certain amount of time is required before the
*“tiK^uished frdnftreatment' tteirffi£T&3^
'diagnosis of persistent'vegetative" staarcan" be-madepends the dying process without providing any possible
with a high degree of medical certainty. It is not until
cure. Medical treatment, including the medical provi­
the patient’s complete unconsciousness has lasted a
sion of artificial nutrition and hydration, provides no
prolonged period—usually 1to 3 months—that the con­
benefit to patients in a persistent vegetative state, once
dition can be reliably considered permanent. During the
the diagnosis has been established to a high degree of
initial period of assessment and evaluation, it is usually
medical certainty.
appropriate to provide aggressive medical treatment to
sustain the patient.
III.
When a patient has been reliably diagnosed as
Even after it may be clear to the medical profes­
being in a persistent vegetative state, and when it is
sionals that a patient will not regain consciousness, it
clear that the patient would not want further medical
may still take a period of time before the family is able
treatment, and the family agrees with the patient, all
to accept the patient’s prognosis. Once the family has
further medical treatment, including the artificial
had sufficient time to accept the permanence of the
provision of nutrition and hydration, may be forgone.
patient’s condition, the family may then be ready to
A. The Academy believes that this standard is con­
terminate whatever life-sustaining treatments are
sistent with prevailing medical, ethical, and legal prin­
being provided.
ciples, and more specifically with the formal resolution
B. The view that there is a major medical or ethical
passed on March 15,1986 by the Council on Ethical and
distinction between the withholding and withdrawal of
Judicial Affairs of the American Medic&l Association,
medical treatment belies common sense and good medi­
entitled “Withholding or Withdrawing Life-Prolonging
cal practice, and is inconsistent with prevailing medi­
Medical Treatment."
cal, ethical, and legal principles.
B. This position is consistent with the medical com­
C. Given the importance of an adequate trial period
munity^ clear support for the principle that persistent
of observation and therapy for unconscious patients, a
vegetative state patients need not be sustained indefi­
family member must retain the ability to withdraw
nitely by means of medical treatment.
consent for continued artificial feedings well after in i­
While the moral and ethical views of health care
tial consent has been provided. Otherwise, consent will
providers deserve recognition, they are in general sec­
have been sought for a permanent course of tr e a tm e n t
ondary to the patient’s and family’s continuing right to
before the hopelessness of the patient’s condition has
grant or to refuse consent for life-sustaining treatment.
been determined by the attending physician and is fully
C. When the attending physician disagrees with the
appreciated by the family.
126 NEUROLOGY 38 Jan u ary 1988
,
THE LANCET, APRIL 1 1972
734
Points of View
order to facilitate communication, betw een doctors or
w ith patients’ relatives or intelligent laym en, about its
im plications.
CLINICAL SYNDROME
PERSISTENT VEGETATIVE STATE
AFTER BRAIN DAMAGE
A Syndrome in Search o f a Name
B ryan J ennett
InstituteofNeurological Sciences,
GlasgowGS14TF
F red P lum
NewYorkHospital—Cornell Medical Center,
NewYorkCity, N.Y., U.S.A.
Patients w ith severe brain damage due
S u m m a r y tQ ttaum a or isch sn u a m ay now survive
indefinitely. Som e never regain recognisable mental
fun ction , but recover from sleep-like com a in that
they have periods o f wakefulness when their eyes are
open and m ove; their responsiveness is lim ited to
prim itive postural and reflex m ovem ents o f the
lim b s, and they never speak. Such patients are best
described as in a persistent vegetative state, which
should b e clearly distinguished from other conditions
associated w ith prolonged unresponsiveness. W hat is
com m on to these patients is th e absence o f function in
the cerebral cortex as judged behaviourally; the lesion
m ay b e in the cortex itself, in subcortical structures o f
the hem isphere, or in the brain-stem , or in all o f these
sites. B u t the exact site and nature o f the lesion is
unknow n to the bedside clinician, and the nam e for
th e syndrom e should n ot im ply m ore than is known.
" . . . if we have a conception for which no name exists, which
we need frequently to speak of, it is not wise, I think, to shrink
from an attem pt to give it a name.”—Sir ’William G owers.
N e w m ethods o f treatment m ay, b y prolonging the
lives o f patients w ith conditions w hich were formerly
fatal, result in situations never previously encountered.
A nd n ew situations call for new names i f they are to
be accurately understood and discussed.
T w enty
years ago F re n c h 1 com m ented that patients who
sustained brain lesions w hich deprived them o f the
ability to perform the intuitive and protective functions
necessary for survival rarely lived m ore than a few
days or, exceptionally, two or three weeks. H e then
described five patients w ho had survived for many
m onths w ith profoundly altered consciousness, but
h e d id not suggest a name for their clinical condition.
W ith the development o f intensive-care units it has
now becom e almost com m onplace for patients to
survive w ith devastating brain damage, usually the
result o f head trauma, a brain-stem stroke, or a cardio­
respiratory crisis associated w ith hypoxia. Clinical
and pathological reports about such cases are begin­
ning to accumulate, whilst the ethical, m oral, and social
issues are provoking com m ent both in the health
professions and in the com m unity at large. O nce past
the acute stage these patients are neither tinconscious
nor in com a in the usual sense o f these term s, both o f
w hich im ply a sleep-like insensibility. There is clearly
need for an acceptable term to describe their state, in
I n th e first w e e k or so after in ju ry th e se p a tie n ts are in
d eep co m a , n ev er o p e n in g th e ir e y e s ; an d w h e n th e y d o
react to stim u li th e y sh o w v a ry in g d egrees o f ex ten so r
resp o n se in th e lim b s. H o w e v e r , u n less th e y h a v e bilateral
th ir d -n e r v e p aralysis, th e su rvivors b e g in , w ith in tw o o r
th r ee w eek s, to o p en th eir ey e s— at first o n ly in resp o n se to
p a in , th e n to less a rou sin g stim u li. S o o n after th is th e y
h a v e p erio d s w h e n , w ith o u t a n y p r o v o ca tio n , th e y lie fo r
p erio d s w ith th e ir ey es o p e n ; at o th e r tim e s th e y se em t o
sle ep .
I t m a y b e d ifficu lt to d eterm in e w h e th e r th e ir
sle ep /w a k e rh y th m s h a v e a n orm al d iu rn al p a ttern , b eca u se
su c h p a tie n ts are h a v in g in te n siv e n u rsin g ca r e ; th is
in v o lv e s b e in g tu rn ed ev ery tw o o r th r e e h o u r s, a n d th e
lig h ts in th e ir ro o m s m a y n ev er b e p u t o u t. T h e e y e s are
o p e n a n d m a y b lin k to m en a ce, b u t th e y are n o t a tten tiv e;
a lth o u g h ro v in g m o v em e n ts m a y b riefly se e m to fo llo w
m o v in g o b jects, carefu l o b serv a tio n d o es n o t co n firm an y
c o n sis te n c y in th is op tim istic in terp retation . I t se e m s that
th e r e is w ak efu ln ess w ith o u t aw aren ess.
T h e ex ten so r resp o n se in t h e lim b s is c o n u n o n ly referred
t o as d ecerebrate rig id ity , after S h errin g to n 's d e sc r ip d o n o f
th e lim b p o stu res o f an im als after m id b ra in tra n sectio n . I t
can a lso b eg in to w ear o f f after tw o o r th r e e w eek s, and
a lth o u g h for a tim e so m e ex ten so r m o v e m e n ts m a y still
o c c u r , a n o x io u s stim u lu s m a y n o w p ro v o k e a flexor
w ith d ra w a l, b u t o n ly after an ab n orm al d ela y , an d the
m o v e m e n t it s e lf is rath er slo w a n d d y sto n ic a n d never
takes t h e form o f n orm al brisk r esp o n se. A sig n ifica n t grasp
reflex o fte n appears, an d th is m a y b e p ro v o k ed b y ch an ce
to u c h o f th e b e d c lo th e s; t o th e in e x p e r ie n c e d ob serv er o r
h o p e fu l fam ily th e resu ltin g m o v e m e n t m a y lo o k as th o u g h
it w a s in itia ted b y th e p a d en t a n d m a y ev en b e regarded
a s p u rp o sefu l o r volu n tary.
