#19146: — 03/19  at  10:00 AM
Obviously, everyone needs a living will. My problem with only pulling the feeding tube is this: How long will she starve until she dies. Is that barbaric? Or is that as kind as we should be?

#19149: Orac — 03/19  at  10:41 AM
I'm a doctor. I support patient autonomy and the patient's right to withdraw support. However, I have grave concerns about this specific case. For one thing, Shiavo will die not of starvation (which can take 30-60 days, depending upon the lean body mass of the patient), but rather of dehydration, which usually takes somewhere between a week and 10 days, give or take. It is most unpleasant (very intense feelings of thirst and hunger will develop relatively quickly, for one thing). If she does have any ability to feel pain or suffering or that very intense hunger and thirst, she will suffer for at least several days before her kidneys shut down and she lapses into a coma. That is one reason I have always had a hard time with removing feeding tubes as a means of withdrawing support. It's different with withdrawing ventilator support, because the end is usually not protracted and, with a bit of sedation, the feeling of suffocating can be minimized quite effectively.

I agree that a living will is imperative for pretty much everyone, even 20-something year olds, who view their deaths as something that is very far off. Although, embarrassingly, I have to admit that I don't have one yet. Maybe it's time to get off my duff and do it...

#19150: Hank Fox — 03/19  at  10:50 AM
I think the reason they remove the feeding tube and allow a terminal/braindead person to starve is just that it is the least objectionable way to go about it. There's some back-thought of "letting nature takes its course" or "allowing god's will to take over" – thereby putting SOME of the blame for the person's death on an impersonal external force rather than the people who actually participate in it.

Although many people seem perfectly comfortable with killing convicts on death row, or blowing innocent bystanders to bits in "war," we're squeamish about accepting responsibility for the deaths of hospitalized patients.

(So much so that terminal cancer patients, so I've read, have long had a tough time getting adequate medication for pain. Doctors unconsciously want to err on the side of “I didn’t have anything to do with that guy’s death – it was the cancer, not the morphine.”)

It’s all understandable, when you think about it. I don’t feel really great about this Sciavo situation either. But ...

We’re left with this question: Who does your life belong to? I can think of a couple of arguments that conclude “If your life doesn’t belong to YOU, you’re basically a slave to the people who DO claim it.”

My feeling in the Sciavo case is mainly that it’s none of my business, and I’m kinda disgusted that it’s become such a circus.

Yet I continue to have moderately strong feelings about the right of the husband to have his way in this, based in part on this “slavery” argument. The intervention of congress and churches, etc., to me falls clearly in the category of turning Terry Sciavo into a POSSESSION – these external entities assume they have every right to intervene in the determination of her life and death, as if she, a total stranger, somehow belonged to them – and not her husband or family.

Aside from Sciavo’s specific life or death, the precedent set if Congress and these other strangers have their way in this case will be that none of us belong to ourselves. The slippery-slope extension of that is that nothing we own belongs to us either – not our possessions, not our families, not our intellectual property, not our minds. We become slaves, possessions, of somebody else.

Resisting a trend in that direction is well worth pursuing. I’m sorry for the way the woman’s parents will be affected by this, but I’m glad the husband is fighting this fight.

His tenacity in the face of all this strikes me as uncommonly courageous, even heroic.

#19151: GrrlScientist — 03/19  at  10:52 AM
Speaking of formalized idiocy .. can you believe that Congress subpoenaed Terri Schiavo to testify before a Congressional committee? Did you know that she could be charged with contempt of congress if she doesn't show up, as commanded? It might be the effects of the early hour when I first heard this news on the radio, but I think that "Contempt of Congress" is most appropriate in this situation.

#19152: Hank Fox — 03/19  at  10:56 AM
PZ, at the Pharyngula Phan Club meeting last night, you'll be happy to know that when the vote came up on the question of "What if PZ becomes a mindless hulk?", the greatest number of votes went to "Honor his wishes and pull the plug." However, "Have him bronzed" came in a close second, and there was even one vote for "Take souvenirs."

#19153: — 03/19  at  11:07 AM
Is the penalty for contempt of Congress a prison term or only a fine? If it's a fine then it'll be downright evil to charge her husband, whereas if it's a prison term it'll be comic rather than hurtful stupidity.

#19156: Michael Feldgarden — 03/19  at  11:11 AM
A question I would like to ask all of those who want to keep Schiavo alive is when do you pull the plug? If it's murder now, isn't it murder a decade (or four) from now?

