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2005/12: Should brain-damaged woman Terri Schiavo's feeding tube have been removed?
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What they said ...
'The base of Terri Schiavo's brain still functions, and although there's still a lot of discussion [about the consequences of severe cortical damage], there's no consensus at all that this constitutes death'
Dr Timothy Quill
'I have no doubt that Terri Schiavo is in a persistent vegetative state and that her cognitive and neurologic functions are unfortunately not going to improve'
Dr Timothy Quill
The issue at a glance
On March 18, 2005, the feeding tube supplying food and water to a 41-year-old brain-damaged American woman, Terri Schiavo, was removed for the third and final time. Thirteen days later Terri Schiavo died, apparently as a result of heart failure brought on by this removal of food and water.
Prior to her death, Terri Schiavo had become the centre of an enormous ethical, political and medical controversy.
Background
It is generally held that Terri Schiavo was in what is termed a 'persistent vegetative state'. This means she had suffered major brain damage effecting her cerebral cortex and had little or no volition or conscious awareness. Her brain stem was still functioning and so she was able to breathe, move and perform a number of other vital functions.
Terri Schiavo had been in this condition for fifteen years. Her husband, Michael Schiavo, had applied to a Florida court, (the Schiavos lived in Florida) to have his wife's feeding tube removed eight years after the incident that left her brain damaged. (Under Florida law a spouse automatically becomes an incompetent person's medical proxy if that person has not made other arrangements prior to incapacitation.)
At the time Mr Schiavo made this application Florida law would not have allowed his wife's feeding tube to be removed as such an act would have been regarded as euthanasia, the deliberate ending of a patient's life.
Florida has no legislation permitting euthanasia. It does, however, have legislation allowing life-prolonging medical procedures to be ended if there is no hope of a cure and if the patient wants this treatment ended.
In between Mr Schiavo's application and the court's ruling that Mrs Schiavo would have wanted the tube removed, Florida law was changed so that the artificial administration of food and water to a person in a persistent vegetative state was reclassified as a 'life-prolonging procedure' which a patient in a condition like Terri Schiavo's could choose to end.
Terri Schiavo's parents repeatedly challenged the court's ruling and were supported in this by the Florida state government, especially its Governor, Jeb Bush (the brother of the current president).
The case ultimately came to involve a conflict between two branches of government, the executive (Governor Bush's administration) and the judiciary (the courts). Groups representing the disabled claim the case demonstrates prejudice against the disabled as Mrs Schiavo was brain damaged, not suffering a terminal condition. There was also much dispute as to whether food and water should be regarded as a medical procedure which can legitimately be ended at the request of the patient or his/her proxy. There are those who hold that this is not legitimate and is a form of passive euthanasia.
Clarification of terms
1. Euthanasia, commonly referred to as 'mercy killing', is generally understood to mean deliberately ending the life of a suffering, terminally ill person. However, in legislation recently passed in the Netherlands, euthanasia and doctor assisted suicide are available to people who are not suffering a terminal or life-threatening condition.
Passive and active euthanasia.
2. Passive euthanasia refers to the failure to take an action that may prolong a patient's life.
A possible example of passive euthanasia is the withdrawal from a patient of food and sometimes water. This is what is sometimes done in the case of grossly deformed newborn babies who have no long-term life expectancy. (The removal of Terri Schiavo's feeding tube has been classed by some as passive euthanasia. This is not what it is termed under Florida law.)
A similar procedure is what is sometimes referred to as 'terminal sedation', where a patient suffering a fatal condition is sedated and food and sometimes water are withheld.
Passive euthanasia is not usually the focus of public debate and is not what advocates of euthanasia legalisation are seeking. (What attracted media attention to this case is that Terri Schiavo's parents repeatedly disputed her husband's court-endorsed decision to have the feeding tube removed.)
3. Active euthanasia means that steps are taken to bring about the patient's immediate death. The most commonly discussed example of this form of active euthanasia is the deliberate administering of a lethal injection by a physician.
Voluntary and involuntary euthanasia.
4. Voluntary euthanasia indicates that the person euthanised has requested his or her own death.
5. Involuntary euthanasia occurs when another person, either the treating physician or a family member, decides that the patient is to be euthanised, without the expressed consent of the patient.
In the euthanasia debate as a whole, the cases of babies, young children, the mentally deficit and those incapacitated and perhaps unconscious as a result of illness are particularly problematic.
Euthanasia and doctor-assisted suicide
Euthanasia occurs when a physician or some other person acts to deliberately bring about the death of another, usually terminally ill person. For euthanasia to have occurred, the doctor would have to have administered the fatal substance or have otherwise been the direct cause of death.
6. Where the patient self-administers a lethal substance supplied by a doctor and that doctor possibly oversees this act this is referred to as doctor-assisted suicide or medically assisted suicide.
Medically assisted suicide appears very closely related to active euthanasia, in that the doctor sets up circumstances where a lethal dose can be given to a patient, however the final act of administering the lethal substance is performed by the patient, not by the doctor.
Laws that allow euthanasia and/or medically assisted suicide
1. The Netherlands - Termination of Life on Request and Assisted Suicide (Review
Procedures) Act 2001
In the Netherlands euthanasia and assisted suicide continue to be criminal offences, but doctors will not be liable to prosecution in certain circumstances.
