Schiavo situation is a complicated affair
The sad story of Terri Schiavo has stimulated intense commentary, emotions and controversy.
The rhetoric of the controversy, although undoubtedly sincere, has in some cases diminished thoughtful understanding of underlying issues. In my opinion, the column by Jeff Ackerman (March 29) was an unfortunate example of such problematic and potentially harmful commentary.
In reporting the final court decision, Mr. Ackerman says, “the court said it was OK to starve her.” In fact, the court ruled that her spouse was legally entrusted with decisions about her medical care. In the absence of an Advance Directive and based on testimony as to the patient’s values and previous statements, the court upheld the legal guardian’s right to refuse continued medical intervention in the form of a feeding tube.
In so ruling, the judge acted in accord with case law developed over many years and jurisdictions, including the U.S. Supreme Court. Clearly, there are numerous other contentious and difficult aspects of this case. In order to understand what this woman’s story means to each of us individually and to society, it will be helpful to be clear about the central legal and ethical issues.
I would like to frame the court’s decision more completely in order to better serve those who might face such issues themselves. Her legal guardian made a choice between two undesirable outcomes: prolonging her existence in a persistent vegetative state by continued life support or withdrawal of life-sustaining medical intervention to prolong life in a state which “she would not want.”
That her parents preferred otherwise is heartbreakingly understandable. The courts weighed the differing views and made a heavy decision, but one which is consistent with end-of-life law and ethics.
Many families will face similar decisions in the care of loved ones with Alzheimer’s disease, devastating strokes, head injuries and many other severely destructive conditions. Loving people make hard choices every day, which sadly may include forgoing life-sustaining medical care. I believe it is necessary to promote well-informed, compassionate dialog among well-intentioned individuals and the professionals who serve them. Harsh, overly simple language like “starvation,” without acknowledgment of the whole picture, is harmful and disrespectful to those who experience the anguish of such terrible choices.
Essential to understanding of the legal and ethical principles in this difficult case are the following concepts: Medical interventions are a means to achieving health-related goals. Goals of medical care range from indefinite prolongation of life, to buying time to allow recovery (or time for negotiation of conflicting views!), to providing comfort in the face of overwhelming illness and the dying process. Current bioethical thinking emphasizes that tube feeding is a medical intervention and therefore a choice, based on the goals of care.
Hard decisions on the appropriate use of such tools must address the values and beliefs of the individuals involved. Quality of life and prognosis for recovery, as well as the burden of suffering resulting from the care, are all factors that most individuals weigh in trying to do the right thing. This applies equally to patients deciding for themselves and to surrogate decision makers trying to act in the best interest of loved ones.
Cessation of artificial nutrition and hydration is a difficult and emotional decision. It may be the most compassionate choice when there are no other positive options. The patients in question are always very ill due to underlying disease, which has already led to loss of appetite, bed-bound status, inability to eat naturally or cognitive unawareness. Dehydration is not usually uncomfortable. This is because skilled hospice professionals provide moisture care to the mouth with attention to all aspects of physical comfort. The passing of such individuals is typically very peaceful and dignified.
Health-care decisions in a setting of severe brain damage with a poor prognosis are extremely difficult and distressing. Individuals with differing beliefs make decisions in a variety of ways, often with intense controversy.
All of the above deliberations sometimes lead to no clear decision, because many issues are ultimately unresolvable. In such a situation it is most useful to honestly look at the question: who is suffering here? Legal, interpersonal and ethical quandaries often dissolve in the face of sincere answers to this question.
I hope that this article is helpful in thinking about questions that arise from the sad case of Terri Schiavo. I truly hope that all of her family can find peace and reconciliation. Complete your Advance Directives. But also, please understand that there are compassionate, ethical choices that can be addressed with the help of knowledgeable professionals.
Brad Miller is the medical director for Hospice of the Foothills.
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