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Exploring the Terri Schiavo Ethics Meltdown
(3/21/2005)

I really don't know whether Terri Schiavo is "alive" or not, and neither does anyone else with 100% certainty. She lingers in the grey area of existence, which living or not, is certainly some form of Hell. Somehow, the awful plight of this Florida woman and her suffering family has become the catalyst for one of the nation's rare full-blown ethical meltdowns, in the grand tradition of the Clinton-Lewinsky affair and the 2000 Florida recount. Let us examine the major components of this epic controversy, which from an ethical point of view is more depressing than instructive.


Terri's Condition

Neurologists appointed by the Florida courts have determined that Terri Schiavo, the victim of a heart attack 15 years ago that left her paralyzed and severely brain damaged, has no cerebrum activity at all, and thus her brain functions only at a primitive level of reflex and autonomous responses. This means that while her expression will change in response to light and sounds, and despite the fact that she will blink her eyes, she is no more aware of her surroundings or capable of interacting with them than a cantaloupe, and hence is described as being in a "vegetative state."

If this isn't "dead," it is certainly analogous to being "undead," like the wandering, brain-eating zombies in George Romero's horror film "Night of the Living Dead" and its many progeny. Romero's zombies can't think; they have lost every shred of humanity except cerebellum and brain stem impulses that allow them to shamble around committing mayhem. Never, in these films, do any relatives of the zombies argue that their former loved ones shouldn't be put out of their misery, that they are going to recover or that stopping their rampages is "murder," though, to be fair, there have never been any Republican Congressmen in a zombie film. And it is true that Terri Schiavo's remaining brain activity only causes her to smile, cry, laugh and blink, rather than to moan, wander, and eat people's brains. Yet in terms of human existence, she is probably no more alive than the fictional zombies…just better company.

Now, Schiavo's parents have convinced themselves that their daughter is in fact still capable of human response and have found some doctors who will back them up. Four observations about this: 1) It is very common for observers of vegetative patients to mistake their reflexive eye movements and other responses as awareness of their surroundings, when in fact they are not. 2) One can usually find an expert who will support almost any point of view imaginable. 3) They could still be right. 4) The Florida courts chose to believe that they were wrong.

Thus, in due course and according to the laws of the state, it has been determined in court (correction: courts) that Terri Schiavo is in a vegetative state and will not recover, thus permitting her husband to authorize the removal of her feeding tube. The attacks on the legitimacy of this process by Terri's parents, media pundits and politicians are biased and indefensible. For example, some have said that it is "outrageous" that the judge who rejected the most recent appeal by Terri's parents didn't visit and observe Schiavo himself. This is nonsense. He has no expertise to assess Terri Schiavo's condition (neither do her parents); he is obligated to rely on the judgement of doctors who know how to evaluate it. To do otherwise would be unethical. Another absurd and dishonest criticism has been that Terri has been denied "due process." There has probably never been an individual in a vegetative state who has received as much due process before his or her family was permitted to withhold an external means of prolonging life.


The Feeding Tube

Despite the disinformation put out by the legions of the Right on this matter, medical ethicists are largely in agreement that a feeding tube in a case like Terri Schiavo's is no different than a respirator: it constitutes an extraordinary life support measure that can be ethically removed when there is no chance of recovery. Here are some comments on the topic by Dr. John Collins Harvey, who chairs the bioethics committee at Georgetown University Hospital, in an interview on PBS's Religion and Ethics Weekly. It is long, but useful to anyone who wants to understand this key ethical issue:

Q: As both a moral theologian and a physician, do you make a distinction between keeping someone alive on a respirator and keeping someone alive on a feeding tube?

A: No, and that's a very misunderstood thing. What's important to understand is certain illnesses cause pathological conditions so that an organ system does not work -- let's say kidney disease, and certain kidney diseases will destroy the total function of the kidneys in the body. We can substitute now a machine that does the physiological work of the kidneys. That's renal dialysis machines. And people with kidney disease who would otherwise have died can remain alive being dialyzed maybe two or three times a week and they can go on, for many years, living.

