Hungering and Thirsting After Righteousness:
Providing Nutrition and Hydration to Patients in the Persistent Vegetative State -- Moving Beyond the Problems Toward a Christian Response


Endnotes:

1 Crisci C. The Ultimate Curse. Journal of Medical Ethics 1995; 21: 277. [Back]

2 Jennett B and Plum F. Persistent vegetative state after brain damage: A syndrome in search of a name. Lancet. 1972, 1 ;7753:734-737. (The syndrome is also referred to as the chronic vegetative state or the permanent vegetative state. In 1976, this relatively newly identified syndrome engendered all kinds of wild speculation as to whether we now could keep patients "alive forever". Part of the confusion is a simple failure to accurately assess the medical realities of the case. No one can be alive "forever" with the technology extant in 1976 or today.) [Back]

3 Rappaport M, Dougherty A M, Kelting, D L. Evaluation of coma and vegetative states. Arch Phys Med Rehabil, 1992, 73; 7: 628-634. [Back]

4 The permanent vegetative state. Review by a working group convened by the Royal College of Physicians, J Royal Coll Physicians London, March/April, 30;2, 1996. [Back]

5 Andrews K. The vegetative state -- background and ethics, JR Social Med 1997, 90: 593-96. [Back]

6 The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state. NEJM. 1994, 330: 1499-1508. [Back]

7 Ibid. [Back]

8 Cruzan v. Director [Back]

9 Ibid. [Back]

10 Smith DR. Legal recognition of neocortical death. 1986. Cornell Law Rev 71: 850-858. [Back]

11 Rae S. Moral Choices: An Introduction to Ethics, 1995, Grand Rapids, MI: Zondervan 175. [Back]

|2 U.S. Catholic Bishop's Committee for Pro-life Activities. "Nutrition and hydration: moral and pastoral reflections", National Conference of Catholic Bishops Secretariat for Pro-Life Activities, Washington DC, 1992. [Back]

|3 The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state. NEJM. 1994, 330: 1499-1508. [Back]

14 Ibid. [Back]

15 Andrews K, Murphy, L, Munday R, Littlewood C. "Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit". British Medical Journal, 1996; 313: 13-16. [Back]

16 Ibid. [Back]

17 Ibid. [Back]

18 Jennett B and Plum F. "Persistent vegetative state after brain damage: A syndrome in search of a name". Lancet. 1972, 1; 7753: 734-737. [Back]

19 Andrews K, Murphy, L, Munday R, Littlewood C. "Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit". British Medical Journal, 1996; 313: 13-16. [Back]

20 The Permanent vegetative state. Review by a working group convened by the Royal College of Physicians, J Royal Coll Physicians of London, 30;2, March/April, 1996. [Back]

21 Kennard C, Illingworth R. Persistent vegetative state (Editorial) Neurosurgery and Psychiatry, 1995, 59;4: 347-348. [Back]

22 Wilson S, et al. Constructing arousal profiles for vegetative state patients -- a preliminary report. Brain Injury, 5, 1991: 393-400. [Back]

23 Pilon M, Sullivan S. Motor profile of patients in minimally responsive and persistent vegetative states. Brain Injury, 1996, 10; 6: 421-437. [Back]

24 Childs N, Mercer W. Brief Report: Late improvement in consciousness after past-traumatic vegetative states, NEJM, 1996, Jan 4, 334; 1: 24-25. [Back]

25 Andrews K, Murphy, L, Munday R, Littlewood C. "Misdiagnosis of the vegetative state: Retrospective study in a rehabilitation unit". British Medical Journal, 1996; 313: 13-16. [Back]

26 Horton S. Persistent vegetative state: What decides the cut-off point? Intensive and Critical Care Nursing. Feb 1996, 12; 1: 40-44. [Back]

27 "The persistence of mind". (Editorial) Lancet, July 13, 1996, 348; 9020:69. [Back]

