Wednesday, October 01, 2003

Schiavo, Reeve, and the "right" to die

I had this very discussion with another student Monday night. She's a grown woman who works in the medical profession. She's all in favor of disconnecting Mrs. Schiavo's feeding tube, but when I put to her directly the same question I put to Sparki , that is, what her answer would be if Mr. Reeve asked her to turn off the ventilator, her answer was no. (She did agonize a moment.) All that this demonstrates to me is the effect on our judgement when one patient is fully conscious and of undiminished faculties and the other is not. It is the same line of thinking that allows so many babies to be aborted – they are undeveloped, their capacity for a properly sensate, fully human experience not yet present and, until they cross some very poorly defined line, deemed to be at the mercy of others in a position to judge. That they do experience life at an age-appropriate level, that life itself is a continuum along which one must inhabit the earlier stages if he is ever to achieve the later, that, in short, you can't get here without first having been there, does not seem to sway the opinions of many. Terry Schiavo has undergone a developmental reversal; she has, in a sense, turned around and crawled back into the womb, and is once again at the mercy of those "in a position to judge." Her umbilical cord is a feeding tube, and unless the grace of God performs some great work, it will soon be cut. That other womb, the law of our land and the protections it might afford, is no longer one of safety and sustenance. It is her enemy.

You all know this as the "quality of life" argument. We don't like it. We want to save Terry. So we might turn to Church documents to clarify our convictions. And in a pastoral reflection offered by the NCCB, we find sentences like the following: "…we should not assume that all or most decisions to withhold or withdraw medically assisted nutrition and hydration are attempts to cause death." (Uh-oh). Or this: "But the teaching of the Church has not resolved the question whether medically assisted nutrition and hydration should always be seen as a form of normal care." (My frown deepens.) And this: "Decisions by others to deny an incompetent patient medically assisted nutrition and hydration for reasons of cost raise additional concerns about justice to the individual patient…" (No kidding?) And more: "Even Catholics who accept the same basic moral principles may strongly disagree on how to apply them to patients who appear to be persistently unconscious- that is, those who are in a permanent coma or a 'persistent vegetative state'." (Great.) And finally: " Further complicating this debate is a disagreement over what responsible Catholics should do in the absence of a final resolution of this question."

"In the face of the uncertainties and unresolved medical and theological issues…"

"It is not easy to arrive at a single answer to some of the real and personal dilemmas involved in this issue."

Please, Your Excellencies, I'd rather not see so many reservations sprinkled amidst otherwise solid stuff. It's easy to see how someone seeking guidance might get confused. Fair time is also given to those "moral theologians" who would argue for the withholding or withdrawing of Terry's tube, highly educated Catholic folk who claim that physical life is not the ultimate good, that good being founded on spiritual union with God, which cause can only be "advanced…by human acts, i.e., conscious, free acts." (Goodbye unborn). The bishops then refute this. At least I think that's what they did. They say such an argument is "not theologically conclusive" and that they "are not persuaded by it," while the reader longs for a simple "This is not acceptable." The virtues of maintaining a civil tone are limited.

Let's get back to basics. We may not do evil that good may come (I'm getting tired of saying it, but it's a mantra for life.) We may not, by act or omission, purposely intend the death of another for whatever reason. We may allow nature to "take its course" if there is no hope of recovery (from a terminal condition), rendering the course of treatment excessively burdensome to the patient and, in effect, merely prolonging his suffering with no hope of improvement. This is not to intend his death. Death is coming on its own and in its own time. We are not committing murder; nature is (metaphorically). Nor are we doing the same by omission because, whatever we do or fail to do, we cannot win. This does not describe Terry Schiavo's case. Her case is, in my opinion (and I intend no cruel wordplay), a no-brainer. She is not dying. She is living. She needs to be fed and that is all. This is a thing we do for each other, as for newborn babies. Her only problem (society's problem, actually) is that she is severely mentally retarded. She is not participating in the life of the world as others would like. Being alive is not enough. Her life is now "not worth living." That is the opinion of the world. That you are human and in existence no longer grants you an inherent and infinitely precious worth. This is the position you must convince the world to abandon. Good luck.

