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June 15, 2005

Highbrow Hentoff: Didion, Schiavo, and bulimia

Joan Didion distorts the record on Terri Schiavo in the June 9th issue of the New York Review of Books.

Didion disingenuously implies that there is little evidence that Schiavo suffered from bulimia:

However comforting it may have been to believe this, the suggestion (no diagnosis exists) of an "eating disorder" appears to have been entirely assumptive, based on no evidence beyond the unexceptional facts that she had some years before gained weight, gone on a diet, and lost the weight. We do know that on Theresa Schiavo's initial testing the level of serum potassium was 2.0, not only well below the "normal" range, which is 3.5 to 5.0, but also below the level, 3.0, at which cardiac effects may be expected. Bulimia, or any vomiting at all, can cause potassium deficiency. Since other common causes include kidney disorders, colon polyps, and the ingestion of diuretics, laxatives, asthma medications, certain penicillins, or even large amounts of licorice, the lowered serum potassium level on its own does not tell us what led to the deficiency that is believed to have triggered the cardiac arrest.

"What was finally diagnosed as the reason for what happened to her?" Larry King asked Michael Schiavo on CNN on March 21.

"They're speculating that she had bulimia," Michael Schiavo said. (Who "they" might be was left unexplored.)

"Did you have any knowledge of that?" Larry King asked.

"No, I did not," Michael Schiavo said.

If the NYRB has any fact-checking standards at all, Joan Didion must be disingenuous when she says that "no diagnosis exists" of Schiavo's bulimia. Of course no diagnosis exists. That's how Michael Schiavo was able to successfully sue Terri's doctors for failing to diagnose her bulimia, despite overwhelming evidence that she was suffering from a severe eating disorder:

During the malpractice case, at least one of Schiavo's friends testified they knew she was bulimic because after meals out, she always immediately excused herself to go to the bathroom. Her husband also knew she had peculiar eating patterns but did not realize they were dangerous, Fox said.

Medical records from the hospital where Schiavo was treated after her collapse note that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10-15 glasses of iced tea."

Fox said that in the months before her collapse, Schiavo went to the doctor because she had stopped menstruating. It was a silent "cry for help," the lawyer said. But the doctor did not take a complete medical history that might have revealed an eating disorder.

The jury put the damages at $6.8 million but reduced the verdict to about $2 million because it felt [Terri] Schiavo was partly at fault for her collapse. [AP/USA Today]

Didion apparently knows about the lawsuit, but distorts the substance of the case:

In 1992 [Schiavo] had pursued (and finally settled, for approximately $1.1 million after fees) a medical negligence suit against the doctors who had supervised Theresa Schiavo's infertility treatment, arguing that they had failed to pick up the potassium imbalance.

Wrong. Michael sued Terri's doctors for failing to pick up on the pattern of symptoms that pointed almost unequivocally to bulimia. Her medical records document several major warning signs including recent history of massive weight loss, excessive concern about eating and weight, amenhorrhea, and, of course, infertility.

Despite what Didion says, Schiavo didn't sue Terri's doctors for failing to detect a potassium imbalance, per se. That would have been unrealistic. There's no reason to believe that Schiavo had a chronic potassium imbalance that would have been detectable at any specific medical checkup. The hypokalemia that ultimately destroyed Terri was probably induced by intense bingeing and purging near the time of her death. Obviously, as a bulimic, Terri might have been hypokalemic on a regular basis. However, electrolyte imbalances are not invariably, or even usually fatal. Of course, if Terri had been found to have been hypokalemic at any of her checkups and her doctors hadn't asked about bulimia, that would have been even more evidence of malpractice. However, I don't know whether any of Schiavo's bloodwork revealed any prior hypokalemic episodes.

Since Schiavo's autopsy results became public, various media reports have stressed that the autopsy showed no proof of an eating disorder. No doubt this statement is accurate, but it is of little probative value. There's no reason to expect that Terri's eating disorder would have been evident upon autopsy, seeing as it had been over 15 years since her last possible bulimic episode.

