The story of Terri Schiavo should be disturbing to all of us

The Terri Schiavo case raises complex and emotional issues about the end of life

Schiavo case shows what kind of president Bush would be

So what was known about Terri Schiavo's wishes and values? Since she unfortunately left no written advance directive, the next step would be to meet with her closest family members and try to understand what she would have wanted under these medical circumstances if she could have spoken for herself, drawing on the principle of “substituted judgment.” Some families unite around this question, especially when there is a shared vision of the patient's views and values. Other families unravel, their crisis aggravated by genuine differences of opinion about the proper course of action or preexisting fault lines arising from long-standing family dynamics.

Schiavo case, 10 years later, still a 'tragedy'

Having viewed some of the highly edited videotaped material of Terri Schiavo and having seen other patients in a persistent vegetative state, I am not surprised that family members and others unfamiliar with this condition would interpret some of her apparent alertness and movement as meaningful. In 2002, the Florida trial court judge conducted six days of evidentiary hearings on Ms. Schiavo's condition, including evaluations by four neurologists, one radiologist, and her attending physician. The two neurologists selected by Michael Schiavo, a court-appointed “neutral” neurologist, and Ms. Schiavo's attending physician all agreed that her condition met the criteria for a persistent vegetative state. The neurologist and the radiologist chosen by the patient's parents and siblings, the Schindler family, disagreed and suggested that Ms. Schiavo's condition might improve with unproven therapies such as hyperbaric oxygen or vasodilators — but had no objective data to support their assertions. The trial court judge ruled that the diagnosis of a persistent vegetative state met the legal standard of “clear and convincing” evidence, and this decision was reviewed and upheld by the Florida Second District Court of Appeal. Subsequent appeals to the Florida Supreme Court and the U.S. Supreme Court were denied a hearing.

Let us begin with some medical facts. On February 25, 1990, Terri Schiavo had a cardiac arrest, triggered by extreme hypokalemia brought on by an eating disorder. As a result, severe hypoxic–ischemic encephalopathy developed, and during the subsequent months, she exhibited no evidence of higher cortical function. Computed tomographic scans of her brain eventually showed severe atrophy of her cerebral hemispheres, and her electroencephalograms were flat, indicating no functional activity of the cerebral cortex. Her neurologic examinations were indicative of a persistent vegetative state, which includes periods of wakefulness alternating with sleep, some reflexive responses to light and noise, and some basic gag and swallowing responses, but no signs of emotion, willful activity, or cognition. There is no evidence that Ms. Schiavo was suffering, since the usual definition of this term requires conscious awareness that is impossible in the absence of cortical activity. There have been only a few reported cases in which minimal cognitive and motor functions were restored three months or more after the diagnosis of a persistent vegetative state due to hypoxic–ischemic encephalopathy; in none of these cases was there the sort of objective evidence of severe cortical damage that was present in this case, nor was the period of disability so long.

A family photo of Terri Schiavo, taken at Terri's hospital ..

This sad saga reinforces my personal belief that the courts — though their involvement is sometimes necessary — are the last place one wants to be when working through these complex dilemmas. Although I did not examine her, from the data I reviewed, I have no doubt that Terri Schiavo was in a persistent vegetative state and that her cognitive and neurologic functions were unfortunately not going to improve. Her life could have been further prolonged with artificial hydration and nutrition, and there is some solace in knowing that she was not consciously suffering. I also believe that both her husband and her family, while seeing the situation in radically different ways, were trying to do what was right for her. Her family and the public should be reassured and educated that dying in this way can be a natural, humane process (humans died in this way for thousands of years before the advent of feeding tubes).

Terri Schiavo Utilitarianism - Outside The Beltway

On March 18, 2005, Ms. Schiavo's feeding tube was removed for a third time. The U.S. Congress then passed an “emergency measure” that was signed by the President in an effort both to force federal courts to review Ms. Schiavo's case and to create a legal mandate to have her feeding tube reinserted yet again. The U.S. District Court in Florida denied the emergency request to reinsert the feeding tube, and this decision was upheld on appeal. Multiple subsequent legal appeals were denied, and Ms. Schiavo died on March 31, 2005, 13 days after the feeding tube was removed.

Euthanasia and Terri Schiavo ..

The right of competent patients to refuse unwanted medical treatment, including artificial hydration and nutrition, is a settled ethical and legal issue in this country — based on the right to bodily integrity. In the Nancy Cruzan case, the Supreme Court affirmed that surrogate decision makers have this right when a patient is incapacitated, but it said that states could set their own standards of evidence about patients' own wishes. Although both the Schiavo and Cruzan cases involved the potential withdrawal of a feeding tube from a patient in a persistent vegetative state, the family was united in believing that Nancy Cruzan would not want to be kept alive in such a state indefinitely. Their challenge, under Missouri law, was to prove to the court in a clear and convincing manner that this would have been Nancy Cruzan's own wish. The Schiavo case raises much more challenging questions about how to define family and how to proceed if members of the immediate family are not in agreement.