Now if her heart condition kicks up again, things could change. A case could be made for withdrawing the tube if it became part of the treatment in her fight against a heart failure that will not relent. But that is not the case at the moment.

Which leads us to the question of how her situation differs from, or resembles, that of Christopher Reeve. The most obvious difference? One is conscious, the other barely so (or so we are told). The most obvious similarity? One is being kept alive by a tube that (allegedly) breathes for him, the other by a tube that feeds her, but does not do the eating for her. Are they (these latter two) in fact the same? I say no. One is an involuntary function, the other voluntary. One is a fatal condition, the other is not. Under normal circumstances, I cannot breathe for you, but I can feed you. Some will not admit this difference, but I think it's crucial. Mrs. Schiavo's feeding tube is no different than a spoon held to her lips, and that's why I said in my comments that the possibility she might be taught to take food from a spoon was a matter of no relevance. I think (and many of you will not like this) that a stronger case can be made for letting Mr. Reeve go than for Mrs. Schiavo. The only thing that gives us pause is Reeve's awareness. If he were lying in permanent coma, interested parties would be lining up, and the courts swinging into action, to "relieve" him of his burden. Is his life more valuable than Schiavo's? Before you answer, you might want to ask her parents.

Even as I say such a case can be made, I do so with strict qualifications, and I'd like to present them by addressing comments made by certain of the participants.

Sparki says, "It's not easy to judge these things when one has never been in the circumstance." Circumstances can cloud the mind, but cannot be allowed to dictate one's decision. That's called situation ethics and is to be avoided like the plague. However, if your conscience inhibits you from taking the action requested, you should, as you are inclined to do, follow it. She also tells the story of her husband's grandmother who died while hooked up to various things, including a breathing machine. But she doesn't say how they knew she had died, and maintains that no machine can prevent this. If this is true, we're going to have a lot of people living by machine. I knew a man once, the husband of a friend, who received a fatal head injury in a car accident. The machine kept his heart and lungs going for a week even while his EEG was flat. This could have gone on indefinitely had the wife not given permission to have the respirator turned off. But Sparki's reluctance to grant Mr. Reeve's request has some validity, which we will return to in a moment.
Denise says that "the usual choice to shut off a respirator or remove a breathing tube is made when a person is having no brain activity, no ability so sustain life without profound artificial help."

Remember, our hypothetical posits that Reeve has requested this, and a ventilator is indeed a "profound artificial help" in sustaining life. She further worries that her distinction between Reeve's current level of awareness and that which would attend an irreversible coma might be "artificial." No it is not. If he were in such a coma (I'm assuming some minimal brain activity), and the medical judgement was that he would die without the machine (God is in the details), I would see no moral difficulty in turning it off, although the prudent course of action (as in the case of Karen Anne Quinlan) might be to "wean" him from it. If he could not breathe on his own, this would quickly become apparent. The distinction becomes artificial only if we compare Reeve's consciousness with Schiavo's lack of it as a means of measuring one's right to life. They share this right equally.

Then Terry wonders: "But does it matter *when* the decision is made? Would it have been different to have refused the tube in the beginning--"If he can't make it on his own, he can't make it and we must let him go" versus deciding 10 years after the fact that he is tired of the whole process and wants to disconnect?" This seems to me an insightful question, for it asks what is often avoided: how did we get to this place? And it brings Sparki's reluctance back into play. The decision even to begin certain kinds of treatment sometimes seems questionable, but I imagine that in the crisis of the moment the doctors cannot know for certain what the prognosis might be. So they attach a ventilator to preserve life until they can determine what hope might remain. I should think this is their duty. Eventually they discover that Christopher Reeve will never again breathe on his own. But this discovery does not then entitle anyone to flip the switch to the "off" position. When Christopher Reeve awoke from his accident, he found himself reborn, so to speak, into a new life, one that he did not ask for, but that we gave him, and though we gave it, it is not ours to take away. It seems to me that once a treatment is initiated, we have entered into a morally binding contract with the patient, and further, that if this patient is capable of making his wishes known, it should now be up to him to decide when enough is enough. He may not ask you to hurry him along - by requesting, for example, a fatal injection - but I don't see how his right to be free of a burdensome, life-prolonging treatment, a device which is literally interfering with his dying, can be denied him. Due passage of time may be required, his soundness of mind to be judged by those closest to him - wife, pastor, whomever - but it is a fact that sometimes people know when it is their time to go to God, and I, for one, would not gainsay him.

