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Consciousness and persistent vegetative states
THE LANCET
Consciousness and persistent vegetative states SIR—I agree with your correspondent Newmark (Aug 24, p 549)1 that persistent vegetative state must be an intolerable form of suffering. Surely, however, we are only justified in killing the body “shell” if we can presume that consciousness or personhood is already dead. If not, we must consult the person first. But if we cannot reach the person or cannot be heard we can only presume that existence is preferred to nonexistence. I would rather write to The Lancet and have my letters rejected than not be able to write at all. D J King Department of Therapeutics and Pharmacology, Queen’s University of Belfast, Belfast BT9 7BL, UK
1
Newmark RW. Euthanasia, physician-assisted suicide, and persistent vegetative state. Lancet 1996; 348: 549.
Simplified way of counselling parents about outcome of extremely premature babies SIR—Doctors and nurses working amidst the emotional cauldron of neonatal intensive care units are often asked, “What is the chance of survival and handicap?” of extremely premature babies. Such a question may be posed by mothers in premature labour or by those who have delivered babies of less than 30 weeks’ gestation. I have found it convenient to use an easy-to-remember rule for counselling parents. The survival and the percentage of the survivors without handicap depend on gestational age in weeks: Gestation (wk)
Survival %
% survivors without handicap
24 25 26 27 28 29
40 50 60 70 80 90
40 50 60 70 80 90
The above table shows a simple and fair formula, based on published data,1–3 for predicting the potential outcomes in extremely premature babies, with the numbers for 24 weeks’ gestation being optimistic. Thus, for example, parents are told that at 25 weeks’ gestation, their baby has a 50% chance of survival, and if it survives, a 50% chance of being handicapped. Of course the figures are dependent on other
Vol 348 • October 5, 1996
Department of Neonatology, Canberra Hospital, Canberra, ACT 2605, Australia
1 2 3
Rennie JM. Perinatal management at the lower margin of viability. Arch Dis Child 1996; 74: F214–18. Bohin S, Draper ES, Field DJ. Impact of extremely immature infants on neonatal services. Arch Dis Child 1996; 74: F110–13. Doyle L. Outcome to 2 years of infants 23–27 weeks’ gestation born in Victoria in the post surfactant era. Proceedings of 14th Annual Congress of the Australian Perinatal Society, 1996: A57.
Changes in the use of radical prostatectomy for treating prostate cancer in the USA SIR—Data from the Surveillance, Epidemiology, and End Results (SEER) programme of the US National Cancer Institute has shown a trend toward the increased use of radical prostatectomy for treating prostate cancer, especially among white men, from 1983 through 1991.1–2 However, in the early 1990s several authors noted unresolved issues concerning the use of prostate cancer screening and aggressive therapy, and the need for randomised trials before definitive public health recommendations can be made.3–4 Morbidity and mortality associated with radical prostatectomy have also raised concerns about its therapeutic efficacy.4–5 As public awareness of the controversial aspects of aggressive therapy for prostate cancer have become better known, a decline in the use of radical prostatectomy may be expected. We report the proportion of men with prostate cancer treated with a radical prostatectomy (figure). These proportions are based on a set of geographically defined population-based tumour registries in the USA, contracted to the US National Cancer Institute (SEER). Large variations exist in the proportion of men treated with a radical prostatectomy by year of diagnosis, age group, and race. Through the early 1990s the proportions rapidly increased, primarily in the age groups 50–69, 60–69, and 70–79, in both whites and blacks. A decline in proportions occurred in each age group for whites and in the two oldest age groups for blacks. The percent change in proportions for whites from 1992 to 1993 are –4·6% for ages 50–59, –6·8% for ages 60–69, and –13·7% for ages 70–79. The percent 70
White men
Black men
60 50–59 50 60–69 40
70–79
30
80+
20 10 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Department of Obstetrics, University Hospital Z urich, CH-8091 Z urich, Switzerland
Thhg Koh
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Josef Wisser
factors, which include maternal wellbeing, administration of steroids, presence of infection, and expert care.
Percent
can take place. It is, however, up to the federal and/or state legislatures to regulate the counselling concept. The 1995 national law is not explicit about women who refuse counselling. The Bavarian state parliament rectified this unclear situation by defining what the counselling required by the court decision should entail. Their amendment therefore did not, as you state, add restrictions to the federal law, but clarified what is meant by counselling in order to correctly interpret and implement the federal court’s decision. With reference to your comment on “strong Roman Catholic forces”, it should be noted that the Bavarian state parliament is not controlled by the Roman Catholic Church; it must, however, comply with the decisions of the Federal Constitutional Court.
Year of diagnosis Figure: Proportion of men in the USA with prostate cancer treated by radical prostatectomy Rates are age-adjusted to 1990 USA population.