Didion goes on to claim that it's doubtful that Schiavo suffered a heart attack. This is a semantic game that Schiavo conspiracy-mongers are fond of. Colloquially, we refer to most cardiac arrests as "heart attacks." Medically, the term "heart attack" maps roughly onto the term "myocardial infarction." A myocardial infarction occurs when the blood flow to the heart is interrupted and parts of the heart muscle die from lack of oxygen. Cardiac arrest may ensue if the infarction knocks out enough of the heart muscle. Usually, myocardial infarctions are caused by blood clots and/or narrowing of the arteries. Terri Schiavo's heart stopped, but not because the blood supply to her heart was cut off. We know this because doctors found no evidence of disease in her heart or blood vessels. As Didion notes, she was suffering from severe potassium depletion at the time of her collapse. Potassium deficiency impairs the heart's ability to conduct the electrical impulses that sustain a normal heartbeat. If Didion wants to be a stickler for terminological precision, she might want to describe Terri's collapse as "a cardiac arrest" rather than "a heart attack"--but there are no honest rhetorical points to be scored by this distinction.

The rest of Didion's article is a meandering, pretentious recycling of the conventional wisdom as reflected by mainstream news coverage. In fairness, it must have been written long before the Schiavo autopsy results became public.

Update: Great post on Schiavo's autopsy from Jonathan, an internal medicine resident blogging at J Train, including a link to the full autopsy report.


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From the article:

"Since other common causes include kidney disorders, colon polyps, and the ingestion of diuretics, laxatives, asthma medications, certain penicillins, or even large amounts of licorice..."

A kidney disorder would have been otherwise evident from her labs. Colon polyps are not going to cause this level of acute hypokalemia, especially in a 20-year-old. It would have taken a gallon of asthma medication (albuterol) to do this, as it would for the antibiotics. Licorice? I think someone might have noticed the anise breath.

Laxative abuse falls under the heading of "bullemia", and diuretic abuse is not uncommon among those desparate to drop a few pounds.

The autopsy report itself includes the medical examiner's report, in which he goes to some length to explain away the low potassium. He's really reaching, as Didion is here. There just aren't many ways to put these facts together except to say that Terri had an eating disorder.

(I write a bit more at my LiveJournal, linked above.)

I've always thought of Didion the way I now think of Hitchens -- a very talented writer who's opportunistic and self-promoting to the point of sleaziness. She tends to sero in on high-profile stuff.

What level of credibility should we award to an author who writes an almost entirely speculative piece and tries to pass it off as being based on reliable facts? I cannot imagine any author who would seek to publish something like this before all of the evidence was in.

Why are there so many blank pages in the Autopsy Report?

"Why are there so many blank pages in the Autopsy Report?"

You weren't supposed to notice that. Expect a knock on your door tomorrow night.

By the way, why would it be "comforting" if she had bulima? I'm inclined to think that this makes it sadder and more disturbing, but that's me...

The Didion piece is special pleading; it seemed motivated by something totally unrelated to the Schiavo case. She kept asking why nobody was seriously considering the key issue of quality of life as if it was a discussion that needed to take place urgently.

The part that threw me most was her account of the politicians who sought to capitalize on Schiavo. In a sentence or two, she said "they always do that." I love Didion, and she's written brilliantly on how politicians capitalizing in nasty ways on foolish thoughts, especially in the NYRB. Her whole beat for the NYRB has been how conservative politicians stir things up, and she doesn't even mention (if I remember correctly) the fact that a bunch of pseudo-preachers overturned a specific court-ruling to whip up the base. Weird.

Her last book on California was pretty good, and contra John Emerson, had nothing to do with self-promotion or opportunism.

What blank pages? I went through the entire thing and there were zero blank pages. Each new section started on a fresh page so there were some half pages, but that is normal for an official document.

Salon ran a piece on Didion's essay on May 27th, with absolutely vomit-inducing gushing praise from their tech writer. (What makes him qualified to comment on the issue is beyond me, but that's what happened.) I sent an extremely angry (and profane) e-mail demanding to know Didion's expertise in the area and pointing out that Salon had rightly castigated Bill Frist for making far less inflammatory remarks about the case. I did get a reply from one of the Salon editors: I was told that Didion's daughter had been terribly ill, Didion's husband had died suddenly, and "the issues" of the Schiavo case were very much on Didion's mind. In my second e-mail I asked why Didion's tragic personal situation gave her license to lie about the facts of the case -- I haven't had a reply yet.

Let's not be too nice to Didion. The facts she so happily distorts are part of the public record.

Her last book on California was pretty good, and contra John Emerson, had nothing to do with self-promotion or opportunism.


Did you hear any of the NPR interviews she gave in support of that book?

Didion is loathesome, and I really don't get why anyone thinks she's a good stylist or a coherent thinker. Unlike Hitchens, she doesn't even have something worthwhile in her back catalogue to point to.