S o m e tim e s fra g m e n ts o f
c o o rd in a ted m o v em e n ts m a y b e se e n su c h as sc ra tc h in g , or
ev e n m o v em e n t o f th e han d s tow ard s a n o x io u s stim u lu s,
an d p ostu ral alteration s in th e lim b s m a y b e p ro v o k ed b y
n eck m o v e m e n ts. C h e w in g an d te e th g rin d in g are co m m o n
an d m a y g o o n fo r lo n g p e r io d s; liq u id a n d fo o d p laced
in t h e m o u th m a y b e sw allow ed .
G r u n tin g o r groan in g m a y b e p rovok ed b y n o x io u s
st im u li, b u t m o st o f th e se p a tie n ts are sile n t; t h e y n eith e r
sp eak n o r m a k e a n y m ea n in g fu l resp o n se to t h e sp o k en
w o r d . S h o u tin g , lik e a n o x io u s stim u lu s, m a y p r o d u ce a
n o n -s p e c ific so m a tic an d v e g eta tiv e resp o n se w ith e y e o p e n in g , grim acin g, a ltered resp iratory p a ttern , a n d ev en
so m e stere o ty p ed lim b flexion .
F e w w o u ld d isp u te th a t in t h is c o n d itio n t h e cerebral
co r te x is o u t o f action . T w o rep orted p a tie n ts w ith ex ten ­
siv e n eo co rtica l n ecrosis h a d sh o w n th is clin ica l state for
sev era l m o n th s after cardiac arrest.5 H o w e v e r , it is also
p o ss ib le fo r th e fu n ctio n s o f th e co rtex to b e in activ a ted
w ith o u t th a t stru ctu re its e lf b ein g d a m a g ed , b eca u se , w h en
a c r iu c a l am ou n t o f d am age is su sta in e d b y th e reticu lar
a ctiv a tin g sy stem eith er in th e b ra in -ste m or in th e basal
gan glia or su b cortical areas, th e co rtex th erea fter fails to
fu n c tio n effe ctiv ely . P a tien ts w ith h ea d in ju ry w h o su rvive
in th is sta te freq u en tly p ro v e to h a v e ex ten siv e lesio n s in
th e w h ite -m a tter, w ith a lm o st c o m p le te sp a rin g o f th e
co rtex an d b r a i n - s t e m , b u t o th ers h ave seco n d a ry b rain ­
ste m co m p ressio n or ex ten siv e ischaem ic brain d am age in
t h e co r te x an d su b co rd ca l stru ctu res.
In th e first few w eek s after in ju ry th e electroen cep h a lo ­
gram ( e . e . g .) m ay resolve d o u b ts a b o u t w h eth er t h e p atien t
is really a tten tiv e; i f th ere is e x te n siv e n eocortical d eath th e
record w ill in itia lly b e flat, as in t h e tw o cases o f B rierley
e t al.* w h o h ad iso e le ctr ic records fo r m an y w eek s. H o w ­
e v e r , th is is rare, a n d th ere is v ery little in form a tio n
,
735
THB LANCBT, APRIL 1 1972
about the significance of E.E.G. changes months after the
initial incident; there may be high-voltage slow waves or,
occasionally, some alpha rhythm , but the activity is un­
responsive to visual, auditory, or noxious stimuli. The
occurrence of a wakeful e.e. g. record which is unmodified
by stimuli, in patients who are unresponsive, has been
reported previously with pontine lesions.1**
EXISTING NAMES
A critical review o f th e terms w hich are used for
this and related disorders gives an opportunity to
discuss th e differential diagnosis o f this condition and
to em phasise that none o f th ese terms is quite appro­
priate. T h e y fall naturally into two categories, the
better o f w hich are th ose that attempt to capture the
essence o f the syndrom e descriptively. T h ose which
im ply or im pute a particular anatomical or patho­
logical basis, when it is already clear that both the site
and th e nature o f the lesio n m ay vary w idely, are
obviously less suitable.
BrainDeathComaDdpassi *
T h is applies to patients in whom structural or
anoxic insults have left n o evidence o f function in the
nervous system above th e spinal cord: the pupils are
fixed, spontaneous respiration has ceased, and the
E.E.G. is always isoelectric, but cardiac function may
continue for days and th ere m ay be stim ulus-evoked
lim b m ovem ents due to persisting spinal reflexes.
Before concluding that su ch a state is due to brain
death it is essential to b e certain that there has been
neither excessive dosage w ith depressant drugs nor
hypotherm ia, because eith er o f these m ay produce a
reversible suspension o f brain activity. Brain death is
never survived by m ore than a few days, and then only
by reason o f respirator support. T h e syndrome we
are d iscu ssin g m ay p ersist for m onths or even years,
provided nutrition is satisfactorily supplied, because
respiration is adequate (although som e patients have
had a short period o f assisted ventilation in the acute
stage o f their illness).
AkineticMutism{Coma Vigile)
Comavigile is an old term , probably first used by
the F rench to describe th e state o f patients with
severe typh us or typhoid fever. Akinetic m
utismwas
coined b y Cairns • in 1941 to describe an interm ittent
disturbance o f consciousness in an adolescent girl
w ith a craniopharyngiom a. She lapsed into this state
three tim es in nine m on th s, and each tim e she re­
covered w h en the cyst w as aspirated. Cairns com ­
m ented o n th e eyes b ein g open, apparently attentive,
and “ givin g the prom ise o f speech ” , Skultety 10 has
reviewed th e literature w h ich has accumulated since
then, and h e also reports th e attempts w hich he and
others h ave made to produce this state in laboratory
animals. H e concludes that the term presents con­
siderable sem antic problem s and em phasises that
akinesia and m utism d o n ot always go together. In
particular, the m utism m ay be only relative— Cairns’
patient w ould answer in whispered m onosyllables,
w hilst som e other reported patients w ould use sign
language to com m unicate. T h e lesions reported in
patients w ho showed th is rather loosely defined and
potentially recoverable state range from the brain­
stem through the basal ganglia to bilateral cingulate
gyrus destruction.
Skultety considered that akinetic m utism was pri­
m arily a disorder o f responsiveness and that three
different types o f disorder rather than separate sites o f
lesions could be recognised. T hese were loss o f critical
amounts respectively o f the afferent input, o f the
activating reticular system , or o f the efferent m echa­
nism s (but the de-efferented, locked-in syndrome is
clinically distinguishable— see below). Attem pts to
produce thie syndrome o f akinetic m utism in cats
produced a variety o f states w ith akinesia and m utism
seem ingly independently affected. But animal species
at different phylogenetic levels w ill react differently to
having the brain-stem disconnected from th e cortex.
Furthermore, how closely m utism in a cat (a relatively
silent animal) corresponds to speechlessness in man is
at best an open question.
Permanent, Irreversible, or ProlongedComa, Stupor,
or Dementia
Certainly we are concerned to identify an irre­
coverable state, although the criteria needed to
establish that prediction reliably have still to be con­
firmed. U ntil then “ persistent ” is safer than “
” or “
” ; but
is not
strong enough, and unless it is quantified it is m eaning­
less. T h is state cannot be called “
” , as ordin­
arily defined; in particular, it is not a continuation o f
the com a w hich characterises the early stages of these
particular patients’ clinical course.
m ight be
acceptable, but its established use for schizophrenic
catatonia m ight lead to confusion.
by its
conventional usage suggests a progressive state o f
brain dysfunction, and it is in such com m on use for
alert patients who are quite responsive that it seem s
inappropriate in the present context.
manent
irreversible
prolonged
coma
per­
Stupor
Dementia
Decerebrateor DecorticateState
T h ese terms are m ost often applied to different
types o f m otor dysfunction, and, w hilst it is usual for
the m ental state which we are defining to be associated
w ith severe motor disorders, the pattern o f this is b y
no means consistent. M oreover, decerebration w as
originally used by physiologists to describe the state
o f animals after brain-stem transection, and if the term
w ere used for the clinical state under discussion it
m ight not only focus attention on the m otor dys­
function but it m ight also m isleadingly im ply that th e
lesion was in the brain-stem. T h e same argum ent
tells- against
. In any
event this is a m eaningless tag o f jargon, and th e
same goes for
— which,
m ight be used for any condition from the p ostconcussional syndrome to brain death. Both
and
m ight be taken to im ply a specific
structural lesion: such terms are unsuitable for bed­
side diagnosis, w hen the nature of the lesion can seldom
be accurately predicted and never be proved.
tion
chronic brain-stem syndrome
post-traumatic encephalopathy
decerebra­
decortication
Apallic Syndrome
T h is was proposed in 1940 by K retschm er,11 a
psychiatrist, to describe patients who were open-eyed,
uncomm unicative, and unresponsive from a variety
o f lesions, including cerebral arteriosclerosis, lues,
and gunshot wounds. H is paper was concerned w ith
terms used to describe cortical dysfunction, and he
suggested that
was in line w ith the words
apallic
736
,
»
THB LANCET, APRIL 1 1972
apraxic and agnosic, but
that it indicated the sim ul­
taneous disturbance o f several cortical functions. T h e
full syndrom e h e considered m uch less com m on than
partial or incom plete forms, and he im plied that
recovery was possible because he described the
psychiatric features o f the recovery period.