The same situation occurs when people have difficulty breathing. We have a machine that will breathe artificially for somebody. So we put a tube down their trachea, attach it to the machine, and it will do the breathing for them. We have the ability to have an artificial heart that will do the work of the normal heart when the heart has failed. The point is that if you can do, substitute the physiological mechanisms artificially for those that have failed, we use that. If the situation is a fatal, pathological condition that can never, ever be overcome, then one has to look at the boons and the benefits of this artificial, physiological mechanism.

Q: Why is a feeding tube, in your view, the same as keeping someone alive on a respirator or through dialysis, and not elementary comfort care?

A: Because if it's being done where there's fatal pathology, it is just as if you were using the kidney machine on somebody who has no kidneys. They can stay alive, but if they decide that they don't want to undergo this, it's too much of a burden, it's perfectly moral to stop.

When somebody has a condition in which they can never bring food to their mouth by use of their arms; they can never chew food if it's placed in their mouth, because the muscles of mastication are paralyzed; if they can never move the bolus of food that they have put in at the front of the mouth and then moved by the tongue back to the esophagus, where automatic peristalsis takes place, and down the food goes to the tummy and then is absorbed and whatnot -- if that is a fatal pathology that they never will recover, the ability to chew and swallow, then if we use administration of food and fluid artificially, we're prolonging biological life. We're not prolonging an individual to where cure can take place, and then we remove that artificially administered fluid. Just because it's such a simple machine, such a simple tool, it makes it no different from a respirator, from an artificial heart, or from kidney dialysis machines.

The best way I can explain that is if an individual has what we call a tetanus infection, which is caused by a bug, an organism that grows in a small wound anyplace on the body, and it produces a poison, tetanus toxin, and the tetanus toxin affects all the muscles of the body, but particularly the muscles of mastication. It's known as "lockjaw," because as it advances, it makes the mouth clench. The body is stretched so that the person forms an arc because the back muscles are very tense and tight. We can treat the wound where the bug is growing and putting tetanus poisons into the system by antibiotics, like penicillin. Over a period of a month, we can get rid of that wound, overcome the infection; and the effects of the toxin gradually wear off, so that the individual will be able to recover fully the ability to eat normally. If we did not use a tube to feed that individual during this time of terrible physiological defect, he or she would die, because they would get no nutrition. So it would be mandatory to feed this type of individual.

But in the persistent vegetative state, there is no hope ever of recovery of this normal physiology of eating, swallowing, and giving food to yourself.

Q: What is "fatal pathology," in the medical view?

A: It's a pathology brought about by a disease process that can never be cured and is going to ultimately lead to the individual's death.

Q: How do you decide that someone is truly in a persistent vegetative state?

A: We know the ability for an individual to express what we call his or her personhood -- to love, to think, to remember, to talk, to move is all done by the biological substrate in the brain called the cerebral cortex; that's the upper part of the brain. The lower part of the brain controls the vegetative activities of the body, like making sure the heart is beating at its given time, that we're breathing regularly, that the kidneys are making urine, that the bladder is being able to fill it up and then expel the urine through the urethra. These are all vegetative activities in the body which we're not even aware of.

The cerebral cortical cells and the vegetative area of the brain -- if they are deprived of oxygen for given periods of time, they will die. The cerebral cortical cells can only tolerate the lack of oxygen for about six minutes, and then they die. And the death is irreversible, and no new brain cells ever grow up. Over a period of time, the cerebral cortex degenerates, disintegrates, and it just becomes in the skull kind of a bag of mush. The vegetative cells in the lower part of the brain can withstand the lack of oxygen for 40 to 50 minutes, and they will continue to function.