#19158: PZ Myers — 03/19  at  11:15 AM
Great! Send me the list of fan club members and their addresses, and I'll write into my living will that my remains should be fed into a giant Ronco Veg-A-Matic, and each member should be mailed a quivering, gooey, lumpy cube of PZ.

#19159: Chris Clarke — 03/19  at  11:15 AM
Hank, I think you could do a better job of representing the wishes of the "pull the plug now" faction.

#19160: Hank Fox — 03/19  at  11:25 AM
Chris, the "pull the plug (on PZ) now" people are not members of the Pharyngula Phan Club.

That's the Pharyngula Phoes. They're evil.

(We in the PPC have sprayed "Pharyngula Phoes Suck!!!" on their clubhouse numerous times.)

#19162: Ron Sullivan — 03/19  at  11:42 AM
Orac, thanks for that. We -- my sibs and I -- faced that same dilemma when our mother had her second stroke. She was left unable to speak or communicate any other way, but, as happens with strokes, there was at first a period when some recovery might have been possible, and there's no way (as far as I know) to determine that except to try as much therapy as possible and see what the results are. Because she couldn't swallow, we allowed a gastrostomy tube to be placed to feed her.

Then we were looking at a long hard period when she was in nursing homes, a fate she'd explicitly feared. None of us was able to a/ stay home and not work for a living and b/ provide the skilled nursing care she needed. So there she was and there we all were, for six years. Six years, and every one of us thought about Mom every day and hurt for what she must be feeling, if anything. We honestly couldn't tell -- and a couple of us have had some experience with stroke patients, and a teaspoon or two of expertise in "reading" them. Her docs said they thought she had no cognition. We hoped that was true.

But we also knew that starvation/dehydration isn't painless -- I've watched it myself, in conscious, non-brain-damaged people -- and none of us was willing to risk life in prison for putting a pillow over her face, or finding the drugs to end it all faster. So the ordeal dragged on until she got pneumonia and died. What was interesting, in a rather barbed way, is that in the three months before her death, she rallied a little: started dragging herself around the halls in her wheelchair, using the handrails; seemed to recognize some of her kids and grandkids, reacted strongly when one of my out-of-town sisters visited. I was getting vacation time and funds together to visit too, from across the continent, when she died.

We all have turned the problem over again and again: did we do the right thing? Were we right about how pulling the feeding tube would have hurt? Were we right about how much cognition she had left? How badly did we hurt her, seemingly with no other choices?

I can't imagine how much more painful it would have been to have the legal and media circus at our elbows, baying for some damned quack or cleric or legal body to take over. And I do know that, if faced with evidence as strong as Terri Schiavo's brain scans, we'd have let her go immediately. I do believe that pain is the last thing that goes away.

#19164: Tyson Burghardt — 03/19  at  12:15 PM
Abstract Appeal has some great information on the case. Apparently, many of us have misunderstood that Michael made the decision to pull his wife's feeding tube. In fact, he waved his right to do so (as guardian) and invoked Florida law to allow a court to hold a trial to discern Mrs. Schiavo's wishes. Two trials were eventually held, in which Michael stood for Terri's wish to pull life support, and the Schindlers (her parents) stood opposite. In both cases, the court was able to find "clear and convincing" evidence--the highest standard in civil law cases--that Terri would have wanted her G-tube discontinued. Apropos of this, the case of the man who offered Michael $1 million to give up his guardianship is absurd, as even if the Schindlers had guardianship, it's the court's decision, as mediated by two trials that applies here.

I'm only a medical student, so I'll defer to Orac; although my understanding of the case is that most or all of Terri's cerebral cortex has withered and atrophied, and that she is incapable of experiencing pain--or anything else for that matter.

But I will concur with Hank Fox--this is a case that is frankly none of the public's (and especially not Congress's) business, but has blown up because A) the Schindlers, a lost cause in the courts, took their case to the real in modern America, and B) many officeholders with stakes in the illusion of their unquestionable kindness to life are hoping to ride this horse to reelection.

That Congress wishes to hold hearings on the state of health-care for people like Mrs. Shiavo is surreal. I was given to think that the law regarding individual wishes and heroic measures has been maturing over the past ten to twenty years. There is no defect in her treatment besides the alleged malpractice that led to her cardiac arrest in the first place. This is about how palatable decisions to end treatment are to the public, and I'm afraid any legislation arising from this is just going to rob thousands of people of their dignity in their last days.

But most galling of all--and naive, rhetorical question alert--how does Congress go about thinking they can interfere with something in all probability Terri would have wanted?