The term seems to have been largely ncglectcd until its
recent adoption by the Viennese neurologists and neuro­
pathologists to describe survivors of severe head injury,,2'la
anoxic insults, or poisoning. Gcrstenbrand 11 also suggests
that there are degrees o f the syndrome, that considerable
amounts o f the telencephalon seem still to be functioning
in most cases because the E .E .G . is not isoelectric, and that
recovery is possible. Ingvar 16 suggests that less severe
forms might be termed dyspallic or incomplete apallic, and
both he and Gerstenbrand refer to the difficulty o f dis­
tinguishing this clinical state from the effects of a massive
lesion o f the dominant cerebral hemisphere, producing
global aphasia, apraxia, and agnosia. The characteristics
o f the complete apallic syndrome, according to Ingvar, are
a complete loss of higher (telencephalic) function with an
isoelectric E .E .G . and much-reduced cerebral blood-ilow
and metabolism in supratentorial structures.
Attempts have been made to produce apallic cats by
making brain-stem lesions and using intensive-care tech­
niques to ensure prolonged survival.14 These experiments
are most interesting in showing the amount o f complex
activity which eventually returns after extensive lesions;
surgical decerebration of infant monkeys is likewise followed
by the return o f a considerable repertoire o f responsive
motor behaviour, and observations on anencephalic humans
surviving for some weeks reinforce the view that an appre­
ciable range o f activity and responsiveness is possible in the
absence o f the cortex. However, none o f this evidence
bears on the problem of mental function in adult man,
whilst even at the level o f motor behaviour there are diffi­
culties in extrapolating from animal experiments or studies
in young infants, because o f the varying degrees of depen­
dence o f subcortical structures on cortical influence in
different species and at different stages of development.
Once encephalisation has occurred, phylogenetically or in
the individual, it prevents for evermore the return to full
function of lower structures that may operate very well in
primitive animals. Collicular sight is a good example.
T h e term
used in a clinical sense seem s to
us m ore to confuse than to clarify the issue "under
discussion. In the first place, it is an uncom m on word
even in m edicine, and its usage m erely adds to the
unnecessarily arcane jargon that often makes neurology
needlessly difficult for others to understand.
In
addition, the term is potentially m isleading, not only
because partial or incom plete syndromes are adm itted,
but because it assumes an improved pathology; and
there rem ains am biguity about whether the structure
or th e function o f the cortex is taken to be absent.
A s already noted, the clinical syndrome w e are describ­
ing can be produced by lesions w hich largely spare
the cortex structurally, and the e.e.g. m ay even show
persisting alpha rhythms.
apallic
Locked-in Syndrome ( . De-efferented State)
T h is term was coined by Plum and Posner in
1965 17 to describe the tetraplegic, m ute but fully
alert state w hich results w hen the descending m otor
pathways are interrupted by an infarction o f the
ventral pons.
Such patients are entirely awake,
responsive and sentient, although the repertoire o f
response is lim ited to blinking, and jaw and eye
m ovem ents. One p a tie n t11 still alive after 18 m onths
has full bladder control and signals by M orse code,
using blinks and jaw m ovem ents, that she appreciates
a full range o f sensation from skin and joint position.
In her, noxious stim uli provoke decerebrate posturing;
the e . e . g . is normal, and during 4 -6 hours at night
shows the usual sleep changes.
P E R S IS T E N T V EG E T A T IV E STATE
W e propose this as the m ost satisfactory term to
describe this syndrome, for several reasons. I t de­
scribes behaviour, and it is only data about behaviour
w hich w ill always be available, and in every patient,
because such observations are independent o f special
procedures such as e.e.g. and measurements o f cerebral
blood-flow or cerebral m etabolism . T h is term pre­
sum es neither a particular physio-anatom ical abnor­
m ality nor a specific pathological lesion, matters w hich
can seldom be settled beyond doubt at th e bedside;
it therefore invites further clinical and pathological
investigation o f the condition rather than giving the
im pression o f a problem already com pletely under­
stood. T h e word
itself is n ot obscure:
is defined in the
as
“ to live a merely physical life , devoid o f intellectual
activity or social intercourse (1740) ” and
is used to describe “ an organic body capable o f
growth and developm ent b u t devoid o f sensation and
thought (1764)
It suggests even to the layman a
lim ited and prim itive responsiveness to external
stim uli; to the doctor it is also a rem inder that there
is relative preservation o f autonom ic regulation of
the internal m ilieu. L astly this term has already
occasionally been used to describe patients such as
th is, although w e are unaware o f any attem pt to
define the lim its o f the syndrom e to w hich it could
properly be applied.
D eath, recovery, or survival “ as a vegetative wreck ”
were the three outcomes o f severe head injury recently
recognised by Vapalahti and Troupp *•; their patients
w ith vegetative survival were described as incapable o f
com m unication and w ithout h ope o f recovery as social
hum an beings. In our view the essential com ponent
o f this syndrome is the absence o f any adaptive
response to the external environm ent, the absence of
any evidence o f a functioning m ind w hich is either
receiving or projecting inform ation, in a patient who
has long periods o f wakefulness. Akinesia is relative*
because postural adjustments and stereotyped primi­
tive withdrawals are usually possible. A ll th e patients
are speechless and also fail to signal appropriately by
eye m ovem ents, although they som etim es follow
m oving objects in a slow interm ittent pattern. Initially
the e.e.g. m ay be isoelectric, but considerable activity
and even alpha rhythm m ay b e found once the state
has lasted many m onths. W hat is com m on to all
patients in this vegetative, m indless state is that, as
best can be judged behaviourally, the cerebral cortex
is not functioning, w hether the lesion be in the
cerebral cortex itself, in subcortical structures, the
brain-stem , or in all these sites. However, w e cannot
yet accurately predict the specific pathological sub­
strate or the precise E.E.G. abnormality w hich w ill be
found in association w ith the persistent vegetative state.
vegetate
vegetative
OxfordEnglishDictionary
vegetative
,
THB LANCET, APRIL 1 1972
Exactly how long such a state m ust persist before it
can be confidently declared permanent w ill have to
be determ ined by careful prospective studies, using
th e criteria w hich w e have set down here, and w e are
already undertaking such an investigation. It is already
clear that patients destined to make a reasonable re­
covery (including those w ho w ill have considerable
perm anent disability) do n ot usually pass through the
vegetative state as a p hase in their recovery from
com a. In th ese more hopeful cases, once wakefulness
returns, there are other signs o f returning cortical
function, and it is the discrepancy between prolonged
periods o f wakefulness and the absence o f any
behavioural or physiological evidence o f cortical
function or mental activity w hich characterises the
vegetative state. A lthough w e w ould not deny that a
continuum m ust exist between this vegetative state
and som e o f the others described, it seems w ise to
m ake an absolute distinction betw een patiei.ts w ho do
m ake a consistently understandable response to those
around them , whether b y word or gesture, and those
w ho never do. It m ay w ell becom e a matter for dis­
cussion how worth w hile life is for patients whose
capacity for m eaningful response is very lim ited, but
it still seem s to us that th e im m ediate issue is to
recognise that there is a group o f patients who never
show evidence o f a working m ind. T h is concept may
b e criticised on the grounds that observation o f
behaviour is insufficient evidence on w hich to base a
judgm ent o f mental activity: it is our view that there
is n o reliable alternative available to the doctor at the
bedside, w hich is where decisions have to be made.