28 Kinney H et al. Neuropathological findings in the brain of Karen Ann Quinlan-the role of the thalamus in the persistent vegetative state. NEJM, 1994, 330; 1469:75. [Back]

29 McLellan DR, et al In Papo I, Cohadon F, Massaroti M, eds. Traumatic coma. Padova: Liviana Editrice, 1986: 165-85. [Back]

30 Kinney HC, Samuel MA. Neuropathology of the persistent vegetative state -- a review. J Neuropathol Exp Neurol. 1994; 53: 548-58. [Back]

31 Adams JH, et al. The Neuropathology of the vegetative state after head injury (source 1999). [Back]

32 Adams JH, et al. The neuropathology of the vegetative state after an acute brain insult. Brain, 2000; 123: 1327-1338. [Back]

33 Ibid. [Back]

34 Zeman A. Persistent vegetative state. Lancet, 1997; 350: 795-99. [Back]

35 Levy DE, Sidtis, JJ, Rottenberg DA. Differences in cerebral blood flow and glucose utilization in vegetative versus locked-in patients. Ann Neurol 1987; 22: 673-82. [Back]

36 Andrews K. Vegetative state -- background and ethics. JR Soc Med. 1997; 90: 593-596. [Back]

37 Andrews K et al. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ 1996, 313: 13-16. [Back]

38 Ibid. [Back]

39 Childs, Mercer and Childs. Accuracy of diagnosis of persistent vegetative state. Neurology, 1993, 43, 1465-1467. [Back]

40 Giacino JT, Zasler ND. Outcome after severe traumatic brain injury: coma, vegetative state and the minimally responsive state. J Head Trauma Rehabil 1995; 10: 40-56. [Back]

41 Bernat JL. The boundaries of the persistent vegetative state. J Clin Ethics 1992; 3: 176-180. [Back]

42 The Multi society task force on PVS. Medical aspects of the persistent vegetative state. NEJM 1994; 330: 1572-9. [Back]

43 Wade DT, Johnston C. The permanent vegetative state: practical guidance on diagnosis and management. [Review] BMJ 1999; 319: 841-844. [Back]

44 Andrews K. Vegetative state -- background and ethics. J R Soc Med. 1997; 90: 593-596. [Back]

45 Ibid. [Back]

46 Andrews K. Prediction of recovery form post-traumatic vegetative state. Lancet. June 13, 1998, 351: 1751. [Back]

47 Whyte J, DiPasquale MC, Vaccaro M. Assessment of command -- following in minimally conscious brain injured pts. Arch Phys Med Rehabil, 80; June 1999: 653-660. [Back]

48 Gill-Thwaites H. The Sensory Modality Assessment Rehabilitation Technique (SMART) -- A tool for assessment and treatment of patients with severe brain injury in a vegetative state. Brain Injury. 1997, 11; 10: 723-734. [Back]

49 Ibid. [Back]

50 The Persistence of Mind. (Editorial), Lancet, July 13, 1996. 348; 9020: 69. [Back]

51 Jennett B. A quarter century of the vegetative state: an international perspective. J Head Trauma Rehabil 1997; 12: 1-12. [Back]

52 The Multi-society task force on PVS. Medical aspects of the persistent vegetative state. NEJM 1994; 330: 1572-9. [Back]

53 Andrews K. Prediction of recovery from post traumatic vegetative state. Lancet, June 13, 1998; 351: 1751. [Back]

54 Laureys S. Restoration of thalamocortical connectivity after recovery from persistent vegetative state. Lancet. May 20, 2000, 355, 1790-91. [Back]

55 Reider-Grosswasser I et al. CT findings in persistent vegetative state following blunt traumatic brain injury. Brain Injury, 1997; 11; 12: 865-870. [Back]

56 Rudolf J et al. Identification by positron emission tomography of neuronal loss in acute vegetative state. Lancet. Jan 8 2000; 355: 115-116. [Back]

57 Kampfl A et al.Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. Lancet, June 13, 1998; 351: (page number) [Back]

