A Reasonable Length of Recovery From a Death of a Family Member Is Minimally

Proc (Bayl Univ Med Cent). 2005 Oct; 18(iv): 303–310.

From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury

Robert L. Fine

¹From the Function of Clinical Ethics, Baylor Health Care System, and Department of Internal Medicine, Baylor Academy Medical Centre, Dallas, Texas.

The battle over the life and death of Terri Schiavo was only the most recent medical ethics case to catch the public's attending. This instance asked both the individuals involved and our guild in full general to brand moral judgments virtually the appropriateness of a determination to maintain or withdraw life-sustaining treatment. As a practicing medical ethicist and an observer of the case, I was startled by the degree of misunderstanding almost dissimilar types of encephalon injury and by more than a few misstatements virtually the medical facts of the instance. Mrs. Schiavo was described at various times as comatose, brain dead, vegetative, minimally witting, locked in, and disabled. These are mutually sectional conditions. This failure of the media, politicians, and fifty-fifty some physicians who should know ameliorate to accurately draw Mrs. Schiavo'due south medical condition was particularly disturbing, because good medical ideals begins non with the discipline of ethics but with adept clinical medicine. Appropriate moral judgments about medical treatment decisions cannot exist made without first agreement the relevant clinical medicine. In this commodity, I review the differences betwixt coma, brain expiry, the vegetative state, and other profound brain injuries. I then review the Quinlan, Cruzan, and Schiavo cases to explore various legal aspects and close with reflections on some of the ethical issues related to treatment of patients with profound brain injuries.

TYPES OF BRAIN INJURY

Coma, brain decease, vegetative land, locked-in country, and minimally witting state are split up and distinct conditions, although a patient may laissez passer from some of these states to another. For example, a patient may present in a coma, and then pass through the vegetative state to the minimally witting state, and finally render to a country of normalcy. In some cases, this transition may be and so rapid as to make the individual states barely noticeable, as if the patient went from coma to normal all at once, while in other cases there may exist boring progress or no progress at all. The parts of the encephalon injured and the patient's basic neurological functions in these states are summarized in Table ​ 1 . When reviewing this table, it is worth noting that unconscious patients cannot suffer; suffering is an emotive event that requires consciousness. This volition become of import in the moral analysis that follows the medical and legal review.

Table 1

Anatomic injury and functional status in different types of encephalon injury

	Anatomic status		Functional status
Condition	Upper encephalon	Encephalon stem	Sleep/ Wake cycle	Optics	Body motility	Gag/ breathing	Ability to endure
Brain death	−	−	−	Closed	−	−	No
Coma	−	±	−	Closed	−	± (ordinarily −)	No
Vegetative state	−	+	+	Open/ roaming	Reflex	+	No
Minimally conscious land	±	+	+	Open up/ tracking	None to purposeful	+	Yep
Focal brain injury and dementia	±	+	+	Closed and open up/tracking	Variable purposeful	+	Yes

Blackout

Nigh serious encephalon injuries begin with a coma, which is best thought of as an "eyes-closed unconsciousness." Information technology is as if the patient is sleeping but cannot be roused. Coma is usually not permanent. Some patients go on to become brain dead; others enter the vegetative stage, go "locked in," or enter the minimally conscious state; notwithstanding others recover completely. Patients who recover may exist normal or may have a functional deficit such as paralysis, weakness, or cerebral damage.

Brain death

Brain death, another mutual sequela of serious brain injury, is the irreversible loss of the clinical function of the whole brain: the cortex (responsible for motor and cognitive function), the midbrain (which might be idea of as integrating higher and lower centers in the brain), and the brain stalk (responsible for vegetative functions such as sleep-wake cycles and breathing). Brain death is a product of mod engineering, fabricated possible past mechanical ventilators and cardiopulmonary resuscitation. Information technology was offset described in the medical literature in 1959 by two French neuropsychologists who referred to le coma depasse, or a state beyond coma (1). In America, we often refer to the Harvard Medical School definition of irreversible coma as the definition for brain decease. This definition was proposed in 1968 and remains the gold standard (ii). Some accept expressed concern that i of the driving forces behind the creation of the Harvard criteria for brain expiry was the need for organs to transplant. This concern is probably valid only does not in itself invalidate or render useless the concept of whole encephalon decease.

The diagnosis of brain death is a clinical judgment past the dr. based upon the total absence of all brain function. The crusade should be reasonably established and reasonably irreversible. It may be related to a master brain injury such as trauma or encephalon hemorrhage or to nonneurological affliction such equally cardiac arrest with resultant anoxic encephalon damage. The diagnosis may be confounded by a number of factors, including drug intoxication, metabolic/endocrine disturbance, severe facial trauma, preexisting pupillary abnormalities, chronic carbon dioxide memory, and hypothermia.

Texas law does not mandate any particular test for the diagnosis of brain death. A number of tests are available, including bedside testing and apnea testing (Table ​ 2). Apnea testing is useful because other technological tests lack both its 100% sensitivity and 100% specificity (3).

