Withdrawing Treatment or Assisted Suicide
People in CLIS are ventilator-dependent and in need of artificial feeding. Hence, if they have decision-making capacity, they do not need to commit AS, as withdrawal of treatment offers them a viable way of ending their life.
1 Unlike assisted suicide, the latter is legal in the vast majority of countries. But also, beyond legal considerations, switching off life supporting machines while being supported by supportive care might seem more reasonable than administering pentobarbital through a gastric catheter. Still, for the purpose of this article, we focus on assisted suicide via BCI since we believe that our arguments concerning assisted suicide could be similarly applied to withdrawal of treatment. The most notable difference in assisted suicide and withdrawal of treatment is that assisted suicide requires a wilful action (the person’s physical control of the pharmakon), while withdrawal of treatment solely needs the communication of treatment preference to the attending physicians (i.e., for the ending of treatment). In this way, assisted suicide has more extensive normative requirements. It is central to our argument that if these requirements can be met for assisted suicide, they can also be met for withdrawal of treatment.
In addition, some patients in CLIS might also have reasons to prefer assisted suicide, e.g., because it gives them better control about the time and mode of their death. Similar to other patients, patients in CLIS should have the choice between assisted suicide and withdrawal of treatment, where assisted suicide is legal. This choice however is subject to having decision-making capacity and, in assisted suicide, having physical control.
Decision-Making at the End-of-Life: The Example of Self-Administration in Assisted Suicide
Self-administration by the person requesting assisted suicide is a fundamental requirement in most countries where assisted suicide is legal, including in Switzerland. Assisted suicide is legal in Switzerland if the assistance is not provided because of selfish motives according to the Swiss Penal Code, Article 115. Access to AS requires decision-making capacity (henceforth, capacity) and physical control over the administration of the lethal drug. Physical control can go as far as having a mechanical device linked to muscle activity opening a gastric catheter containing pentobarbital (Bosshard et al.
2003). This device renders it possible to “provide an easy-to-handle remote control which they can activate with a small movement (e.g. a finger, toe or jaw) to start the attached pump”
2. In CLIS, this movement is impossible and hence this small movement could only be replaced by action through a BCI.
Internationally, self-administration has been introduced as a safeguard in many countries that allow for assisted suicide, for example it has been a core component in policies on assisted dying since the 1994 Death with Dignity act in Oregon and several other states in the United States which have instated AS policies since then (Thyden
2017). In the Australian state of Victoria, self-administration is preferred, however, if “the patient is physically incapable of self-administering or digesting the voluntary assisted dying medication then the coordinating medical practitioner may assist the patient to die by administering the medication” (Victoria State Government
2021). Several other countries have instated both self-administration and practitioner-administration in policies on assisted suicide (British Medical Association
2021).
In strict self-administration policies, both criteria, capacity and control, serve to safeguard autonomy in these end-of life decisions. However, control is in some cases of CLIS an unsurmountable obstacle; more specifically for people with CLIS in the context of amyotrophic lateral sclerosis and other neurodegenerative diseases. Similar problems exist in Huntington’s disease. From the perspective of disability rights, Alicia Ouellette (
2017, 5) has argued that
The requirement of self-administration poses particular problems for Huntington’s sufferers. Huntington’s disease is a progressive, neurodegenerative disorder that is inevitably fatal. Marked by involuntary movements, swallowing disorders, the inability to speak, and cognitive impairments, Huntington’s patients may lose the ability to self-ingest prescription medicine before they are eligible for PAD [physician-assisted dying], by being deemed within six months of death, or by completing the multistep process of approvals. The self-ingestion requirement becomes an impenetrable barrier for those seeking PAD, leading families of individuals with Huntington’s to argue in court briefs that the so-called protective procedures discriminate based on disability status.
In ALS however, the progressive nature necessitates invasive ventilation for long-term survival (Hayashi and Oppenheimer
2003) and a thorough evaluation of capacity.
Capacity as a Gatekeeper for BCI-Assisted Suicide—The Case of ALS
Decision-making capacity and its different components (e.g., understanding or reasoning) can be established by the treating physician through unstructured or structured interviews (MacCAT-T; Grisso, et al.
1997) but remain reliant on a clinical judgement by the physician (Hermann et al.
2020). Hence, in most cases of CLIS from traumatic brain injury leading to minimal conscious states (MCS), capacity is difficult to establish because of the lack of adequate and reliable communication. For example, Cabral and Illes (
2017) argue that communication via fMRI imaging fails to establish capacity in patients with traumatic brain injuries in general. However, as pointed out earlier, not all patients in CLIS have traumatic brain injuries and only a very small number of BCIs are based on fMRI. Nonetheless, the general point stands, that in certain cases of CLIS where communication via BCI is unreliable, any evaluation of decision-making capacity will be difficult.
Typically, when it is impossible to assess capacity, surrogates will decide about possible end-of-life options. In cases of severe brain injury where capacity is unclear, Joseph Fins has argued for a more nuanced approach to assess capacity in minimally conscious states (MCS), encompassing both surrogate decision-making and self-determination via neuroprosthetics. Fins calls this the “mosaic approach to decision-making, which seeks to achieve a proportionate and prudent balance between unbridled self-determination and conventional surrogate representation” (Fins
2018, 164).