I t is advantageous to have a term w hich avoids the
m ystique o f highly specialised m edical jargon to
describe a condition likely to be discussed w idely out­
side the profession. T h is is our m ain objection to
la
, the users of
w hich them selves w rite: 44
peut-Stre u tile
ces
” . s® Certainly the
indefinite survival o f patients in this state presents a
problem w ith humanitarian and socioeconom ic im pli­
cations w hich society as a whole w ill have to con­
sider.*1-*8 I f it were possible to predict soon after the
brain dam age had been sustained that, in the event o f
survival, th e outcome w ould be a vegetative m indless
state, then the w isdom o f continuing supportive
measures could be discussed. U ntil reliable predictive
criteria em erge it is inevitable that the price o f reducing
m ortality from severe brain damage, and enabling
m any patients to make a reasonable recovery, will be
the survival o f some patients in a permanent vegetative
state.
stupeur hypertonique post-comateuse
Un terme nouveau serait
pour nommer dtats
REFERENCES
1.
F rench, J. D , Archs Neurol. Fsychiai. 1952, C3» 727.
2% B rie rle y , J . B ., A d a m s, J . H ., G r a h a m , D . 1 ., S im p s o n , J . A . L a n ce t,
1971, ii ,
3 . S tr ic h , S .
4 . S tr ic h , S .
5 . C h a tr ia n ,
6.
7.
8.
9.
10.
56j0.
J . J . N e u ro l. N e u ro s v rg . P sych iat. 1 9 5 6 ,1 9 , 163.
J . L a n ce t , 1961, i i , 4 4 3 .
G , E ., W h ite , L . £ . , S h aw , C .- M . Electroenceph. c litt.
N tu r o p h y s io l. 1964, 1 6, 28 5 .
K a a d a , B . JR., H a rk m a rk , W ., S to k k e , O . ib id . 1961, 13, 78 5.
M o h a n d a s , A ., C h o u , S . N . J , N e u ro s u rg . 1971, 3 5 ,2 1 1 .
M o U a ret, P . , G o u lo n , M . R e v. N e u ro l. 1959, 101, 3.
C a ir n s , H . , O ld fie ld , R . C .» Pecm yb& cker, J . B ., W h itie rid g c , D .
Brain, 1 9 4 1 , 6 4 , 273.
S k u lte ty , M . F . A rchs N e u ro l . 196 8 , 19, 1.
References continued a t fo o t o f next column
737
Dogma Disputed
TH E FO UR Q UARTERS OF PREGNANCY
Derek Llewellyn-Jones
Department of ObstetricsandGynacology,
Universityof Sydney
I n the days w hen pregnancy was considered to last
nine calendar m onths, obstetricians found it con­
venient to divide this period into three trimesters.
E ven though m ost obstetric educators now recom m end
that the duration o f pregnancy should be calculated
in weeks rather than m onths, the concept o f three
trimesters persists, although it is neither chrono­
logically accurate nor particularly valuable as a concept.
For several reasons the tim e has now com e for the
division o f pregnancy into trimesters to be abandoned,
and for medical students to be taught that a pregnancy,
w hich has a m ean duration o f 40 weeks from the
first day o f the last m enstrual period in a woman
w hose menstrual cycle is o f normal duration, may
conveniently be divided into four. 10-week periods.
W e should, in fact, talk about the four quarters of
pregnancy.
T h e reasons for recom m ending this change can be
discussed under several headings.
Abortion.
— T h e W o rld H e a lth O rgan isation h a s reco m ­
m e n d e d th at “ a b o rtio n s ”— referrin g to t h e p rod u cts of
co n c e p tio n — sh o u ld b e te rm ed early fetal d e a th s; a n d th e
w o r d ab ortion sh o u ld o n ly refer to th e p ro cess o f ex p u lsio n .
O v er 50% o f k n o w n sp o n ta n e o u s ab ortion s o ccu r before
t h e 10th w eek o f p reg n a n cy , a n d , w h ere legal ab o rtio n is
p e r m itte d , th e m o rb id ity an d m o rta lity o f t h e p ro ced u re is
v e r y m u c h le ss i f th e term in ation is m ad e b efore t h e 10th
g estation al w e e k .1’2 I n fa c t, m a n y a u th orities reco m m en d
th a t legal ab ortion sh o u ld b e in d u c ed after th e e n d o f th e
1 0 th gestation al w eek o n ly i f th e re arc stro n g m edical
reason s.
— In B ritain th e d efin itio n o f v ia b ility req u ires
to b e ch an ged . T h e R eg istra r-G en era l still a ccep ts th a t
stillb irth s are d efin ed as b a b ies b orn after 2 8 w eek s’
g esta tio n w h o d o n o t sh o w a n y sig n s o f life after sep aration
fro m th e m o th e r , th e p r e su m p tio n b ein g th a t in fa n ts born
b efo re th is tim e are n o t v ia b le. T h is is n o t tru e. E v id en ce
fro m several n ation s sh o w s th a t 7 -1 2 % o f in fa n ts born
b efo re th e e n d o f t h e 2 8 th gestation al w eek su rvive. T h is
fa ct is reco g n ised b y th e W o rld H ea lth O rgan isation ,
w h ic h has reco m m en d ed th a t th e p erin atal m o rta lity shall
b e calcu lated b y in c lu d in g all in fa n ts w h o w e ig h 5 0 0 g. or
Viability.
PROF. JENNETT, p r o f . p l u m : REFERENCES—
continued
11. K rctschm er, E. Zbl. ges. N em ol. Psychiat. 19*10,169, 57G.
12. G erstenbrand, F, in T h e Late Effects o f H ead Injuries (edited by
A. I'. W alker, \V. t \ Caveness, and M . C ritchley); p . 340.
Springfield, Illinois, 1969.
13. Jellinacr, K ., Sciielbcrger, F. ibid. p. 16S.
14. G erstenbrand, F. D as T raum atische Appallische Syndrom . V ienna,
1967.
15. Ingvar, D . H . Arch. Psychiat. N ervK rankh. (in the press).
16. D olce, F ., F rom m , H . Scatid. J . Rehab. M ed. (in the press).
17. P lu m , F ., Posner, J. B. T h e D iagnosis o f Stupor and Coma. Phila­
delphia, 2nd ed. 1972.
18. Feldm an, M . H . Archs Neurol. 1971, 25, 501.
19. V apalahti, M ., T ro u p p , II. Hr. nud. J . 1971, iii, 404.
20. Fischgold, H ., M athis, P, Electrocnccph. din. Neurophysiol. 1959,
suppl. 11.
21. l^ancet, 1971, ii, 590.
22. ib id . 1970, ii, 915.
23. Jen n e tt, B. ibid. p. 1249.
JL-
6th September
SLP/JT.
Tour Bef* WJR/CT/AED.
V.J. Hobson,
F.B.C.S. Consultant - A.E.D*
Royal Liverpool Childrens Hospital,
Alderhey,
Eaton Road,
Liverpool. L12 2AP.
Dear Br. Robson,
Thank you very much for your letter of the 1st of September,
the contents of which I h a w noted.
I think it would be very helpful if I could see a copy of
the booklet which you are preparing. This sounds a very
interesting idea and al#it well be of use in other situations
as well.
Tours sincerely,
S.L.Popper,
H.K.Coroner,
89.
LIVERPOOL HEALTH A U T H O R IT Y
ROYAL LIVERPOOL CHILDRENS HOSPITAL
ALDER HEY
Eaton Road, Liverpool
L12 2AP
Telephone: 051-228 4811
Ref:
Our Ref:
W J R /C T /A E D
If telephoning please ask fo r:E X T . 2 2 6 1
1st September, 1989
Dr. S. L. Popper,
Coroner,
Medico-Legal Centre,
Watery Street,
Sheffield,
S3 7ET
Dear Dr. Popper,
Thank you for your helpful letter of the 16th August which I received on
return from leave today.
