Wednesday, March 23, 2005

An apolitical post about Terry Schiavo's case

Wow, I can't sleep. I just spent a while reading a blog by a radiologist, who offers his opinion of the Terry Schiavo case. I couldn't resist adding a comment on that site. Meanwhile, I have resisted using this blog as a forum for my personal opinions regarding the case. Honestly, I don't know enough about it, and neither, I believe, do 99% of the people we hear blathering on about it on the news. In any case, I would like to offer some basics of medical ethics -- the ideas upon which this case is founded.

After the horrors committed in Nazi Germany in the first half the 20th century, the international medical community developed four overarching principles of medical ethics to which all physicians must adhere when making medical decisions. These principles are, in no particular order: 1) Beneficence -- the physician must try to help the patient; 2) Non-maleficence -- the physician must not try to harm the patient; 3) Justice -- the physician must consider the impact of the patient's care upon the society, both locally and at large (e.g. using limited resources on exhorbitant treatment for a dying patient is unjust if it deprives other patients of their opportuninity for treatment); 4) Autonomy -- the physician must respect the decision making capacity of the patient, and must not administer treatments against the patient's will. It is this latter ethical principle that comes into play in the Terry Shiavo case. From the standpoint of medical ethics, it doesn't matter if the family wants Terry to live, or if Michael Schiavo wants her not to live. The ONLY issue in question should be, 'What would Terry want for herself?' That is the principle of autonomy in action. We must respect what Terry would have wanted. That is the reason why Michael Schiavo has won every court case to date regarding Terry's treatment: he offers testimony (whether you believe it or not) as to what Terry expressed to him she would want done under such circumstances as she now faces. It's the only thing that matters.

Also, we have this large problem of having to remove a feeding tube in order to allow Terry to pass away. Some people see such an act as tantamount to murder; she was alive, then the doctor did something to her, and then she began to die. However, a well-established precedent exists that the withdrawal of treatment is no different, from a medicolegal and medical ethical standpoint, than never offering treatment in the first place. So taking the feeding tube out -- even 15 years after its placement -- becomes a question of whether or not Terry would have wanted in the first place to undergo an invasive procedure in order to obtain nutrition that would maintain her in her present state. The issue becomes more thorny because the court order Michael Schiavo recently obtained also contains prohibitions against Terry receiving anything by mouth, such as food or even water. I must admit that I'm a bit out of my depth in dealing with that particular issue -- perhaps the family could be allowed to care for her, sans tube, as a compromise that still respects Terry's autonomy? I just dont' know.

In any event, this case has become a terrible conundrum (gee, Ian, thanks for that insight). The take-home point, though, is this: make sure that your loved ones understand your wishes if, God forbid, anything should happen to you. Making clear, illustrative statements such as, "I do not want to have any medical treatment if it means living in a persistent vegetative state," is a good thing. Better yet, capture those wishes in print in the form of a living will that provides guidance for your loved ones. Better still, if you know of an authoritative figure who can make well informed, dispassionate decisions on your behalf, obtain legal documentation to appoint that person as your durable power of attorney should you lose decision making capacity. For example, many physicians have a fellow physician as a proxy decision maker. The idea is that this person would be educated about the pertinent issues and would not let emotion stand in the way of faithfully representing what you would have wanted. Moreover, certain pitfalls associated with a living will can be avoided, because written documentation is by nature static and finite, and cannot delineate exactly how caregivers should act under an infinite number of circumstances. Whatever you do, remember that it's never too early to think about this sort of thing; Terry Schiavo is a prime example.

Okay, I'm sleepy now. Hopefully I kept this post relatively free of opinion, restricting it instead to background info and general advice.


At 8:58 AM, Blogger KarbonKountyMoos said...

Okay, my 2 cents?

I think that everyone who is so up in arms over this - whatever side, whatever opinion...
Every single one of you - right to lifers, congresspersons, media mavens, judges, etc... and so on so on so on - needs to volunteer in a nursing home. Not for a couple of hours, but for a few days a week for the rest of their lives.

That's all.

At 5:58 PM, Blogger L said...

this is THE water cooler topic of the year at my company...

At 9:00 PM, Blogger kingfelix said...

I have to hold up my hand and say that I am really NOT interested in this case. I worry about the involvement of religious groups, as I believe these issues should be determined at the level of the family, if possible, and finally, in the courts, if agreement cannot be reached.

I would not support having Christian principles providing the framework for how these situations should play out. That infringes the rights of those, such as myself, who live (and perhaps would choose to die) without involving themselves with religion. The last thing I'd want to do is persist in a vegetative state because of Christian fundamentalists! That really would be their final act of vengeance on me.

If, at the personal level, someone has a faith, and that makes some difference to the course of their treatment (non-treatment), then fine, let them go their way.

On the wider point, yes, we should all appoint someone to safeguard our interests.

At 11:58 PM, Blogger Ian said...

Thanks for the comments. It's just a shame that this poor woman's plight has become such an incendiary political topic, and a source for such buzz in the media. It's enough to make a person turn off the t.v., that's for sure.

At 1:14 PM, Blogger Janine said...

I agree Ian - the most striking part of the entire story is how media and media players (politicians) have played this for their gains.

At 12:49 PM, Blogger Rachel said...

I am a little late posting on this. Your post is insightful and passes without judgement. I agree that most issues in the media do not and cannot cover the story. Though this case really has me thinking about my own will and the need to get it done. I will take your words as anothe nudge to get my affairs in order, just in case.


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