Direct euthanasia (termination of life on request) and assistance with suicide will not be treated as criminal offences if carried out by a physician following agreed 'due care' criteria.
These 'due care' criteria require, among other things, that the doctor
* believes that the patient's request is voluntary and well-considered;
* believes that the patient's suffering is lasting and unbearable;
* has informed the patient about the situation he is in and about his prospects;
In The Netherlands euthanasia or assisted suicide may be carried out where a person is not suffering an incurable, terminal condition. A person can request euthanasia or assisted suicide to escape 'unbearable' physical or psychological suffering.
2. The United States - The Oregon Death with Dignity Act 1997
Only one American jurisdiction currently allows doctor-assisted suicide - the state of Oregon. Oregon allows a doctor to prescribe medication for a patient over 18 suffering a terminal disease so that patient may end his or her life.
Current legal situation in Australia
Within Australia, the law and accepted practice mean that a form of treatment may be withheld from a patient because it is viewed as unduly onerous and ultimately futile. Where the intention is assumed to be to reduce suffering, rather than to hasten death, such an action is not usually considered euthanasia and is not outside the law.
Similarly, a drug administered or supplied to a patient to relieve pain may have the incidental side effect of hastening the patient's death, but if the physician's primary purpose is to control pain, rather than end the patient's life, then the act is legal and is not regarded as euthanasia.
Most Australian states and territories have legislative or common law provisions dealing with the rights of the terminally ill, however, these laws allow a physician only to supply pain relief or to refrain from taking extraordinary measures to prolong life.
It is not legal to deliberately end a patient's life or to supply patients with the means to end their lives. Though suicide is not an offence, it is currently an offence in all Australian states and territories to assist someone commit suicide.
Legal provisions in the United States re euthanasia and the cessation of life-prolonging medical procedures
In the United States, as in Australia, the laws regarding euthanasia and cessation of life-prolonging medical procedures are generally determined by state, not federal, legislatures.
Oregon is the only US state to have passed a law allowing doctor-assisted suicide. Other states have laws which allow patients to have life-prolonging procedures ended. If the patient cannot make this decision for him/herself due to coma or mental incapacity a proxy may make the request for him/her, especially where the wishes of the patient are known.
Some relevant Florida legislation
In April 1999 - House Bill 2131 was introduced in the Florida legislature by the Florida Elder Affairs & Long-Term Care Committee to amend Section 765 (Civil Rights) of the Florida Statutes. The amendments to Section 765.101 were that 'artificially provided sustenance and hydration, which sustains, restores or supplants a spontaneous vital function' be added to the legal definition of 'life-prolonging procedures'. This is significant as Florida law allows patients, under certain defined circumstances, to refuse 'life-prolonging procedures'.
The amendment became law on October 1, 1999.
Terri Schiavo chronology
1963
December 3: Terri Schiavo (nee Schindler) was born in the Huntingdon Valley area of Pennsylvania.
1982
Terri met Michael Schiavo at Bucks County Community College in Newtown, Pennsylvania. Five months later, Terri and Michael were engaged.
1984
November: Michael Schiavo and Terri Schindler were married.
1986
April: Michael and Terri Schiavo moved to Saint Petersburg, Florida.
1989
Michael and Terri Schiavo began visiting an obstetrician and received fertility services.
1990
February 25: Terri Schiavo collapsed (apparently with a heart attack) and fell into a coma.
May: Terri Schiavo emerged from her coma but remained unconscious.
May 12: Terri Schiavo was discharged to a rehabilitation facility.
June 18: Court appointed Michael Schiavo as his wife's legal guardian without objection from her parents, the Schindlers.
June 30: Terri Schiavo was transferred to Bayfront Hospital for further rehabilitation efforts.
September: Terri Schiavo was taken home to be cared for briefly by her family. She was then returned to the rehabilitation facility.
November: Michael Schiavo took Terri to California for an experimental procedure using a thalamic stimulator implanted in her brain. After several months, the procedure proved unsuccessful.
1991
January: Michael and Terri Schiavo returned from California to Florida. Terri Schiavo was admitted to a brain injury center in Brandenton.
March: Dr. W. Campbell Walker performed a bone scan on Terri Schiavo. The scan showed prior traumatic injuries to multiple ribs (on both sides), both sacroiliac joints, both knees, both ankles, several thoracic vertebrae, and her right thigh. In addition, the scan showed a minor compression fracture of her L1 vertebra.
Michael Schiavo began studying nursing at St. Petersburg Community College. He eventually became a respiratory therapist and an emergency room nurse.
Terri Schiavo's physician concluded that she was in an irreversible persistent vegetative state (PVS).
1992
Michael Schiavo brought a medical malpractice suit against the obstetrician who had been treating Terri for infertility. The jury found the obstetrician had not properly diagnosed Terri's condition. The case was appealed.
1993
January: The medical malpractice suit against Terri's obstetrician was settled before an appeal was decided. Terri Schiavo received $750,000. Michael Schiavo received $300,000. Terri's award was placed in a trust fund controlled by a third party for her medical care.
February 14: Michael Schiavo and Terri's parents disagreed on how they should spend the award money. Both parties were no longer on speaking terms following this event.
1994
The administration of one nursing home attempted, unsuccessfully, to get a restraining order against Michael Schiavo because he was demanding more attention for his wife at the expense of other patients' care.