There have been several developments since my
letter of the 27th July.
The situation about the report displayed in a library was clarified to me by
one of the parents. As you point out, this has now been withdrawn.
Several of the post mortem reports which you sent to solicitors have been
photocopied and sent to relatives for the purpose of bereavement counselling.
I have found this situation satisfactory and therefore now require no personal
copies of post mortem reports.
Following a request from social workers and parents I am preparing a glossary
of medical terms which are commonly used in post mortem reports. I do not
think this will interfere with any potential legal proceedings. However, if
you wish to have a copy before the booklet is distributed to social workers
and relatives please contact me as soon as possible.
Yours sincerely,
W.Uj. ROBSON, F .R .C .S .,
Consultant - A.E.D.
J
JMJ/VSC
1 S e p t e m b e r 1989
'
Dea r Mr- and Mrs lUand
It is w i t h o b v i o u s regret that J h a v e - '
d i s t r e s s i n g circumstances i n w hi ch yc
the o u ts e t,
s a y t h a t you h a v e my
to te
■
- r i t e to you a b o u t the very
son Tony presently is* Can T a t
sympathies at this difficult time.
-T'hp. r,,.pTOcfl o f rriV w r i t i n g l a t o c j a r i f y t h e r o i e ,of t h e West M i d l a n d s
P o l i c e and i n p i r t i c i l a r my p r e ^ n a i j n v o l v e m e n t i n a -r e c e n t d i s c u s s i o n
vn t h Her M a j e s t y ' s C o r o n e r a t / h e f f i e l d .
l do
a misunderstanding as to my ^nvolversent and T
^ou
uuea a
e x p ] anation.
"
‘
H-,r> r n r n n e r Dh P o p o e r , made c o n t a c t w i t h me and a s a r e s u l t 1 •
h ad V number"of d i s c u s / i o n s w i t h him i n c l u d i n g a v i s i t
Tn.yrsaay ^
a.
j „u m 1 ‘o h i s Office/in Sheffield*
The C o r o n e r was c o n c e r n s
a
t e l e p h o n e c o n v e r s a t i o n he had had w i t h t h e s p e c i a l i s t l o o R i r ^ a ^ e r
T o n y ' s m e d i c a l c a s e , Dr Howe. It was toe v iew oi u.ie oo, o n , i
r
c i r c u m s t a n c e s d e s c r i b e d by Dr Howe and a c o n s i d e r e d C ° u r ^ o t ^ i u n , d i
nn< a c a u a i n t w i t h t h e rftles a s t h e y a r e presently u n d e , o c a .
Wdtui a y»
a s ^I arc a c t ing a s h i s k r o n e r ' s O f f i c e r , t h e c o r o n e r d i s c u s s e d this
1e l e p h o n e c o n v e r s a t i o n with rae.
I a g r e e d w u n t n e - u o r o n e r tna- *.ie _
m ^ d i r a l management o f y o u r s o n was a m a t t e r f o r Dr Howe anu .w s medJ<-edl.
nu a i i ^ i e - d ' t o l l e a g u e s and t h a t i n d i s c h a r g i n g t h a t prcu e s » i o n « ^ » o l e . 5 1
would*1>e /appropriate f o r him t o comply w i t h t h e r u l e s .
Follow !ng .h a t
conversation I do know t h a t t h e C o r o n e r wrote t o Dr Howe making at q | H e
c l e a r t h a t he ha d a d u t y t o re m i n d Dr Howe o f t h e c o n d i t i o n s urn ^
m e d i c a l a nd c a r i n g r e s p o n s i b i l i t i e s s h o u l d be d i s c h a r g e d - H o w e v e r t h e
rorcsnor is n o t , n o r l i k e l y t o b e , in a position t o know a l l t h e
c i J c u m s t a n c e s a n d , t h e r e f o r e , it was a
m a t t e r f o r Dr Howe
s i m i l a r l y 1 am not o b v i o u s l y m e d i c a l l y
q u a l i f i e d n o r am I a w a r e lof
t h e c ir c u m s t a n c e s s u r r o u n d i n g Tony’ s p r e s e n t medical
history? I , _
/ t h e r e f o r e , c a n n o t and did n o t g i v e any
d i r e c t i o n s to .,he
-i
' Howe on how t o manage t h i s c o s e
Cc
v n -)
c s -y
;
-
:
i/fiD M ir
p— i
Th L
1 h a v e s i n c e t e l e p h o n e d t h e C o r o n e r t o d a y and advised him of' y o u r v e r y
o b v i o u s c o n c e r n , e s p e c i a l l y a s 1 am g i v e n t o u n d e r ' s l a n d that you b e l i e v e
t h a t i t i s my di r e c t l o n w h i c h h a s influenced Dryflowe, As j h a v e a l r e a d y
I n d i c a t e d t h i s i s n o t t h e c a s e a l l I c a n s a v / ' a n d ha ve a d u t y t o do s o ,
3s t h a t p e r s o n s m ust s t a y w i t h i n t h e law, /The C o r o n e r i s of t h e same
o p i n i o n and t h a t if; t h e l i m i t o f hi a a d v i c e .
As a r e s u l t o f o u r
t e l e p h o n e c o n v e r s a t i o n t h e C o r o n e r inUffidy l o s a k e e a r l y contactwith Dr
Howe w i t h a s u g g e s t i o n t h a t t h e l a t t e r c l a r i f i e s w i t h you e x a c t l y t h e
p osition.
1 am v e r y s o r r y t h a t t h i s i s ob/iously a d d i n g l o y o u r distress, b u t I am
s u r e you w i l l a g r e e t h a t w h a t e v e r we do we a l l h a v e a d u t y t o comply w i t h
t h e la w o f t h e l a n d .
Thus y d riot t o m i n i m i s e i n a ny way our- s i n c e r e
c o n c e r n and s y mp at hy for tjae d i s t r e s s i n g p o s i t i o n w h i c h you and Mrs B la nd
p r e s e n t l y occupy.
I t h i n l f t h e way i n w h i c h my officers ha v e c o n d u c t e d
t h i s w i t h you h a s d e m o n s t r a t e d c l e a r ' intent on o u r d e s i r e t o h e l p you a s
much a s we p o s s i b l y cab".
i o u r
sincerely
A s s i s t a n t Chief C o n s t a b l e
(H illsb o ro u g h Inqui r y )
ira rn
^
a /\ r~ UJ/£#JiJtJ W—*
A 4 ^ t^
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t, k / y
U J P tn c P
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D ear Dr Howe,
I r e f e r t o my c o n v e r s a t i o n s w i t h you s£|©ttt /
, ®San<i wh° I u n d e r s t a n d
from you i s i n a v e g e t a t i v e s t a t e b u t a o t
You i n d i c a t e d
t o me t h a t i n y o u r v i e w an<^
t h e r e was no h o p e o f r e c o v e r y f o r t h i s
cir c u m sta n c e s e f f o r t s to p ro lo n g l i f t
.-P^-
c o n su lta n t c o lle a g u e s
an(* it: w as
t ^ie
ft ab an d on ed and t h a t h e
tf
I u n d e r s t o o d from you t h a t
s h o u l d be a l l o w e d t o p a s s away p eacefu l'-*
h i s f a m i l y w e r e i n a g r e e m e n t w i t h y o u 1* ^ 3
i@ p r o p o s e d m an agem en t.
£ > c ^ (L
i s proposed t o d is c o n t in u e
I n t h i s c o n n e c t i o n you m e n t io n e d t l # t ? >
i w a t e r w h i c h I p resu m e
m e d i c a l t r e a t m e n t and a l s o t o w i t h # * #
is
# or p o s s ib ly in tr a v e n o u sly .
i n f a c t b e i n g s u p p l i e d by n a s o g i w t f * ^
You c o n t a c t e d me i n o r d e r t o o b t a i n
A
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I e x p l a i n e d t o you t h a t I
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v i e w s on y o u r p r o p o s e d a c t i o n .
