The Terri Schiavo Case: Joining a National Conversation

These words are being written on Good Friday, 2005, a commemoration virtually displaced in our public consciousness by Theresa Marie Schindler Schiavo, who lies dying in America's arms. The media have wheeled her sickbed into our family rooms, and her story has become our national parable. Public fascination with this patient has been as loud as it has been reflective. It's good to talk as a nation about dying, and death, and values associated with life's end.

It's a conversation Christians are obligated to join--not to register their moral vote on the Schiavo case, but to testify to the realities involved in dying.

Our contribution to this conversation can be made on two levels.

The first level requires talking. Christians need to explain how and why, after sin entered the world and altered life in creation, decisions involving medical treatment can at times be morally uncertain and ambiguous. (Incidentally, I have read no sufficient argument that would justify removing the feeding tube from Terri Schiavo, or refusing to reinsert it. Some features of this case are ambiguous, but this is not one of them.) Christians needs to explain why in extreme cases, careful and patient reflection often leads us to realize that the shortest answer isn't necessarily the right or the best answer.

The second level takes us beyond talking, to implementing some very personal decisions. Decisions about durable power of attorney, living wills, healthcare directives, preplanned funerals--all of them tools for framing the way we die, microphones for amplifying the sound and reach of our Christian testimony.

Background

Terri Schiavo is a 41-year old woman lying at the center of an international debate about end-of-life medical decisions.

In 1990, when she was 26 years old, Terri collapsed in her home when her heart temporarily stopped, cutting off oxygen to her brain and leaving her severely brain damaged.

The diagnosis of her current medical situation has generated significant debate. Some claim that Terri is not dying, she is not terminally ill, she is not brain-dead, and she is not in a coma. Some experts diagnose Terri as being in a "persistent vegetative state" (PVS; a phrase coined in 1972 by neurologists Drs. Fred Plum and Bryan Jennett, to describe a condition in which a patient is presumed awake but not aware, due to injury or illness of the brain). Other experts dispute this diagnosis, insisting that Terri is in a "minimally conscious state" (MCS; a neurological diagnostic criterion first defined in 2002).

Terri can breathe on her own without the aid of a ventilator. She was depending on a feeding tube to supply liquids and nourishment. Because she is able to swallow her own saliva, some experts are convinced that she could regain her ability to swallow fluids by mouth if she received adequate therapy. Healthcare professionals caring for Terri have testified that as recently as 1997 she could swallow fluids and Jell-O, follow people with her eyes, and even speak.

At the time of her collapse, Terri did not have a written advance medical directive or living will. Since her disability, medical decisions have been made--on the basis of a court judgment--by her husband, Michael Schiavo. In 1998, Michael Schiavo petitioned the court to have Terri's feeding tube removed.

Inescapable decisions

Those people are mistaken who imagine that difficult medical decisions could have been avoided if Mrs. Schiavo had prepared a living will granting power of attorney to a relative. Every new technology for enhancing and sustaining life confronts us with new healthcare possibilities, new medical questions, and new moral decisions. These include the following:

• Does a proposed continued treatment prolong life or merely postpone death? How is this determined, and who determines it?
• Are we "playing God" when we insert the plug, or only when we pull the plug? When we insert the feeding tube, or only when we remove it?
• Should the standard for making difficult medical decisions include what is obligatory or also what is proportional? Should they include considerations of usefulness and burdensomeness?
• What is a permanently vegetative state, and how is it verified?

My concern is that, for a variety of reasons, well-meaning Christians may underestimate both the need for facing such questions and the intense uncertainty that accompanies their answers.

People who wish to avoid "making the wrong decision" often look for an anchor of moral certainty.

Some look to nature to supply that anchor, declaring that human life is absolutely or infinitely valuable, so that we should "let nature takes its course." The Bible, however, nowhere teaches the absolute or infinite value of human life. And in a creation marred and distorted by sin, it is very difficult to define what, in the course of illness and dying, is "natural."

A second anchor is technology, which supplies us with an array of options. Technology drives medical decisions in at least two ways. First is the technological imperative, which says that any possible treatment is required treatment. For example, this can be reduced to the supposed obligation to keep someone alive as long as possible. The second version is the technological permission, which insists that any possible treatment or technique is permissible. Here, technology is reduced to an instrument whose use is evaluated apart from any moral context. (For example, if a woman can become pregnant through in vitro fertilization, she need not be married.)