Have you read the autopsy report (not just the press reports)? It's here:

You'll see that the medical examiner doesn't think she was bulimic. He doesn't think the low potassium had anything to do with bulemia. He doesn't give credit to the existence of any "warning signs" of bulimia. If you think that the evidence conclusively demonstrates that she was bulimic, then you think the autopsy report is incorrect. Simple as that.

Maybe you think the medical examiner is an idiot, or maybe he's a lying sack of shit who's covering up for someone. So that would put you squarely in the Randall Terry camp, wouldn't it?

I mentioned this in the comments at No More Mister Nice Blog last month: I think Didion should be given a pass on this one because she's had some tragedy in her personal life in the last year or so that I think has interfered with her objectivity. I wish that she had said so in the piece, given her penchant for inserting the personal, but she opted not to do so.

I have read the ME's report. I don't think he's stupid or lying. He didn't find any evidence of bulimia at autopsy and he said so. However, I'm not sure what signs of bulimia could possibly have been evident at autopsy after 15 non-bulimic years in PVS. Maybe the ME was saying that Terri didn't have scars on the back of her hand from sticking her fingers down her throat, but then again neither do most bulimics.

The ME argued that Terri's low potassium level could have been an artifact of the resuscitation attempts. It could have been, but let's look at the balance of probabilities. Bulimia is very common in women Terri's age. Spontaneous cardiac collapse is extraordinarily rare in this demographic. The ME didn't find any evidence of trauma, nor did medical personnel on the scene. Catastrophic but mark-free trauma is utterly far-fetched, especially when there's no evidence of physical abuse in the Schiavo's marriage (not medical, not biographical).

Terri was never diagnosed with bulimia during her lifetime. However, as the ME's report notes, both sides in the malpractice suit assumed that she was bulimic. That's what's dishonest about Didion's report. She distorts the medical/legal record. If she wants to challenge the bulimia claim, she's welcome to do so, but she shouldn't lie about the substance of the malpractice trial.

Nobody saw Terri purging, and she didn't tell anyone she had an eating disorder. But then again, most bulimics don't purge in front of an audience. Her friends and her husband testified about her marked preoccupation with eating and weight, her bizarre dietary rituals, her habit of sneaking off to the bathroom after meals, etc. Terri's massive consumption of iced tea is also consistent with bulimia. Bulimics often consume huge amounts of fluids to curb their appetites, facilitate vomiting, and offset purge-induced dehydration. The fact that she wasn't menstruating at the time of her collapse would be another indication of an eating disorder. Terri didn't have any of the other conditions that might have explained amenorrhea in a woman her age (not pregnant, no pituitary tumor, etc.).

Oh, I thought Didion's article was dreadful. But I'm trying to make a different point. The guy at J-Train, in what you call a "great post," says that "the medical examiner is really reaching in a lot of places, particularly in trying to explain Terri's low potassium." That is, he thinks that the autopsy report is less than fully persuasive on the eating disorder issue. Well, unless you're a genuine expert yourself, you can't pick and choose. Either you trust the ME in all he does, or you distrust him in all he does. You can't say, "the ME is wrong about the potassium but right about the visual cortex." Once you say that, you deny that the report has any authoritative weight and you're back to where you were before the report was issued. And since you (and I) have no genuine expertise, we are open to the criticism that we select facts that support our preconceived positions and reject the rest. You, for example, find the J-Train guy more credible than the ME. Why is that?

More generally, this is the question of authority as a way of knowing. "I know this is true because [the ME, my professor, the author of my textbook, my minister, my mom] told me it's true." After sense impression it's the most important source of knowledge that we have, but it's fraught with difficulties.

I already have someone in my comments claiming that Terri was so not blind. The balloon! Her eyes followed it! How can an edited tape lie?

Thanks for pointing out the "heart attack" idiocy on the part of the media and Didion, where they forget deadly "heart attacks" happen all the time to athletes and anorexics due to rhythm disturbances which are explained by electrolyte imbalance.

Oh, I thought Didion's article was dreadful. But I'm trying to make a different point. The guy at J-Train, in what you call a "great post," says that "the medical examiner is really reaching in a lot of places, particularly in trying to explain Terri's low potassium." That is, he thinks that the autopsy report is less than fully persuasive on the eating disorder issue. Well, unless you're a genuine expert yourself, you can't pick and choose. Either you trust the ME in all he does, or you distrust him in all he does. You can't say, "the ME is wrong about the potassium but right about the visual cortex."