Some might object: but aren't you contradicting your prior principle that we may not intend the death of another? I don't think so. What would we be intending if we acceded to his wish? Would you not be intending that, as the machine went off, his breathing went on, that he live? Of course you would. And in the event he did not go on breathing, you would be allowing the dying process (nature) to finish its course, accompanied by the hope that Mr. Reeve finds rest in the arms of God.

But, apart from his request, he remains untouchable.

As to the manner of death in each case, the difference is that in the one the choice belongs to the victim, and in the other it does not. Or perhaps I should say that it's being taken from her. That her life is hers no matter what others think of it is a guiding principle in rapid decline. I don't know how it will be retrieved.
The quality of life crowd thinks she's as good as dead, not really there. But I had a student once, a very young man, who had suffered a terrible head injury in a recreational vehicle accident, one of those three-wheelers I believe. He spent some time in a coma. He attended my class in a wheelchair. His speech was slurred, his physical movements bordering on the spastic. He had an awful time writing in class, but gutted it out. On first meeting, I imagine many thought him sub-intelligent, until they learned to decipher his words and realized quite the opposite. He made an A. A real A, not a gift. We judge so easily and quickly by appearances.

You see, I know Terry Schiavo's in there. The "soul is the form of the body." The soul is intact, but the body gravely injured. The soul has lost access to the instrument of its expression, but it's in there. And I think that before a judge or a husband kills her, they ought to have to prove me wrong.

One other thing I'd like to see. Just once. A miracle. I'd like to see God bring a Terry Schiavo out of her persistent vegetative state so that the world would know what's hiding behind it. But I guess I shouldn't always be seeking after a sign.
I'd like to thank the following for participating:

Jeff Culbreath of El Camino Real
KTC of the Gospelminefield
Alicia of Fructus Ventris
Sparki of Fonticulus Fides
Micki of Smockmomma
Denise of Ave Maria Rosaries
Terry Southard of Summamamas
Earl Appleby of CURE
          ______________________

Reader Comments:

There is another story recently of a Jason Childress of Virginia. His parents disagreed about removing life support. The Mother got the judge to order life support removal. They removed it and now he is breathing on his own and has been moved to a nursing home.http://home.hamptonroads.com/stories/story.cfm?story=60169&ran=51446
Posted by Jeff Miller email at February 27, 2005 03:50 AM

I apologize for not responding to your follow up comments in your earlier post in a timely fashion--the blog invariably moves fast, and I, mea culpa, all too often slow.While I cannot concur with the exception you carve out in your hypothetical, your gut reactions to the NCCB pastoral are sound indeed. It is but another in a series of manifestations of what I termed "Catholic" euthanasia in one of my first Vital Sign’s columns for Human Life International. I also wrote about the pastoral that rightly causes you concerns. In the hope these columns may shed some light on this growing problem that has cost the lives of numerous Catholics--Catholics like Terri Schiavo, I would be pleased to e-mail them to you or any of your readers on request.Yours in Defense of Life and TruthEarlEditor, Times Against HumanityDirector, Citizens United Resisting Euthanasia
Posted by Earl Appleby email at February 27, 2005 03:52 AM

Jeff, I don't know the specifics of the Childress case, so I can't know who was right as to the decision to remove life support. But it reminds me of Karen Quinlan, who everyone was convinced would expire at once; instead, she kept on breathing. These 'signs of contradiction,' if you will, that prove the experts wrong seem to do little to move public opinion. To many, people like Karen and Terry are 'as good as dead,' and you'd be surprised how many think the same of Reeve, though they'd probably say 'better off dead.' I think, in our well-fed, prosperous world, that we'd simply rather not be bothered by the burden they place upon us, and by the affront they present to our notions of a life worth living. By the way, I know you take the trouble to read these overly long 'things' I write, and I appreciate it.Mr. Appleby, I hope my readers take advantage of your offer, and I will visit your sites as time permits to do some more reading. If your columns are not available online, you might consider archiving them at one or both of the sites you mention above. Any available links you are free to post here.
Posted by William Luse email at February 27, 2005 03:54 AM