58 Zandbergen E, et al. Systematic review of early prediction of poor outcome in anoxic-ischemic coma. Lancet. 1998; 352: 1808-12.) [Back]

59 Randolph AG, Guyatt GH, Richardson WS. Prognosis in the intensive care unit: Finding accurate and useful estimates for counseling patients, Crit Care Med. 1998, 26; 4: 767-772. [Back]

60 Laureys S et al. PET scanning and neuronal loss in acute vegetative state (Correspondence) Lancet. May 20, 2000, 355: 1825-1826. [Back]

61 Plum F and Posner JB. The diagnosis of stupor and coma. 1983, Philadelphia: FA Davis. [Back]

62 Shewman DA, Holmes GL, Byrene PA. Consciousness in congenitally decorticate children: developmental vegetative state as self-fulfilling prophecy. Dev Med and Child Neurol. 1999, 42: 364-374. [Back]

63 Bjursten LM, Norrsell K, Norsell U. Behavioral repertory of cats without cerebral cortex from infancy. Experimental Brain Research. 1976, 25: 115-30. [Back]

64 Zafonte R, Watanbe T, Mann N. Case study -- Amantadine: a potential treatment for the minimally conscious state. Brain Injury. 1998, 12; 7: 617-621. [Back]

65 Piguet O, King AC and Harrison D. Assessment of minimally responsive patients: Clinical difficulties of single-case design. Brain Injury. 1999, 13; 10: 829-837. [Back]

66 In the Matter of Karen Quinlan, an Alleged Incompetent, 70 N.J. Super 227; 348 A. 2d. 801, 1976. Attorneys associated with the litigation characterized the social implications of the case luridly. In a coauthored reflection on the case, New Jersey's attorney general offered eerie images of hospital life and "phantom beings". He wrote, "Today in every hospital in the country, a shadowy community exists comprised of phantom beings tenaciously clinging to worldly existence. Sharing the attributes of both life and death, they form a new generic class of existence. The startling progress that has taken place in medical science and technology has obliterated the distinction between life and death and raised serious questions regarding the care and treatment of these unfortunate people." (Hyland and Baime 1976, "In re: Quinlan-- a Synthesis of Law and Medical Technology, Rutgers Camden Law Journal 37: 37-64.) One can hardly help being struck by the silliness of the exaggerated prose. The distinction between life and death has not been "obliterated". PVS patients are not "phantom beings", nor do they "share the attributes of both life and death" any more than any other very severely brain damaged person does. Perhaps some lawyers were undergraduate drama majors. [Back]

67 Stevens ML. The Quinlan Case Revisited: A History of the Cultural Politics of Medicine and the Law. Journal of Health Politics, Policy and Law, Summer 1996, 21;2: 347. Stevens views the Quinlan case as in part an unanticipated consequence of the 1968 redefinition of death (brain death), and views Quinlan's chief legacy as its offer to the medical profession of freedom from criminal prosecution when removing life support from patients in the persistent vegetative state. [Back]

68 Council for Scientific Affairs & Council on Ethical and Judicial Affairs, "Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support", Journal of the American Medical Association. 1986, 263; 3: 426-430. [Back]

69 Cruzan v. Director, Missouri Department of Health, 110 S. Ct. 2841 (1990). [Back]

70 Valko N. Analysis of Cruzan and Busalacchi Cases. Media Watch Network Notice. Pro-life Office, Missouri Nurses for Life, 8424 Knollwood, St. Louis Mo 63121. Jan 14, 1991. The cases of these PVS patients bear resemblance to Roe v. Wade and other landmark abortion cases in addition to their basis in the supposed "right to privacy". Norma McCorvey, the "Roe" in Roe v Wade claimed she had been raped and was pregnant as a result. Her case led to the legalization of abortion on demand. Years later, the full story came out that she made up the rape story, and that she indeed did have the baby. There was no public or media outrage that the landmark abortion case was based on a lie. Much the same situation occurred with the "right to die" cases of Nancy Cruzan and Christine Busalacchi. In the case of Nancy Cruzan, she apparently did take food by mouth after her accident (indicating that she might not have been in the PVS). She was married at the time of her accident. Her parents got court permission to dissolve her marriage and replace Nancy's husband as guardians. (Valko, 1991) As previously mentioned, Christine Busalacchi was not in the PVS. Therefore, these high profile cases are based on false information such as Roe v Wade. The legal system has shown a lack of ability to get to the facts of a medical case involving PVS. [Back]

