The Ethical Issues Raised by the Terri Schiavo Case

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                                                                                  MEDICAL ETHICS

The Ethical Issues Raised by the Terri Schiavo Case

Ming-Liang Lai

Department of Neurology, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Terri Schiavo lost consciousness in 1990 due to ventricular arrhythmia. She was later diagnosed as being in a persistent
vegetative state. Her husband first applied to the court to remove her feeding tube in 1998. In 2005, her tube was
removed for the third time and she died 2 weeks later. The parameters of the four box method developed by the
University of Washington in Seattle were applied. The parameters include the patient's medical indication, patient's
preference, quality of life and social contexture were evaluated. The main issue in the Terri Schiavo case was that we
did not know exactly what she preferred with respect to living in a persistent vegetative state. According to the regula-
tions in Taiwan, it would have been illegal to withdraw the feeding tube of Terri Schiavo. (Tzu Chi Med J 2006; 18:


                                                                patient's relatives or legal guardian (in Taiwan, this
                                                                means the spouse or a direct adult blood relative such as
                                                                the father, mother, child or grandchild). Basically, PVS
     On March 18, 2005, the feeding tube of Terri               patients must still be treated with respect and must be
Schiavo was removed by court order for the third time.          given medical treatment and home care. The advice of
Terri Schiavo died on March 31, 2005. This incident             the doctor to abstain from emergency treatment in PVS
sent shockwaves throughout the world [1].                       patients is therefore reasonable.
     A discussion on the medical ethics at the Univer-
sity of Washington in Seattle proved that clinical cases
are often analyzed from four different viewpoints. They                      PATIENT'S PREFERENCE
developed the four box method including: the patient's
medical indication, the patient's preference, the patient's          Since Terri Schiavo did not leave any statement re-
quality of life and the social contextual factors [2].          garding her wishes, further discussion on that subject
                                                                was not possible. In a social context, we learned that
                                                                Michael Schiavo gave up his right to the inheritance he
                                                                would have received after the death of Terri Schiavo.
                                                                Although he never divorced Terri Schiavo, he had two
     After the diagnosis of persistent vegetative status        children with another woman after Terri Schiavo was
(PVS) has been confirmed (this must be done using the           declared in a PVS. Therefore, we feel it was inappropri-
results of expert neurological evaluation and diagnosis)        ate that Michael Schiavo was still the legal guardian of
in a patient, the attending physician is responsible for        Terri Schiavo. The parents of Terri Schiavo had the
discussing the PVS or the chances of recovery with the          strong conviction that Terri wanted to live. Since the

Address reprint requests and correspondence to: Dr. Ming-Liang Lai, Department of Neurology, National Cheng Kung
University Hospital, 138, Sheng Li Road, Tainan, Taiwan

Tzu Chi Med J 2006     18   No. 5                                                                                     QMN
M. L. Lai

parents were next of kin, they should have been the le-       demned Michael Schiavo's actions, the question of
gal guardians, yet during the 15 years from 1990 to 2005,     whether Terri and Michael had different religious be-
they did not provide any substantial care to their daugh-     liefs was probably not an important factor.
ter nor did they give Michael Schiavo any financial help.          The main point of dispute in this case was the first
Thus, it is difficult to understand the motives of either     of the four principles of medical ethics: the patient's
Michael Schiavo or the parents.                               medical indication. Another factor is that the legal guard-
                                                              ian must act according to the patient's wishes, beliefs
                                                              and values to determine what medical action the patient
                 QUALITY OF LIFE                              would have wanted or what medical action would be
                                                              the most beneficial to the patient. However, when the
     The survival time of PVS patients is normally 2 to 5     patient's wishes are not known, a dilemma arises. In
years, and it is unlikely for their survival time to exceed   1989, the American Academy of Neurology [4] an-
10 years. It is assumed, however, that after having been      nounced its principles of treatment, stating that the ad-
in a vegetative state for more than 15 years, there is only   ministration of water and nutrients is a form of treatment,
a one-in-fifteen thousand to a one-in-seventy-five thou-      so if it is almost medically impossible that the patient
sand chance of regaining consciousness [3]. PVS pa-           will recover (such as in PVS patients), it is acceptable to
tients are unable to respond to their environment and         stop such treatment after due discussion. The definition
require 24-hour care for feeding and maintaining per-         of cardiopulmonary resuscitation (CPR) in article 3, sec-
sonal hygiene. Without the round the clock care, sur-         tion 3 of Taiwan's Hospice Palliative Care Act [5] that
vival of these patients is problematic. Since PVS pa-         was accepted in 2000 mentions that "so-called CPR
tients' sense of pain is inconsistent and they do not show    means intubation, external cardiac massage, emergency
any significant clinical responses, it is speculated that     medicine injection, defibrillation, frequency modulation
they also do not have high levels of functional activity      by cardiac pacing, or other emergency treatment in ter-
(including thought) of the cerebral cortex. Simply said,      minal patients or patients with no vital signs". Whether
the quality of life for PVS patients is far from ideal.       "other emergency treatment" includes the administra-
                                                              tion of water and nutrients has yet to be generally agreed
                                                              upon [6]. Government authorities should therefore call
                 SOCIAL CONTEXT                               together experts in the field of medicine, law, religion
                                                              and ethics to deliberate on this topic to reach a consensus.
     Due to the fact that in the case of Terri Schiavo her
husband and her parents had different opinions, the medi-
cal team had relatively little involvement, and no rele-
vant precedents were available, economic factors may
have formed the major provocation. After taking care of
his wife for 13 years, little probably remained of the         1.       !"#$%&'()*+ JJ  !"#$%&'
million dollars awarded to Michael after a medical mal-                 !"#$%&'(=2005
                                                               2.       !"#$%&'()*+,-JJ  !"#$%&
practice lawsuit at the end of 1992. Although he was
                                                                        !"#$%& ' ()*'(+,-./=2005
offered $1 million to give up his guardianship of Terri,       3. Practice paramater: Assessment and management of
Michael Schiavo did not accept, as by doing so, he would          patients in the persistent vegetative state (summary
probably have been slandered as only being after mate-            statement). Neurology 1995; 45:1015-1018.
rialistic gain. Another factor in the decision to discon-      4. Executive Board AAN: Position of the American Acad-
tinue the medical treatment may have been that he                 emy of Neurology on certain aspects of the care and
wanted to marry another woman. We do not know the                 management of the persistent vegetative state patient.
                                                                  Neurology 1989; 39:125-126.
religious beliefs of Terri and Michael Schiavo. How-
                                                               5.        !"#
ever because almost all religious organizations con-           6.        !"#$%&'()*+=1996; 3:51-73

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Tzu Chi Med J 2006   18   No. 5                                             QMP