Exploring the Terri Schiavo Ethics Meltdown
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
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
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
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,
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,
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
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
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
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
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
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
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.