Withdrawing and/or withholding life support has become completely common in American hospitals. For example, 65,000 chronic dialysis patients die each year in the U.S. due to withdrawal from dialysis (Moss, 2001), and the number of deaths in neonatal intensive therapy units due to the withdrawal of therapy has increased nearly fivefold in the last thirty years from 14% to 66% (Shooter and Watson, 2000). This is why, as the editors say in their introduction to this indispensable collection of material on the Schiavo case, "[t]o many in the bioethics, theology, and legal communities, the bitter battle over the fate of Terri Schiavo was a complete surprise. From an ethical and legal point of view many of the key issues that were being keenly debated regarding Terri Schiavo had been settled" (21).
This collection of material is an attempt to understand why the Schiavo case received the public attention it did, and to reflect on whether there are any enduring lessons to be learned from it. The book does a masterful job in achieving these tasks and the editors are to be congratulated for including all of the essential material one needs in order to consider the Schiavo case comprehensively, as well as setting that material in context with short, accessible, and intelligent introductions to the various parts of the book.
Part 1 ("Setting the Stage") sets out the medical, legal, and ethical background of withdrawal of life support. Included here are the medical descriptions of PEG tubes and permanent vegetative states (PVS), the classification of artificial nutrition and hydration (ANH) as a medical procedure, and the distinction between ordinary and extraordinary medical interventions. Regarding the legal precedents, the editors have provided the 1990 ruling of the Cruzan case, which stipulated that people in a PVS do not loose their right to reject medical treatments, based both on privacy and the doctrine of informed consent. Hence, so long as there is clear and convincing evidence of the patient's wishes, referred to as the substituted judgment standard, it is allowable to withhold or withdraw life support systems, including ANH.
Part 2 ("Florida Controversies") deals specifically with the legal and political situation in Florida. As the excerpt from the Florida "Life Prolonging Procedure Act" (75-79) makes clear, not only can a guardian -- which is almost always the spouse -- use substituted judgment, she or he can also use the best interests standard whereby judgments are made based on what the guardian believes is in the best interests of the patients when they are terminally ill or in a PVS (72).
But the fact that Florida, and the U.S. in general, has clear law on these matters made little difference as other events conspired to complicate the Schiavo case. Terri Schiavo's parents, the Schindlers, were devoutly Catholic and they disagreed vociferously with Michael Schiavo. As a Catholic herself, her parents argued, Terri would have followed Church doctrine, which prohibits withdrawal of ANH. In a fascinating series of articles contained in Part 4 ("Catholic Controversies"), this claim turns out to be much more complex than that. As O'Rourke and Norris make clear in their essay (213-219), there are actually three different positions on this issue that are current within the Catholic Church. Only one of those positions, albeit the one endorsed in a statement by Pope John Paul II (231-235), condemns the withdrawal of ANH for people in a PVS. The other two positions are in the tradition of Pope Pius XII and the 1980 Vatican Declaration on Euthanasia, which allows for such withdrawal when, as the Bishops of Texas expressed it, "the means used to prolong life are disproportionately burdensome compared with the benefits to the patient" (191).
These fine distinctions, however, made absolutely no difference as the right to life movement zeroed in on the case, and it became political in the important swing state of Florida. Governor Jeb Bush rushed to institute a specific law to prohibit the removal of Terri Schiavo's PEG tube (102). But 'Terri's law', as it came to be known, proved to be unconstitutional (103-121), and the battlefield changed from the state to the federal level. This is discussed in Part 3 ("Federal Controversies") which includes the President's and various congressional statements and actions. This section, unfortunately, places many prominent politicians in a bad light. Here we get Senator Rick Santorum's repeated claims (130, 143) that convicted murder Scott Peterson had his constitutional rights respected to a greater extent than Terri Schiavo despite the fact that she had her case examined more thoroughly in court than any patient in the history of the American legal system. We also get a diagnosis of Terri from Senator (and physician) Bill Frist without ever bothering to visit her. At least one bioethicist comes across very badly as well. In an affidavit to the court, William Cheshire said that he could simply "sense" Terri Schiavo's neurological state by standing in a room with her. "Although Terri did not demonstrate ... any verbalization, conscious awareness, or volitional behavior, yet the visitor has the distinct sense of the presence of a living human being who seems at some level to be aware of some things around her" (169). Given actions such as these, no wonder that over 80% of Americans said they disagreed with President Bush and the Congress for attempting to intervene in the case to force the continuation of life support (126).
Is there anything to be learned from the case? First and foremost, we should all write a living will if we have particular wishes regarding end of life care. But we already knew this. We also learned the incredible lengths politicians and special interest groups will go pursuing a matter when they believe there is political gain to be made. Senator Mel Martinez made this point most clearly when a memo of his was leaked which suggested that the Schiavo controversy should be exploited by the Republican party as "a great political issue" (126). But, unfortunately, we knew this as well. Perhaps then, there really wasn't anything new in the Schiavo case and that what's old is depressingly new again.
Moss, A. 2001.Shared decision making in dialysis: A new clinical practice guideline to assist with dialysis-related ethics consultations. Journal of Clinical Ethics. 12.4: 406-414.
Shooter, M., A. Watson. 2000. The ethics of withholding and withdrawing dialysis therapy in infants. Pediatric Nephrology. 14: 347-351.
© 2007 Robert Scott Stewart
Robert Scott Stewart, Professor of Philosophy, Cape Breton University