Table ii

Bedside and apnea testing for brain death

Bedside testing	Apnea testing
• Absent-minded grimace or withdrawal response to pain	•Pretest criteria: euvolemia, temperature ≥36.5°C, systolic blood pressure ≥ninety mm Hg, PCOtwo ≥forty mm Hg
•Pupils unresponsive to light
•Absent corneal reflex	•Preoxygenate with 100% oxygen to achieve POtwo>200 mm Hg, disconnect the ventilator (or prepare rate at 0), evangelize 100% oxygen at half dozen L/min by cannula into the endotracheal tube
•Absent gag reflex
•Absent cough reflex to suctioning
• Absent oculocephalic response: the eyes plough with the head; no eye motion	• Test arterial claret gases at 8 to ten minutes
	• Exam is positive if no respiratory movement is present and PCO2 ≥60 mm Hg
• Absent vestibulo-ocular (caloric) response: the eyes fail to deviate abroad from the side irrigated with ice water; no center move	• Test is inconclusive if PCO2<60 mm Hg, systolic blood pressure <90 mm Hg, oxygen saturation <80%, or cardiac arrhythmia is nowadays

PCO₂ indicates fractional pressure of carbon dioxide; PO₂, fractional pressure of oxygen.

Encephalon death is legal death in all 50 states. However, ii states, New Jersey and New York, have exceptions, initially based on cultural sensitivity to the belief of the orthodox Jewish customs in a cardiorespiratory standard of death. One does not take to be an orthodox Jew to believe that both eye and lung part must stop before a person may be considered expressionless. Many neurologists and ideals consultants accept worked with such families. A specially interesting example of this phenomenon occurred before this year in Utah. Jessie Koochin, a 6-year-onetime boy with a brain tumor, met all of the standard criteria for brain death and was declared brain dead by multiple doctors. His family rejected the entire notion of brain expiry and persuaded a state judge in Utah to declare that he be kept alive on a mechanical ventilator despite meeting the legal criteria for encephalon death. This represents a striking example of a judge rejecting established police force in an effort to placate social and political pressures. I personally find this a worrisome phenomenon if it were to be repeated in other jurisdictions. Nevertheless, there is no legal nor moral obligation to maintain treatment for encephalon-dead patients. Across Baylor Health Intendance System, nosotros will maintain organ-sustaining treatments for 24 to 48 hours to permit family members time to assemble and say goodbye to their loved one.

Vegetative state

The vegetative state, some other product of modern technology, was first described in 1972 (4). The vegetative state is best understood as an "eyes-opened unconsciousness"; in that location is a disassociation betwixt wakefulness and sensation. While patients may appear awake, there is a lack of evidence that the upper brain receives or projects information. The upper encephalon and the midbrain are not integrated in part with the brain stem or the rest of the body, although the brain stem continues to manage the vegetative functions. This is the condition that Karen Quinlan, Nancy Cruzan, and Terri Schiavo were in following their serious brain injuries upwardly until the moment of their deaths.

The most administrative published information on the vegetative state come from the Multi-Society Task Strength on the Persistent Vegetative State. This group established definitive diagnostic criteria and published authoritative outcomes data on 700 patients (5, 6).

As with the diagnosis of brain death, the diagnosis of a vegetative land is a clinical judgment based on several criteria (Tabular array ​ iii). The notion of a "sustained and reproducible voluntary response" is important in the diagnosis. Hope is eternal in families. They want to believe that their loved one is witting, and they report instances when their loved one responds to them. As an ethics consultant, I oftentimes endeavor to be at the bedside with family members who believe their loved one is responding to them. I insist that we first remain quietly at the bedside without agonizing the patient during a wake wheel for prolonged periods of time. These patients may have a variety of nonpurposeful movements. Information technology is of import for families to see these movements occurring in the absence of any external stimuli earlier they endeavour to elicit a purposeful movement; otherwise, to the untrained eye, these patients may appear to be interactive when they are non. Truly vegetative patients will non have reproducible responses to stimuli.

Table 3

Criteria for clinical diagnosis of a vegetative state^*

• No interaction with others or awareness of cocky when awake

• No comprehension or expression of language

• No sustained and reproducible voluntary or purposeful response to external stimuli

• Spastic limbs may move nonpurposively

• Baneful stimuli may crusade reflex withdrawal

• Some emotive events may occur, such as smiles or grimaces, but non every bit a reproducible response to stimuli

The prognosis for recovery is a key concept and is an essential characteristic of the moral assay dealing with patients in a vegetative state. Prognosis is determined by the cause of the injury, the length of time the patient has been in the vegetative land, and comorbid conditions. Posttraumatic vegetative patients have a better chance for some recovery than anoxic encephalon injury vegetative patients (Table ​ 4). Although not reflected in the table, the job strength plant no returns to consciousness in patients like Quinlan, Cruzan, and Schiavo, who had been vegetative with an anoxic injury for over ii years.

Table iv

ane-year outcomes in patients in the vegetative state*

	Upshot 1 year later
Patient group	Dead	Vegetative	Witting
Traumatic causes of vegetative country
Vegetative at 1 month	28%	18%	54%
Vegetative at 3 months	31%	thirty%	39%
Vegetative at six months	28%	53%	nineteen%
Nontraumatic causes of vegetative country
Vegetative at 1 calendar month	47%	39%	fourteen%
Vegetative at 3 months	36%	58%	6%
Vegetative at 6 months	eighteen%	81%	1%

The elapsing of the vegetative land besides affects nomenclature. A elapsing >1 month is said to exist persistent. When the crusade of the vegetative state is nontraumatic—such as an anoxic injury after cardiopulmonary resuscitation—a duration >3 months is said to be permanent, merely when the crusade of the vegetative state is traumatic, a patient must remain vegetative for >12 months before the condition is defined as permanent. The distinction between outcomes from posttraumatic versus anoxic brain injuries may play into the moral decisions we must face when confronted by profound brain injury.