U ~ t
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“ # j u r i s d i c t i o n o v r an y l i v i n g
a s c o r c f n®r
my j u r i s d i c t i o n wc|m W C®
th ft.ca ssf w ere t r a n s f e r r e d
t© me) o n l y when t h e y o u n g man was
I d i d h o w e v e r s a y t h a t i n my
vimt
propose#- ©ftifse of c o n d u c t w as
w h ich I c o u ld n o t ap prove a n i
J f e l t t h a t y o u w e r e e x p o s i n g y<
t o a v e r y s e r i o u s r i s k o f c ^ a d o a f t . U t i l i t y , I s u g g e s t e d t h a t b e f o r e you
' .|
u n d e r t o o k an y s t e p s you s h o u l d OOftisia f l e a r l e g a l a d v i c e and t h a t i n any
c a s e I n e it h e r co u ld condone o r
your su g g e ste d c o u r se o f co n d u c t.
'
In
a l a t e r c o n v e r s a t i o n w i t h yi% y e s t e r d a y y o u c o n f i r m e d t h a t you w o u ld
n o t t a k e axj^of t h e s t e p s metet$OBja4 * # £ e p t t h a t i t w as y o u r i n t e n t i o n
n o t t o a d m in ster a n t i b i o t i c t a e r ^ y .
I h a v e s i n c e had an o p p o r
i t w i t h s e n i o r members o f
t o e p n s i d e r t h e m a t t e r f u r t h e r (a n d d i s c u s s
. M id lan d P o l i c e who a r e e n g a g e d i n t h e
H i l l s b o r o u g h d i s a s t e r enqu
I n t h e l i g h t o f t h e s e d i s c i i p s i # ^ : . I am now w r i t i n g t o y ou t o c o n f i r m t h a t
s tr ic tly
I a s c o r o n e r am n o t i n v o l v e d i n t h i s m a t t e r u n t i l t h e d e a t h h a s
L
b e e n r e p o r t e d t o me. However a s i t h a s b e e n r a i s e d w i t h me and
t h a t i t h a s s e r i o u s i m p l i c a t i o n s b oth e t h i c a l l y
I co n sid er
a n ^ l e g a l l y I m u st a g a i n
make i t i d e a r t h a t I c a n n o t c o u n t e n a n c e condone a p p r o v e o r g i v e c o n s e n t t o
an y ‘a c t i o n o r i n a c t i o n w h i c h c o u l d b e o r c o u ld b e c o n t r u e d a s b e i n g d e s i g n e d
o r i n t e n t e d t o s h o r t e n o r t e r m i n a t e t ’t t# l i ^ *
t h i s young man. T h i s p a r t i c u l a r l y
a p p l i e s t o t h e w i t h h o l d i n g o f t h e n e c c a s itfA ® ’® ° f l i f e
s u c h a s f o o d and d r i n k
c l o t h i n g and warmth ( a n d , on r e f lectio# fftis i n c l u d e s m e d i c a l c a r e
i n c l u d e a n t i b i o t i c c o v e r w h e r e n ece
I w o u ld b e g r a t e f u l i f
th a t t h is i s
wefiiy
you w o u ld p l s t s e f
u n d e r s t o o d and t h a t no
by r e t u r n and c o n f i r m
styfch a c t i v i t y
or i n a c t i v i t y w i l l
be u n d e r t a k e n i n r e l a t i o n t o t h i s pgttiltfttt-
I am a w a r e t h a t t h e r e a r e o c c a s i o n s
p eo p le a r e te r m in a lly i l l
say
from c a n c e r t h a t a c l i n i c a l d e c i s i o n / . >wy b e t a k e n n o t t o s e e k t o p r o l o n g
life
by h e r o i c m e d i c a l i n t e r v e n t i o n fatod
t h i s may i n c l u d e t h e w i t h h o l d i n g
o f say a n t i b i o t i c d ru gs.
I
f
p r o b le m i n t h i s c a s e i s t h a t g l l t h o u g h t h i s y ou ng man may b e s e v e r e l y
b r a i n damaged i t i s - c l e a r from w | t o t you s a i d t h a t h e i s
n o t b r a i n dead
and indeed may not be termnallyj ill in the c o n v e n t i o n a l i s m s ^ ^
"1 'Sett ' i i t ' i w i # :4 i | ? f l e n i t y - t e I h a v # n e v e r
f o r h i s c l i n i c a l management and i^n any c a s e h a v e no j u r i s a i l T i
n o t d e a d . However i t m u st b e a p p a r e n t t h a t t h e r e m u st be a d i f f e r e n c e i f
h e d i e s a s a r e s u l t o f s a y l i f p o # i e b r a i n damage o r i f
tr *
1
.- . .
o f some "new a c t " im p le m e n te d t j e c j u s e i t
and q u a l i t y o f l i f e
a r e s u c h h<
You w i l l a l s o a p p r e c i a t e t h a t
he d ie s a s a r e s u l t
f
2
is
th o u g h t t h a t h i s p r o g n o sis
m ig h t be b e t t e r d ea d t h a n a l i v e .
any c l i n i c a l d e c i s i o n s w h ic h y ou may t a k e
a r e o f c o u r s e y o u r s o l e r e s p o ^ s i ^ l l t y and y ou h a v e a l w a y s t o be i n a p o s i t i o n
t o d e f e n d them and t o show t h a t r.hey c o m p ly w i t h t h e la w o f t h i s l a n d .
I h a v e no d o u b t t h a t y o u r l e f f a t l i t d v i s o r s w i l l be a b l e t o g u i d e y o u f u r t h e r
in t h i s m a tter.
I th in k t h a t I m igh t j u s t B f f n t i o a t h a t i f
y ou f e e l t h a t you n e e d c l a r i f i a t i o n
o f t h e l e g a l p o s i t i o n w i t h r^ egard t o an y o r a l l o f y o u r p r o p o s e d a c t i o n s
t h i h i t m i g h t be w o r th a s k i ng jdjfiS l e g a l a d v i s o r s w h e t h e r i t w o u ld b e p o s s i b l e
t o make an a p p l i c a t i o n t o t ; h e t h e H ig h C o u r t f o r d i r e c t i o n s and g u i d a n c e .
J
y
W
6* ^
C y v U fiA .
*
2
f/r v o -,
(J & M
o
/
L
*r, TjZ*
fi-b
/y
*
u
t
AIREDALE HEALTH AUTHORITY
TELEPHONE: STEETON 52511
Your Ref:
Airedale General Hospital
Skipton Road
Telephone enquirie*on this
Our Ref:
matter shoultf be made to
JGH/JPS
Steeton
Keighley
.Mrs..J.. Stafford
West Yorkshire
BD20 6TD
Ext
460
Dr S L Popper
HM Coroner
Medical Legal Centre
Watery Street
SHEFFIELD
S3 7ES
23 August 1989
Dear Dr Popper
ANTHONY DAVID BLAND - DOB 21.09.70
AT PRESENT ON WARD 3, AIREDALE GENERAL HOSPITAL
Thank you for your very full and frank conversation today.
In view of what you told me about the police attitude, we have not withdrawn
artificial feeding in the unfortunate patient we discussed.
Please find enclosed photocopies of two articles about persistent vegetative
state after brain damage. The article from the Lancet in 1972 was the first
thorough description of the syndrome and a proposal for a satisfactory name,
which is now widely used. The second article is a statement of the American
Academy of Neurology's attitude to the care and management of patients with
persistent vegetative state and it is an attitude which I, myself, would want
for me or my family or any patients with whom I am in contact.
Our patient's family were satisfied that there had been no sign of improvement
and feel very strongly that prolonging this boy's life by artificial feeding is
no longer justifiable. They do not, however, want to see me get into trouble
over it and so they are prepared to continue seeing him being fed but do not
wish us to treat any infections, should they arise.
I would be interested to hear your comments on the American Neurologists'
statement and would also be interested to hear what the local police think
about it as well. This is an important and distressing subject and it would be
helpful if there were clear guidelines to help doctors and relatives deal with
the problem.
I look forward to hearing from you in the near future.
Thank you once again.
Kind regards
Yours sincerely
J G HOWE
C o n s u lta n t
P h y s ic ia n
FILE NOTE
1.9.89
Dr. Howe rang me at Q.M.C. I thanked him for calling.
I explained to
him that we were disturbed because apparently the Blands were blaming
the police for the fact that care of their son was proceeding.