#19166: Lindsay Beyerstein — 03/19  at  12:40 PM
The court ruled that Schiavo wouldn't want a feeding tube. If she wouldn't have consented to the tube, it follows that she would have been resigned to the consequences of not having it.

Besides, why should we think that Terri Schiavo is capable of suffering the subjective effects of dehydration? Her higher brain centers have been destroyed. She has no detectable mental life.

Are there drugs that could reduce her brain function any further without killing her? Can PVS patients be put into drug-induced comas. If yes, then I would argue that all such measures should be taken, as much for the sake of concerned onlookers as for the patient herself. If there is no way to reduce her brain function any further without killing her, that suggests to me that she isn't sufficiently aware to suffer.

I would support a law permitting voluntary euthanasia by advance directive, but I wouldn't support true euthanasia in Schiavo's case because there is no reason to believe that she desired this outcome before she succumbed.

Ron, thanks for discussing your experiences so frankly. I'm glad your mother is at peace. She was lucky to have such a concerned family.

#19169: Orac — 03/19  at  01:17 PM
The problem, of course, is that, as much as partisans on both sides of the issue like to pontificate and make sweeping statements one way or the other, we don't truly know whether Schiavo is capable of feeling the very unpleasant effects of dehydration that will now occur over the next several days, at least not with the data available.

As for the CT scan, yes that's bad. It's very bad. There's undeniably marked hydrocephalus and severe atrophy of the cerebral cortex. But showing just the CT scan is a red herring. There are quite a few demented senior citizens in nursing homes with CT scans that look as bad or almost as bad (I've seen them on occasion when nursing homes shipped their patients to the hospital for one reason or another), not to mention a few patients who are status post anoxic brain injuries, and we aren't proposing pulling the plug on them, are we?

Or are we?

Personally, I think Respectful of Otters and Alas, a blog are just a bit too quick to dismiss the use of functional MRI or other functional neurologic imaging studies as being pointless in this case. At the very least, such studies might answer the question of the extent to which Schiavo is capable of feeling, as Lindsay put it, the "subjective effects" of noxious or painful stimuli, which is an important question to answer before any sort of withdrawal of care that would cause suffering in a person with higher mental function. If noxious stimuli caused no changes in activity in the higher cortex on functional MRI, that would be pretty conclusive evidence that there are no higher mental functions, at least with respect to the subjective suffering caused by noxious stimuli. I honestly can't understand what the objection is to doing such studies is.

#19171: — 03/19  at  01:30 PM
PZ,

Won't you have a clause in your living will that you be used as squid kibble?

#19174: Chris Clarke — 03/19  at  01:38 PM

Personally, I think Respectful of Otters and Alas, a blog are just a bit too quick to dismiss the use of functional MRI or other functional neurologic imaging studies as being pointless in this case

A good point in general, which the legal finding of Sciavo's wishes renders moot in this case.

Won't you have a clause in your living will that you be used as squid kibble?

And then we use the squid ink to print the Pharyngula Phestschrift! And the painted ponies go up and down.

#19180: Lindsay Beyerstein — 03/19  at  02:13 PM
Orac, is your primary objection to removing the tube that Schiavo might suffer? Taken by itself, this is not a convincing objection.

The courts found clear and convincing evidence that Schiavo wouldn't have wanted a feeding tube. Now that this decision has been made, the tube must be taken out. Those who dispute Terri's wishes or the fitness of Michael Schiavo to serve as her legal guardian have already had their days in court. Now that the facts have been heard and the legal avenues exhausted, it would be immoral and illegal for doctors to continue to feed Schiavo by tube.

A functional MRI would be beside the point. I have serious doubts that an fMRI could reveal anything meaningful about Schiavo's state of mind. Suppose that her vestigial brain registered metabolic activity upon noxious stimuli. We would be begging the question if we concluded that this metabolic activity was evidence of consciousness. Nobody doubts that her brain stem works. The relevant evidence is behavioral--does she respond mindfully to stimuli? Does she show signs of being aware of her own internal or external milieu? Her family claims that she does, but neither the doctors who have actually examined her, nor the judge who evaluated their findings give any credence to these claims.

The "potential sentience" argument cuts both ways. How are we to know that she isn't suffering in her current state?

We know because she doesn't behave as if she's suffering. Michael Schiavo wouldn't be allowed to argue that every moment is a living hell for Terri, despite neurophysiological and behavioral evidence to the contrary. So why should we give credence to the similarly unsupported opposing view?