Finally, comorbid weather are of import factors in determining prognosis. There is a significant difference in survival for the otherwise healthy 25-year-old vegetative patient and the 75-year-erstwhile vegetative patient who also has multiorgan system failure. Younger patients, in particular, may survive for decades with bogus nutrition and hydration (ANH). Although these patients may be cared for at home, they often end upwardly in nursing homes. Unless the family is quite wealthy or the patient has extraordinary insurance, the patient often winds upward in a Medicaid nursing home where the quality of care tin can be marginal, with one registered nurse for every twenty or 30 patients. If ANH is not withdrawn, these patients typically die of pneumonia, urinary tract infections, or sepsis related to peel breakdown.

Over the years, a variety of treatments take been attempted to effort to contrary a vegetative state. None of the treatments has been successful enough to become routine exercise. Some neonatologists have suggested promising experimental outcomes with neural stalk cells and predict that clinical applications may be available in the side by side decade or two. It is of more than than passing interest that many people who opposed the withdrawal of ANH in the Schiavo example also oppose stalk cell research, which might 1 twenty-four hours aid care for such patients.

Locked-in state

In the locked-in state, consciousness is preserved simply the patient is paralyzed except for eye movement and blinking. A particularly of import volume on this condition is The Diving Bell and the Butterfly: A Memoir of Life in Death (vii). When immature physicians tell me they wish to study clinical ethics and mayhap work as an ideals consultant, I insist that they read this book. The author, Jean-Dominique Bauby, wrote this book ane alphabetic character at a time while he was in the locked-in land. Born in 1952, he became locked in every bit a result of stroke on Dec eight, 1995, and died on March 9, 1997. A therapist set up upwardly a alphabetic character board with the letters of the alphabet arranged in the club they are most usually used in the French language. The therapist then pointed to one letter at a time on this chart until Jean-Dominique blinked, indicating the letter of the alphabet he wanted. The book is an extraordinary tale of the want to survive and live in this condition.

In my 25 years in medicine, I've probably communicated with four or five patients who were locked in, spending many hours over many days with them to determine their wishes. None of these patients wanted to stay alive in that condition once they comprehended that they were going to exist locked in. Notwithstanding, some physicians report patients who wish to survive in a locked-in state.

Minimally conscious land

Late in the course of the Schiavo case, people such as Senator Beak Frist looked at the videos of Mrs. Schiavo and offered the opinion that she was minimally conscious. One cannot diagnose the minimally conscious state or any other severe brain injury by viewing a videotape of a patient. In that location is no consensus however within the neurology community about a definition of the minimally conscious land, but the general standards are equally follows:

• Sleep-wake cycles exist, just as in the vegetative state.

• Arousal levels range from obtundation to normal arousal.

• There is reproducible but inconsistent show of perception, advice power, and/or purposeful motor activeness.

• Visual tracking is oftentimes intact but typically inconsistent.

• Communication ranges from none to unreliable, with inconsistent yes-no responses, verbalizations (typically fewer than vi words), and gestures (8).

Although technically the minimally witting country represents a less severe degree of brain malfunction than the vegetative state, every bit explained above, I fright it represents a land of greater suffering and thus greater moral jeopardy for those who insist we should keep patients alive in this status.

LEGAL CASES INVOLVING A PERSISTENT VEGETATIVE Land

Plato said, "Ethics belongs to the body polis"—that is, to the political body, the community. In the modern arena, what a social club decides is ethical is ultimately determined through politics, and nosotros have seen that played out in the Terri Schiavo example in a dramatic way.

I volition focus on iii cases, Karen Quinlan, Nancy Cruzan, and Theresa Schiavo. In the first case, that of Karen Quinlan who became vegetative in 1975, legal arguments connected for about 1 year. In the second, that of Nancy Cruzan who became vegetative in 1983, legal arguments went on for near iii years. In the third instance, that of Terri Schiavo who became persistently vegetative in 1990, legal arguments started in 1998 and continued for 7 years before final resolution. This progressive elongation of medicolegal debate in each successive case is somewhat of a worrisome trend.

The first "right-to-die" case: Karen Quinlan

In 1975, Karen Quinlan had a "respiratory arrest." (I consider this term to be a modernistic euphemism for death; before cardiopulmonary resuscitation was invented, when a patient stopped breathing, life was over.) She was resuscitated and left in what was initially described in the records as a blackout. Later it was determined she was vegetative. Karen's parents asked that her mechanical ventilator be removed and then that she might die, and the doctors refused. In the legal documents, the doctors indicated that they thought removing life-sustaining treatment was the equivalent of murder; they felt they had an inherent duty to protect life and specifically to keep Ms. Quinlan alive.

The case was eventually adjudicated in the New Bailiwick of jersey Supreme Court. In 1976, this court supported the parents in their request to permit removal of the ventilator, based on the right to privacy. The court found that families are acceptable surrogates for incapacitated patients who did not and could not make their wishes known. Remember that although living wills are now fairly mutual, they were rarely used in the 1970s as a means for patients to make their wishes known. California was the first country to provide for living wills equally a affair of police in 1975, and Texas was the 2nd country to do so in 1976.

