Excellent entries on the biomedical ethics of the case by
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rivka here at Respectful of Otters and especially by Hilzoy
here.
jemyl, I'd particularly be interested in your thoughts on these entries, since we seem to be on opposite sides on these questions.
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Date: 2005-03-21 05:10 pm (UTC)Not as opposite as you think!
Date: 2005-03-21 07:13 pm (UTC)I hold that there is a big difference between refusing treatment and reversing treatment. I don't think that there would have been this hue and cry over Terri had her husband and parents been able to agree on a course of tapering off her feedings until she succumbed. Michael is afraid her parents will keep her alive unnecessarily and use up the money he won in the lawsuit. My point is still that once he made the decision to allow the feeding tube, he has accepted that form of treatment unless and until something more is found to be wrong with her. He has every right and has refused any other forms of medical treatment for her.
I am in total agreement that a person or their health care surrogate has the right to refuse medical treatment. My mother and my husband have both let me know that should either of them have a stroke at this point, or a massive heart attack or slip into a coma, I am not to call the paramedics, but just let them slip away naturally. Depending upon the way things are going with them and all I will likely do just that. Other than an obvious stroke or coma, however, I will likely let the docs decide about what has to be done and at least give me the odds before I refuse all treatment for them. As a medical first responder, I have seen people die, sometimes in my arms or under my hands doing cpr. There is something very special about the moment of death and I have also seen that it usually cannot be prevented, nomatter what.
As for Terri, I notice that her family is Roman Catholic. I cannot help but wonder if this is not part of the problem. I also cannot help but wonder why Michael Schiavo continues to fight so hard instead of just allowing the parents to care for her. Most patients like this will die fairly young anyway. The only way I can support the removal of that tube is if Michael Schiavo didn't OK its insertion in the first place.
If her brain is as bad as is said, her systems will shut down anyway. That is why I think something is wrong here. The way she is living is contrary to everything I know about severely brain damaged, to the point of saying her brain stem is gone, or to the point of that supposed xray of her brain shows, person's bodies generally start shutting down. It takes brain cells to regulate almost every bodily function. Something just doesn't jive here.
Re: Not as opposite as you think!
Date: 2005-03-21 07:40 pm (UTC)Re: Not as opposite as you think!
Date: 2005-03-21 08:42 pm (UTC)I must correct an earlier misstatement of mine: apparently, Michael did not decide that the feeding tube should be removed. He said he believed that would be Terri's wish, but he asked the court to decide, and the court did, evaluating the statement of Michael, her parents, and other witnesses as well. The court decided that the evidence indicated clearly and convincingly that Terri would have wanted the tube removed.
Michael is afraid her parents will keep her alive unnecessarily and use up the money he won in the lawsuit. As explained on this site referenced above:
I really don't think he's in it for the money, but as the above website owner says, we can't know. I ran across a site yesterday which gave an accounting of how the money has been spent that was won in the malpractice lawsuit, but I can't find that link now. According to the Miami Herald here, taxpayers and a hospice are paying for her care now. The malpractice settlement is almost entirely used up; it was spent on her care and the various legal costs. Michael Shiavo does not have control over the guardianship fund. So he couldn't have raided it for his own use, anyway.
As for Terri, I notice that her family is Roman Catholic. I cannot help but wonder if this is not part of the problem. I believe this is certainly true, particularly based on statements they have made in the press.
More re: feeding tubes.
Date: 2005-03-22 03:58 pm (UTC)Third, I think it's important to underline the point that as far as the law is concerned, taking out a feeding tube does not count as killing someone, but as not subjecting them to further feeding when they do not want to be fed. (Consider: one could achieve the same result by leaving the feeding tube in but not putting any more food into it.) It looks like killing someone since it involves doing something. But legally it isn't.