This mosaic approach to decision-making and other approaches to decision-making of people in MCS have been discussed widely (Fins
2018; Peterson
2019; Fins
2019). Walter Glannon has argued for a “a weaker version of informed consent and decisional capacity” for “minimally conscious patients with a higher level of awareness and cognitive function who can clearly express their preferences about life-sustaining care through BCI-mediated binary responses” (Glannon
2016, 5).
However, there are more clear-cut cases where capacity could be preserved in CLIS. This is the case of amyotrophic lateral sclerosis. ALS is generally recognized as a terminal neurodegenerative disease of the motor neurons with progressive muscle weakness and atrophy requiring invasive mechanical ventilation and leading to first LIS, then CLIS. While in LIS, eye movement is preserved, enabling communication by eye movement. However, barring an earlier death, some patients suffering from ALS unfortunately enter CLIS (Murguialday, et al.
2011). While population-based studies show that almost half of people with ALS remain cognitively unimpaired (Phukan, et al.
2012), some even so in CLIS (Fuchino et al.
2008), cognitive impairment including frontotemporal dementia is nowadays recognized as a hallmark of ALS (Giordana, et al.
2011; Pender, Pinto-Grau, and Hardiman
2020) and worsens with the progression of the disease, especially when there is bulbar impairment (Chiò, et al.
2019). Full-blown dementia with major frontotemporal impairment can be diagnosed in 14 per cent of people with ALS (Pender, Pinto-Grau, and Hardiman
2020) encompassing symptoms such as “personality change, irritability, obsessions, poor insight, and pervasive deficits on frontal executive tests” (Phukan, Pender, and Hardiman
2007, 994). Given the heterogenous nature of cognitive impairment in ALS, it is important to evaluate capacity individually in each case. As some forms of BCI communication are sufficiently reliable (e.g., P300-speller) and have been used for cognitive testing (Lulé, et al.
2018), this can enable capacity evaluation.
If reliable communication can be established through a P300-speller BCI, this would permit to distinguish between absence and presence of capacity for different types of decision-making, including end-of-life decisions. However, if we only think of communication within narrow constraints on the complexity via BCI, for example the binary responses envisioned by Glannon (
2016), there will probably be a number of cases where it is impossible to establish whether a person has capacity to make an informed decision or not. Using a BCI spelling device, capacity can be established in the same way it would in non-locked in people showing cognitive impairment. The process of capacity evaluation, however, would be more time consuming.
Diachronic Autonomy of Individuals With ALS in CLIS
In contrast to the rapid nature of traumatic brain injury, in neurodegenerative diseases decision-making has an extended temporal dimension. In contrast to other cases of CLIS, the progressive nature of ALS enables anticipating CLIS from diagnosis on. People with ALS could therefore prepare end-of-life decisions in advance, as with the withdrawal of treatment (Moss et al.
1996). However, an advance directive requiring assisted suicide is not sufficient due to the need to self-administer the drug. One could ask whether, from an ethical standpoint, on the one hand the presence of an advance directive on assisted suicide in these ALS patients in CLIS would permit to accept some uncertainty in capacity evaluations via BCI. On the other hand, the advance directive could also only be procedural, directing the terms necessary to guide capacity evaluation and assisted suicide during CLIS.
This means that if people with ALS have a very stable wish to decide their own fate if they ever enter CLIS, a lower standard of communication could be deemed acceptable because they just reiterate a previously stable wish. Indeed, ALS might be the only case where the reliability of communication and the training of algorithms on BCI data is feasible because individuals can still communicate well before CLIS. Furthermore, training of the algorithm is also possible as long as people with ALS in LIS have not advanced to CLIS with the convergence of eye-tracking communication and BCI communication. This might give more certainty and credibility to the evaluation of capacity and communication of choice via BCI later.
Physical Control and Self-Administration via BCI
Even if capacity could be established in some cases of ALS, physical control of the intake of the lethal substance must also be established, as this remains a major safeguard for autonomy in self-administered assisted suicide. Prima facie, there seems to be a plausible case to treat BCI control and ordinary muscular control the same because legally, responsibility for misconduct via BCI is attributed to the person using the BCI (Bublitz, et al.
2018). Bringing about harm or damage to other persons or objects with the use of BCI does not exempt the person who used it from legal ramifications. Physical control, tort liability, and criminal responsibility are innately linked and that, if users of BCIs (e.g. patients in CLIS) are liable for actions committed against others (Thompson
2019), they should be able to be responsible for acts against themselves (e.g. assisted suicide), too. Rainey and colleagues (Rainey, Maslen, and Savulescu
2020) have argued that while foreseeability and issues of control distinguish BCI actions to some extent from conventional actions, in cases where “there is a clear reason for the use of a BCI technology for assistance or owing to disability, it appears easy to assimilate this kind of action” (56). For the context of control via BCI in CLIS, the reasons for its use are clear: there is no other option for enacting one’s end of life. On this view, end-of-life decisions enacted via BCI are the only option of patients in CLIS.