All of the cells of the body can be deprived of oxygen for different periods of time. The fingernails, for instance, can still metabolize and whatnot without being supplied by oxygen for a period of 24 hours. The kidneys also can work deprived by oxygen, so that very often people that are pronounced dead because their heart stops and their respiration stops -- the bladder will be filled, will have urine accumulated in it after death has been pronounced because the kidneys are still doing a little work. The death of cells is at a different time rate after oxygen has stopped being circulated, which means the heart has stopped beating and the lungs are not aspiring so that oxygen is supplied to the blood. In the persistent vegetative state, the individual has been without blood going to the head for at least six minutes, so the cerebral cortical cells have died. How does this come about? It comes about because the heart stops beating. The heart can stop beating from a heart attack, from a coronary occlusion. The heart can stop beating if the individual is electrocuted by lightning on the golf course. The heart will stop beating if the individual is drowned. And sometimes, the heart will stop beating when there's a terrible severe trauma to the head. The heart does not stop beating when an individual is poisoned by drugs and is put into a permanent coma by a drug, like the Quinlan case. Severe trauma does not always make the heart stop, but it can discombobulate the cells of the cerebral cortex, so that we see people who are in coma for 10, 15 years, and very rarely you will hear they woke up one day. That's because they are not in the persistent vegetative state, because they did not have cessation of oxygen going to their brain at any time during their illness. But individuals who have had that, and the oxygen has not gotten to the brain over that period of time that I described -- they are never going to recover, because they do not have any brain cells to recover. Brain cells that are discombobulated by drugs, alcohol, or by a trauma -- their physiology is just disrupted, but maybe over 20 years it finally returns to normal.

***

And yet during the extraordinary Sunday night debate over Schiavo in the House of Representatives, one Republican Congressman made a fatuous and false analogy between Schiavo's feeding tube and the fact that his one year-old child also "needed assistance to eat." This argument is either blatantly dishonest, shockingly dumb, or inexcusably ignorant. The child is being fed for a relatively short period of time until he can feed himself. Terri will never be able to feed herself, and the majority medical opinion is that her quality of life cannot improve. There is no comparison with a healthy one year-old infant.


Michael Schiavo and the Schindlers

No one should harshly judge either of the primary adversaries in the battle over Terri's fate. Both her husband and her family are coping with a now public tragedy that would test anyone's judgement, emotions, ethics and sanity. But the sad fact is that the Schindlers (Terri's parents) have not taken an ethical path. They and their allies have, in essence, accused Michael of trying to kill Terri for money (although the $700,000 he and Terri received in a malpractice suit are virtually gone), lying to the courts and in public by maintaining that his wife had verbally authorized him to terminate life support, intentionally withholding therapy and treatment that would allow her to improve and recover, and even of bringing about her condition through spousal abuse. He, on the other hand, has consistently avoided making any attempt to vilify them. On any ethics scale, Michael Schiavo's conduct towers over that of Terri's parents.


The U.S. Congress

If there are true villains in this saga, the GOP majority in Congress has almost all of them. Sorting out this gumbo of ethics, law and politics is just about impossible, but a few conclusions are unavoidable.

  • Senator Bill Frist, an MD (but a surgeon, not a neurologist), has chosen to discard his medical ethics for political showboating. Viewing nothing but the videotape that the Schindlers have been using for years to "prove" Terri is aware of her surroundings, Frist criticized and challenged the diagnosis of doctors who have examined her. To cite just one authority on the medical ethics standards Frist trampled on, the American College of Physicians' Ethics Manual states unequivocally that it is "unethical for a physician to disparage the…service of another physician to a patient or a third party or imply that a patient has been poorly managed...without substantial evidence." Needless to say, viewing a home video of the patient isn't "substantial evidence." Frist is using his medical background to give his opinion more weight than a mere law-maker, and violating his profession's ethical standards to do it.