71 In the Matter of Christine Busalacchi, Incompetent. Brief of the International Anti-Euthanasia Task Froce as Amicus Curiae. No. 73677. Supreme Court of Missouri On Remand to the Probate Court of St. Louis County. June 1992. [Back]

72 Cruzan v. Director, Missouri Department of Health, 110 S. Ct. 2841 (1990). [Back]

73 Uzych L. Advance Directives and the Critically Ill. Southern Medical Journal. 1991; 84: 540. [Back]

74 Valko N. Analysis of Cruzan and Busalacchi Cases. Media Watch Network Notice Pro-life Office, Missouri Nurses for Life, 8424 Knollwood, St. Louis Mo 63121. Jan 14, 1991. [Back]

75 Time. March 19, 1990. [Back]

76 St. Louis Post Dispatch, October 29, 1989, page 1A. [Back]

77 Kevin O'Rourke, a Dominican priest, and the director emeritus of the Center for Health Care Ethics at St. Louis University Medical Center, has been an advocate of withdrawing food and hydration from patients in the PVS. See "When Life Support Doesn't Help" St. Louis Post Dispatch, March 19, 1993. [Back]

78 Cranford RE. The vegetative and minimally conscious states: Ethical implications Geriatrics 1998; 53 (suppl 1): S70-S73. [Back]

79 Ibid. [Back]

80 The Aspen Neurobehavioral Conference Work Group. The minimally conscious state: diagnosis and prognosis. Neurology. 2002, 58. [Back]

81 Giacino et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002, 58: 349-353. [Back]

82 Bernat, JL Questions remaining about the minimally conscious state. Neurology 2002; 58: 337-338. [Back]

83 Strauss DJ et al. Life expectancy of children in vegetative and minimally conscious states. Pediatric Neurology. 2002, 23; 4: 312-319. [Back]

84 Coleman D. The minimally conscious state: definition and diagnostic criteria. (Letter) Neurology. 2002; 58: 506-507. [Back]

85 Nelson LJ, Cranford RE. Michael Marin and Robert Wendland: beyond the vegetative state. J Contemp health law Policy 1999; 15; 427-457. [Back]

86 In re Conservatorship of Wendland. Probate Case NO. 65669, Cal Sup Ct. Jan 21, 1997, Mar 8, 1998. [Back]

87 Coleman D. The minimally conscious state: definition and diagnostic criteria. (Letter) Neurology 2002; 58: 506-507. [Back]

88 Ibid. [Back]

89 Diane Coleman JD, President of Not Dead Yet. (Correspondence) Neurology. 2002, 58 Feb 1 of 2: 506. [Back]

90 Shewmon DA. (Correspondence). Neurology. (2002) 58, Feb 1 of 2: 506. [Back]

91 Bernat, JL Questions remaining about the minimally conscious state. Neurology 2002; 58: 337-338. [Back]

92 Sheehan MN. Feeding tubes: Sorting out the issues: Efficacy of artificial nutrition and hydration is determined by several clinical factors. Health Progress. Nov/Dec 2001: 22-27. [Back]

93 Position of the American Dietetic Association: Ethical and legal issues in nutrition, hydration and feeding. Journal of the American Dietetic Assoc. May 2002, 102; 5: 716-726. [Back]