Dr.
Howe said that he was very sorry about this.
He had tried to make"it
clear to them that this was not in fact a police initiated action but
that he obviously had not succeeded in putting this accross.
He would
try and see the Blands again and make it absolutely clear
that this did
not arise, or was not the fault of the police.
I repeated to Dr. Howe that one of the prime motovating factors had
been that we, I was very concerned that he should not imperil hims e l f
by undertaking or failing to undertake any actions which could lay him
open to legal process or even the Blands.
I pointed out that the
situation was bad enough, that it would be infinet|?y worse if such
consequences were to flow, Dr. Howe entirley agreed.
Dr. Howe confirmed that he fully understood the reason for the points
which I had made, that he had received my letter and that he had
replied to it.
He also mentioned that he understood that the Blands had been advised
that they perhaps should make their lad a Ward of Court and that they
might apply to the court in order to force him to take certain actions.
I said that this was obviously something which they would have to
nsider for themselves,
Isaid that this was one of the reasons I had
ntioned in my letter that he might like to consider making application
for directions if he thought it was appropriate.
f
I expressed to him how much we felt for him and for the family in this
terrible situation in which they find themselves , but that ......... we
were very concerned that nothing should be done which could fall foul
of English Law.
He asked me if I had any views on the AmericanMarologists
position and I explained
that I was not in a position to comment on
that with all the circumstances.
He said he quite understood that.
We left it that he would go and ss the Blands in the evening and try
and make it clear that the police would not be blamed for this.
He
did in passing mention that the Blands on the whole blamed the police
anyway for the whole disaster and that this might be some of the reasoning.
He also indicated that on the whole they hads*tT been a very remarkable
family with very little i n In i t n I .
m m worn
24.8.89, u r n ® ® convehsation with me. p.r. csaggs,
om OF 111 SOLIOITOIS
II 111 y q m b b i h regional health authority.
I asked whether lie had spoken to Mr. Howe.
He said no, tut
he was one of the solicitors. I «q>lained that we were sending
a copy of our letter to Mr. Howe because the actsawhich he is
proposing with regard to other patients was not* 1 wasn't happy with.
I said that Mr. Howe said that he had spoken to the Health Authority
hut that 1 felt that although this could he construed as a medical
prohieinrl *1tfeerogfalitit•was, raiher+toea!e:Jhsn that if the patient was
in one of their hospitals.
He asked if I would sent the letter to Mr. R.H.D. Chapman, Regional
Solicitor, Yorkshire Regional Health Authority, Windsor House,
Cornwell Road, Harrogate HG1 2W,
H I S HOXB BAUD 2 4 .8 .8 9 . TEIUIHQSB CONVERSATIOH WITH MR. TURNBULL AT 9.44».m .
AEffiOXIMilELY.
...... ................... ...... ...................
I asked Mm what had transpired between Mm and Dr. Howe.
He
said Dr. Howe had spoken to him about 3 weeks ago and inquired
what th e position would be if this man was switched off.
Mr.
Turnbull had been under the impression, wrightly or wrongly,
that t M s man was brain dead.
He had explained to Mr. Howe
that in the circumstances of tMs being a Hillsborough case,
he would wxpect me to take tMs case over and in those circumstances,
Mr. Turnbull would go along with aoytMng wMch I agreed with.
Mr. Turnbull made it quite clear that he had not understood
that t M s man was not brain dead and he would have taken a
different line if that had been in M s perception.
He also
said that Mr. Howe said that he was going to deal with the
matter when he returned from M s holiday wMch Jim found a
little surprising if in fact the man was brain dead, that he
had made no further comment on it.
n a
IQfS BfflB 54.8.89. fSEBMOii CONVERSATION WIfl M R . B M M f Til M.P.S
Hr. Barker apparently had been a coroner in Dr. Price’s area in
London until he transferred to the M.P.S.
I said that I was
ringing because I was sending him^a copy of the letter to Dr. Howe,
one of his members. I wasn*t quite sure whether Dr. Howe had been
in touch but I felt it was important that a copy of the letter should
go to them.
I explained briefly the situation and I said that obviously
it was a matter for them, but no doubt they would want to consider
what advice if any they gave to Dr. Howe.
for getting in touch with him.
Hr. Barker thanked me
I explained that I was ringing so
that when the letter arrived in the morning there would be somebody
who would have some idea as to why it was sent, particular as I
did not know who Dr. Howe might or might not have contacted.
He. Barkea^aentioned that he had been one of the doctors supporting
a Dr/Handy^in the case in Derbyshire and that in that case quite
a loxHaSbeen made of the question of feeding and not feeding
the infant.
He mentioned that treatment of course was a matter
of clinical judgement but food and water was perhaps in a slightly
different class. I explained that I was not really in a position
to sake any comment on this, and that I felt perhaps in this case
even medical care should be maintained (see letter).
He felt
that it was obviously inappropriate for me to seek to give
advice on management apart from the sort of advice which I had
giTen such as to get in touch with the Defence Organisation.
He also could see the point that my jurisdiction did not arise
until after whoever was concerned was dead.
FILE NOTE
23.8.89
Telephone conversation with M r . J. Tyson of Linskills ______________
I queried his reference to Legal Aid for the inquest, I said that I
wasn't aware that this was available.
He said they had Legal Aid for
civil proceedings and he felt this covered getting information though
he realised it wouldn't cover him for attending the inquest.
I said it
was a matter entirely for him but I though I would just point it out.
FILE< NOTE
23.8.89
Telephone conversation with Dr. Howe, Airdale
ext. 460 (secretary extension).
Conversation at about 11.00 a.m.
Hospital 0535 5251
23.8.89 re: Mr. Bland.
Dr. Howe rang to say that this was a Hillsborough individual who had
unfortunatly suffered severe hypoxic brain damage.
He was in a
vegative state.
He opened and shut his eyes he appeared to sleep, he
grunted but there did not seem to be any
— activity and what
is more there was no hope of a recovery.
Dr. Howe said that in consultation with the family they felt that the
kindest thing would be to allow this you ngster to die and they were
therefore proposing to cease all active medical treatment and in
addition to stop giving him fluids and food.
He said he had spoken to Dr. Turnbull who had said that he should
speak to me.
I explained to Dr. Howe that my jurisdiction did not arise until a
person was dead but that I was not at all happy with what he was saying
that no way could I give my consent to it.
Further more I considered that he was laying himself open to considerable
risk.
He mentioned that this matter had been discussed in America and that
the consensus of the conference had been what they were proposing had
been both ethical and legal.
I still maintained that although it was strictly nothing to do with me bet:
because I had no jurisdiction, nevertheless I certainly could not agree
with it and I didn't and certainly would not authorise it.
He said
that he would consult with the Regional Health Authority Solicitor
and also his defence union, legal people
I thought would be very
advisable.
oUe*I said that I would be meeting with somebody late in the day and perhaps
raise the point with them.
had a word with Malcolm from West Midlands Police and put the
to him, he entirely agreed with me that withholding his food and water
would lead the doctor open to various areas of charges.
I asked if he
would mention it to Mervyn and see if he had any different or alternative
views.
I felt that it was a dangerous pgesiTTSTtt it this was permissable and— eou-ld
cans.Q al 1. -e n d . I was not very happy with i t .
I telephoned Dr. Howe back at about 12.30 and explained to him that I
had spoken with the West Midlands Police and their view was that
withholding food and water was definitly going too far and would lay
him open to serious charges.
He expressed a little bit of surprise at
this view but he was grateful that I had rung and told him.
He said
that %5e-y would not do anything other that the withholding of active
medical treatment e.g. antibiotics.
In the meantime he had already
spoken to the regional solicitor who wasn't much help but he would
get in touch with his Medical Protection Society to get their advice.
He would also send me a copy of the article.
I t o l d h i m i t was q u i t e p o s s i b l e t h a t Mr. Jones or s o m e b o d y f r o m West
Midlands w o u l d w a n t t o g e t i n t o u c h w i t h h i m .
He s a i d h e w o u l d
Wellcome
it
so
that
it
could
be
discussed.
