Medical Ethics of Schiavo Case

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• JIM LEHRER:

  Jeffrey Brown handles our Schiavo discussion tonight.

• JEFFREY BROWN:

  One extraordinary week after the feeding tube was removed from Terri Schiavo, she remains in a hospice in Pinellas Park, Florida. Doctors have said she would likely die within a week or two after the tube's removal. Much about her case continues to raise important and difficult questions. And tonight we look at the situation through two different lenses.

  Dr. Russell Portenoy is a neurologist and chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York. Robert George is a member of the President's Council of Bioethics and a professor of jurisprudence at Princeton University. And welcome to both of you.

  Starting with you, Dr. Portenoy, a week after the removal of the feeding tube, what would a patient such as Terri Schiavo be experiencing?

• DR. RUSSELL PORTENOY:

  Well, typically patients who are toward the end of life and do not have access to nutrition or hydration slowly get quieter and sleepier; they lapse into coma. The coma gradually deepens and then finally they die.

• JEFFREY BROWN:

  Now in this case, Terri Schiavo is in a persistent vegetative state. We've been hearing about that all week. Can you tell us as neurologist what exactly does that mean?

• DR. RUSSELL PORTENOY:

  Well, neurologists typically define consciousness into the level of consciousness and the content of consciousness. The level of consciousness means how awake a person is. And the content of consciousness means things like thinking, emotion, memory.

  A patient in a persistent vegetative state can appear to have a normal level of consciousness with alertness and with normal sleep cycle but they have no content of consciousness. They don't experience emotion. They can't think. They can't interact with the environment. They have no memory.

  So the persistent vegetative state is actually a very difficult condition for caregivers because the patient can look as if he or she is awake and interactive but there's really no… nothing left of that person there.

• JEFFREY BROWN:

  So is removing a tube from someone in that state different from removing a tube from someone in a conscious state?

• DR. RUSSELL PORTENOY:

  Oh, absolutely. Patients in a persistent vegetative state give no sign of experiencing pain and suffering in any way that we can relate to. Patients who have the tube removed… if a normal person or a person who was conscious and interactive might experience some period of thirst or hunger, the patient in the persistent vegetative state would not.

• JEFFREY BROWN:

  You say they give no sign of it. Is there a way of knowing whether they're experiencing pain?

• DR. RUSSELL PORTENOY:

  Well, neurologists will evaluate a patient in a persistent vegetative state in a variety of different ways seeking any indication at all that there is functioning higher cortical interaction with the environment. They'll try to get the patient to interact, to speak. They'll try to get the patient to follow commands. They'll try to get the patient to react to sounds or pictures.

  A patient in a persistent vegetative state doesn't do any of these things. And also there's often ancillary evidence that the brain damage has been extreme.

  For example, in the… in this case, the CAT Scan has demonstrated that there has been massive injury to the brain and the EEG, which measures the electrical activity of the brain, from what the media reports say, is essentially flat showing that there's no cortical functioning.

• JEFFREY BROWN:

  And in a typical case, what kind of care would be given right now in terms of preventing any discomfort?

• DR. RUSSELL PORTENOY:

  Well, there's no discomfort in patients with a persistent vegetative state and yet, as a person in a persistent vegetative state dies, medical professionals have the obligation to treat that person with dignity in the same way that you would treat a person who was conscious and interactive.

  So I'm sure that in the hospice program within which she resides she is being cared for carefully; she's being protected. When she's turned, her skin is being protected. So there's no sense here that there is suffering. And yet the care would reflect a high level of concern as it would for any human being.

• JEFFREY BROWN:

  Professor George, let me bring you into this. You come from a very different perspective. What concerns do you have about the process that's under way?

• ROBERT GEORGE:

  Well, of course, my first concern is that Miss Schiavo is being deprived of nutrition and hydration on the basis of a judgment that she probably wouldn't have wanted nutrition and hydration to be given to her in this state. But I think that judgment is based on evidence that's at the very best questionable.

  I think it's very unlikely that Terri Schiavo ever contemplated the circumstance that she's in and contemplated the deprivation of nutrition and hydration as being what would be available to her in something that she would want. So my fundamental concern is with depriving a woman of food and water with the objective of bringing about her death.

• JEFFREY BROWN:

  Well, some people have been using the term "starvation" for what's happening now. Do you see that? Do you see this as a cruel process?

• ROBERT GEORGE:

  Well, we don't know whether it's cruel. Dr. Portenoy has just given one opinion about whether a person in Terri Schiavo's condition would be feeling pain and therefore there would be cruelty involved. Over the course of the past week I've been reading a lot of conflicting accounts by medical people, physicians, nurses, people who are on the spot, people who've looked at the data. And they're just conflicting opinions about that.

  So I can't say whether, in fact, there's cruelty here, but there's at least some experts who do believe that she's experiencing pain as a result of starvation, of being deprived of nutrition and hydration. But I don't think anyone can really know for sure. There's a good deal of ambiguity and uncertainty.