  • Rep. Tom DeLay (I wonder if DeLay gets as tired of being cited for ethical misconduct as I get tired of cataloguing them all?) got on television and vehemently denied that the GOP effort to use the legislative processes of the US government to interfere with Florida, the courts, and Michael Schiavo's legal rights were politically motivated. Then a memo surfaced from GOP leaders to Republican Senators:

    "This is an important moral issue, and the pro-life base will be excited that the Senate is debating this important issue," said the memo, as reported by ABC News. "This is a great political issue, because Senator Nelson of Florida has already refused to become a co-sponsor and this is a tough issue for Democrats."

    Sure, Congressman, we believe you: it isn't political; it's principle! After all, when have you ever put politics over principle?

  • The GOP Majorities on the Senate Health, Education, Labor and Pensions Committee and the House Government Reform Committee cynically and unethically used their powers to issue patently disingenuous and false subpoenas supposedly designed to get Terri Schiavo to "testify" (the woman hasn't been able to speak for 15 years) at their hearings. Awfully clever, those Republicans: subpoenaed witnesses are under Congressional protection, so it would be theoretically unlawful to, say, remove a feeding tube from one. Luckily a Florida judge refused to respect this blatant abuse of the Congressional subpoena power and declared it a sham, which it undeniably was. The message sent by Republican Senators and Congressmen by this dishonest action is that process, integrity, precedent, rules and honesty can and will be thrown aside as long as they believe in the virtue of their cause…which, of course, isn't the least bit political.

  • Congressional Democrats are setting new records for craven opposition, even for them. As their Republican adversaries irresponsibly use the national legislature to insert the Federal Government into a family dispute involving the life of just one woman that has been thoroughly contested in state courts, the Democrats are running for cover. This is a time for responsible legislators to educate the public about what Congress' job is, and to expose the Republican majority's egregious abuse of power and process in this instance. Just as the Republican members' conduct should make any American wonder if they should be trusted with the power to govern, the pathetic cowardice of the Democrat members should cause a mass search for a third party. Ethics require courage, and from the looks of it, the Democrats in Congress are fresh out.

  • Congressional Republicans, unfettered by serious Democratic opposition, went ahead and passed a bill that over-rides Florida's courts and procedure and directs that a Federal Court should have jurisdiction over the question of whether Schiavo's feeding tube should be removed. It is quite possible, some say even probable, that this move is unconstitutional. But whether it is or not, it sets new highs for hypocrisy for a party that purports to champion federalism, a limited scope for the Federal Government, the supremacy of the states, and the separation of powers. Republican leaders attempted to wiggle out of their obvious abandonment of core governmental principles by saying that the life of Terry Schiavo "takes precedence" over governing ideology. Again, this is patently dishonest. What the bill shows is that Federalism is paramount unless it results in ends that conservative Republicans find objectionable. This is hypocrisy in its purest form…conduct proving that a person didn't really believe what he or she claimed to believe, conduct demonstrating that a position was all show and no conviction.

    Ditto their abandonment of the principles of the separation of powers, which Republicans had been invoking as they condemned "legislation from the bench" by liberal judges. Now, they blatantly interfere with the judiciary, for no reason other than the fact that they don't like its decision in a particular case.

    And while we're on the topic of dittoes, Rush Limbaugh, who can spin with the best of them, made a game attempt to frame the GOP Congressional power-grab in the Schiavo case as consistent with Republican ideals. Why, he said, the liberals are just terrified that the GOP is finally stepping in to stop out-of-control judges! Nice try, Rush, but it won't wash. Deciding a dispute between two parties that rests on whether a patient is vegetative or not and whether her husband can remove her feeding tube based on hearsay testimony that she authorized it is what judges do.

This is no abuse of judicial power. This is an abuse of Congressional power. And the most unethical thing is that the members who are doing the abusing know it.


The Terri Schiavo case will have a lasting impact on how the law deals with the unfortunate individuals who dwell in the purgatory between life and death. It will also stand as disturbing evidence of how easily our elected officials will toss aside ethical principles for political gain.

 

   
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