Michael Schiavo accepted the diagnosis that his wife was in an irreversible persistent vegetative state. In consultation with Terri's physician, Michael Schiavo halted most therapy for his wife.
Terri Schiavo developed a urinary tract infection. Following a doctor's recommendation, Michael chose not to treat it. Michael entered a 'do not resuscitate' order, which he later rescinded after the Schindlers protested.
1995
Michael Schiavo began a relationship with Jodi Centonze.
1998
May: Michael Schiavo filed a petition to discontinue life support for Terri Schiavo. Terri's parents fought the petition. This was the first legal battle between Michael Schiavo and the Schindlers.
November: Terri's parents became aware of the bone scan report that was performed in 1991. Terri's parents and Dr. William Hammesfahr claimed the trauma shown in the bone scan was a result of Terri being abused by Michael Schiavo. Provided with only the scan information, forensic pathologist, Dr. Michael Baden suggests a head injury caused the trauma. After learning Terri's full history, Dr. Baden agreed that the trauma was consistent with her cardiac arrest, fall, CPR attempts, and eventual resuscitation. The Schindlers petitioned the Pinellas-Pasco Circuit Court for a full evidentiary hearing to evaluate the new evidence. Judge George Greer denied the motion.
1999
October: Florida law amended so that the artificial administration of food and water was reclassified as a life-prolonging medical procedure. As such procedures can be ended under certain circumstances, this made it legally possible for Terri Schiavo's feeding tube to be removed.
2000
Michael was issued a license for nursing by the State of Florida, Department of Health.
February: As a result of Michael Schiavo's petition in 1998, the court ruled that Terri Schiavo would choose to have the tube removed.
2001
Dr. Ron Cranford (neurologist) assessed Terri Schiavo's brain function as part of a court-ordered examination. (One, Dr. Ron Cranford, is a proponent of euthanasia.) His examination showed that Terri Schiavo's cerebral cortex has been completely destroyed; he found that her upper brain was 80% destroyed, and there was much damage to the lower brain.
March: Three Florida neurologists viewed 12 of Terri Schiavo's CT scans. Dr. Leion Prockop said it was the 'most severe brain damage [he'd] seen.' Dr. Walter Bradley said that he 'doubt[ed] there's any activity going on in the higher levels of her brain.'
April 26: Terri Schiavo's feeding tube was removed for the first time. It was reinserted two days later on an appeal by her parents.
2002
A trial was held to determine whether or not new therapy treatments would help restore any of Terri Schiavo's cognitive function.
A new CAT scan showed severe cerebral atrophy. An EEG showed no measurable brain activity.
Five doctors were selected to provide their expert opinion: two by the Schindlers, two by Michael Schiavo, and one by the court.
The doctors selected by the parents said Terri Schiavo was not in a persistent vegetative state.
One, Dr. Maxfield, was the Schindler family's doctor, and is a radiologist rather than a neurologist. The other, Dr. Hammesfahr, made several claims about therapies supposedly developed by him which the court found to be a non-standard and generally unrecognised procedure with little chance of success.
The doctors selected by Michael Schiavo and by the Court said Terri was in a persistent vegetative state.
Terri Schiavo's parents videotaped Terri for four and a half hours. The video was edited down to several clips totaling four and a half minutes. The Schindlers cited the testimony and affidavits of 33 physicians and therapists (including 15 neurologists) who, after reviewing these four and a half minutes of video segments, believed that Terri Schiavo should have received further tests and/or would have beed likely to have responded to therapy. Only two of these physicians had access to her full medical history and examined her in person. (The four and a half minute clips were later released publicly. The four and a half hours of raw footage has not been released by the parents.)
Judge Greer ruled that Terri Schiavo was in a PVS and was beyond hope of significant improvement.
November 22: Judge Greer denied a motion from Terri Schiavo's parents for a full evidentiary hearing to evaluate new evidence, the 1990 bone scan, which had only recently come to their attention. Greer stated that the issue of trauma twelve years earlier was irrelevant to the current case.
Florida's Second District Court of Appeal reviewed all the evidence and upheld the trial court's decision.
2003
September 11: Petition by Terri Schiavo's parents, including affidavits from three speech therapists and two nurses (Heidi Law and Carla Sauer Iyer) was rejected.
October 10: The final remaining appeal filed by the Schindlers was dismissed.
October 15: Terri Schiavo's feeding tube was removed for the second time.
October 21: The Florida Legislature passed 'Terri's Law'. Governor Jeb Bush immediately ordered the feeding tube reinserted.
December: Dr. Jay Wolfson reported to Governor Bush, 'within the testimony, as part of the hypotheticals presented, Schindler family members stated that even if (Terri) had told them of her intention to have artificial nutrition withdrawn, they would not do it. Throughout this painful and difficult trial, the family acknowledged that (Terri) was in a diagnosed persistent vegetative state.'
2004
May 19: Florida Judge W. Douglas Baird overturns 'Terri's Law'. The ruling was appealed.
September 23: Florida Supreme Court agreed that 'Terri's Law' was unconstitutional.
2005
January 24: The U.S. Supreme Court refused to hear the case.
February 25: Judge George Greer ordered Terri Schiavo's feeding tube removed on March 18.
