Best interests in persistent vegetative state.

Letters Best interests in persistent vegetative state SIR While I agree with several points raised in your recent editorial' on my paper, Applying best interests to persistent vegetative state-a principled distortion?,2 I must respond to a number of other issues which you raise. I agree unreservedly with your caveat that both doctors and judges must act within the law. My paper, however, sought to expose that the paradox for the court in the Bland case3 lay in struggling to attain: 1) a morally "right" outcome (withdrawal of life-prolonging treatment (LPT)); while at the same time 2) remaining within the bounds of the current law. As the current law stands it permits allowing patients to die in certain circumstances, whilst prohibiting intentional killing. We should not believe , however, that this state of affairs compels us to accept it as the best we could hope for. Changes to the law may be justified if sufficient moral support exists for making such changes. Although medical ethics, as a discipline, places considerable reliance on moral values, the relationship of law and morality has been traditionally fraught. This latter tension is reflected in the strained semantics of the persistent vegetative state (PVS) decisions. Thus, far from condoning any flouting of the criminal law, I submit that we, as decision makers, need to embrace more honestly the moral content of LPT withdrawal decisions, if decisions are to be clearer and more consistent. Your editorial suggests that my article implicitly equates "not in" a patient's best interests with "against" best interests. I accept that this is the effect of my approach. However, I adopt this position on the basis that any further distinction regarding best interests is ineffective. While your proposed three categories of "in"; "not in" (presumably neutral); and "against" a patient's best interests are viable regarding "interests" as such, I would argue that the addition of the superlative "best" seeks the optimal action for the patient. This absolutist tone creates an either/or situation, such that an action can only be "in" or "not in" the patient's "best interests". Any further distinction, such as actions which are "not in" or are "against" a patient's best interests, merely represents examples from the same category; namely a non-optimal solution. It is therefore a distinction without difference. Furthermore, while your Smith/Jones example is warranted regarding the patient's interest in other patients' treatment, the LPT decision in PVS obviously …