963
Consciousness and persistent vegetative states SIR—I agree with your correspondent Newmark (Aug 24, p 549)1 that persistent vegetative state must be an intolerable form of suffering. Surely, however, we are only justified in killing the body “shell” if we can presume that consciousness or personhood is already dead. If not, we must consult the person first. But if we cannot reach the person or cannot be heard we can only presume that existence is preferred to nonexistence. I would rather write to The Lancet and have my letters rejected than not be able to write at all. D J King Department of Therapeutics and Pharmacology, Queen’s University of Belfast, Belfast BT9 7BL, UK
1
Newmark RW. Euthanasia, physician-assisted suicide, and persistent vegetative state. Lancet 1996; 348: 549.
Simplified way of counselling parents about outcome of extremely premature babies SIR—Doctors and nurses working amidst the emotional cauldron of neonatal intensive care units are often asked, “What is the chance of survival and handicap?” of extremely premature babies. Such a question may be posed by mothers in premature labour or by those who have delivered babies of less than 30 weeks’ gestation. I have found it convenient to use an easy-to-remember rule for counselling parents. The survival and the percentage of the survivors without handicap depend on gestational age in weeks: Gestation (wk)
Survival %
% survivors without handicap
24 25 26 27 28 29
40 50 60 70 80 90
40 50 60 70 80 90
The above table shows a simple and fair formula, based on published data,1–3 for predicting the potential outcomes in extremely premature babies, with the numbers for 24 weeks’ gestation being optimistic. Thus, for example, parents are told that at 25 weeks’ gestation, their baby has a 50% chance of survival, and if it survives, a 50% chance of being handicapped. Of course the figures are dependent on other
Vol 348 • October 5, 1996
Department of Neonatology, Canberra Hospital, Canberra, ACT 2605, Australia
1 2 3
Rennie JM. Perinatal management at the lower margin of viability. Arch Dis Child 1996; 74: F214–18. Bohin S, Draper ES, Field DJ. Impact of extremely immature infants on neonatal services. Arch Dis Child 1996; 74: F110–13. Doyle L. Outcome to 2 years of infants 23–27 weeks’ gestation born in Victoria in the post surfactant era. Proceedings of 14th Annual Congress of the Australian Perinatal Society, 1996: A57.
Changes in the use of radical prostatectomy for treating prostate cancer in the USA SIR—Data from the Surveillance, Epidemiology, and End Results (SEER) programme of the US National Cancer Institute has shown a trend toward the increased use of radical prostatectomy for treating prostate cancer, especially among white men, from 1983 through 1991.1–2 However, in the early 1990s several authors noted unresolved issues concerning the use of prostate cancer screening and aggressive therapy, and the need for randomised trials before definitive public health recommendations can be made.3–4 Morbidity and mortality associated with radical prostatectomy have also raised concerns about its therapeutic efficacy.4–5 As public awareness of the controversial aspects of aggressive therapy for prostate cancer have become better known, a decline in the use of radical prostatectomy may be expected. We report the proportion of men with prostate cancer treated with a radical prostatectomy (figure). These proportions are based on a set of geographically defined population-based tumour registries in the USA, contracted to the US National Cancer Institute (SEER). Large variations exist in the proportion of men treated with a radical prostatectomy by year of diagnosis, age group, and race. Through the early 1990s the proportions rapidly increased, primarily in the age groups 50–69, 60–69, and 70–79, in both whites and blacks. A decline in proportions occurred in each age group for whites and in the two oldest age groups for blacks. The percent change in proportions for whites from 1992 to 1993 are –4·6% for ages 50–59, –6·8% for ages 60–69, and –13·7% for ages 70–79. The percent 70
White men
Black men
60 50–59 50 60–69 40
70–79
30
80+
20 10 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Department of Obstetrics, University Hospital Z urich, CH-8091 Z urich, Switzerland
Thhg Koh
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
Josef Wisser
factors, which include maternal wellbeing, administration of steroids, presence of infection, and expert care.
Percent
can take place. It is, however, up to the federal and/or state legislatures to regulate the counselling concept. The 1995 national law is not explicit about women who refuse counselling. The Bavarian state parliament rectified this unclear situation by defining what the counselling required by the court decision should entail. Their amendment therefore did not, as you state, add restrictions to the federal law, but clarified what is meant by counselling in order to correctly interpret and implement the federal court’s decision. With reference to your comment on “strong Roman Catholic forces”, it should be noted that the Bavarian state parliament is not controlled by the Roman Catholic Church; it must, however, comply with the decisions of the Federal Constitutional Court.
Year of diagnosis Figure: Proportion of men in the USA with prostate cancer treated by radical prostatectomy Rates are age-adjusted to 1990 USA population.
963