a clinical ethical analysis of the te...

a clinical ethical analysis of the terri schiavo case

Posted in the Terri Schiavo Forum

Since: Oct 06

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#1 Mar 14, 2007

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, but written directives are difficult to overturn. The Schiavo case would not likely have occurred as it did if Terri Schiavo had a written living will. I urge everyone to prepare living wills.

The principle of autonomy leads to the notion that surrogates should follow the standard of “substituted judgment,” which means making the decision the patients would have made for themselves, but this does not always happen. Michael Schiavo stated that his wife would not have wanted to go on in a persistent vegetative state, yet he waited a long time to make that claim; thus, he could be said to have ignored his wife's 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. Under cross-examination during trial, her parents also stated that they would have amputated all four of her limbs and sought open-heart surgery if needed to keep her alive. Again, this sentiment represents a clear 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 pain in a reproducible fashion. There is no evidence that vegetative patients experience hunger, thirst, or physical, psychological, social, or spiritual pain. Suffering is a conscious 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 way to assess for psychological, social, or spiritual suffering in patients in a persistent vegetative state, but the best medical science available suggests that they do not experience these dimensions of suffering. Locked-in and minimally conscious patients may experience significant suffering—physical, psychological, social, and spiritual. Because suffering 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 conscious state, as some have tried to claim, the tragedy of her case was multiplied, as such patients cannot reliably and consistently use words to tell us of their suffering, nor are they likely to be able to attribute meaning 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-beneficial treatments based upon the classic goals of medicine, which are, according to Hippocrates,“the complete removal of the distress of the sick, 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). There is a traditional duty to relieve suffering, nicely restated by Sir William Osler:“To cure sometimes, to relieve often, to comfort always.”

Since: Oct 06

Location hidden

#2 Mar 14, 2007
Justice in the arena of medical ethics refers to distributive justice and challenges each of us to ask,“What is a fair or just distribution of scarce medical resources?” I share the pope's fears about turning human life into a commodity; that is a real concern for practitioners and health care systems. Yet I believe we must collectively face up 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 factor in bankruptcy. The same leaders of Congress who intervened in the Schiavo case, such as Senator Frist and Congressman DeLay, have also cut 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 charity care to patients in the past year. Even those who provide charity care need to consider where those dollars go. I believe there is a very cogent argument in favor of supporting patients who can experience joy in life rather than those who are merely vegetating and cannot experience any joy in life.

Another question of distributive justice relates to insurance. Can a society that cannot find enough resources to insure the 44 million persons (25% of whom are children) with no government or private health insurance really afford 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 Institute of Medicine, 18,000 deaths per year are directly attributable to a lack of health insurance. Cancer mortality rates are twice as high for uninsured persons as for insured persons according to reports from the Kaiser Foundation. As you consider your own answer to this question, remember that at any one time, there are 10,000 to 100,000 patients in a persistent vegetative state in the USA.

Since: Oct 06

Location hidden

#3 Mar 14, 2007
The Schiavo case 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 little medical knowledge attempted to play both doctor and judge. Decisions near the end of life, whether to maintain a treatment that may not be beneficial or to withdraw or withhold a life-sustaining treatment, should be effectively handled in the majority of cases by the primary treatment team. Ethics consultations are available and can be particularly valuable in cases of uncertainty or conflict. Palliative care consultations are available in cases of uncertainty or when needed to help manage complex symptoms, including physical, psychological, social, and spiritual suffering. Such suffering is often at the root of many an apparent conflict, and when the suffering is properly addressed, the conflict resolves. When these efforts fail to resolve conflict over decisions near the end of life, the rule of law suggests that the conflict be resolved in a court and not in legislative deliberations for a single patient.

At the end of all of the medical, legal, and ethical argument, it is most important to remember that no matter how certain any of us may be of our analysis, decisions near the end of life should never be easy. We must remind ourselves that true wisdom comes with the acknowledgment of uncertainty and admitting that we cannot know all there is to know. This uncertainty is neither an excuse to engage in endless moral relativism or to engage in intellectual nihilism, refusing to search for the best possible solution or the least terrible outcome for a troubling moral problem. As individuals and as a society, we must do a better job of following the wisdom of the sage Martin Buber, who teaches us that we show the greatest respect for our patients, loved ones, and all humanity by treating each person as our moral equal, embracing the I-Thou relationship and avoiding the I-It relationship.

Hershey, PA

#4 Mar 14, 2007
Thanks so much, Patti, for your many contributions to this topic and discussion. The links and articles you provide are superlative.

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