The relevant medical facts contributing to Ms. Schiavo’s condition
While the case of Terri Schiavo remains disturbing, it was one of the most litigated medical cases in history, which focused on medicine, ethics, law and the role of the family in decision-making. Many case studies have claimed that all the responsible stakeholders worked so poorly to cater for the needs of a patient who was left in a persistent vegetative state after suffering severe hypoxia for several minutes (Quill, 2005).
From the available medical facts, Terri suffered a cardiac arrest on February 25, 1990 because of severe hypokalemia that originated from an eating disorder (Perry, Churchill, & Kirshner, 2005). Terri developed a condition of “severe hypoxic-ischemic encephalopathy in the subsequent periods” (Quill, 2005) and she did not show any signs of higher cortical function. Computed tomography indicated that Terri suffered strong atrophy on brain cerebral hemispheres. In addition, she had flat electroencephalograms (Quill, 2005). This implied that her cerebral cortex was degenerated while the neurologic analysis showed a constant state of vegetative punctuated by sleep and wakefulness. In addition, there were few cases of reflexive reactions to lights and noise with minimal swallowing and gag (Preston & Kelly, 2006). Terri did not show any forms of emotions, cognition functions or willful activities (Cyranoski, 2012).
Examination results indicated that Terri was suffering due to a lack of conscious awareness because of the impaired cortical activity.
Terri showed some forms of minimal cognitive and motor activities in few identified cases several months after the state of persistent vegetative was declared. However, the severe cortical impairment affected any long-term reactions.
A brief summary of the legal history specific to Ms. Schiavo’s case (an individual’s right to refuse medical care)
Prior to the case of Terri Schiavo, there were other cases involving persistent vegetative states and minimal conscious state (MCS). In all these cases, medical experts must intervene to determine the differences between persistent vegetative state and minimal conscious state (Fins, 2008).
In 1972, persistent vegetative state was defined as “wakeful unresponsiveness” with open eyes but no self-awareness or awareness of others (Fins, 2008). The case of Terry Wallis of Arkansas involved MCS, but he emerged from the condition after 19 years and regained speech abilities.
In a landmark ruling in New Jersey in 1976, the Supreme Court allowed the removal of Ms. Quinlan’s life support because of “the irreversible nature of her vegetative state” (Fins, 2008). The expert physician argued that Ms. Quinlan was “forever and irretrievably lost the possibility of returning to a “cognitive sapient state” (Fins, 2008).
The case of Cruzan involved the use of the Patient Self-Determination Act of 1991. The Supreme Court recognized the constitutional rights of a competent individual to reject life-supporting procedures. It also led to the use of “advance directives in the healthcare institutions and Courts” (Fins, 2008). Advance directives required healthcare providers to inform their patients about state laws governing patients during attempts to improve end-of-life care.
Some of the legal considerations of relevance in Ms. Schiavo’s case
During the period of 1990s, Mr. Schiavo and Terri’s parent worked together to ensure her recovery. However, Schiavo learned that her wife’s condition was irreversible and that Terri would not wish to be kept in a state of vegetative for long. On the other hand, Terri’s parent insisted that she would recover and therefore should continue with the artificial nutrition and hydration to remain alive. Consequently, both families were unable to reach a consensus.
Mr. Schiavo requested the intervention of a local Florida Court to make an independent assessment of Terri and decide whether to continue or discontinue with the life supporting processes. In the year 2000, the Judge held a trial to determine Terri’s individual rights of privacy, liberty interest and the issue of life sustaining medical intervention if she were able to talk (Perry et al., 2005).
The State of Florida had its laws to resolve the end-of-life guardianship (laws may differ from state to state). The laws and statutes recognize an individual’s right to make independent decisions irrespective of communication abilities. In this case, it was established that Terri was unable to communicate and did not leave any written advance directive. The State of Florida takes into account any previous oral statements that meet the standards of “clear and convincing evidence” (Perry et al., 2005).
The opposing parties presented new evidence, mainly medical history and witnesses’ accounts. The Court established that Terri met statutory definition of the persistent vegetative state and she could not regain her consciousness or communication abilities.