The court likewise determined that quality of life is a legitimate factor for consideration when life and death hang in the medical balance. The judges acknowledged that physicians had a full general interest in preserving life; notwithstanding, they went on to note a correct to reject life-sustaining treatment, a right that increased as the "chance for a return to a cognitive sapient existence declines." This was a formative values judgment. These judges were expressing in their judicial ruling the value of something near and dear to their own personal lives: the value of intellect and cognition over other attributes of human being. Not all persons may place such importance on cognition; however, most do.

The judges in the Quinlan example likewise argued in favor of judicial restraint and noted that such cases do not generally belong in court. They mandated the germination of a "prognosis commission," which was a concept that evolved into what we today refer to as a clinical ethics committee. Even several decades after this ruling, no clinical ethics committee was consulted in the Schiavo case. At Baylor, members of our ethics consultation service take worked with many a divided family. Thankfully, in 20 years of ethics consultation, we have never come across a family and then divided that we could not somewhen reach some sort of reasonable resolution.

Although the judges ruled in favor of the family and the mechanical ventilator was withdrawn, Karen Quinlan turned out not to be dependent on the ventilator. Recollect that she was in the vegetative country, and such patients exercise not crave mechanical ventilation in the absence of centre or lung disease. Her parents did not request removal of her "feeding tube," and thus she lived for 10 years in a nursing abode supported past ANH earlier dying from pneumonia.

The first "right-to-die" case to reach the Us Supreme Court: Nancy Cruzan

Nancy Cruzan'south headstone tells a story (Figure ​ i). The electrocardiogram line on information technology says "thank you" before becoming flat. The headstone indicates that she was born on July xx, 1957; departed on January xi, 1983 (the twenty-four hours she had a car wreck and was establish dead past the side of the road); and was at peace on December 26, 1990 (the 24-hour interval her centre and lungs were finally allowed to finish). The case of Nancy Cruzan was the get-go correct-to-dice instance to go far to the Us Supreme Court.

The headstone for Nancy Cruzan. Photo courtesy of Chris Cruzan White.

Nancy Cruzan was already breathing without the aid of a mechanical ventilator by the fourth dimension it became apparent she was persistently vegetative. At this point, her parents began efforts to have her feeding tube removed so that she might be allowed to die. Physicians caring for Ms. Cruzan refused this parental asking and were supported in their refusal past then Missouri Governor John Ashcroft.

The Supreme Court ruled on the example in 1990, the aforementioned twelvemonth Terri Schiavo suffered a cardiac abort. The ruling was complex, only the ultimate result was that the parents were immune to direct the withdrawal of ANH and let Nancy to dice. The courtroom ruling supported the idea that patients have a fundamental right to refuse life-sustaining treatments simply added that states may regulate the circumstances under which life-sustaining treatments may be withdrawn when the patient cannot speak on his or her own behalf. For example, states may decide the level of proof about a patient'southward wishes needed to support a decision to withdraw life-sustaining handling. Interestingly, the level of proof in Missouri for Cruzan proved be the same every bit in Florida for Schiavo; there was no living volition in either case. Still, while at that place was disagreement amid family members in the Schiavo case, there was no family disagreement in the case of Nancy Cruzan.

The Theresa Marie Schiavo case

In February 1990, Terri Schiavo had a cardiac abort. Although we will never know exactly why this happened, I suspect it was related to bulimic behaviors. We do know that at one bespeak this patient weighed over 200 lbs; at the time of her cardiac arrest, she weighed about 110 or 120 lbs. I don't know how i achieves such weight loss in the absence of surgery or severe caloric restrictions, which might be achieved through bulimic behaviors. Interestingly, bulimia is sometimes linked psychologically to parental control issues, which seemed to be a factor as the case played out in the courts and media.

In June 1990, the court appointed Michael Schiavo, Terri's husband, as her legal guardian, and Terri's parents, Mr. and Mrs. Schindler, did not object. The Schindlers and Michael Schiavo were partners in Terri's intendance for 4 years. In Nov 1990, Michael Schiavo took his wife to California for experimental therapy, including placement of a thalamic stimulator implant. From November 1990 to April 1994, Terri also received concrete, occupational, and spoken communication therapy at two rehabilitation facilities.

In January 1993, a malpractice claim against an obstetrician-gynecologist possibly related to Terri's suggested eating disorder resulted in a $1 one thousand thousand settlement. Michael Schiavo was given $300,000 for loss of consortium, and $700,000 was placed in trust for Terri Schiavo's care.

In March 1994, 4 years after entering the vegetative state and 2 years afterward completion of both experimental and rehabilitative therapy, Terri Schiavo was transferred to a nursing home.

Finally, in May 1998, 8 years afterwards Terri entered the vegetative land—which was at present clearly permanent—Michael Schiavo filed his starting time petition asking a court to allow removal of Terri'south gastrostomy tube. His position was that Terri would not want to be kept alive in a vegetative state. Terri's parents took the opposite position. The court did non rush to judgment. After well-nigh 2 years of testimony with methodical due process, Judge Greer (a Republican) ruled that there was "clear and convincing testify"—i.eastward., the highest standard of testify in a civil trial—that Terri was in a permanent vegetative state and that she would cull to discontinue life-prolonging medical intendance.

