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The Terri Schiavo Case: Legal, Ethical, and Medical Perspectives

Joshua E. Perry, JD, MTS; Larry R. Churchill, PhD; and Howard S. Kirshner, MD
[+] Article, Author, and Disclosure Information

From Vanderbilt University, Nashville, Tennessee.

Acknowledgments: The authors thank the editors and 3 anonymous reviewers for insightful comments on an earlier draft of this article.

Grant Support: None relevant to this article.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Joshua E. Perry, JD, MTS, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 507B Light Hall, Nashville, TN 37232.

Current Author Addresses: Mr. Perry: Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 507B Light Hall, Nashville, TN 37232.

Dr. Churchill: Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, 319 Oxford House, Nashville, TN 37232.

Dr. Kirshner: Department of Neurology, Vanderbilt University School of Medicine, 2100 Pierce Avenue, Nashville, TN 37232.

Ann Intern Med. 2005;143(10):744-748. doi:10.7326/0003-4819-143-10-200511150-00012
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Although tragic, the plight of Terri Schiavo provides a valuable case study. The conflicts and misunderstandings surrounding her situation offer important lessons in medicine, law, and ethics. Despite media saturation and intense public interest, widespread confusion lingers regarding the diagnosis of persistent vegetative state, the judicial processes involved, and the appropriateness of the ethical framework used by those entrusted with Terri Schiavo's care. First, the authors review the current medical understanding of persistent vegetative state, including the requirements for patient examination, the differential diagnosis, and the practice guidelines of the American Academy of Neurology regarding artificial nutrition and hydration for patients with this diagnosis. Second, they examine the legal history, including the 2000 trial, the 2002 evidentiary hearing, and the subsequent appeals. The authors argue that the law did not fail Terri Schiavo, but produced the highest-quality evidence and provided the most judicial review of any end-of-life guardianship case in U.S. history. Third, they review alternative ethical frameworks for understanding the Terri Schiavo case and contend that the principle of respect for autonomy is paramount in this case and in similar cases. Far from being unusual, the manner in which Terri Schiavo's case was reviewed and the basis for the decision reflect a broad medical, legal, and ethical consensus. Greater clarity regarding the persistent vegetative state, less apprehension of the presumed mysteries of legal proceedings, and greater appreciation of the ethical principles at work are the chief benefits obtained from studying this provocative case.





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The Vegetative State is not the Point
Posted on November 19, 2005
Thomas I Cochrane
Harvard University
Conflict of Interest: None Declared

The recent review and ethical analysis of the Terri Schiavo case by Perry, Churchill, and Kirshner is generally excellent.1 The authors do, however, make one important incorrect claim: "the Schiavo case rests critically on the concept of the persistent vegetative state (PVS)". This mistake is made by most observers of the case, and tends to detract from, rather than contribute to, the discourse over Terri Schiavo's case.

Robert and Mary Schindler went to great lengths, including distributing videos of their daughter, to convince the court and the public that their daughter was not in a PVS. Much of the effort of the courts was spent on determining whether she was in PVS. Senator Frist thought it was important to point out that he did not believe Mrs. Schiavo was in PVS, based on his review of the video footage.2 The Schindlers apparently continue to believe that the diagnosis was incorrect, and that a different diagnosis"”-presumably minimally conscious state (MCS)"”-would have led to a different ethical and legal analysis. The media and the public mistakenly believed that the autopsy would provide more certainty than was already available about her diagnosis, and that this in turn would determine "who was right" in the case.

This was all wasted effort. The distinction between PVS and MCS was irrelevant. Even if the Schindlers had agreed that the proper diagnosis was PVS, it seems clear that they would not have chosen termination of hydration and nutrition. Conversely, even if his wife had been in MCS, Michael Schiavo probably would still have concluded that her condition was unacceptably poor from her perspective. He even could plausibly have believed that her interest in terminating hydration and nutrition would be stronger if she were in MCS.

What should have been important to everyone was the prognosis, not the diagnosis, and prognosis for further recovery from either PVS or MCS after 10 years is probably equally poor.

The particular diagnosis in this case is irrelevant to any analysis that does not take the position that one has a right to refuse hydration and nutrition if one is vegetative, but does not have that right if one is minimally conscious. The proper ethical analysis in this case, elegantly delineated by the authors, rests a right to refuse treatments on individual liberty and a right to self-determination, and does not limit such a right to particular diagnoses.

1. Perry JE, Churchill LR, Kirshner HS. The Terri Schiavo Case: Legal, Ethical, and Medical Perspectives. Ann Intern Med 2005:744-748.

2. Babington C. Viewing Videotape, Frist Disputes Fla. Doctors' Diagnosis of Schiavo. Washington Post. Washington, D.C., 2005:A15.