What are you talking about? The J-Train post doesn't say the ME was wrong about the potassium, and neither did Lindsay's post. The most anyone said was that the examiner listed some potential causes that were probably pretty unlikely. That's a completely different statement.

Jonathan and the ME disagree about whether the resuscitation is the most likely cause of Terri's low potassium level. Jonathan isn't saying it's impossible, the ME isn't claiming it's a sure thing. I'm trained as an EMT-B and I work as a medical writer, but my expertise pales beside either of them. Maybe some of our other MD, RN, and paramedic readers would like to weigh in on the electrolyte issue.

The ME>agrees that if Terri's potassium level wasn't an artifact, then "bulimia nervosa would be high on the list of differential diagnoses."

I think the issue is the balance of probabilities. The ME can't confirm that Schiavo was bulimic. However, he's not an expert on eating disorders, nor is it likely that he'd find unequivocal evidence of bulimia at autopsy 15 years after the fact. He acknowledges in the topline summary that numerous experts testified at the malpractice trial that Terri's symptoms were consistent with bulimia and that both Schiavo and the doctors he sued conceded that Schiavo's collapsed was caused by her bulimia. The most logical malpractice defense would have been to argue that Terri didn't collapse because of bulimia. After all, if her collapse were unexplained, then there'd be no reason to think that her doctors missed the clear warning signs of whatever killed her, and they'd therefore be off the hook.

In a sense, the autopsy puts us back at square one. No evidence of abuse, no direct proof of bulimia. However, let's remember the logical options: bulimia, unexplained collapse + artifactual hypokalemia, and alternative pathological cause for hypokalemia. We can pretty much eliminate hypothesis that Terri collapsed from some other cause of hypokalemia. Josh does a good job of explaining what those other hypotheses are and why each is either unlikely, or consistent with bulimia nervosa.

According to the ME's report, Terri wasn't tested for diuretics or caffeine at the time of her collapse. She was tested for amphetamines and other street drugs, but not for OTC diet pills, herbal preparations, or laxatives.

How likely is it that Terri had so many of the symptoms of bulimia but died of some physiologically mysterious cause. Without the hypokalemia, we wouldn't even have a proximate mechanism to explain her collapse.

Eli, J Train and Majikthise are arguing with the ME. Read what they wrote, that's what they're doing. The ME says he thinks the bulimia is not proved ("says" because "reaching" implies a degree of conscious dissimulation, not mere error); they think it is. And that's fine, a cat can look a king, as they say. But it's not consistent to take issue with the ME on potassium and then to invoke him as an authority on other issues. Once you take issue with the ME, he becomes just another voice in the debate -- you've denied that his views are privileged in a way that should silence other speakers.

The J Train guy is a resident in internal medicine. Lindsay is a doctoral candidate in philosophy. The ME is a qualified and experienced pathologist. I for one am not competent to judge this debate on the merits. Other than the merits, what criteria can I use to decide who I agree with? Loyalty, perhaps- I'm a regular reader of Majikthise and I've never heard of the ME before. Narrative coherence- the version of the story that makes Terri out to be a bulimic is more satisfying than not knowing what happened to her, and we human beings have a strong prediliction to impose narrative form on experience. Bias- the bulimia version provides an alternative to the Michael-as-abusive-husband story line, which is unacceptable to those of us who have chosen sides with Michael and against the Schindlers. These are all reasons that people have when they choose to believe things, and they have nothing to do with truth.

That leaves authority. And I for one choose to go with authority this time. Not a great way of knowing, but the best under the circumstances.


The ME discussion regarding the potassium (bottom of page 29 in the PDF) is in regard to the 1990 episode - not the results of the autopsy. I would agree that the ME has authority with regard to the autopsy results and pathology, but with regard to the earlier events, any number of medical professionals (including JTrain) can have competing authority, as they all have access to the same facts.

pebird- that's true, although I expect that the ME has thought longer and harder about these issues than J Train has, and that he has perhaps more complete access to facts.

But look at where we are. We have two competing theories:
(1) Schiavo was bulimic. (2) Schiavo was abused (perhaps strangled) by her husband.