During the course of the trial, the Schindlers used two good witnesses. Ane was William S. Maxfield, a radiologist from the Manatee Diagnostic Clinic in Florida and formerly of the Maxfield Clinic and Hospital of Dallas. Dr. Maxfield stated: "In my opinion, there'due south a meaning probability that she would improve with hyperbaric oxygen therapy based on what I accept seen in the CT of the encephalon, the SPECT scan, and my ascertainment and test of the patient." Based on prognostic data available in the peer-reviewed literature for patients who take been in the vegetative state for 8 years, using the words "significant probability" is extraordinary. Approximate Greer responded: "Information technology is interesting to notation the absence of any case studies since this therapy is not new and this status has long been in the medical arena."

The second practiced chosen by Terri's parents was William Hamasfar, Md, a lath-certified neurologist from the St. Petersburg Medical Clinic and a proponent of a privately patented vasodilatory therapy for cognitive ischemia. Dr. Hamasfar gave Terri Schiavo 105 commands and asked her 61 questions. He also had Mrs. Schindler inquire Terri questions and give commands. Based on 12 hours of videotape, Judge Greer stated, "The court saw few actions that could be considered responsive." The judge continued:

He [Dr. Hamasfar] testified that he has treated about l patients in the same or worse status than Terri Schiavo since 1994 but he offered no names, no example studies, no videos and no test results to support his claim that he had success in all but i of them. If his therapy is as effective as he would pb this courtroom to believe, information technology is inconceivable that he would not produce clinical results of these patients he has treated. And surely the medical literature would be replete with this new, now patented, process.

Michael Schindler chose as expert witnesses Ron Cranford, Md, professor of neurology at the University of Minnesota, widely recognized within the profession equally an skillful on the vegetative land, and Melvin Greer, MD, professor of neurology at the University of Florida and former chief of the Department of Neurology at the University of Florida. The judge picked an independent expert as well: Peter Bambakidis, MD, professor of neurology at Instance Western Reserve Academy and clinical doc at the Cleveland Clinic. All three of these board-certified academic neurologists concluded that Terri Schiavo was in a persistent vegetative country and in fact a permanent vegetative state, given the corporeality of fourth dimension that had passed since the injury. They said she had no chance of recovery. Medically, Terri Schiavo's brain had little if any normal tissue; well-nigh of her brain had been replaced by liquid (Figure ​ ii). Dr. Cranford further indicated that Terri's electroencephalogram was "flat line," which is very unusual in the vegetative country and technically indicates whole brain expiry, even though it is clear she was not whole brain expressionless.

Computed tomography scans of (a) a normal brain and (b) Ms. Schiavo's encephalon in 2002. The scan shows all-encompassing cortical regions filled with spinal fluid. The brilliant spot about the center is an intrathalmic stimulator placed in December 1990. Image courtesy of Dr. Ron Cranford.

In addition to these expert witnesses, all physicians who ever treated Terri Schiavo, both before and after legal deportment were taken, always wrote in their medical notes that she was in the vegetative state.

After the ruling, Terri's parents appealed. Over the next v years, there were multiple courtroom challenges. All came to the same conclusion. ANH was discontinued twice and then restarted, in 2001 and 2003. On October 21, 2003, the Florida House and Senate passed "Terri's Police force," permitting Governor Bush to have Terri Schiavo's feeding tube reinserted. This may have been the commencement time a governor directed that a specific medical act be carried out on a patient. The Florida Supreme Courtroom struck down Terri's Law on September 23, 2004, non on the footing of either medical facts or medical ideals, but on the basis of separation of powers. It is of note that we physicians, and medical ethicists in item, approach cases such as this from a medical and ethical perspective. Nosotros like to speak of the medical facts and relate them to such moral concepts equally benefit/brunt assay or proportionality. Note the court'south language, even so, which focused solely on problems of law:

We are called upon to make a collective, objective decision apropos a question of law. Each of u.s.a., however, has our own family, our own loved ones, our own children … just in the end, this case is non about the aspirations that loving parents have for their children… . Rather, every bit our determination today makes clear, this case is about maintaining the integrity of a constitutional system of government with three independent and coequal branches…. If the Legislature with the assent of the Governor can practice what was attempted hither, the judicial branch would be subordinated to the last directive of the other branches…. The essential core of what the Founding Fathers sought to change from their experience with English rule would exist lost, particularly their belief that our courts exist precisely to preserve the rights of individuals, even when doing and then is opposite to pop will.

Although I personally agree with the Florida Supreme Courtroom justices' last ruling, information technology is worth noting that discontinuing ANH in this instance was not opposite to the public volition, as reflected in diverse stance polls.

From October 2004 to Feb 2005, at that place were further legal maneuvers, each 1 decided in favor of the opinion of Terri's husband. The gastrostomy tube was removed on March 18, 2005, at about 1:00 pm. On March 21, 2005, the US Congress passed and President Bush signed a federal constabulary directing a review of the Terri Schiavo case in federal courts—disagreeing with 7 years of rulings by 19 judges and 6 different courts, including 3 appeals to the U.s. Supreme Courtroom. This new review came to the same conclusion reached past all other judges. Federal District Judge James Whittemore declined to direct that ANH be restarted. Other federal judges, including the appellate court by a vote of ten to 2 and the Us Supreme Court, supported the decision of Gauge Whittemore, who was supporting Guess Greer. Terri Schiavo died peacefully and painlessly from dehydration that she could not feel on March 31, 2005.