• JEFFREY BROWN:

  Well, how much ambiguity? If there are a few experts on one side and if Dr. Portenoy is expressing a view of the majority, let's say, of neurologists out there, what kind of balance do you give it?

• ROBERT GEORGE:

  Well, I don't know how to make the call myself because I'm not a neurologist, but I do know that there are responsible and respected people who are on both sides of that particular issue. There may be a preponderance on one side, but there are responsible people on the other. If I recall years ago, the famous case of Karen Ann Quinlan, when she was… when people at the hospital were contemplating removing her from a respirator, as they eventually did, medical opinion was unanimous that she would die, or almost unanimous that she would die when removed from the respirator.

  One expert, Professor Robinson from Georgetown, said she wouldn't die and it turned out that one expert was right and she lived on for another, for a decade, as a matter of fact. So we're working in an area here of some uncertainty.

• JEFFREY BROWN:

  To the extent that there is this uncertainty, how far would you… how far would you take the argument? I suppose this kind of thing must hit many people in our audience or will hit it, these kinds of end-of-life decisions. If there's always a question of some doubt, when is there finality?

• ROBERT GEORGE:

  Well, my judgment is that where there's any doubt at all, of course, we should err on the side of life. And the courts have decided the other way in this particular case and that, I think, is what's responsible for the controversy.

• JEFFREY BROWN:

  Dr. Portenoy, would you like to respond to some of what you've just heard?

• DR. RUSSELL PORTENOY:

  I think most palliative medicine specialists like myself very much want the expressed wishes of the patient not to be lost in the… in all the attention being paid to this case. This case has been adjudicated in the courts for a long time and the judges involved have felt that there has been evidence that this patient expressed the desire not to live in a persistent vegetative state if there was no reasonable hope that she would ever get better.

  It's important to realize that the goals of advanced directives, meaning to say the attempt in our society to make sure that every patient gives a healthcare proxy to someone or writes a living will so that his or her decisions about the kind of care that they would receive if they can't make decisions for themselves later on, that whole approach developed because of concerns about a paternalistic attitude in the healthcare field such that patients who would not have wanted to end up in a persistent vegetative state were kept alive in that state, or patients who had no desire to go into an intensive care unit were placed in an intensive care unit.

  So I think the concern here is not to forget the express wishes of this patient. If there is some disagreement about whether those wishes were truly expressed, all that I can say is that this was in the courts for a long time and the courts were satisfied that those wishes were expressed. So that's a decision to remove the tube in essence, is the patient's decision, not the decisions of those around her.

• JEFFREY BROWN:

  Dr. Portenoy, to what extent are these kinds of doubts or uncertainties that Professor George has raised, is that a common thing in cases that you have to deal with?

• DR. RUSSELL PORTENOY:

  The doubt that a patient is in a persistent vegetative state is actually very small. There's no question that recently science has identified a group of patients who have what's called a minimally conscious state. And there's no question that there are isolated cases in the medical literature of people who were in a minimally conscious state or perhaps a persistent vegetative state who improved over many years, never to become independent but at least to become more interactive.

  But in this particular case, she has been examined by multiple physicians over many years, more than a decade. And the objective evidence of brain damage on the CT Scan and the EEG as it's been reported in the media suggests that the higher functioning of her brain has been irreversibly damaged by really massive brain injury.

  So I think one can say there's always a possibility that the… that the unforeseen can happen, but in this particular case over a loft examined by competent people and with objective evidence of massive brain injury the likelihood of reversibility is nil.

• JEFFREY BROWN:

  Well, Professor George, how do you respond there, because that is — if the preponderance of the evidence is that there is little or no chance — I should say no chance really of improvement, except for the possibility that the doctor just raised, the slim possibility, how long does this go on?

• ROBERT GEORGE:

  Well, there is a slim possibility, that's true. But the question is not a question of reversibility. There are really two questions here and I think we have to be clear about them. First is whether Terri Schiavo is in a persistent vegetative state or is in a minimally conscious state.

  And that has been disputed and that has been disputed by competent experts. The second question is whether she did, in fact, make an express or express a wish to die if she was in a vegetative state.

  As I've examined the record, I see no evidence whatsoever that she contemplated being in a persistent vegetative state or envisaged herself in such a condition and then made a conscious choice and expressed the choice to be starved to death in that condition. That's just not in the record. We're going here as if she had written something out or said something very clearly envisaging a particular state of consciousness, a persistent vegetative state. But the fact is, she didn't.

• JEFFREY BROWN:

  Dr. Portenoy, a final medical question. When Miss Schiavo does die, what will she die of?

• DR. RUSSELL PORTENOY:

  Well, patients who have hydration and nutrition develop biochemical changes in the blood. These biochemical changes progress and at a certain level of abnormality they are associated with abnormal heart beat, arrhythmias of the heart. And so ultimately she will die when her heart stops.

• JEFFREY BROWN:

  All right. Dr. Russell Portenoy and Professor Robert George, thank you very much.