Schiavo Reprise I
1. What is the issue here?
Morally and legally, the Terri Schiavo case is about a patient's right to refuse medical treatment. This piece by an editor of the American Journal of Bioethics gets to the heart of the matter. (I believe the author is Professor Glenn McGee.) As he notes, there is an overwhelming consensus any adult has the right to refuse any medical treatment. Disabled and incapacitated patients retain this right. The only difference is that these patients must be represented by guardians charged to speak on their behalf.
The Schindlers and their supporters have no principled objections to the system by which guardians are appointed. They aren't arguing that parents are more appropriate guardians than spouses in general, or that the Federal courts should arbitrate all guardianship cases, or even that the withdrawal of feeding tubes is unethical. All they care about is reversing a decision on a case in which they have a personal stake.
2. What's NOT at issue here?
This case has nothing do with with euthanasia. Terri Schiavo's feeding tube has been removed because the Florida courts have determined that she would not have wanted it. She is not being deliberately killed, she is being allowed to die the death she would have wanted.
It is an insult to the hospice professionals who care for Terri to insinuate that she will die a grisly death. Terri is in the hands of skilled and compassionate professionals who will ensure that her death is as peaceful as possible. We have no evidence that Terri is capable of any subjective mental life, let alone suffering. But even those who dispute this point must admit that hospice professionals routinely manage the removal of feeding tubes in patients with normal levels of consciousness. There is nothing unethical about removing a feeding tube from a fully conscious person who doesn't want it. On the contrary, it would be medical malpractice not to honor the patient's wishes. The same principle applies to Terri Schiavo.
This case has nothing to do with the lurid gossip surrounding Terri's marriage. The courts have heard the allegations of abuse, infidelity and avarice and dismissed them as unfounded and irrelevant. The issue is whether Terri would have wanted a feeding tube. The courts decided that she wouldn't, based in part on Michael Schiavo's testimony. Michael Schiavo is Terri's legal guardian, but he chose to allow the court to make the final determination as to whether Terri would have wanted to be maintained in her current state.
In May of 1998 Michael Schiavo filed a petition for a court to determine whether Terri's feeding tube should be removed. In February of 2000, Judge Greer of the Circuit Court for Pinellas County ruled that there was clear and convincing evidence that Terri Schiavo would not have wanted a feeding tube (.pdf via Abstract Appeal, linked to previously).
Note to the too-much-TV crowd: If you think any of the soap opera allegations are relevant, read the actual decisions before repeating any more gossip. The decisions explicitly address the potential for conflicts of interest on both sides.* I guarantee that the presiding judges were better informed than you or I, having actually heard the testimony. If you still think that your contrary hunch about Michael Schiavo's motives is relevant, please explain why society at large should care about your inklings. On TV, you get to keep appealing the verdict until you get a result you like. In real life, the judge is generally considered the binding arbiter. Your disagreement about the import of various pieces of evidence doesn't count unless you can show a defect in his legal reasoning or a gross misrepresentation of the facts presented to the court.
The Second District Court affirmed Greer's decision in January, 2001, concluding:
In the final analysis, the difficult question that faced the trial court was whether Theresa Marie Schindler Schiavo, not after a few weeks in a coma, but after ten years in a persistent vegetative state that has robbed her of most of her cerebrum and all but the most instinctive of neurological functions, with no hope of a medical cure but with sufficient money and strength of body to live indefinitely, would choose to continue the constant nursing care and the supporting tubes in hopes that a miracle would somehow recreate her missing brain tissue, or whether she would wish to permit a natural death process to take its course and for her family members and loved ones to be free to continue their lives. After due consideration, we conclude that the trial judge had clear and convincing evidence to answer this question as he did.
Over the next several years, the Schindlers sought to reverse the decisions, arguing that new evidence had come to light about Terri's wishes and that new treatment could improve her condition. The "new evidence" in question consisted primarily of affidavits from Michael Schiavo's ex-girlfriend claiming that Schiavo had confessed to perjury. (Not surprisingly, they got relatively little milage out of this particular ploy.)
In October of 2002 Judge Greer held a new trial on the medical treatment issues. In his ruling, the judge addressed the major medical evidence, including the vaunted balloon footage:
At first blush, the video of Terry Schiavo appearing to smile and look lovingly at her mother seemed to represent cognition. This was also true for how she followed the Mickey Mouse balloon held by her father. The court has carefully viewed the videotapes as requested by counsel and does find that these actions were neither consistent nor reproducible. For instance, Terry Schiavo appeared to have the same look on her face when Dr. Cranford rubbed her neck. Dr. Greer testified she had a smile during his (non-videoed) examination. Also, Mr. Schlinder tried several more times to have her eyes follow the Mickey Mouse balloon but without success. Also, she clearly does not consistently respond to her mother. The court finds that based on the credible evidence, cognitive function would manifest itself in a constant response to stimuli. [Emphasis added.]
For a more detailed discussion of the medical facts, see Rivka's excellent post at Respectful of Otters. The author is not only a lucid writer but also a clinical psychologist with post-graduate training in neuropsychology, not to mention a long standing interest in disability issues. Compare Schiavo's scan to that of a normal brain at Alas, a Blog.
Finally, this case is not about the semantics of the term "persistent vegetative state." As I will argue in my next post, there is no doubt that Terri Schiavo satisfies the clinical criteria for this diagnosis. Nor is there any doubt that her condition is permanent. Her higher brain centers have been destroyed and replaced by fluid. I'm putting the PVS material in a subsequent post because I think it ultimately detracts from the central issue of the case--Terri's wish not to continue as she is.
* Judge Greer found that the Schindler's financial motivations were just as conflicted as those of Michael Schiavo. Michael was awarded $300,000 for his own loss, and the Schindlers demanded that he share it. The money was paid out in February 1993. Schiavo and the Schindlers last spoke on February 14 of that year. Judge Greer wrote that that the Schindlers fell out with Schiavo over Michael's share of the malpractice settlement. (See the 2000 ruling linked to above)