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CMAJ - July 14, 1998JAMC - le 14 juillet

CPR for patients in a persistent vegetative state?

CMAJ 1998;159:19

See response from: C. Weijer
Dr. Weijer argues eruditely for CPR when demanded by families as a matter of cultural and religious conscience. The force of his argument derives from his assertion that this is a contest of values between physicians who hold that such life is not worth living and family members who believe in its sanctity and require that all means be used to prolong it. While such conceptualization of a battle of beliefs may be forceful, it casts doubt on physicians' respect for life and advances a faulty construction of the rationale and motive supporting do-not-resuscitate (DNR) orders in such cases.

In Weijer's editorial, beneficence is correctly understood to be patient focused, subject to independent, verifiable clinical judgement and common sense, and applicable to a patient conceived as an intellectual, social and spiritual — and not merely physical — being. A patient irretrievably incapable of experience, such as a person in a PVS, cannot benefit. Just as the incapacity for conscious experience removes any burden of suffering that would proscribe CPR, so too it removes any hope of benefit that would prescribe it. Such patients are beyond benefit. Their physical existence is a necessary but insufficient ground for CPR. Prolonging unconscious life through aggressive medical treatment could be considered one definition of "bad medicine."

As physicians, we do not seek to judge the worth of a life but to judge all life worthy. Rather than the "smuggling in" of the premise that "a permanently unconscious life is not worth preserving," DNR orders in cases of PVS respectfully and ethically reflect a clear commitment to medicine's time-honoured mandate to mend and a humble understanding of its limitations. This is the wisdom behind the joint statement's position on DNR in cases involving a PVS.

Bruce W. Jespersen, MD
Calgary, Alta.

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