On Friday, May 31, 2019, on the feast of the Queenship of Mary, the French government filed an appeal against the decision by the Paris Court of Appeals that had ordered the resumption of food and hydration for Vincent Lambert, after it had been stopped that same morning.
This relentlessness in wanting to make a patient die is really euthanasia under another name. This affair is an opportunity to demonstrate the incoherence of French law, but especially to set out the principles that clarify everything about this question.
In a matter that can be considered as moral—although the word and the thing are hardly appreciated by modern minds—various aspects need to be examined: the medical point of view, which cannot be ignored, the “ethical” point of view, the legal point of view, and finally, the teachings of the Church. A Catholic cannot separate these elements. We will treat the medical aspect here, then the other aspects in subsequent articles.
The Medical Aspect
A practical attitude cannot be taken without knowledge of the material under consideration. A moral choice must be based on elements that are as solid as possible, but which, most of the time, remain imperfect and susceptible to change. In this case, our knowledge of so-called “minimal” states of consciousness.
For decades, the term coma seemed entirely satisfactory to describe the disappearance of consciousness. The current definition, “General Absence of Consciousness, Awareness, and Sensibility,” describes a state whose depth was measured in four stages.
Stage 1, vigil coma in which the patient responds appropriately to various stimuli, sound, or pain.
Stage 2, light coma in which the reactions have more or less disappeared, even regarding painful stimulation, or remain inconsistent.
Stage 3, deep or unreactive coma is revealed by abnormal movements to stimulation and neuro-vegetative disorders (acceleration or slowdown of the heart, abnormal pupils, changes in body temperature, sweating or dryness of the skin, etc.).
Stage 4, unresponsive coma is the equivalent of brain death.
But this classification, though still useful, is now obsolete.
Changes in Consciousness
With medical advances, especially in the area of resuscitation, some patients find themselves in a situation called “long-term coma,” then called “chronic vegetative state” (CVS). In fact, it was not a coma, as subsequent studies showed. Because these patients have phases of wakefulness and sleep, and they have not lost awareness, a loss that characterizes coma.
Yet awareness is not consciousness—it is only one necessary condition. The states of chronic changes of consciousness in alert people are thus states of wakefulness without clearly detectable voluntary communication.
These people are awake: they open or close their eyes, but show little or no signs of self-awareness or awareness of what surrounds them.
Let us digress: it is necessary to distinguish these states from “Locked-in Syndrome” (LIS) in which awareness, consciousness, and knowledge are preserved, but associated with a complete or almost complete paralysis which can sometimes regress, according to the cause. The book: The Diving Bell and the Butterfly (1997) was “written” by a patient in this state. A Tear Saved Me (2013), describes a regressive case. End of digression.
In awake people with impaired consciousness, two states have been characterized, according to the depth of this alteration: the state of wakefulness without response, to avoid the term “vegetative” considered disrespectful; and the state of minimal consciousness, or pauci-relational.
In the first state, there is no language, no suitable response to sense stimuli, no sign of self-consciousness or of surroundings, no language comprehension.
In the second state, the patient will respond or give signs of consciousness, more or less reproducible, and often fragmentary and inconsistent according to the moment or the situation, and evolving occasionally over time.
It should be noted that the distinction between these two states is anything but easy. According to the National Consultative Council of Ethics (CCNE), some studies have shown that the diagnosis of a state of wakefulness without response could be wrong in up to 40% of cases (CCNE comments to the attention of the Council of State of the May 5, 2014).
An Area of Constant Evolution
It should be added that the classification is constantly evolving, thanks to the important work done in this field, particularly in Belgium, France, and Germany. Thus Dr. Lionel Naccache, Professor of Medicine at the Pitié-Salpêtrière and researcher in cognitive neuroscience at the Institute of the Brain and Spinal Cord, author of a very remarkable article on the subject in 2018, believes that these methods now allow new assessments of all people in a comatose state of long duration. Currently in France, their number is estimated to be 1,700 patients.
Finally, therapeutic approaches are multiplying. Several teams have recently obtained results that would have been judged recently as unhoped-for, by often different means.
Finally, let us mention the case of people who have returned to consciousness after spending a more or less considerable time in a vegetative state. Here are some examples among others. In 2018, an Emirate, injured in a traffic accident in 1991, returned to consciousness after 17 years in a state of minimal consciousness. In 2017, the University Hospital of Lyon managed to raise a man who lived for 15 years in a state of wakefulness without response to a state of minimal consciousness through a kind of “cerebral pacemaker.” And in 2007, a Polish man who had been in a so-called “vegetative” state for 19 years fully recovered consciousness: “I fell asleep under General Jaruzelski's regime and woke up under a right-wing regime!” Admittedly, these rather rare cases must not lead to a generalization, still they allow for much hope.
The CCNE, about which many criticisms can be made, made a very accurate statement in the above-mentioned report: “The absence of detectable proof of consciousness does not constitute proof of the absence of consciousness.”
A very important medical issue needs to be emphasized: the care and treatment required by the people in this state are simple. They do not require any intravenous therapy or special treatment (i.e., apart from an added disease such as diabetes) or a respirator. They essentially need to receive food and drink, physical therapy to avoid stiffening of the muscles and joints, and nursing care to avoid complications related to a static position (pressure sores especially).
Thus it is more than certain—and that is the fundamental issue here—that these people are not at the end of life, nor subject to heavy treatments for an indefinite time, nor even to palliative care according to the medical definition of the term.