THE ETHICS OF Artificial NUTRITION AND HYDRATION

Medical ethics, at least as skilful at the bedside in the form of clinical ideals, properly starts with medical science and so moves to human behavior, spirituality, health law, and finally moral argumentation. That's why moral argumentation appears at the end of this article. Much of the ethical debate in the Schiavo case has focused on ANH for patients in the vegetative state. Although many moral traditions have contributed to that contend, it is particularly helpful to consider the Cosmic tradition. In the field of clinical ethics, we oftentimes appeal to concepts such as benefit and burden analysis, proportionality, or double result, concepts commonly associated with the Catholic moral tradition. In improver, Terri Schiavo, Karen Quinlan, and Nancy Cruzan were all Catholic. The Catholic tradition offers two competing viewpoints on the morality of withholding or withdrawing ANH.

View #ane: Artificial diet and hydration is morally obligatory

On March 20, 2004, Pope John Paul II delivered a papal allocution on the vegetative state and other brain injuries. In this statement, he pronounced that ANH is morally obligatory and must be maintained in most cases of persistent vegetative state (nine). This pronouncement has been quite controversial. My personal opinion as a physician clinical ethicist is that the pope's medical upstanding arguments are fatally flawed not considering his moral globe-view is in any way flawed but considering he did not start with a correct understanding of the medical science related to brain injuries.

First, the pope stated that the prognosis for persistent vegetative state is non certain, and he used this statement to justify much of his moral argument. There are times, especially early in the course of a vegetative state, when some dubiety about prognosis clearly exists and physicians should not blitz to judgment. Nevertheless, at other times, the vegetative state is obviously and unequivocally considered permanent, equally reflected in the work of the Multi-Lodge Job Forcefulness on the Persistent Vegetative State (five, 6). Furthermore, relatively few patients in the vegetative state have just a profound brain injury. Many have other significant medical bug, which take definite prognostic implications.

2nd, the pope stated that ANH is "ordinary and proportionate, and as such morally obligatory" as long as it obtains the goals of "providing nourishment to the patient" and "alleviating suffering." Concepts such as ordinary and proportionate are important to near of united states in clinical ideals and are always understood in relationship to the goals of medical action, especially although not exclusively the patient'southward goals. Once once again, I experience the pope did non have the medical facts clear when making a moral pronouncement virtually medical treatment. ANH definitely provides nourishment, just it is not nourishment that alleviates suffering because vegetative patients don't suffer. Such patients lack function in those parts of the encephalon necessary for consciousness and thus for the feel of suffering.

Tertiary, Pope John Paul II said that withdrawal of ANH is "euthanasia by omission … which past its very nature and intention brings about expiry with the purpose of eliminating all pain." Again, I believe this is not a medically accurate statement. The purpose in withdrawing ANH is not the removal of hurting that cannot be experienced by the patient. Those who argue in favor of withdrawal of ANH from vegetative patients typically do and then based upon a number of beliefs, including respect for patient autonomy and the correct to be left alone, or a belief that persons created in the divine image should not be maintained in a mindless country of existence, which they perceive as anything only divine.

Finally, the pope stated that feeding tubes and the nutrition and hydration they provide are not "technological support," nor practice they represent a "medical act." I don't call back I've ever met a gastroenterologist or surgeon who placed a gastrostomy tube who believed they were non performing a medical human action.

Pope John Paul II did limited concern well-nigh the slippery gradient. I share that concern. And he expressed a strong fear that ANH is withdrawn not to do good the patient but to lessen societal and family unit burdens. This is a legitimate moral concern worth considerable examination; however, other statements in Catholic thinking indicate that information technology is acceptable to lessen familial and societal burdens.

View #2: Artificial nutrition and hydration is morally optional

The view that ANH is morally optional and may be withdrawn in most cases of persistent vegetative country was common in much of Cosmic thinking prior to March 2004.

Part of that before view is based upon what is for some the sacred notion that the spiritual life is more of import than the physical life. Pope Pius XII expressed this in 1957, 2 years earlier le blackout depasse was described. He said: "Life, health, all temporal activities are in fact subordinated to spiritual ends" (10), suggesting that our bodies are here to back up our spirit. Fr. Kevin O'Rourke has argued that ANH is "not just futile, because it is ineffective in helping the patient pursue the higher goals of life, but is excessively burdensome because it maintains persistent vegetative state patients in a condition in which this pursuit will never again exist possible" (11).

The Texas Catholic Bishops also addressed the moral appropriateness of ANH in 1990:

The morally appropriate foregoing or withholding of bogus nutrition and hydration from a permanently unconscious [vegetative] person is not abandoning that person. Rather, it is accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded from taking the final step (12).

Fr. Richard McCormick fabricated this observation:

Imagine a 300-bed Catholic hospital with all beds supporting PVS patients maintained for months, even years, with gastrostomy tubes…. An observer of the scenario would eventually be led to ask: Is it true that those who operate this facility really believe in life after death? (thirteen)

Although these alternative views do not carry the weight of papal authorization inside Catholicism, I believe they are important moral arguments that non-Catholics may wish to seriously consider. Many devoutly religious persons have told me during my medical practice that they prefer a life in heaven to a life in a profoundly brain-injured country.