In modern society, yet a third principle directs medical decisions, namely, the sovereignty of the self, or autonomy. All choices, medical or otherwise, are evaluated as good or bad strictly in terms of self-fulfillment, self-gratification, or self-satisfaction.

Medical uncertainty and moral ambiguity often go together. When treatment options multiply and success rates plunge, the moral sky turns gray. Most of us realize that we can no longer "let the doctor decide." In addition, people are coming to realize that we cannot "let the medical technician decide." In the face of these developments, many eagerly offer us hooks on which to hang our overloaded ethical backpacks. "Preserve life at all costs" is one of them. "Let nature take its course" is another.

Unavoidable subjectivity

The legal profession has a saying that "hard cases make bad laws." This means that in deciding complex judicial cases that involve an appealing victim, a sympathetic judge or jury, and the lack of legal authority, the existing law gets stretched, perhaps misapplied, in order to provide a fair outcome. Such new application of the law becomes part of case law that defines the rights of future parties in litigation. In a hierarchical judicial system, the higher the court that made the new application of the law, the greater the number of lower courts that are obligated by the precedent-setting decision.

The Terri Schiavo case is a hard legal case. And it is a difficult moral situation. I have been unable to find any sufficient argument to justify withdrawing the feeding tube from a patient diagnosed as being in a persistent vegetative state (a phrase which itself is laced with problematic assumptions). But this is not to suggest that we are obligated always and at any cost to preserve life. To "choose life" does not mean doing everything possible to keep a heart beating as long as possible.

Situations involving the termination of medical treatment are among the most complex and difficult, legally, medically, and morally. At many points along the route of decision, subjectivity is inescapable and objective standards are unavailable.

Both theorists and practitioners have employed a number of criteria to help determine whether a course of treatment is to be undertaken. These include withholding or withdrawing a medical treatment that (1) is medically futile, (2) increases suffering, (3) worsens the patient's already deteriorating health, or (4) is clearly refused by the patient.

(1) A medical treatment is medically futile if it offers no likelihood of sustaining the patient's health. If a patient has suffered a massive stroke, such that there is no evidence of brainwave activity, infections and other complications arising in this stage of dying would not be treated any longer.

(2) A medical treatment increases suffering when such treatment increases already intense suffering to the point that it begins to resemble torture. Clearly, the subjective element is more prominent here, since one patient can endure more than another.

(3) A medical treatment that worsens the patient's already deteriorating health refers not to improving or sustaining health, but to reducing health.

(4) Finally, a patient should not be forced to undergo, or continue undergoing, a medical treatment. (Whether or not this refusal is morally culpable is not in view at the moment.)

It is important to distinguish medical treatment from palliative care--this latter referring to making the dying patient as comfortable as possible, managing pain and easing the symptoms of terminal illness. Palliative care is always obligatory. Clearly, care must continue after the search for any cure is suspended.

When considering any medical treatment, however, theorists and practitioners alike regularly employ considerations that involve a high degree of subjectivity. Such considerations include whether a proposed treatment entails excessive cost, excessive pain or inconvenience, no reasonable expectation of benefit, or merely prolongs an agonizing dying.

Mention of excessive cost may be the most troubling of all these considerations. But please understand that this consideration may not be isolated from the others, such that it functions as the only, or the primary, consideration. Please understand as well that the very creation of treatment options confronts the medical community with the problem of allocating resources, which necessarily involves considerations of costs and benefits. For example, whether to transplant a kidney into an 86-year old or a 15-year old requires such considerations. Of course, if a kidney transplant were medically impossible, we wouldn't have to think about the choice, would we?

Neither right nor left

Unfortunately, the Terri Schiavo case furnishes more than enough material for demagoguery. A demagogue operates by winning support by exciting people's emotions rather than by persuading with good ideas. As we are seeing, it's a technique used rather effectively by conservatives as well as liberals. We have yet to assess the extent of injury to a Constitution crafted to protect both the separation of powers (Articles 1-3) and state's rights (Tenth Amendment) by President Bush's early morning signing of an emergency congressional bill intended to rescue Terri Schiavo from death.

Meanwhile, we must watch and wait as Terri Schiavo dies, while with hushed tones we dare to speak of life in the midst of death. For this is Good Friday, when we remember the One who, as he hung dying, created new life, when in reply to the criminal's plea of faith, answered: "Today you will be with me in Paradise." But then let us also speak of our commitment to this Life-Giver, demonstrate his Life-Power, and enact these commitments also with a view to dying in the Lord (Rom. 14:7-8).