Leaving the law aside, while there are important moral distinctions between doing things that cause X and merely refraining from doing things that prevent X, that difference itself is probably not the crucial one. Consider: most people think that there's a difference between killing someone and not taking steps to save them. That's why the fact that most of us do not give all our disposable income to charities that save lives does not, in most people's eyes, make us murderers. Now suppose I write out a check to some charity, but decide not to put it in the envelope and mail it. That's "not saving lives". Suppose instead, however, that I write the check, put it in the envelope, put the envelope in my mailbox where the mail person normally picks up the mail; and then, on further reflection, conclude that I can't afford it. If I go out to the mailbox and retrieve my envelope before the mail person picks it up, does the fact that I am doing something to prevent the money from getting to the charity, and not just failing to send it, mean that I am guilty of murder? (Example from a philosopher named Shelly Kagan.)
In any case, there's a really important practical reason to treat removing a feeding tube (or a respirator) not as 'killing' but as 'withholding future treatment'. Doctors are not allowed to kill, but they are allowed to withhold treatment in accordance with a patient's wishes. If removing a feeding tube or a respirator counted as 'killing', then once it was in place, it could not legally be removed. Now: there are lots of people who do not want to be kept alive if (for instance) they would have to spend the rest of their lives in a hospital, hooked up to machines. And there are a lot of operations and other medical interventions that have a good chance of curing the patient, but also a non-negligible chance of leaving them in the situations these patients do not want to be in. Often these operations involve the temporary use of feeding tubes and ventilators. If it were not legal to remove feeding tubes and ventilators once they had been put in place, then patients would have to decide before the operation whether the chance of being cured was worth the chance of ending up hooked up to machines (or whatever.) If they really didn't want to end up hooked up to machines for the rest of their lives, they might forego treatment that had a good chance of curing them in order not to be stuck in a situation that was odious to them. Because feeding tubes and ventilators can be removed, however, these patients can undergo treatment and then, if it doesn't work, have the feeding tube or ventilator removed. That is: they can take the chance that they'll be cured without having to weigh it against the chance of being stuck in a position they don't want to be in, since if the treatment doesn't work, they can then have the feeding tube or ventilator removed. This saves the lives of those patients who, faced with this choice, would forego treatment, and protects the autonomy of those who would undergo it, but who do not want to be forced to live under certain conditions.
Peg here: this makes sense to me. I think of the removal of the feeding tube not as "killing" or as "reversing treatment" but as "withholding future treatment, because that is the patient's wish."
Re: More re: feeding tubes.
Date: 2005-03-25 12:56 am (UTC)Personally, I think he thought that she would die sooner of some complication if he just didn't let anyone give her therapy or other treatment. When it came about that she could live a lot longer than he had planned, then Michael suddenly decided that SHE never wanted to live this way in the first place. If he made a bad decision in the first place, then I think he should have to live with that decision. Had he even said, in the early trials, that HE wanted to keep Terri with him and take care of her even though she may have preferred otherwise, then I would be all for his stance now. He didn't do that.
I also think that his lawyers saw a patsy coming on this one and have kept it going in order to get the rest of the money. Follow the money is not a bad adage in things like this. Without the lawyers, without all of the media attention, I think that Michael may have been amenable to just taking a settlement amount and walking away. This case has been blown all out of proportion. I think it is because Mr. Felos wants to make a name for himself and to spend down or out the money won in the medical malpractice suit.
Oh, and putting food into a feeding tube is not a matter of just liquifying one's dinner and shoving it into the tube! Tube food comes in either hanging bags or cans and has to be either pumped in or put in via a 60cc syringe using either gravity feed or a slowly assisted feed. It is not a natural operation and how to do it, including how to flush the tube, keep it unclogged and give meds through it as well as keeping enough fluids going in and the electrolytes balanced is no mean feat for an adult. Some patients also pull their tubes out and the tube has to be changed every 60 to 90 days or so. Medicare will pay for one every 90 days on home care but nursing homes usually switch them out at 60 days. A tube can be out for about 12 to 24 hours before it means surgery to reinsert it. Usually it is removed and another one immediately inserted in the stoma. Surgical jelly is used to lubricate the new tube and its balloon is filled with sterile water. This must be checked and refilled sometimes every week and often the balloon deteriorates so that keeping the tube from slipping out is also necessary. I usually have to tape my husbands to his chest using special hypoallergenic tape which breathes. The stoma, too, must be cleaned of stomach juices that gather there and form a scablike thing which is a skin irritant and can make it impossible to move the tube without causing pain.