Just to clear up the bit about my husband's grandmother: I wasn't there myself, but from how it was explained to me, she simply stopped consuming the oxygen. The machine was still running, but her lungs were no longer taking in air. Still mulling over all your comments, Mr. Luse. More later.
Posted by Sparki email at February 27, 2005 03:55 AM

Thank you, Mr. Luse, for your gracious and generous offer.My HLI Reports columns on the dangers of "Catholic" euthanasia are available on CURE's website: Death of Conscience: Death of Man and "Catholic" Euthanasia--The Killing Continues. CURE's analysis of the NCCB statement, "Moral and Pastoral Reflections" A Pattern of Betrayal, is not on line yet, but I'd be pleased to e-mail a copy in the interim to anyone requesting one. Above all, I urge those who wish to protect their lives and the lives of their loved ones from the growing danger of euthanasia to use CURE's Life Support Directive.Thank you again for your kindness, Mr. Luse, and for your deeply appreciated defense of Terri Schiavo's God-given right to life.May God continue to protect her as the ravenous wolves of the Culture of Death move in for the kill!EarlEarl E. Appleby, Jr. Director, Citizens United Resisting Euthanasia (CURE)
Posted by Earl Appleby email at February 27, 2005 03:57 AM

What a scary roller-coaster! When my husband and I first got married we seriously considered "living wills" that provided only for hydration in the event of a comatose state; and that measure only because my husband said, "Have you ever seen anyone die of dehydration?" I actually remember saying, "If I ever become paralyzed, don't do anything too heroic." (TOO heroic? My, what a relative term!)Then we converted to Catholicism and had our first child. With a baby in the picture, we shifted a little. We added nutrition to the mix -- and I decided I could in fact parent in a wheelchair.After our third child was born (by the way, serious injury to me, concerning pregnancy and childbirth, has crept into the picture) I joked that even if I was just an eyeball on a pillow, "keep me alive! Unless it comes down to me or baby, then focus on baby."At the birth of our last child, my thoughts were the same.It is one year later and I find myself thinking, "My husband would have four children to support. I wouldn't want to be a horrible financial burden. How far do I want my husband to go to keep me alive? I don't want my children watching me die." Where is the fault in this line of thinking? Am I being selfish? Is this false sacrifice? Why am I freaking out? Something doesn't *feel* right, but I don't have the practical theology I'm looking for -- the simple "this is not acceptable" that you mentioned. I also agree that we want a miracle. For the greater glory of God, may Terry get one! Amen and amen.
Posted by Micki email at February 27, 2005 03:57 AM

**Micki** what a wonderful comment. It's amazing what having children (and the Faith) can do for one's scrupulosity. As to your final concern, I'd ask you to stop freaking out. My advice (and it's just my advice) is that you and your husband keep your thinking simple: a dying person may be let go if the cause is hopeless, but no one can do anything to speed him along. If circumstances one day, for example, place upon your husband a burden you'd abhor, it is one he will gladly shoulder. He'll raise those four children because it has to be done. This is what we do for the ones we love. You'll simply have to trust him to know the difference between murder and its opposite. I trust my wife to know, and that's why I'll never sign a living will.--For a powerful look at how little we know about the lives of the comatose, see, if you haven't already, a movie called "Awakenings."
Posted by William Luse email at February 27, 2005 03:59 AM

You have a fine blog here, Mr. Luse. I am glad to have discovered it.Re: your comment that Terri's feeding tube is no different than a "spoon held to the lips," are you sure of this? Is Terri in fact able to swallow, or is she unable to swallow and her nutrition must therefore be inserted further along in the digestive system?Regardless of the details of Terri's case, I ask the following: If a patient in a pvs is unable to swallow and can only be nourished through surgical intervention, doesn't this patient - like Reeve - indeed have a "fatal condition?"
Posted by Rick email at February 27, 2005 04:00 AM