March 11: Media tycoon Robert Herring offered one million dollars to Michael Schiavo if he agreed to waive his guardianship over Terri Schiavo to her parents. Michael Schiavo declined.
March 17: Members of the Florida Legislature considered a bill that would make removing food and water from patients in a persistent vegetative state illegal without a living will. Although this bill was passed by the Florida House of Representatives by a vote of 78 to 37, the Florida Senate defeated a similar measure hours later, 18 to 21.
March 17: U.S. Senators Bill Frist and Michael Enzi announced that Terri Schiavo would be called to testify before the U.S. Senate Committee on Health, Education, Labor, and Pensions on March 28 in Washington. No one expected Terri Schiavo to testify, but the move extended witness protection to her, requiring reinsertion of her feeding tube.
March 18: Greer struck down the subpeona as unconstitutional and Terri Schiavo's feeding tube was removed for the third and final time.
March 20/21: U.S. Congress approved emergency legislation, the Palm Sunday Compromise.
March 21: Bob and Mary Schindler filed a request for an emergency injunction with the U.S. District Court for the Middle District of Florida in Tampa.
March 22: Judge James D. Whittemore refused to order the feeding tube reinserted.
March 23: The Florida Senate again debated this proposed law, which was again rejected, 18 to 21.
The 11th Circuit Court of Appeals in Atlanta denied the request to reinsert the feeding tube. The three-judge panel ruled 2-1.
March 23: Bob and Mary Schindler appealed again to the U.S. Supreme Court.
March 24: The U.S. Supreme Court declined to grant certiorari. Judge Greer issued an injunction denying the Florida State government's right to have the Florida Department of Children & Families take over Terri Schiavo's care.
March 27: Terri Schiavo was given the Anointing of the Sick ('Last Rites').
March 30: The 11th Circuit Court of Appeals in Atlanta agreed to consider a petition by Mrs. Schiavo's parents to have a new hearing to decide whether the feeding tube should be reinserted. Later that day, the court denied the petition.
March 31: Terri Schiavo died
Internet information
Wikipedia, a free online encyclopedia, has a detailed treatment of the Terri Schiavo case.
It considers her early life, her initial medical crisis, rehabilitation efforts, the relationship between she and her husband and the developing legal and medical controversy surrounding her treatment. It is clear and very comprehensive.
The treatment can be found at http://en.wikipedia.org/wiki/Terri_Schiavo
The site is a open to reader additions and edits. In this case it acknowledges the difficulty of an impartial presentation of the facts and has included detailed reader discussion over the various additions and edits that have been made and the biases they represent.
This discussion can be found at http://en.wikipedia.org/wiki/Talk:Terri_Schiavo
The Ontario Consultants on Religious Tolerance has set up a useful site that has a sub section dealing with euthanasia.
The group's writers provide background information on a wide range of ethical issues, attempting to present and discuss a range of views on each.
Their treatment of euthanasia and physician assisted suicide can be found at http://www.religioustolerance.org/euthanas.htm
This supplies a useful set of definitions and much background information on euthanasia as it occurs or has occurred in the United States and other nations, including Australia.
Though the site is generally impartial, please note that when it considers the 'Ethical Questions Raised by Euthanasia' it appears to have a pro-euthanasia bias.
The site provides a detailed treatment of the Terri Schiavo case. This can be found at http://www.religioustolerance.org/schiavo.htm
Abstract Appeal is a web log devoted to Florida law and the Eleventh Circuit Court of Appeals. It has a detailed treatment of the Terri Sciavo case, with a special emphasis on Florida laws as they affected this case.
Though its emphasis is factual and it strives for impartiality, if it has a bias it is toward Michael Schiavo's interpretation of his wife's situation.
This site can be found at http://abstractappeal.com/schiavo/infopage.html
The Internet site for the Florida Senate includes all the statutes which relate to the Terri Schiavo case. These can be found at
http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch0765/ch0765.htm
The Terri Schindler-Schiavo Foundation is a group of volunteers whose aim was to prevent life-prolonging procedures, including the provision of food and water, being withheld from Terri Schiavo. The group was formed in conjunction with Terri Schiavo's parents and siblings, the Schindlers.
It presents only the views of the Schindlers and other like minded people on how Terri Schiavo should have been treated and what was the true nature of her medical condition.
The site can be found at http://www.terrisfight.org/
Not Dead Yet is an American disability rights group opposed to legalised assisted suicide and euthanasia. The lobby group have strongly supported the Schindler's attempts to keep Terri Schiavo entubated. The group is concerned that the removal of Terri Schiavo's feeding tube is part of a general legal and cultural predisposition to see the lives of the severely disabled as of no value. The group's site has a variety of discussions of Terri Schiavo's case, all from this perspective.
It can be found at http://www.notdeadyet.org/
The New England Medical Journal recently published a discussion of the medical, ethical and legal issues surrounding the Terri Schiavo case. It is titled 'Terri Schiavo - A Tragedy Compounded' and was written by Dr Timothy Quill. The article ultimately supports the decisions taken by the courts in relation to Terri Schiavo.
It can be found at http://content.nejm.org/cgi/reprint/NEJMp058062.pdf
This is a pdf file and will require Adobe Acrobat Reader in order to be read.