At this point, the Court realized that it was necessary to focus independently on the rights and autonomy of Terri without family, state or public contributions. After witnesses’ accounts and cross-examinations, the Judge established that Terri would not have wanted to live like that. This was clear and convincing evidence and therefore, the Judge ordered the removal of the life supporting procedures.
The Schindlers appealed this ruling. Still, the Judge maintained his ruling. After few days, The Schindlers presented a new affidavit to assess the current medical state of Terri, which experts established as irreversible neurologic damage and was undoubtedly in a persistent vegetative state, but the Judge found that such claims were unconvincing and not supported by any facts. Nevertheless, the ruling remained the same.
On appeal, the Judge’s decision was reviewed for any substantive or procedural mistakes. The Appellate Court reaffirmed the Judge’s ruling. The ruling observed legal standards designed to maintain the value of life. The value of life relied on personalized decision on life supporting procedures. The Court had confirmed that through previous court proceedings and the decision to remove the PEG tube was held.
However, Terri Law came into effect in 2003 in which the Governor had free discretion to order the resumption of PEG tube. After 11 months, the Florida Supreme Court ruled that Terri’s Law was unconstitutional and the PEG tube was removed. Terri died on March 31 2005. An autopsy showed that Terri had abnormal brain mass with damages and it supported notable hypoxic–ischemic brain conditions.
The Justice system did not fail Terri Schiavo. The Florida State Law was clear and followed based on her medical condition and liberty and privacy interests (Mathes, 2005).
In the previous case of Cruzan, the United States Supreme Court held, “to the possession and control of [her] own person, free from all…interference of others” (Mathes, 2005).
The contextual motivations potentially influencing the following stakeholders
The fundamental concepts that bring various stakeholders in the case of Terri Schiavo are both moral and ethical concerns intertwined with medical and legal perspectives. The current American bioethics emanated from the centrality of patient self-determination, rights, liberty and autonomy (Fins, 2008). However, in some instance, people may not be able to make decisions on medical interventions for themselves and therefore, healthcare providers, close relatives and people who know the patient well will strive to make such treatment decisions based on choices such patients could have made if they were conscious.
Ms. Schiavo’s parents
The patient’s parents had worked hard to ensure her recovery. Nevertheless, medical results proved that Terri’s state was irreversible. They, however, insisted that Terri be kept alive through PEG tube. Terri’s parents recognized the right to sustained life without termination. Hence, their decision was morally justified, but was not supported by any factual evidence or the patient’s wishes.
Her husband
During the 1990s, Mr. Schiavo aggressively fought to rehabilitate the condition of Terri through various physical, occupational, and speech therapies. From medical results, he noted that Terri’s medical state was irreversible and sought for the termination of PEG tube. In addition, he claimed that Terri would not have wanted to live under her prevailing state (Perry et al., 2005). Hence, Mr. Schiavo was obligated to request for the removal of the PEG tube.
The Governor of Florida as a representative of a state’s interest
The State of Florida has its own laws on end-of-life guardianship. The Governor of Florida acted on Terri’s Law, which gave him free discretion to determine such issues. It is also imperative to recognize that Terri’s Law was anchored on the State law that recognized the fundamental rights of an individual to control self. Nevertheless, it did not account for Terri’s wishes and failed to recognize the separation of power.
Taxpayers
Taxpayers represent the public with varied interests and opinion in the case of Terri. They can influence the decisions of Courts and other key stakeholders. In some cases, the public opinion on what takes place in a Courtroom may lack sufficient evidence and facts, and therefore lack credibility too. Nevertheless, taxpayers could have both moral and ethical concerns in such cases.
The disabled community
This case shows that various stakeholders have responsibilities to decide for patients who cannot decide for themselves. In this regard, the decision to remove life-supporting procedures showed a disregard for disabled people or other individuals with poor health status and quality of life.
One must note that the problem with such a case is overgeneralization. Hence, it is imperative to understand cases within their specific contexts of legal and medical grounds.
Ethical position relative to the issue
The major ethical issue in the case of Terri Schiavo is the respect for individual autonomy. However, many critics have argued that a proper moral framework does not take into account autonomy (Perry et al., 2005). Instead, the core issues have been sanctity of life, discrimination against disabled individuals and the moral conduct of people obligated to decide.