LEGAL Issues Nether THE TEXAS Accelerate DIRECTIVES Act

Vegetative patients are at a minimum covered under the irreversible illness clause of the Texas Advance Directives Act. Comorbid weather condition such equally advanced organ failure of whatever sort may qualify the patient equally terminally sick as well. In Texas, life-sustaining treatments, including ANH, may exist withdrawn with consent from either concluding or irreversibly ill patients. Ethics committees may exist consulted if disagreement arises and may corroborate withdrawal of life-sustaining treatment when treatment is futile in certain circumstances following the extrajudicial due process mechanism provided by Texas law (14).

The futility of treatment, however, depends on the state of affairs. Recall that Texas law does not utilise the term "medical futility" but rather the term "medically inappropriate" when discussing whether or not a treatment may be withheld or withdrawn from a patient. Clinical judgment is of paramount importance when considering such issues. Our ethics committee supports the idea that when the persistent vegetative state is an isolated condition, life-sustaining treatment such as ANH may be considered qualitatively futile. That is, handling such equally ANH may keep the patient alive and is thus not physiologically futile, just it does non make the patient well, nor tin the patient perceive any qualitative benefit of being alive. When other comorbid conditions such as multiple organ failure are present, ANH may exist considered not only qualitatively futile simply physiologically futile in that the patient is going to dice from organ failure while in the vegetative land even if ANH is maintained.

In cases of qualitative futility, the ideals committee will counsel the family unit, explaining that keeping someone alive in the vegetative condition is not the purpose of medicine or necessarily a proper goal for human existence. However, the committee will not support the forced withdrawal of a gastrostomy tube in these cases.

On the other hand, in cases of physiologic futility—with organ systems declining and requiring the apply of other interventions—the ethics committee will help the treating physicians withdraw life-sustaining treatment.

A CLINICAL Upstanding ANALYSIS OF THE TERRI SCHIAVO CASE

In formal ethics consultation, we often appoint in moral analysis by appealing to prima facie principles—moral activeness guides that people ordinarily agree are true and good. How do these principles—autonomy, beneficence, nonmaleficence, allegiance, and distributive justice—utilize to the Terri Schiavo instance?

Autonomy

Autonomy, or self-governance, is grounded in our cognition and is thus lost in vegetative, minimally conscious, and brain-dead patients unless the patient prepared a written or oral directive. Oral directives are subject to significant challenge, merely written directives are hard to overturn. The Schiavo example would non likely take occurred as it did if Terri Schiavo had a written living volition. I urge everyone to set living wills.

The principle of autonomy leads to the notion that surrogates should follow the standard of "substituted judgment," which means making the determination the patients would accept made for themselves, but this does not e'er happen. Michael Schiavo stated that his wife would not have wanted to proceed in a persistent vegetative land, yet he waited a long time to make that claim; thus, he could be said to have ignored his wife'south wishes and violated her autonomy for many years. Terri Schiavo's parents stated that even if she had had a living will, they would have ignored it. Nether cross-exam during trial, her parents also stated that they would have amputated all four of her limbs and sought open up-heart surgery if needed to proceed her alive. Again, this sentiment represents a articulate violation of the principle of autonomy.

Beneficence and nonmaleficence

Beneficence (promoting good) and nonmaleficence (avoiding harm) for a specific patient may be difficult to balance in the absence of patient guidance. Vegetative patients experience neither burdens nor benefits. They show no signs of joy or hurting in a reproducible fashion. At that place is no evidence that vegetative patients experience hunger, thirst, or concrete, psychological, social, or spiritual pain. Suffering is a witting experience, and vegetative patients lack consciousness.

Withholding ANH is associated with progressive loss of wakefulness as the patient slips back into a coma before death. There is no fashion to assess for psychological, social, or spiritual suffering in patients in a persistent vegetative country, but the best medical science available suggests that they do not feel these dimensions of suffering. Locked-in and minimally conscious patients may experience meaning suffering—physical, psychological, social, and spiritual. Considering suffering tin can be difficult to assess in patients with severe brain injuries other than brain death or the vegetative state, physicians should err on the side of treating pain and other signs of distress. If Terri Schiavo was actually in the minimally witting state, as some have tried to merits, the tragedy of her instance was multiplied, every bit such patients cannot reliably and consistently use words to tell us of their suffering, nor are they likely to exist able to attribute pregnant to their suffering. The ability to attribute meaning to suffering is an essential component for coping with suffering!

There is no traditional moral obligation to provide non-benign treatments based upon the archetype goals of medicine, which are, according to Hippocrates, "the complete removal of the distress of the ill, the alleviation of the more violent diseases, and the refusal to undertake to cure cases in which disease has already won mastery, knowing that everything is not possible to medicine" (15). At that place is a traditional duty to relieve suffering, nicely restated by Sir William Osler: "To cure sometimes, to salve oft, to comfort e'er."

Justice

Justice in the loonshit of medical ideals refers to distributive justice and challenges each of us to enquire, "What is a fair or just distribution of scarce medical resource?" I share the pope's fears about turning human life into a article; that is a existent concern for practitioners and wellness care systems. Yet I believe nosotros must collectively face to distributive justice concerns. Families may bankrupt themselves caring for patients in a persistent vegetative state, at which point Medicaid steps in. Medical costs are the leading cistron in bankruptcy. The same leaders of Congress who intervened in the Schiavo case, such as Senator Frist and Congressman Filibuster, have also cutting Medicaid spending dramatically. Governor Jeb Bush presided over spending cuts that removed 105,000 Florida children from Medicaid. An ethic in favor of life would need to consider these people as well.