It was made available on the Internet on April 10, 2005
The New England Medical Journal recently published an excellent overview of the legal and ethical implications of cases such as those of Karen Quinlan, Nancy Cruzan and Terri Schiavo, where a person has been in a persistent, vegetative state for many years. The article, by George Annas, gives a detailed account of the legal disputes surrounding Terri Schiavo's case. The article is not impartial as it ultimately concludes that life-prolonging procedures should be ended for those such as Terri Schiavo unless they have specifically indicated via an advance directive that they would want such procedures continued.
It is titled, '"Culture of Life" Politics at the Bedside - The Case of Terri Schiavo'
It can be found at http://content.nejm.org/cgi/reprint/NEJMlim050643.pdf
This is a pdf file and will require Adobe Acrobat Reader in order to be read.
It was made available on the Internet on April 10, 2005
Arguments against Terri Schiavo's feeding tube being removed
1. Terri Schiavo was not brain dead and was capable of responding to external stimuli
In most jurisdictions around the world, any person diagnosed as brain dead is regarded as legally dead and any life support apparatus is able to legitimately be removed. Supporters of Terri Schiavo's feeding tube remaining in place have stressed that she was not brain dead.
Brain death requires that both the cerebral cortex and the brain stem no longer function. In Terri Schiavo's case, though there was a general medical consensus that her cerbral cortex was largely inactive, her brain stem continued to function.
This situation and its consequences have been summed up by Dr Timothy Quill. Dr Quill is a professor of medicine, psychiatry, and medical humanities. He is the director of the Center for Palliative Care and Clinical Ethics at the University of Rochester Medical Center, Rochester, New York State.
Dr Quill has stated, 'In brain death the cortex is not functioning (as in Terri Schiavo's case) but also the base of the brain isn't functioning ... Neurologists agree that shutdown of both the cortex and the base of the brain constitutes a medical reason to stop treatment ...
However, the base of Terri Schiavo's brain still functions, and although there's still a lot of discussion, there's no consensus at all [among experts] that this constitutes death.'
In addition to the accepted position that Terri Schiavo was not brain dead (a position acknowledged even by those who believed that her feeding tube should be removed), Terri Schiavo's parents and siblings claimed that she was capable of responding to external stimuli. The Schindlers created a video tape which they claimed showed Terri Schiavo smiling and nodding at those around her and following a balloon with her eyes. This was offered by the Schindlers as evidence that Terri Schiavo had greater brain function than was generally acknowledged and thus that her life was worth preserving.
2. Terri Schiavo was not suffering a terminal illness and her condition may have improved with further treatment
Terri Schiavo had lived for 15 years after the apparent heart attack which led to her diminished brain function. She required full time nursing, the maintainence of a feeding tube and was suspectible to a range of illnesses associated with prolonged inactivity but her life was not in immediate danger. She appeared to have been in no pain.
Further, Terri Schiavo's parents, the Schindlers, have long maintained that their daughter's brain injury was not irreversible. They have suggested a variety of therapies which they hoped may have been able to improve her condition. A variety of medical experts have claimed that Terri Schiavo may have benefited from further therapeutic treatment. These include Dr. William Hammesfahr, Dr. Alexander Gimon, Dr. Jacob Greene, Dr. Richard Neubauer, Dr. William Russell, Dr. Jay Carpenter, Dr. James Avery, Dr. John D. Young, Dr. William Maxfield, Sarah Green Mele - Speech Pathologist and Myra Stinson - Speech Pathologist.
3. Terri Schiavo had not left a living will or advance directive indicating how she would have wished to be treated in a persistent vegetative state
No one has ever maintained that Terri Schiavo had left a living will or any other written document indicating that she would not have wanted her life prolonged by artificial means.
The claim that this was her wish was made primarily by her husband, Michael Schiavo, Michael Schiavo's brother and his sister-in-law. Critics note that Mr Schiavo only appeared to recall his wife's wishes on this matter some years after her coma and the diagnosis of a persisitent vegetative state. Terri Schiavo's parents dispute that this would have been her view.
Critics also note that as a Catholic, Terri Schiavo would have been likely to support the Catholic Church's position that administering food and water are not extraordinary treatments but are a normal means of maintaining life and so should be continued.
They claim that in the absence of any incontestable indication of Terri Schiavo's wishes the Florida court should have erred on the side of life, as is directed by Florida law on this question.
4. Food and water are not exceptional or extraordinary medical treatments
Most jurisdictions allow a patient to refuse medical treatment, especially where this is judged onerous or extraordinary and where the patient's prognosis is very poor.
Extraordinary care is usually regarded as any excessive measure used to keep alive someone who would otherwise die. Ventilators, pacemakers, dialyses machines, or other devices which keep major organs running artificially are considered extraordinary.
Many medical ethicists, however, view food and water as ordinary care. According to this view, even if given by a feeding tube, nutrition and hydration are still ordinary, natural and necessary care needed to sustain any life.
For example, in Victoria, the 1990 Medical Treatment Act allows a patient to refuse certain treatments and provides for representation should a patient have become incompetent. However, the right to refuse certain treatments does not include the right to refuse ordinary care, such as the provision of food and water.
This is similar to the position adopted by the Catholic Church. On 19 March 2004, at a conference in Rome, Pope John Paul II condemned the removal of feeding tubes from patients in a persistent vegetative state, calling it 'genuine euthanasia by omission'.
