Terri Schiavo–Enduring Questions, Part Three

The sad case of Terri Schiavo has been a wake-up call for many Americans, and has brought to public attention the complex of medical realities and moral decisions that characterize our postmodern age. Medicine has made remarkable advances in recent decades, but cases like that of Terri Schiavo remind us all that medical technologies and medical knowledge have limits, even in this age of modern marvels and life-saving treatments. Beyond all this, the case of Terri Schiavo underlines the inescapably moral character of medical treatment and decision-making. Once again, enduring questions remain.

Fifth, what does this mean for other patients? Medical authorities estimate that at any given time, there are over a thousand patients diagnosed as living in something like a persistent vegetative state [PVS]. Medically defined, a persistent vegetative state is diagnosed when a patient is not in a coma, but shows no signs of alertness, recognition, or consciousness after treatment for at least a month.

Of course, Terri Schiavo’s experience has also revealed the difficulty of determining exactly when a patient is in a persistent vegetative state, over against a state of minimal consciousness–defined as a condition from which some form of recovery might be possible.

The widespread public support for the removal of Terri Schiavo’s feeding tube and hydration indicates that Americans have increasingly accepted a quality of life argument over against a worldview that is deeply rooted in the sanctity of human life. Once life is defined in terms of its supposed quality, humanity is itself redefined. Inevitably, human beings are then sorted according to some scale that would indicate a quality of life. Just as inevitably, that scale is certain to be renegotiated time and time again.

This much is clear: the judicially-mandated death of Terri Schiavo will serve as a precedent and a catalyst for similar decisions in other cases. If anything, this case may actually serve to fuel the “right to die” movement as increasing numbers of Americans determine that they will define the quality of life they will accept for themselves, and reserve the right to choose death over an existence that does not meet their expectations.

In all honesty, no one would choose to be in Terri Schiavo’s condition. Whatever its cause, the damage to her oxygen-deprived brain was massive. Without conceding that she is in a persistent vegetative state, her condition is, at the very least, marked by minimal consciousness.

But does this make her less than human? That is the presumption behind the movement to end her life. Human dignity is asserted with a crucial codicil–human life is worthy of protection only so long as the individual possesses a state of consciousness adequate to pass muster. Once again, humanity faces the ugly reality of a slippery slope towards moral horrors. Where does this logic end? We cannot act as if we do not know.

Terri Schiavo’s plight has led many to investigate the legal mechanisms of a “living will” or advance directive. These instruments are intended to allow an individual to assert his or her wishes concerning the continuation of medical treatment under defined circumstances. Internet Web sites offering model documents for living wills and advance directives have indicated a flood of interest in recent days, undoubtedly driven by concern over the Schiavo controversy.

Nevertheless, these legal mechanisms do not ensure the result those who sign them may expect. As in so many areas of life, the distinctions turn on the definitions. What happens when doctors disagree? Who will interpret the precise wishes of the individual in the urgent context of medical decision-making and crisis?

Furthermore, now that the courts have decided that food and hydration are forms of medical treatment, do those who sign such documents really intend to be starved to death or dehydrated once they can no longer speak for themselves? What are we to make of claims that death by dehydration and lack of nourishment is painless and gentle? Aggressive defenders of the decision to remove Terri Schiavo’s feeding tube and hydration have argued that Terri would feel no pain, discomfort, or anxiety. How can they know this?

Writing in The Los Angeles Times, reporters Karen Kaplan and Rosie Mestel actually claimed that some patients, fully conscious, experience a “sense of euphoria” after deciding to stop eating and drinking. Dr. Perry G. Fine, Vice President of Medical Affairs at the National Hospice and Palliative Care Organization told the reporters, “What my patients have told me over the last 25 years is that when they stop eating and drinking, there’s nothing unpleasant about it–in fact it can be quite blissful and euphoric. It’s a very smooth, graceful and elegant way to go.”

In a chilling addition, Dr. Fine objected to the language used in Terri Schiavo’s case. “The word ‘starve’ is so emotionally loaded,” he chided. “People equate that with the hunger pains they feel or the thirst they feel after a long, hot day of hiking. To jump from that to a person who has an end-stage illness is a gigantic leap.”

Dr. Robert Sullivan of Duke University Medical Center actually claimed that starvation “is not painful or uncomfortable at all. When we were hunting rabbits millions of years ago, we had to have a back-up mode because we didn’t always get a rabbit. You can’t go hunting if you’re hungry.”

Similarly, The New York Times ran an article with this headline: “Neither ‘Starvation’ nor the Suffering It Connotes Applies to Schiavo, Doctors Say.” Reporter John Schwartz, writing in the March 25, 2005 edition of the paper, implicitly criticized Terri Schiavo’s parents and various political leaders for using the word “starvation” in her case.

Schwartz took a more conceptual approach to the issue, arguing that the vocabulary is as much about public relations as medicine. He cited Larry J. Sabato, Director of the Center for Politics at the University of Virginia, as arguing that various groups are “coordinating the use of key words and phrases” in order to frame the debate. In the same vein, Kathleen Hall Jamieson, Director of the Annenberg Public Policy Center at the University of Pennsylvania, claimed that those who oppose the removal of Terri Schiavo’s feeding tube are prone to use language “that increases your perception of her as a sentient human being, whose capacity to tell you that she wants to stay alive is limited only by the fact that she lacks the capacity to speak.” On the other side, those who argue for Terri Schiavo’s death tend to use clinical and medical language in order to imply “that the person who was there is no longer there.” Jamieson suggested that science should intervene where “competing narratives” disagree.