Terri Schiavo was a hospice charity patient: her parents objected to her being supported by government funds. The hospice caring for Terri Schiavo provided $9.5 million of clemency care to patients in the by year. Fifty-fifty those who provide charity intendance demand to consider where those dollars go. I believe at that place is a very cogent argument in favor of supporting patients who can experience joy in life rather than those who are only vegetating and cannot experience any joy in life.

Some other question of distributive justice relates to insurance. Can a society that cannot find plenty resources to insure the 44 million persons (25% of whom are children) with no government or private wellness insurance really beget to maintain patients in a persistent vegetative state at a cost of $40,000 to $100,000 each per year? The lack of health insurance costs lives. According to the Found of Medicine, eighteen,000 deaths per year are direct attributable to a lack of health insurance. Cancer mortality rates are twice every bit high for uninsured persons every bit for insured persons according to reports from the Kaiser Foundation. Equally you consider your own respond to this question, remember that at any once, there are 10,000 to 100,000 patients in a persistent vegetative state in the Us.

Conclusion

The Schiavo instance has been a personal tragedy for Mrs. Schiavo, her husband, Mr. Schiavo, and her parents, Mr. and Mrs. Schindler. It became a political farce when elected representatives with piffling medical knowledge attempted to play both doctor and judge. Decisions near the end of life, whether to maintain a treatment that may non be beneficial or to withdraw or withhold a life-sustaining treatment, should be effectively handled in the majority of cases by the principal treatment team. Ethics consultations are available and can be particularly valuable in cases of dubiousness or disharmonize. Palliative intendance consultations are bachelor in cases of uncertainty or when needed to help manage circuitous symptoms, including physical, psychological, social, and spiritual suffering. Such suffering is ofttimes at the root of many an apparent conflict, and when the suffering is properly addressed, the disharmonize resolves. When these efforts fail to resolve conflict over decisions well-nigh the end of life, the rule of law suggests that the conflict be resolved in a court and non in legislative deliberations for a single patient.

At the end of all of the medical, legal, and upstanding statement, it is most important to remember that no matter how certain whatever of us may be of our analysis, decisions almost the terminate of life should never be easy. We must remind ourselves that truthful wisdom comes with the acknowledgment of doubt and admitting that we cannot know all there is to know. This uncertainty is neither an alibi to appoint in countless moral relativism or to engage in intellectual nihilism, refusing to search for the best possible solution or the least terrible issue for a troubling moral problem. As individuals and as a club, nosotros must practise a better job of following the wisdom of the sage Martin Buber, who teaches the states that we bear witness the greatest respect for our patients, loved ones, and all humanity past treating each person as our moral equal, embracing the I-Thou human relationship and avoiding the I-Information technology relationship (xvi).

References

ane. Mollaret P, Goulon M. Le coma depasse. Rev Neurol (Paris) 1959;101:5–fifteen. [Google Scholar]

two. Study of the Advert Hoc Commission of the Harvard Medical School to Examine the Definition of Encephalon Death A definition of irreversible coma. JAMA. 1968;205:337–340. [PubMed] [Google Scholar]

3. Plum F. Clinical standards and technological confirmatory tests in diagnosing brain death. In: Youngner SJ, Arnold RM, Schapiro R, editors. The Definition of Expiry: Contemporary Controversies. Baltimore, MD: Johns Hopkins Academy Press; 1999. pp. 34–66. [Google Scholar]

4. Jennett B, Plum F. Persistent vegetative state after brain damage. Lancet. 1972;1:734–737. [PubMed] [Google Scholar]

five. Multi-Society Task Forcefulness on PVS Medical aspects of the persistent vegetative country (one) N Engl J Med. 1994;330:1499–1508. [PubMed] [Google Scholar]

6. Multi-Society Job Force on PVS Medical aspects of the persistent vegetative state (ii) N Engl J Med. 1994;330:1572–1579. [PubMed] [Google Scholar]

7. Bauby JD. The Diving Bell and the Butterfly: A Memoir of Life in Death. New York: Vintage Books; 1998. [Google Scholar]

8. Giacino JT, Zasler ND, Katz DI, Kelly JP, Rosenberg JH, Filley CM. Evolution of practice guidelines for assessment and direction of the vegetative and minimally conscious states. J Caput Trauma Rehab. 1997;12:79–89. [Google Scholar]

x. Pope Pius XII. The prolongation of life (November 24, 1957) The Pope Speaks. 1958;4(4):395–396. Reprinted in Origins 2004;33(43) [Google Scholar]

xi. O'Rourke Chiliad. Origins. 2004;33(43):746. [Google Scholar]

12. Texas Conference of Cosmic Bishops On withdrawing bogus nutrition and hydration (May 7, 1990) Origins. 1990;20(4):53–55. [Google Scholar]

13. McCormick R. Origins. 2004;33(43):747. [Google Scholar]

14. Fine RL, Mayo TW. Resolution of futility by due process: early feel with the Texas Advance Directives Deed. Ann Intern Med. 2003;138:743–746. [PubMed] [Google Scholar]

xv. Hippocrates . Hippocratic Writings. London: Penguin Books; 1983. The scientific discipline of medicine; pp. 139–147. [Google Scholar]

16. Buber M. A New Translation, with a Prologue and Notes by Walter Kaufmann. New York: Touchstone; 1970. I and Thousand. [Google Scholar]

chappellhally1981.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1255938/

Share this post