94 O'Rourke K. "When Life Support Doesn't Help" St. Louis Post Dispatch, March 19, 1993. [Back]

95 Gormally L., ed. Euthanasia, Clinical Practice and the Law. Hackett Publishing: 142. [Back]

96 Ibid. [Back]

97 Andrews K. Vegetative state--background and ethics. J R Soc Med. 1997; 90: 593-596. [Back]

98 Ibid. [Back]

99 Weijer C, et al. Bioethics for clinicians: dealing with demands for inappropriate treatment CMAJ 1998, 159; 7: 817-21. [Back]

100 Royal College of Physicians Working Group. The permanent vegetative state. JR Coll Phys Lond. 1996; 3: 119-21. [Back]

101 Medical Futility in End of Life Care: Report of the Council on Ethical and Judicial Affairs. JAMA, March 1O, 1999, 281; 10: 937-41. [Back]

102 Fenwick AJ. Applying best interests to persistent vegetative state -- a principled distortion? J Med Ethics 1998, 24: 86-92. [Back]

103 Ibid. [Back]

104 Ibid. [Back]

105 Siosteen A et al. The quality of life of three functional spinal cord injury subgroups in a Swedish community. Parplegia 1990; 28: 476-488. [Back]

106 Emmanuel L, et al. Advanced directives: stability of patients' treatment choices. Arch Intern Med. 1994, 154: 209-217. [Back]

107 Wilson B, Gracey F, Bainbridge K.Cognitive recovery from 'persistent vegetative state': psychological and personal perspectives. Brain Injury. 2001, 15; 12: 1083-1092. [Back]

108 Phipps E and Whyte J. Medical decision-making with persons who are minimally conscious. Am J Phys Med Rehab 78, 1, Jan/Feb 1999: 77-82. [Back]

109 Weijer C. Cardiopulmonary resuscitation for patients in a persistent vegetative state: Futile or acceptable? CMAJ. 1998; 158: 491-493. [Back]

110 Eiser AR, Seiden DJ. Discontinuing Dialysis in Persistent Vegetative State: the roles of autonomy, community and professional moral agency. Am J Kidney Dis. August 1997, 30; 2: 291-96. [Back]

111 Euthanasia (active) is illegal in the case of the PVS. Physician assisted suicide is now legal under certain circumstances in the state of Oregon. [Back]

112 Beresford HR. Persistent vegetative state: A view across the legal divide. Ann NY Acad Sci. 1997, 835; 386-94. [Back]

113 Ferguson P. Journal of Medical Ethics. 1997; 23: 368-372. [Back]

114 Tony Bland case (1993 AC 789 at 882A). [Back]

115 Hopkins PD. Why does removing machines count as "passive" euthanasia? Hastings Center Report. May/June 1997: 29-37. [Back]

116 Executive Board of the American Academy of Neurology. Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state. Neurology. 1989, 39: 125-26. [Back]

117 Beresford HR. Persistent vegetative state: A view across the legal divide. Ann NY Acad Sci. 1997, 835; 386-94. [Back]

118 Resolution of Executive Board of the American Academy of Neurology. July 7, 1995. [Back]

119 Beresford HR. Persistent Vegetative State: A view across the legal divide. Ann NY Acad Sci. 1997, 835: 386-94. [Back]

120 Levy DE et al, 1987. Differences in cerebral blood flow and glucose utilization in vegetative versus locked-in patients. Ann Neurol. 22: 673-682. [Back]

121 Smith DR. Legal recognition of neocortical death. 1986. Cornell Law Rev 71: 850-858. [Back]

122 In the Matter of Karen Quinlan, an Alleged Incompetent, 70 N.J. Super 227;348 A. 2d. 801, 1976. [Back]

123 Beresford HR. Persistent Vegetative State: A view across the legal divide. Ann NY Acad Sci. 1997, 835: 386-94. [Back]

124 Coats TJ, Kirk CJC, Dawson M. Outcome after severe head injury treated by an integrated trauma system. J Accid Emerg Med 1999, 16: 182-185. [Back]

125 Eker C et al. Reduced mortality after severe head injury will increase the demands for rehabilitation services. Brain Injury. 2000, 14; 7: 605-619. [Back]