The ability to understand various approaches of moral frameworks is imperative. In this regard, the need to understand autonomy as a fundamental ethical issue remains the central area of focus. At the same time, one can evaluate the weaknesses of other moral frameworks. For instance, others expressed their concerns that the case of Terri reflected “a struggle between the quality of life and sanctity of life” (Fins, 2008). While some argued that social conservatives valued the intrinsic values of all life, the social liberals focused on the quality of life. Nevertheless, one must understand whose idea of sanctity or quality matters. In this respect, decision-makers must consider the liberty interests and autonomy of the patient as the most important point of reference (Ditto, 2006).
In all other previous rulings, the Courts have held and maintained the prerogative of people to make their own decisions based on their own values, even if they cannot communicate for themselves.
The health policy considerations
Perry et al. (2005) rejected the claim that the decision on the case of Terri Schiavo had far wide-ranging public policy consequences. According to these authors, such claims are nothing but a kind of overgeneralization. In this sense, the case of Terri Schiavo should not be used to make future decisions for individuals in a similar state of persistent vegetative. The decision to withdraw the PEG tube was made solely on individual autonomy and liberty interests. It was not meant to influence public policy.
By highlighting liberty interests and autonomy, it implies that the main central issue is that a person would be able to make his or her own decision and therefore, any prior communications about an individual’s wishes may be considered as legitimate, honored and used for decision-making purposes. Hence, persistent vegetative state should not influence public policy issues.
Experience from the case of the Terri Schiavo and advance directive
From the case of Terri Schiavo, an advance directive remains the most effective and fair approach to any case of persistent vegetative. However, Court interventions could affect the central issue of discussion as observed in this case. Individuals, therefore, should provide advance directives to reduce litigation and other associated issues.
As the case of Terri indicated, it became clear that the decision-making was transferred to other persons who could have not expressed entirely how Terri wanted her end-of-life to be. The problem emanated because Terri had not legally identified who should make such decisions in case of any eventuality. From physicians, judges, bioethicists and the public’s views, this case shows the challenge of not providing an advance directive. Advance directive will deter any interference with personal choices, autonomy and liberty interests. It will uphold the voice of patients even if they have lost abilities to communicate. It will ensure self-determination as declared in the American legal and political establishments.
Recent and further studies have shown that there are possibilities of communicating with individuals in vegetative state (Cyranoski, 2012). Hence, people may not require advance directives after all.
Conclusion
The case of Terri Schiavo raised major medical, legal and ethical issues in history. Most importantly, it brought about the relevance of individual autonomy and liberty interests when one is unable to communicate. In this case and other previous cases, the Courts have always upheld “to the possession and control of [her] own person, free from all…interference of others” (Mathes, 2005). This is self-determination as entrenched in the US Constitution.
The case of Terri Schiavo highlights the importance of advance directives when one is unable to communicate. Recent research, however, has shown that it would be possible to communicate with individuals in vegetative state. This discovery may eliminate the need for advance directives.
References
Cyranoski, D. (2012). Neuroscience: The mind reader. Nature, 486, 178-180.Web.
Ditto, P. H. (2006). What Would Terri Want? On the Psychological Challenges of Surrogate Decision Making. Death Studies, 30, 135–148. Web.
Fins, J. J. (2008). Brain Injury: The Vegetative and Minimally Conscious States. In M. Crowley (Ed.), From Birth to Death and Bench to Clinic: The Hastings Center (pp. 15-20). Garrison, NY: The Hastings Center.
Mathes, M. (2005). Terri Schiavo and End-of-Life Decisions: Can Law Help Us Out? MEDSURG Nursing, 14(3), 200-202.
Perry, J., Churchill, L., & Kirshner, H. (2005). The Terri Schiavo Case: Legal, Ethical, and Medical Perspectives. Annals of Internal Medicine, 143, 744-748.
Preston, T., & Kelly, M. (2006). A Medical Ethics Assessment of the Case of Terri Schiavo. Death Studies, 30, 121–133. Web.
Quill, T. E. (2005). Terri Schiavo — A Tragedy Compounded. The New England Journal of Medicine, 352, 1630-1633. Web.