Conflict of Interest:

None declared

Re: The Vegetative State is not the Point
Posted on December 12, 2005
Joshua E. Perry
Vanderbilt University
Conflict of Interest: None Declared

On 21 November, Dr. Cochrane posted a Rapid Response complimenting our article on Terri Schiavo and Persistent Vegetative State (PVS), but suggesting that the distinction between PVS and Minimally Conscious State (MCS) in the Schiavo case was "irrelevant." Dr. Cochrane was writing in response to our claim that "the Schiavo case rests critically on the concept of the persistent vegetative state (PVS)." At least as a matter of legal importance, we do feel that the diagnosis of PVS is critically important to the case.

The operative Florida statute specifically classifies PVS as one of only three conditions in which artificial life prolonging procedures can be withdrawn. The Florida statute defines PVS as "a permanent and irreversible condition of unconsciousness in which there is: (a) The absence of voluntary action or cognitive behavior of any kind. (b) An inability to communicate or interact purposefully with the environment." 1

To the extent that a diagnosis of MCS would not be explicitly covered under the Florida law governing Mrs. Schiavo's fate, the fact that the court concluded on two separate occasions (the 2000 Trial and 2002 Hearing) that Mrs. Schiavo was in a PVS is, from the perspective of the law, a fact of critical importance to all relevant decision makers.

Additionally, the medical certainty of the diagnosis of PVS is much greater than that of MCS, which has not been as well defined, nor as well documented in terms of poor prognosis. Families can much more easily accept a diagnosis with a wealth of medical documentation than one with less certain implications.

1. Fla. Stat. Ann. sec. 765.101(12)

Conflict of Interest:

None declared

The Terri Schiavo Case: A Tragic Outcome
Posted on December 9, 2005
Kenneth J. Simcic
University of Texas Health Sciences Center/San Antonio
Conflict of Interest: None Declared

Perry, Churchill and Kirshner argue that the outcome of the Terri Schiavo case is "an example of good standards and processes in medicine, law, and ethics". I disagree for the following reasons. Although Terri's husband, Michael, was her decision maker by law, I feel that he became unfit when he began an intimate relationship with another woman. This relationship eventually produced two children. Terri' parents were in a much better position to speak for her wishes. Unlike Michael Schiavo, they had no apparent conflicts of interest. They did, however, face serious inconvenience and financial hardship had their wish been granted to assume Terri's care and decision making. Judge George Greer and the American legal system failed Terri in this regard.

The authors have seemingly no doubt that Terri was in a persitent vegetative state(PVS). However, they fail to mention that it was widely reported that Terri was given intravenous morphine in the final days of her death by dehydration. Had she truly been in a PVS, it is very unlikely that she could have exhibited the discomfort necessary to demand analgesics.

They state that, "It is descriptively inaccurate to refer to a person in the persistent vegetative state as being disabled". I find this statement surprisingly insensitive with regard to the disabled community. Will the next step be to say that the words "human" and "person" are also descriptively inaccurate when applied to PVS patients?

Conflict of Interest:

None declared

Wide moral pluralism
Posted on December 14, 2005
Oswaldo Castro
Howard University College of Medicine
Conflict of Interest: None Declared

The Perspective on the Terri Schiavo case (Ann Intern Med 2005;143:744) concludes that it is an example of good standards and processes in medicine, law and ethics. However, the medical and legal arguments presented support such a conclusion only if one also accepts self-contradictory concepts such as moral pluralism or changing ethics. While the medical facts in cases that pose ethical questions change all the time, ethical principles do not. It is never ethical to deliberately put to death, by commission or by omission, an innocent human being. Even if Mrs. Schiavo had left a notarized document requesting to be put to death if she ever went into PVS, the ethical duty of her family, her doctors, and our judiciary, would have been to protect her life by disregarding such a directive. True, autonomy is a cherished principle basic to our way of life, but it would not be rational to invoke it to justify suicide or assistance in suicide. Our Declaration of Independence is morally sound in prioritizing our rights by listing life as the first good our government needs to protect. The ethical deviations that occured in the Schiavo tragedy can be given names such as moral pluralism or moral diversity, but in the end they remain immoral, even if sanctioned by law.

Conflict of Interest:

None declared

End-of-life decisions for patients in PVS
Posted on December 21, 2005
Thomas E. Baudendistel
California Pacific Medical Center
Conflict of Interest: None Declared

In their concise review of the Schiavo case, Perry et al. point out that by upholding the views of Mrs. Schiavo, as expressed through her surrogates, the courts were neatly aligned with the ethical precept of an individual's primary right to self-determination [1]. Although they review clinical features of the persistent vegetative state (PVS), the authors delegate this diagnosis to secondary importance in determining an incapacitated individual's best interests and in so doing avoid the opportunity to extend our understanding of the impact of the persistent vegetative state (PVS) on decision-making at the end of life.