The pontiff further stated, 'The sick person, in a vegetative state, awaiting recovery or his natural end, has the right to basic health care, and to the prevention of complications linked to his state ... The administration of water and food, even when provided by artificial means, always represents a natural way of preserving life... not a medical procedure.'
It has been argued that the view of the Catholic Church on this issue is significant as Terri Schiavo was a Catholic.
5. Michael Schiavo's motivations for wanting his wife's feeding tube removed are suspect
Many of those who opposed the removal of Terri Schiavo's feeding tube distrust her husband's reasons for originally applying to have the tube removed.
Terri Schiavo's parents, the Schindlers, have claimed that Michael's desire to have the feeding tube removed coincided with he and Terri being awarded a combined settlement of some one million dollars as compensation for supposed neglicence on the part of Terri's obstetrician for failing to diagnose bulemia.
It has also been noted that Michael Schiavo is now in a long-standing relationship with another woman by whom he has had two children. It has been suggested that he may have been reluctant to divorce Terri as he would then have lost access to her share of the compensation money. The implication is that Terri Schiavo would have had to die while still his wife for Michael Schiavo to get the remainder of the payment.
The Schindlers have also suggested that Michael Schiavo may have abused their daughter prior to her coma and brain injury. Bone scans taken in 1991 showed prior traumatic injuries to multiple ribs (on both sides), both sacroiliac joints, both knees, both ankles, several thoracic vertebrae, and her right thigh. In addition, the scan showed a minor compression fracture of her L1 vertebra. Some commentators have suggested that these injuries resulted from her initial fall and from attempts to resuscitate her. The Schindlers have claimed they are the result of physical abuse from her husband. They have also claimed that prior to her coma and brain injury Terri Schiavo was planning to leave her husband because she found him overly controlling.
6. There was sufficient funding to continue Terri Schiavo's care for the rest of her life
Terri Schiavo required full time nursing, the maintainence of a feeding tube and was suspectible to a range of illnesses associated with prolonged inactivity. In 1992 her husband won a medical settlement which, after appeal, resulted in $750,000 being directed toward Terri Schiavo's continued medical care. Thus the cost of her treatment was not an issue.
Terri Schiavo's parents, the Schindlers, also indicated that they were prepared to meet the cost of their daughter's medical treatments for the remainder of her life.
7. Removing Terri Schiavo's feeding tube could lead to actions being taken to end the lives of other disabled persons
It has been claimed that the removal of Terri Schiavo's feeding tube could set an unfortunate precedent and alter public opinion in a way that acted against others with severe disabilities.
According to this line of argument, those who favoured the removal of Terri Schiavo's feeding tube did so primarily because they believed her quality of life was so poor that it was an affliction to her and so should be ended.
Groups such as 'Not Dead Yet', representing the severely disabled, are fearful that quality of life arguments may be used in the case of anyone with a serious disability. They are concerned that there will be a greater likelihood of newborn babies with disabilities being allowed to die, of foetuses showing disabilities being aborted and of disabled people with serious illnesses being ordered not for resuscitation.
Twenty-six disability rights organisations adopted a position in support of Terri Schiavo's right to continue to receive food and water. Among the groups which opposed the removal of Terri Schiavo's feeding tube were Not Dead Yet, Disability Rights Center, National Council on Independent Living, National Disabled Students Union, National Spinal Cord Injury Association, Society for Disability Studies, World Association of Persons With Disabilities and World Institute on Disability.
8. Starvation and dehydration may have caused Terri Schiavo distress
It has been argued that dying as a result of starvation and dehydration can be physically and mentally distressing and as no one knows the exact level of Terri Schiavo's awareness she should not have had this potential suffering inflicted upon her.
The 'exit protocols' apparently prepared to assist those overseeing Terri Schiavo once her feeding tube was removed included the following comments, "When she starts going into the dehydration stage, her metabolism will start to change. Her electrolytes will get imbalanced. She's going to get uncomfortable and will start to writhe ... The nasal cavities will start to dry, crack and bleed. The stomach will get dry and shrink, causing vomiting and heaving,"
Arguments in favour of Terri Schiavo's feeding tube being removed
1. Terri Schiavo's higher mental functions had ceased
A number of doctors and several court rules have determined that Terri Schiavo was in a persistent vegetative state. This means that her higher cortical functions had largely ceased.
Early brain scans showed that Terri Schiavo's cerebral cortex - the part of her brain responsible for higher cognition - probably ceased to function soon after she was brought to a hospital in 1990.
The cerebral cortex controls personality, the ability to interact and communicate, awareness and memories. Terri Schiavo's brain stem continued to function and thus she was able to breathe, blink and move her body.
In the mid-1990s, a group of medical societies, including the American Academy of Neurology, published guidelines defining a vegetative state as 'persistent' after a month. In this condition, patients show:
-No evidence of awareness of self or environment and an inability to interact with others.
-No evidence of sustained, reproducible, purposeful or voluntary behavioural responses to visual, auditory, tactile or noxious stimuli.
-No evidence of language comprehension or expression.
-Intermittent wakefulness manifested by the presence of sleep-wake cycles.
-Sufficiently preserved brainstem function to permit survival with medical and nursing care.
-Bowel and bladder incontinence.
-Variably preserved cranial nerve function and spinal reflexes; that is, the person may blink or smile.