The ME discusses the evidence for both and rejects both. Obviously the readers of this blog are predisposed to (1) and not (2) because (2) is not consistent with the belief that Michael was a proper guardian, which is something you must believe if you have concluded that Schiavo would have wanted the feeding tube removed. (There is no inherent contradiction between (1) and (2) - a rational person could believe both (1) and (2), although no one seems to do so.)
No one on this thread has criticized the ME's conclusion that the apparent trauma detected in 1991 was the result of osteoporosis, not beatings, which is open to question on the same grounds as his conclusions about potassium.
The ME's report is highly unsatisfying on these point, because human beings simply can't accept ambiguity and lack of knowledge. We impose patterns and narrative on random facts. We look at the moon, we see shadows and spots, our minds turn these into a face, and we make up a story about the man in the moon. The conclusion that we cannot know what happened is just not acceptable.
So, we find another expert - an unknown person posting at a blog - who gives us the story we want to believe. And so we believe him. Who knows, perhaps he's even right! This is what human beings are like. And it has nothing to do with finding the truth.

I may be wearing out my welcome, but one more point: the J Train guy's statement that the ME is "reaching" is an assertion that the ME is being less than frank. Why? Perhaps, J Train is inviting us to speculate, the political pressures were too great to permit him to be fully honest. Perhaps he had to be silent on the cause of the injury and so he simply discredited both narratives.
In my view, this sort of speculation is irresponsible and dangerous. There are times when it is necessary to show respect for an authority as a source of truth unless and until there is a clear reason to conclude that the respect is unwarranted. This in my opinion is one of those times.

It's not very parsimonious to argue simultaneously that Schiavo was bulimic, and that she was abused, and that she was fatally strangled or smothered by her husband who left no marks.

All of the above could be true simultaneously, but there's strong evidence for the first assertion, and none for the other two.

Do you think it's plausible that an intruder broke in and strangled Terri, again, leaving no marks? If not, not, why would you take seriously the hypothesis that Michael Schiavo did anything similar? We've only got the physical evidence to go on.

Granted, when someone dies, you look to their intimate partner first. However, by the ME's own account, there's no physical evidence to point to Michael or anyone else as an attacker.

Michael Schiavo had no prior history of violence, nor did he ever been connected to any subsequent violent incidents. It's pretty far-fetched to imagine that this non-violent guy strangled his wife without warning and without leaving any incriminating marks and went on to live an exemplary life (by any objective and reputable measure). It's unfair to publicly entertain that hypothesis absent some further evidence, especially considering that he his wife had severe hypokalemia on admission and a long history of eating disordered behavior affirmed under oath by her husband and at least one of her friends, not to mention several physical signs of an ED.

Sure it's logically possible that she was strangled, but she had no "battered wife" or "strangled person" medical history and a raft of "ED otherwise unspecified/bulimia" signs and symptoms.

If you want to explore all logical possibilities consider (3) Cardiac arrest due to dehydration/caffeine intoxication/bulimia nervosa and (4) Further potassium depletion due to resuscitation efforts.

I agree with the ME in that there are alternate possibilities. I believe that he has to present his information in this way, because there is no "direct" evidence of Terri having an eating disorder.

There is, however, a ton of circumstantial evidence pointing in that direction, and to me it is enough to make the other possibilities extremely unlikely. I can say that, because unlike the ME, I'm not a government official stating an official position, nor am I staking my reputation on it.

I would not likely argue with the pathologists when it comes to the autopsy, but I deal with electrolyte imbalances many times daily, so I'm willing to disagree here.

I don't take the possibility that she was strangled seriously. I don't take the possibility that she was bulimic seriously. I have no serious opinion. I am not competent to have an serious opinion. Here is what I am competent to do: to read the about the ME and to read his report, to judge that he appears to be honest, experienced, serious, and reliable, and to accept his judgment. That is the full extent of my competence. I may have and express opinions that go beyond that, but they are not "serious." They are like the opinions I have about the characters in a novel. They are the kind of opinions that human beings form about all sorts of events of which we are ignorant, because we can't help it. That is how we are built.

There are thousands of trials going on in the country all the time. I represent parties in some of them, and in those cases I generally learn enough to form an opinion. And what I have also learned is that unless you are very close to a case, the opinions you form about it are almost certainly wrong.

And now I have certainly worn out my welcome, and my family will be wanting to know why I am still at work and not at home with them, so I will say goodnight.

And now I have certainly worn out my welcome, and my family will be wanting to know why I am still at work and not at home with them, so I will say goodnight.

Worn out your welcome? Not at all. But have a good evening, all the same.

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