Nomatter how the Schiavo case comes out, Terri will go through a lot of pain. My greatest fear is that she is aware of that. For that reason I am glad that someone said they will allow her pain relieving drugs in her last days.
Re: More re: feeding tubes.
Date: 2005-03-25 04:34 am (UTC)Here is Michael's account of why he waited so long.
I think I pointed to this link before: Michael's attorney hasn't been paid for two years. And again, Michael doesn't have control of the trust fund from the malpractice case. And I believe I read the other day that he has offered to donate the residual to charity, if any is left when she dies, although I can't find the link at the moment.
All right: I admit my temper gets the best of me in what I have to say next, but I've been simmering over this for a while. Consider yourself warned.
What is making this discussion about Terri Schiavo so tremendously difficult is that people are thinking the worst of the other sides' motives and as a result, I think, they are screaming out all sorts of baseless accusations. (Personal example? It was rather difficult for me to manage to reply calmly to you when you accused me, as you did the other day, of wanting to kill babies with Down's Syndrome and autistic children [but perhaps you were speaking of people in generally rhetorically rather than me, personally? Difficult to tell in English where "you" is both singular and plural]). Well, that's rather an understatement. It was extremely difficult. Frankly, I felt damned insulted. You felt so passionately that your moral position was right that you impugned my motives, my morals and my reasoning while making your counter argument.
I am sure that when Terri Schiavo dies, her parents and their supporters will scream in the press that Michael Schiavo is a murderer. Why shouldn't they? Their supporters have been flinging around all sorts of other accusations: he beat her into a coma. He's tried to suppress the "fact" that she's talking and responding. All he wanted was to steal the settlement money. Why shouldn't you believe it? Particularly when they've gotten members of Congress to repeat these wild stories on the Senate floor?
Well, I'll tell you why I don't believe it. I don't believe it because the people who are saying these things are the same people who are urging the governor of Florida to ignore the judge's ruling and violate the law he has taken an oath to uphold. I don't believe it because the people who say that Michael Schiavo beat up his wife and wants to steal the malpractice money are the same people who accuse Judge Greer of burning with the desire to murder Terri Schiavo. And to put it bluntly, they accuse people like me of wanting to murder Downs Syndrome babies and autistic children. And you want me to accept their judgment??? When I hear accusations like that, I know in my gut that that's a crock of (to put it politely) garbage. I can't listen to people who throw around accusations like that. I think the Shindlers are spiking their own argument and shutting down the debate when they resort to tactics like that.
I can accept, if I squint and try really really hard (although the wildness of their accusations make it extremely difficult) that Terri Schiavo's parents want what they think is the best for their daughter. I would wish that for heaven's sake, they would have the simple decency to extend that same courtesy to me and Michael Schaivo and all the rest of the people in this country that don't see things the way they do. Believe it or not, we are moral people, too, who have REAL and ACTUAL ethics that honestly lead them to a different answer.
I will conclude, in a more level tone, that from what I have read from a number of medical sources, there should not be any reason that Terri will suffer from pain at the end. You are right, we can all be grateful for that.
Re: More re: feeding tubes.
Date: 2005-03-25 04:45 pm (UTC)Something to consider
Date: 2005-03-21 11:54 pm (UTC)(no subject)
Date: 2005-03-22 07:28 pm (UTC)(no subject)
Date: 2005-03-22 08:04 pm (UTC)