Let's suppose for the sake of argument that Schiavo has some minimal level of consciousness. Even so, the issue is whether she would want to live as she is now. Her parents are arguing that she would want to live because there are viable treatments that might increase her level of consciousness. This is absurd. There is no way to restore the brain tissue that has been lost and no way to stop the ongoing atrophy of her remaining brain tissue. This case has become an ongoing infomercial for "alties" touting hyperbaric therapy, herbal medicine, homeopathy, off-label Namenda and other unproven treatments. Terri didn't consent to the standard treatments, let alone to unsupervised experimentation on her body.

If there are any doubts about potential suffering, palliative care is the answer, not nonconsensual feeding.

#19182: Moebius Stripper — 03/19  at  03:28 PM
Regarding the brain image, could someone who knows more about these things tell me how that scan differs from that of a person with hydrocephalus ?

#19183: scott pilutik — 03/19  at  03:52 PM
The far right sees this as a fundamental 'right to life', no doubt motivated by religious beliefs, even though the meaning of 'life' has become quite flexible. The Supreme Court held in Rogers v. Tennessee that the "year and a day" common law murder rule (you murder if you proximately cause your victim's death within 366 days) is essentially useless where life can be sustained indefinitely by machinery. And obviously many states have enacted right to die suits. Where there is no evidence of choice, the spouse usually decides intent.

So then, there is an irony here: by seeking to undermine a state-granted right of a husband to decide his spouse's intent in such a situation, Congress is infringing on a right they're planning on arguing is fundamental enough to merit its own Amendment. Sanctity my ass.

Trackback: The purpose of the court system Tracked on: The Liferaft of Love (72.9.234.70) at 2005 03 19 15:57:29
I have only one other Terri Schiavo-related thought. As to Terry Schiavo, her husband, and her family, I could say that I feel great pity. That would be a lie. If I felt a great deal of pity for everyone who deserved it, I'd have no time to do anythi...

#19184: — 03/19  at  04:25 PM
Moebius,

there are lots of answers to that question, and people more qualified than me to give them. But I'll just give you the one that I see as most important: plasticity.

Hydrocephalus is treated, or not, when a person is young, and young brains have a pretty remarkable ability to adapt to abnormalities. If you grow up with an abnormal brain (or suffer a brain trauma while young), there's lots of room for the brain to make accomodations. Just as a way out on the fringe example, there are kids who are born missing an entire hemisphere of their brain, and they do a lot better than you'd ever think.

However, if you suffer the kind of loss of brain tissue evidenced in the CAT scan above as an adult, you're very much out of luck. That's just way beyond the pale.

#19186: — 03/19  at  04:47 PM
Addendum:

also note, that while both brains share the extremely oversized ventricles, the hydrocephalic brain is still pretty dense with tissue everywhere else (as would be expected since it's essentially just being "squished" by the excess CSF). Schiavo's, on the other hand, has numerous gaps even where there is still surrounding tissue of some sort.

#19189: — 03/19  at  05:51 PM
What, no one remembers our earlier promise to (repeatedly) clone Dr. Myers into a Super-race of evil Marxist-Communist-Darwinist-Terrorist-Atheistic baby-killing biologists?

#19190: — 03/19  at  05:54 PM
I have two solutions:

1. That the keep-Terri-alive lobby be given her medical bills to pay.

2. That some leading theologians be convinced to rule that Terri's soul has departed her body, and that what's left is the moral equivalent of donated organs.

I'm sure that that lobby will enjoy paying her medical bills, since they care so much about keeping her alive.

And I think that there is a good theological argument to be offered for the proposition that Terri's body is now soulless. According to the separable-soul theory, the soul is a sort-of symbiont of the body, and it departs from the body when it becomes an unsuitable host, usually by dying. So with her brain largely gone, a good case can be made that her soul has deserted her body as an unsuitable host.

#19192: Mrs Tilton — 03/19  at  07:04 PM
Hank, I don't doubt that there are doctors who will undermedicate terminally ill patients rather than be seen to have hastened them along. That said, I personally know strongly 'pro-life' Roman Catholic doctors who do not hesitate to load up moribund patients on a raft of (relative) comfort, completely unconcerned that they might thereby be (in effect) euthanising them. The doctrine of 'double effect' strikes me as profoundly silly, but if it helps such doctors do the right thing in deeply unfortunate circumstances, I am not going to argue with them.

On a (slightly) less serious note, though the wishes of the patient should normally be paramount, I do not wish to see PZ portioned out pro rata as so many spoonsful of jam. Surely we should do whatever it takes to ensure he becomes part of the fossil record.