You may call it that if you wish, but by a fatal condition I mean one that cannot be ameliorated by treatment. Such a circumstance does not describe Terri's case. The tube indeed treats her condition quite well. Allowed food and hydration, she lives. We do not "allow" Reeve air. We force it into him and further force his lungs to accept it. Remember, Reeve too must be fed by an outside agency. I surmise that you see little or no difference between Reeve's ventilator and Terri's feeding tube. The accurate parallel is not between the two forms of technology, but between Reeve's nervous system and Terri's digestive system, the latter of which works while the former does not.I further surmise that your reservation about my parallel between the spoon and the tube rises from the fact that, in the case of an infant, the spoon is impermanent but the tube is not. But suppose Reeve could breathe on his own, yet still needed to be fed by spoon - permanently. Would you take away his spoon?And lastly, I see that it was necessary to mention PVS as an element of your hypothetical. Would you be asking this question if Terri (or any other patient) were fully conscious like Reeve? I ask because, you see, I don't think it's the tube that bothers people. I think it's her mental condition, her so-called PVS.
Posted by William Luse email at February 27, 2005 04:01 AM

Thank you for your response, Mr. Luse. I haven't come to firm conlcusions on all issues related to ANH, but will assert the following:1. Where a patient can swallow and is not imminently dying, we have a moral duty to provide food, regardless of the patient's consciousness or quality of life. So no, I would not take away Reeve's spoon.Further, this food may be delivered by a feeding tube as a matter of convenience.2. I am not convinced that accepting surgical delivery of nutrition is always morally required for nonterminal patients. Factors that might make declining / withdrawing ANH licit include not only whether the patient is conscious, but whether ANH poses a grave burden on the patient or his or her caregivers. For example, if a patient were fully conscious but 100% paralyzed and unable to swallow, I am not convinced the patient would be morally required to accept ANH.Catholics, imo, are not required to hold that ANH may never be withheld or withdrawn from nonterminal patients. See, for example,http://www.op.org/domcentral/study/kor/90061110.htmIt would also be interesting to look at the ethical directives for Catholic hospitals. I do not believe they require that ANH never be withdrawn, or demand that advance directives from patients declining ANH not be honored, though I am not positive of this.
Posted by Rick email at February 27, 2005 04:04 AM

I am sorry to have been of so little help. If, as you say, you are not "convinced", then I take it you are at least in doubt about the right thing to do in Terri's case. I should think you would then subscribe to the moral duty to do no harm until such time as your uncertainty has been resolved. Which is precisely the position advocated by the NCCB's pro-life committee in this document: http://www.lifeissues.net/writers/doc/doc_26fnutritionhydration.html#nineThis is the only nutrition-hydration resource I have had time to hunt down. The link you provided leads to a document with no doctrinal authority. He may be an ethicist, but he's just another guy, like you and me, trying to figure things out.Your assertion #2 I find to be frightening in its implications. If we begin to weigh the value of an unconscious patient's life by the burden it places on others, a lot of people are going to end up getting bumped off. God's blessing on your journey.
Posted by William Luse email at February 27, 2005 04:05 AM

Thank you for your comments, Mr. Luse, which are indeed helpful.I will refrain from future comments, but do wish to point out that we agree lives may not be valued based on the burdens they may impose on others. Every human life is of incommensurable value. But we may make decisions on *treatment procedures* based on their burdens, as the bishops acknowledge in the document you cite. It is precisely the question of whether ANH may be considered a treatment procedure (when it is not just a convenience, but a requirement because the patient cannot swallow) that I am still undecided upon.Finally, I have found the Bishops "Ethical and Religious Directives for Catholic Health Care Services" online:http://www.nccbuscc.org/bishops/directives.htm#partfiveThese directives have particular relevance to this thread, imo. I reproduce them without comment:57. A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.41
58. There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient.
59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.
Posted by Rick email at February 27, 2005 04:06 AM

Arrived here by way of Touchstone magazine. Regarding Terry Schiavo and our desire for a miracle, the following from Iris Ministries in Mozambique. A young African man is restored and healed after a savage beating:
http://irismin.org/Pages/ON%20WE%20GO%20IN%20JESUS!.htm
Posted by Mort Robinson email at March 13, 2005 09:14 AM





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