Since the 1982 report of the President's Commission on the Study of Ethical Problems in Medicine, Deciding to Forego Life-Sustaining Treatment, many ethicists have argued that PVS itself provides a significant medical basis for the decision to forego life-support. The Report proposed that, when PVS becomes permanent, no patient interests can be served and no medical goals are obtainable; therefore, no duty exists to provide life-sustaining treatment[2]. This medical fact and its moral implications may serve as the grounds for a surrogate's decision regarding the "best interests of the patient." Since permanence of the vegetative state can be objectively determined (as Perry et al. point out), the "slippery slope" regarding notions of quality of life are avoided. According to this line of reasoning, just as no duty exists to continue life-sustaining treatment for an individual declared dead by brain criteria, so too would it be moot to discuss patient preferences when the diagnosis is permanent vegetative state. Although the majority of those surveyed in public opinion polls at the time of the Schiavo case would have opted not to be kept alive by artificial means[3], public consensus has not been reached regarding the fate of individuals in PVS. Analogous to the gradual adoption of brain death after much discussion, we would have liked to see the authors take the lead in discussing the unique ethical quandary of individuals in PVS.

Thomas E. Baudendistel, MD, FACP Albert R.Jonsen, PhD California Pacific Medical Center San Francisco, CA

1. Perry JE, Churchill LR, Kirshner HS. The Terri Schiavo Case: Legal, Ethical, and Medical Perspectives. Ann Intern Med. 2005;143:744- 748.

2. President' Commission for the Study of Ethical Problems in Medicine. Deciding to Forego Life-Sustaining Treatments, Washington, D.C.: Government Printing Office, 1983: 181-182.

3. Eisenberg D. Lessons of the Schiavo battle. Time. April 4, 2005. pp. 26-27.

Conflict of Interest:

None declared

Terri Schiavo: Let's Take a Step Back
Posted on January 3, 2006
Bruno Schettini
Good Samaritan Regional Medical Center
Conflict of Interest: None Declared

Perry et al. (1) review the Terri Schiavo case in respect to the legal reasoning leading to the decision and summarize the basis for that reasoning developed through the Guidelines of the American Academy of Neurology. Before applauding the "objectivity" applied to the decision, I propose that my colleagues take a step back and consider the implications of the reasoning behind the decision.

Persistent Vegetative State is distinct from Brain Death. By withdrawing nutrition and hydration, brain death was induced by the inevitable multi-organ failure.

Nutrition and hydration represent proportionate care, not extraordinary means. The Schindler family did not consider this care to be an undue burden.

Mr. Schiavo was legally considered to be the patient's guardian as he was her husband. As noted in Dr Simcic's response (2), the fact that he was fathering and raising children with another woman should be considered a conflict of interest.

I would have liked a discussion of why the court barred the Schindler's from trying to feed their daughter orally. If she were capable of oral feeding, and accepted the feeding, should we not assume that Terri's will was to live or at the very least not accept starvation as the means to her demise? Was the court concerned that oral feeding would lead to aspiration and possibly death from pneumonia?

The determination of Ms. Schiavo's wishes based on testimony that she had orally declared "she would not want to live like that" brings into question whether pronouncements made in the remote past are valid for one's current situation. Christopher Reeve had asked his wife to help end his life but was urged by her to keep on living (and he did live). Mr. Reeve had actually been experiencing the condition he was going to live through. Terri Schiavo could only have imagined her condition when she was overheard declaring she did not want to live like that. We cannot know if she could have been encouraged to keep on living by her parents.

This case finally concerns my sensibilities that, as a profession, we are making value judgments as to which lives are inconvenient enough to encourage us to consider assisting a remote suicide wish.

I urge any interested physician to review the Joint Statement on Persistent Vegetative State by the Pontifical Academy For Life of the World Federation of Catholic Medical Associations (3). This Document can be searched on the Vatican's website.

1. Perry JE, Churchill LR, Kirshner HS. The Terri Schiavo Case: Legal, Ethical, and Medical Perspectives. Ann Intern Med. 2005; 143: 744 -788.

2. Simcic KJ. The Terri Schiavo Case: A Tragic Outcome. Ann Intern Med/Rapid Response: 12 December 2005.

3. Pontifical Academy For Life: World Federation of Catholic Medical Societies. Joint Statement on the Vegetative State. International Congress on "Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas." (Rome 10-17 March 2004).

Conflict of Interest:

None declared

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