FILE NOTE
23.8.89
TELEPHONE CONVERSATION WITH DR. HOWE, AIRDALE HOSPITAL
I spoke to him and explained to him that I was writing him a fairley
firm letter in which I was reiterating my advice and that on reflection
I was very doubtful whether even the goal of antibiotics was
appropriate.
I said I would be grateful if he would take no steps
whatever of the nature which he discussed with me certainly until
he had seen my letter and even then, I didn't think that he should
do i t . My very strong advice was that he should not embark upon
the course of conduct which he had suggested as I thought he was
laying himself open to very serious criminal charges.
He mentioned that he was posting the document from America to me,
where they had seemed to have sorted things out.
I pointed out
that their legal system was different.
That the States varied
amongst themselves.
That their decisions were only persuasive and
that we were bound by what happened here.
I said that I realised
that he was motivated by wanting to help the lad.
He said it wasn't
even so much the lad but the family, as the lad was beyond help.
I said that I would send copies to the Medical Protection Society,
the Area Health Authority Solicitor who I had understood him to say
had not been very helpful.
He agreed with this and he also agreed
with me when I said that I thought that the Area Health Authority
ought perhaps to take an interest . He said he had not yet spoken
to the M.P.S. because having decided to take no steps, he didn't
see any need to consult them.
I said I thought it would be a good
idea if he did.
The meeting was arranged in order to discuss the problem arising
out of Hr. Howe’s approach to me regarding the management of
Mr. Bland, a patient of Ms at Airdale Hospital, who had been
seriously brain damaged as the result of the Hillsborough Disaster.
I explained that Dr. Howe had contacted me yesterday. That I was
aware that there was a patient up there because I had been informed
by Vest Midlands of this some time agat I assumed that he would
inform me that tMs patient had died.
In fact what he told me was that the patient was severely brain
damaged but not brain dead but that there was no hope of
recovery for Mm. That he had, inconsultation with the family,
felt that the proper course was to discontinue therapy and that
he was proposing to not feed or water tMs young man, so that
eventually he would die.
I formed the impression that Dr. Howe was motivated by compassion
for the family and for the young man. I explained from my
experience in hospitals that it was quite likely that the iMtiatlve
had come from Dr. Howe but that he would have tried to carry
the family with M m before embarking upon any unusual course.
I did say from m y experience that occasionally it happened that
if the families were anxious, the treatment should not be unnecessarily
prolonged in order to reduce the amount of suffering of the loved one.
I also told themthat I checked with Mr. Turnbull. He had In fact
spoken to Sr. Howe some three weeks previous and he had understood
Dr. Howe to say that the patient was brain dead, but he did concede
that he mi^it have misunderstood him. He agreed with me that if
he was not brain dead tMs completely changed the situation. He also
said that what he had told Sr. H
owe was that on the assumption that
he was brain dead, he would go along with whatever would be the
right tMng to do.
W
e discussed the matter at some length. In particular we raised
a question whether if the initiative had arisen from the family
whether there could be some ulterior motive.
I felt that it was quite possible the family would want to reduce
the suffering of their son and also that tMs would also reduce
their own distress 'as finality sometimes was a good tMng..
(Mr. Jones in fact suggested the latter point). On the other hand
I did not think that there would be any financial advantage as it
was likely that from the point of view of recovering damages ( assuming
of course that damages were recoverable), the young manwas probably
worth more alive than dead because of the various costs, looking
after Mmetc.
We spent some time discussing the question of whether tMs could
possibly be a conspiracy and in particular whether the fact that he
had discussed the matterwith me and Mr. Turnbull and the fiegional Solicitor
I pointed towards a conspiracy as opposed to it,
I had felt
from
innoceftt one.
the word go that the
inquirant Dr. Howe was
a
perfectly
That he was trying to sort out the medical, legal and
ethical issues involved with this case.
That he was testing the
waters and sounding out opinions and that I really didn't think
there was very much criminality in the matter except possibly in
the very theoretical way that if he had used the word proposed,
one had to decide whether in fact that was equivalent so to speak
to an attempt.
I didn't feel that this would cut very much ice
with a Jury and doubted very much whether a conviction could be
obtained, particularly as I had truthfully had to say that I could
not remember the precise form of wording which he used and my
impression was that he was telling me what he was intending me to
do and awaiting to hear my reaction.
Mr. Beechey particularly felt that generally speaking, with conspiracies,
matters *were kept quiet whereas in this particular case, it was perfectly
plaon that Dr. Howe was discussing the matter widely.
This of course
had the advantage that he was covering himself and obtaining some
sort of assurance or insurance regarding his conduct but on the other hand
it also pointed against any possibility
of conspiracy.
On balance we felt that this matter didnot really give rise to criminal
aspects provided of course that nothing untoward was done with
regard to the management of the young man.
We discussed the question of medical treatment briefly, but this aspect
of it is very difficult because of course we haven't got his day
to day management nor ever seen Mm, as I have stated inmy letter.
We discussed whether the North Yorkshire Force should be involved
and in the end decided that we would be best dealing with that aspect
of the matter if once I had written to West Midlands, they would write
to North Yorkshire to keep them informed, bearing in mind that this
issue is within their jurisdiction or area.
We also discussed whether I should get in touch with the Regional
Solicitor and Dr. Howe.
We felt that this might be a good thing
and /^?^ic^itri&ious that Dr. Howe should know that the letter
was coming because I had no wish to either upset or offend him.
We then discussed the letter.
A few modifications were made to it
in the li$it of the discussion, and the meeting then broke up.
24th A'agast
SXP/JT.
Me. J, Ifceffn «r<onesf
Aeaisvmt
Constable*
West Ki&lan&s &Oioa HQ,
P.O. Box 52,
lloyi Honse*
Solffio®® OpXettBI QliaeilfRISy*
' Bear
J t e r f p i , ,
1
f- ►<*
►V-ank you far ©isnAiisg Wti?'1© a»£fI#II vltb
m
l nr*
.. il#®
.**.cii®jf <»o &Laoiiaa
.?&
# ^*.
yoTO? coilsssofi
isse sa&tMHf m u o n Baa
<defc*% ^
Hi«» !■
flag
®lU-4Sk J S *4
■*gr*f-
-rr~
«Sr ifflTi Je MbM&i
©’.
re of this pat&tixit who was apparently aaKiowaly SjajweS
at HUlshoxoii^^-*
I 4© not ttrtaik tb*» is any n*»A for as to septat tba facts
of the matters aw 1 know you are folly « « e ©f the*, teat
we aid h a m a u w y full ttfsmasloa regtoaing tbs aattasr.
It It e w t e l ^ r v t ^» 88i© » tlmt Dr. Bow® was awtimttii
ly1ttS''ii#n©<Ke» foe **m»sfamily
patient*
.........
I enclose * copy of the letter which I have seat to him,
and tiMel. X tMafc Atala ulth the issues vhioii ha tall
raised utth, * ami niiiett «e tteewwiet, It follows
sttosfi&maily tna ilrwrt %»M.ea w s Before us at the neeting*
...
— - ._ J8L Sh
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%l^f.in
low s aizko«c«3yv
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’BQjt.m-.Irr_n■p»L«a%
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***-«■ ---- -- ,JL
iffiinmil imi
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-**• ag *«a*. jsbi
S&^Sk JH
F l U HOIS M E D 23.8.89.
at a o m m 10 past 5.
TEESPH01E CONVERSATION WITH MSRfYl JONES
He said he was concerned about the conversation I had had with Dr. Howe.
He thought it was absolutely essential that I write to Dr. Howe and
make it clear that his proposed actions were not acceptable. He thought
this was necessary both to protect myself and also themselves.
wanted a copy of this letter.
He
He felt that if we had to ask for
confirmation in writing from Dr. Howe and this was not forthcoming
that one would have to take it up with the Health Authority etc.
I subsequently rang Mervyn again and had a further discussion with him.
He said that he had had a long talk with some of his colleagues
and they were very worried about it, though everything depended on
the precise form of wording which Dr. Howe had used.
In the end
he felt that the best thing would be if we met to-morrow at Sheffield
to discuss all the aspects and also decide what form the letter should
take.
I agreed to meet with him at 9.30.
I tried to ring Jim Turnbull but he was out.
be available at 9 in the morning.
Apparently he would