Once again, scientific knowledge is presented as the solution to an issue that exceeds what science can know. This deep and reflexive cultural trust in science leaves our society unprepared to deal with troubling moral issues where the scientific reality is itself debated.

Jamieson and Sabato are right about this much–the battle over vocabulary, symbolism, and conceptual supremacy is indeed urgent. As evidence, just consider this statement reported in Schwartz’s article: “No one is denying this woman food and water.” Those words are attributed to Dr. Sean Morrison, Professor of Geriatrics and Palliative Care at Mount Sinai School of Medicine in New York. How can Morrison make this incredible claim? Schwartz explains that Morrison was referring to the normal process of drinking and eating–not to Terri Schiavo’s feeding tube and hydration.

Comments and arguments like these should serve to awaken us all to the fact that life and death, as well as eating and drinking, are being redefined before our eyes. No responsible person can minimize the difficult issues confronting medical doctors, family members, and patients when it comes to matters of life and death. Yet, it is now clear that we have now passed some important barriers of restraint, and we are looking at the Culture of Death on the advance.

Sixth, what does this mean for doctors? As the tragedy of Terri Schiavo unfolded, many Americans came to realize that doctors examining Terri had come to radically different diagnoses and judgments about her prospects for improvement. While media reports constantly stressed that physicians had diagnosed Terri Schiavo as being in a persistent vegetative state with virtually no hope of improvement or recovery, other doctors made contrasting judgments.

Specifically, Dr. William Hammesfahr, a neurologist who examined Schiavo, claimed, “They are truly withholding food from a person who is awake, alert, and can eat and swallow.” Hammesfahr, who had spent at least ten hours examining Schiavo, asserted that she could improve with therapy. Hammesfahr pointed to the fact that Terri Schiavo could swallow liquid, including her own saliva. “That’s liquid, and that’s the most difficult thing to swallow,” Hammesfahr said. “If she can swallow that she can swallow food or pudding.” Another physician, Dr. William P. Cheshire, Jr. of the Mayo Clinic in Jacksonville came to public attention when Governor Jeb Bush attempted to intervene by asking the Florida Department of Children and Families to determine whether Terri Schiavo was in a persistent vegetative state or a state of minimal consciousness.

In his effort, Governor Bush cited Dr. Cheshire as arguing that Mrs. Schiavo was probably in a “minimally conscious state” that could lead to improvement. “Although Terri did not demonstrate during our 90-minute visit compelling evidence of verbalization, conscious awareness or volitional behavior,” Cheshire reported, “yet the visitor has the distinct sense of the presence of a living human being who seems at some level to be aware of some things around her.”

That was just too much for The New York Times, which responded with an absolutely incredible example of anti-Christian bias. In “A Diagnosis with a Dose of Religion,” reporters John Schwartz and Denise Grady identified Cheshire as “a neurologist and bioethicist whose life and work had been guided by his religious beliefs.” The obvious implication of that leading identification is that Schwartz and Grady would prefer a neurologist and bioethicist who is in no way guided by religious beliefs.

The reporters went on to assault Dr. Cheshire for his association with the Center for Bioethics and Human Dignity, a group of leading Christian bioethicists. The reporters went on to claim that Cheshire “is not widely known in the neurology or bioethics fields.” In order to back up that assertion, they cited Dr. Arthur Caplan, Director of the Center for Bioethics at the University of Pennsylvania and a well-known advocate for removing Terri Schiavo’s feeding tube. When asked about Dr. Cheshire, Dr. Caplan replied, “Who?” Presumably, if Dr. Caplan doesn’t know you, you can’t be known in the fields of neurology or bioethics.

Even further animus was demonstrated by Dr. Ronald Cranford, a neurologist at the University of Minnesota Medical School, who examined Terri Schiavo and declared her to be irreversibly brain-damaged. “I have no idea who this Cheshire is,” Cranford responded. “He has to be bogus, a pro-life fanatic. You’ll not find any credible neurologist or neurosurgeon to get involved at this point and say she’s not vegetative.”

How’s that for a frontal assault? According to Dr. Cranford and company, anyone who opposes their diagnosis of a persistent vegetative state “has to be bogus” or “a pro-life fanatic.”

The bottom line is that the medical community is increasingly directed towards the administration and management of death. We can fully understand that trained, qualified, and competent medical specialists may disagree on the particulars of a specific case and even on a diagnosis. But, when medical doctors start throwing around the kind of slanderous anti-Christian language as that directed at Dr. William Cheshire, we can be sure that more than medical ego is at stake. Deep differences over human dignity and the sanctity of human life are evident and undeniable in these examples. This kind of name-calling betrays a sickness at the very heart of the medical profession. Are doctors to cure, or to kill?

These enduring questions are certain to frame both public debate and private decisions for years to come. The tragedy of Terri Schiavo can, sadly enough, help to frame these issues toward moral recovery. At the same time, her case could add fuel and momentum to the Culture of Death. Time will tell.