126 Beresford HR. Persistent Vegetative State: A view across the legal divide. Ann NY Acad Sci. 1997, 835: 386-94. [Back]

127 Andrews K. Vegetative stateÑbackground and ethics. J R Soc Med. 1997; 90: 593-596.Survival for 40 years is odd given that the PVS is said to be a phenomenon of modern health care interventions. 40 years ago was 1962, well prior to the definition of "brain death". [Back]

128 Strauss DJ, Shavelle RM, Ashwal S. Life expectancy of children in vegetative and minimally conscious states. Pediatric Neurology. 2000, 23; 4: 312-319. [Back]

129 Smith WJ. The Culture of Death: The assault on medical ethics in America. 2001 Encounter Books. [Back]

130 Andrews K. Vegetative stateÑbackground and ethics. J R Soc Med. 1997; 90: 593-596. [Back]

131 United States Conference of Catholic Bishops, Ethical and religious directives for Catholic health care services, 2001, Directive 58, p. 31. [Back]

132 "Ad Limina" Address to the Bishops of California, Nevada, and Hawaii, Pope John Paul II October 2, 1998. Available at http://www.cin.org/jp2/jp981002.html [Back]

133 Eberl J. "Thomas Aquinas and the Proper End of Life." Paper delivered at Trinity International University, Center For Bioethics and Human Dignity Annual conference, "Bioethics in the New Millennium" Deerfield IL. July 21, 2000. [Back]

134 Panicola MR. Withdrawing Nutrition and Hydration: The Catholic tradition offers guidance for the treatment of patients in a persistent vegetative state. Health Progress. Nov/Dec 2001: 2833. [Back]

135 Mclean S. Legal and ethical aspects of the vegetative state. J Clin Pathol. 1999; 52: 490-493. [Back]

136 Rae S. Moral choices-an introduction to ethics. Grand Rapids MI: Zondervan: 177-180. [Back]

137 Kilner. Life on the line: Ethics, aging, ending patients' lives and allocating vital resources. Grand Rapids MI: Eerdmans. 1992: 124-125. [Back]

|38 Meilander G. Bioethic: A primer for Christians. Grand Rapids MI: Eerdmans. 1996: 7, 74-75. [Back]

139 Ibid. [Back]

140 Ryan PJ. The value of life and its bearing on three issues of medical ethics. Voices. A publication of Women for Faith and Family. Summer 2000,11 ;2. [Back]

141 Romans 3:8 (NIV) [Back]

142 2 Corinthians 5:8 (NIV) [Back]

143 Genesis 1:26 (NIV) [Back]

144 Joint Submission of the Anglican and Catholic Bishops to the House of Lords Select Committee on Medical Ethics. "Euthanasia-no!" London: The Incorporated Catholic Truth Society, 1993. [Back]

145 Rae S. Moral choices -- an Introduction to ethics. Grand Rapids MI: Zondervan: 176-180. [Back]

146 U.S. Catholic Bishop's Committee for Pro-life Activities, 1992, "Nutrition and Hydration: Moral and Pastoral Reflections", National Conference of Catholic Bishops Secretariat for ProLife Activities, Washington, DC. [Back]

147 Feinberg J, Feinberg P. Ethics for a Brave New World. 1993, Crossway Books: 116. [Back]

148 Waters J. Right to life. Nursing Times. 1996, 92; 4: 24-25. [Back]

149 Proceedings of the American Bar Association, 1992. [Back]

150 Phipps and Whyte [Back]

151 Rae S. Moral choices-an Introduction to ethics. Grand Rapids MI: Zondervan: 87. [Back]

152 Kilner. Life on the line: Ethics, aging, ending patients' lives and allocating vital resources. Grand Rapids MI: Eerdmans. 1992: 124. [Back]

153 Cantor N. Can healthcare providers obtain judicial intervention against surrogates who demand medically inappropriate life support for incompetent patients? Critical Care Medicine. 1996, 24; 5: 883-887. [Back]