Terri Schiavo had been repeatedly judged to be in a persistent vegetative condition. Among those who support the removal of her feeding tube are those who hold that remaining in this diminished condition gave Terri Schiavo so little quality of life that she should not have been required to continue to exist in this state.
2. Terri Schiavo's brain function would not have improved with further treatment
The general medical consensus appears to be that where a patient is in a persistent vegetative state with the degree of cortical damage demonstrated by Terri Schiavo and has been in that state for the length of time Mrs Schiavo had, there is no prospect of significant improvement.
Dr. Timothy Quill is a professor of medicine, psychiatry, and medical humanities. He is the director of the Center for Palliative Care and Clinical Ethics at the University of Rochester Medical Center, Rochester, New York State. Dr Quill has stated in relation to the case of Terri Schiavo, '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 ... in none of these cases was there the sort of objective evidence of severe cortical damage that is present in this case, nor was the period of disability so long.'
Dr Quill has concluded, 'I have no doubt that Terri Schiavo is in a persistent vegetative state and that her cognitive and neurologic functions are unfortunately not going to improve.'
3. Terri Schiavo would not have wanted to continue living in that condition
Michael Schiavo, his brother Scott and his sister-in-law, Joan, all testified before Florida magistrate, Judge Greer, that Terri Schiavo had indicated on a number of occasions that she would not have wanted to go on living sustained by artificial means.
Michael Schiavo's grandmother died in 1988. Doctors had tried to revive the woman despite her written directive that she not be resuscitated. Scott Schiavo testified that Terri Schiavo had said, during a family luncheon after the elderly woman's death, , 'If I ever go like that, just let me go. Don't leave me there. I don't want to be kept alive on a machine.'
Joan Schiavo, the wife of Michael Schiavo's oldest brother, William Schiavo, testified that she had told her sister-in-law about a friend who was forced to end life support to an infant after health problems.
Terri Schiavo is claimed to have told Joan that she would have done the same thing for the baby if its life could not otherwise have been saved.
Michael Schiavo testified that he too had heard his wife express such sentiments several times.
4. The decision to remove Terri Schiavo's feeding tube was made and upheld by a number of courts
In February 2000 Florida Judge Greer ruled that clear and convincing evidence had shown that Terri Schiavo would have chosen not to receive life-prolonging medical care under her current circumstances.
Terri Schiavos parents, the Schindlers, appealed Judge Greer's ruling and the Second District Court then again determined that while a surrogate decision-maker should err on the side of life, the trial judge had had sufficiently clear and convincing evidence to determine that Terri Schiavo would not have wished to continue the life-prolonging measures she needed to live. The appellate court explained:
'[T]he Schindlers argue that the testimony, which was conflicting, was insufficient to support the trial court's decision by clear and convincing evidence. We have reviewed that testimony and conclude that the trial court had sufficient evidence to make this decision. The clear and convincing standard of proof, while very high, permits a decision in the face of inconsistent or conflicting evidence.'
By late March 2005, Florida courts, the U.S. Supreme Court, and Congress had been active in Terri Schiavo's case. Almost all legal approaches to require the re-insertion of the feeding tube appeared to have been exhausted by the time of her death on March 31st .
5. The accusations made against Michael Schiavo are either unsubstantiated or irrelevant
The accusation made against Michael Schiavo that he had been excessively controlling of his wife, may have physically abused her and is motivated by a desire to keep as much as possible of the malpractice settlement money are either hearsay or are inadequately supported. All these claims have been disputed by Michael Schiavo. Also, the injuries detected by the 1991 bone scan may have been caused by Terri's initial fall and subsequent attempts to resuscitate her.
Florida Judge Greer has ruled that the claims made by the Schindler family that Michael Schiavo had physically abused Terri are irrelevant in that they have no bearing on his judgement that Mrs Schiavo's feeding tube should be removed. That decision was based on evidence that Mrs Schiavo was in a persistent vegetative state, that she had no higher consciousness, that her condition was highly unlikely to respond to treatment and that she would not have wanted to be artificially maintained in such a condition.
6. Florida law regards the administering of food and water as extraordinary medical treatment which can be ended under certain circumstances
In April 1999 - House Bill 2131 was introduced in the Florida legislature by the Florida Elder Affairs & Long-Term Care Committee to amend Section 765 (Civil Rights) of the Florida Statutes.
The amendments to Section 765.101 were that 'artificially provided sustenance and hydration, which sustains, restores or supplants a spontaneous vital function' be added to the legal definition of 'life-prolonging procedures'.
This is significant as Florida law allows patients, under certain defined circumstances, to refuse 'life-prolonging procedures'.
Under Florida law, being in a persistent vegetative state is classed with 'end-stage' conditions as grounds for allowing a patient to decline life-prolonging treatments. An end-stage condition is defined as 'an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and [for] which, to a reasonable degree of medical probability, treatment ... would be ineffective.'
7. Terri Schiavo would not have been caused distress by starvation and dehydration
It has been claimed that Terri Schiavo's brain injury was such that she would not have had sufficient awareness to have suffered distress as a result of the withdrawal of food and water.
In an article published on US Today, on March 24 2005, five days after Terri Schiavo's feeding tube was removed for the third and final time it was reported, 'In a process that could take days, weeks or longer, the lack of food and water will cause chemical imbalances that eventually will shut down major organs such as the kidneys, and that ultimately will trigger heart abnormalities or other fatal problems, says Roger Albin, a neurologist at the University of Michigan.
Florida courts have ruled that Schiavo is in a persistent vegetative state, a condition caused by extensive damage to the cortex and other parts of the brain that are responsible for consciousness, higher thinking, memory or even sensations such as pain, hunger and thirst.
"She's not experiencing hunger - she's not experiencing anything," Albin says.'
A similar point has been made by Dr Timothy Quill. Dr. Quill is a professor of medicine, psychiatry, and medical humanities. He is the director of the Center for Palliative Care and Clinical Ethics at the University of Rochester Medical Center, Rochester, New York State. Dr Quill has stated, 'If and when her feeding tube is permanently removed, her family may be reassured that dying in this way can be a natural, humane process.'
8. Many of those supporting the Schindlers did so for political purposes
It has been claimed that Florida Governor Jeb Bush and his brother President George W Bush have supported the Schindlers in their attempt to have Terri Schiavo's feeding tube retained for political reasons. According to this line of argument, both the Bushes were concerned to retain the support of the large and powerful cohort within the Americam electorate who are vehemently opposed to any action which they view as euthanasia or related to euthanasia.
Foreign correspondent for The Age, Michael Gawenda, has claimed, 'For Christian conservatives and their allies in Congress ... Schiavo is being murdered.
In their view, her death will be evidence of what happens when a godless, materialistic, valueless liberal elite, products of violent and aimless protest during the mad and bad 1960s, captures the courts, the media, Hollywood, popular music, popular culture ...
In contrast, Bush and his social conservative allies, are, they say, for "a culture of life". God gave it and only God can decide when a life should end.'
Further implications
At this point it is difficult to determine what will be the enduring impact of the Terri Schiavo case.
One immediate consequence appears to have been a greatly increased interest, at least within the United States, in the drawing up of living wills. This interest appears to exist both among those who believe that Michael Schiavo was acting on his wife's wishes and those who consider he was not. What the case appears to have demonstrated for many people is the importance of making your wishes in the event of terminal illness clearly known in advance. Terri Schiavo's relative youth at the time the incident occurred which caused her brain injury has suggested to many people that such living wills or advance directives may need to be made quite early in a person's life.
There are those who believe that the extent of popular opposition to Terri Schiavo's death may indicate an increasing rejection of euthanasia and related options.
On the other hand, there are those who argue that the Schiavo case has actually led to an increase in tolerance for euthanasia. This argument has been presented on a number of levels. Firstly there are those who consider that the willingness of courts and legislatures to regard the administration of food and drink as a medical procedure that can be withdrawn under certain circumstances has opened the door to a more general acceptance of passive euthanasia. Then there are those who argue that the popular revulsion among some sections of the community at the thought of someone dying of dehydration may actually led them to prefer a more direct means of ending someone's life, such as lethal injection.
Another development is a general rejection of the intrusion of government, politicians, courts and judges into what many people regard as a private matter that should be dealt with by families and doctors. This view, is, however, a little na‹ve. The reason this case attracted the amount of legal and ultimately media attention it did was that there was no agreement within Terri Schiavo's family as to how she should have been treated. Under such circumstances it seems inevitable that families will have recourse to the law.
All that seems certain is that cases such as Terri Schiavo's indicate there is no general consensus on the issues they raise, either in the United States or in Australia.
Newspaper Sources
The Age
March 22, page 13, comment (cartoon) by Michael Gawenda, `The politics of life and death'.
March 25, page 11, news item by Michael Gawenda et al, `Florida fails to get custody of Schiavo' (with photos, boxed information on the history of the case, `A tragic legal and medical minefield', and background analysis, `Forcing the Federal Court to reopen the Schiavo case - an act of compassion or an act for political gain?').
March 23, page 13, analysis (photos) by Tom Noble, `The hardest choice'.
April 2, page 15, news item (photos) by Michael Gawenda, `Schiavo dies but the battle rages on' (with background analysis, `Vitriol and hysteria engulf Republicans').
April 1, page 9, news item by Michael Gawenda, `Judge says Bush's Schiavo law "unconstitutional"'.
March 31, page 23, comment by Michael Cook, `Why the pro-life lobby lost a do-or-die battle'.
March 31, page 23, comment (cartoon) by Michael Gawenda, `Schiavo: playing God and politics'.
March 30, page 10, news item, `Schiavo's husband opts for autopsy'.
The Australian
March 29, page 8, comment (photos) by Andrew Sullivan, `Playing god with Schiavo and the religious Right'
March 29, page 8, news item, `Republican let father die'.
March 28, page 6, editorial `Death, a debate with no winners'.
April 1, page 9, news item (photos) by David Nason, `(Mel) Gibson attacks Schiavo ruling'.
March 23, page 12, news item, `Patient's smiles a false hope: doctors'.
Herald Sun
March 24, page 18, comment by Michael Cook, `When doctors can't be trusted'.
April 2, page 23, news item (photos), `Terri's fight rages on / Legacy a lesson to ponder'.
April 1, page 37, news item (photos), `Tube debate ties two lives'.
March 30, page 18, comment by Rodney Syme, `Alive - but Terri died 15 years ago'.