154 Freeman E. The coma exit chart: Assessing the patient in prolonged coma and the vegetative state. Brain Injury. 1996, 10: 615-624. [Back]

155 Freeman E. Brain Injury. 1997, 11: 837-849. [Back]

156 Cassell E. Clinical incoherence about persons: The Problem of the persistent vegetative state. Annals of Internal Medicine. July 15, 1996, 125; 2: 146-147. "Clinical incoherence about persons" refers to confusion among physicians as to the status of the patient in the PVS. Many doctors believe that patients in the PVS are better off dead than alive and almost half of the physicians polled ( Payne K. Ann Intern Med 1996; 125: 104-110) think that these patients are dead. This it truly astounding, given that these physicians must have some passing familiarity with criteria for brain death. This kind of thinking leads to a push for criteria for "higher brain death" which some are now advocating. Although half of the physician respondents in a survey on the PVS believe that these patients are already dead, four fifths believe that it would be unethical to give them a lethal injection. Most of the responders on the other hand, think that it would be ethical to use the organs of these patients for transplantation. This is odd because doing so would cause the patient's death, and violate the "dead donor rule". This shows how bioethically inept even -- perhaps especially, many physicians are in matters involving the patient in PVS. Attorneys and the general public may be forgiven for lacking accurate medical knowledge regarding the PVS if doctors are so confused themselves. A great deal of bioethical teaching needs to be done at all levels of society. [Back]

157 Nenner F. Listen to the voices. BMJ. Feb 10, 2001, 322; 7282: 372. [Back]

158 "Judge will hold another hearing before deciding fate of Becker". Steven Becker's wife soughtlegal authorization to withdraw nutrition and hydration, while his mother sought to maintain both ordinary care and medical treatment. [Back]

159 Valko N. "Can Steven Becker be neglected to death?" [Back]

160 Lamear-Tucker D, Friedson J. Resolving moral conflict: the Critical care nurse's role, Critical Care Nurse. April 1997, 17; 2: 55-63. [Back]

161 See for example: Hoyt J. A gentle approach: Interacting with a person who is semi-conscious or presumed in coma. Issues in Law and Medicine. 1996, 12; 1. [Back]

162 Gill-Thwaites H. The Sensory Modality Assessment Rehabilitation Technique (SMART) -- A tool for assessment and treatment of patients with severe brain injury in a vegetative state. Brain Injury. 1997, 11; 10: 723-734. [Back]

163 Gill-Thwaites H. The Sensory Modality Assessment Rehabilitation Technique (SMART) -- A tool for assessment and treatment of patients with severe brain injury in a vegetative state. Brain Injury. 1997, 11; 10: 723-734. [Back]

164 Ibid. [Back]

165 Wilson S and Gill Thwaites H. Early indication of emergence from vegetative state derived from assessments with the SMART -- a preliminary report. Brain Injury, 2000, 14; 4: 319-331. [Back]

166 Ibid. [Back]

167 Gill-Thwaites H, Brain Injury, 1997, 11, 10, 723-734. [Back]

168 Wilson B, Gracey F, Bainbridge K. Cognitive recovery from 'persistent vegetative state': psychological and personal perspectives. Brain Injury. 2001, 15; 12: 1083-1092. [Back]

169 McMillan TM. Neuropsychological assessment after extremely severe head injury in a case of life or death. Brain Injury. 1996, 11; 7: 483-490. [Back]

170 McMillan TM, Herbert CM Neuropsychological assessment of a potential "euthanasia" case: a 5-year follow up. Brain Injury. 2000, 14; 2: 197-203. [Back]

171 Andrews K. Should PVS patients be treated. Neuropsych Rehab. 1993, 3; 109-119. [Back]

172 McMillan TM, Herbert CM Neuropsychological assessment of a potential "euthanasia" case: a 5-year follow up. Brain Injury. 2000, 14; 2: 197-203. [Back]

173 Waters J. Right to life. Nursing Times. 1996, 92; 4: 25. [Back]

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