Thus far entire tomes have been written on the blogisphere and in the lay press about this sad case. Until now I have remained quiet since I didn’t have much more to add to my opinions on Schiavo that I originally posted in 2003. The basic issues remain the same. The facts of the case have not changed since then. Please feel free to update yourself on the following articles.
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In part 1 I argued that there is plenty of medical evidence that Mrs. Schiavo is incapable of consciousness and that this case should never have taken up by the legislature with a one-of-a-kind and very politically motivated law.

In part 2 I stated that Terri should be thought of as a terminal patient and that terminal medical patients rarely feel hunger or thirst (even if Mrs. Schiavo was capable of these feelings in her current state).

In part 3 there was more debate on the issue and on what constitutes the “humanness” of a human being.

In part 4 I pointed out that one of the most common fallacies of thought that many conservatives commit in this case is making illogical or erroneous analogies. For example; comparing this case in which Mrs. Schiavo has suffered server anoxic brain damage (lack of oxygen) causing almost complete destruction of her cerebral cortex (the part of the brain that allows for conscious thought) with patients who have suffered far less brain damage such as cerebral palsy or the “locked-in” syndrome that leave them unresponsive or appearing to be in a persistent vegetative state but still capable of consciousness.

In part 5 I address the conservative contention that next-of-kin laws should be rewritten to account for cases such as this one where the spouse has medical decision making ability but apparent conflicts of interest. Obviously such alterations in common law would further degrade patient autonomy and spousal rights, potentially invalidate living wills and advanced directives, and lead to more rather than fewer court battles.
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I’ve struggled to understand the conservative/religious-right mindset as this case nears its inevitable end. In short, I’ve struggled to understand the hysteria involved. But I think I have had a breakthrough (both psychiatrically and intellectually). It would appear that the proponents of keeping Terry Schiavo alive indefinitely have a basic inability to understand or accept the fact there can be a complete disconnect between brain damage and wakefulness in a patient who suffers from a persistent vegetative state. In short, a patient with severe brain damage can appear to be awake like Mrs. Schiavo does.

The problem is that most people equate severe brain damage with a comatose state where the patient does not respond to stimuli nor show signs of awareness i.e. the comatose patient appears to be asleep. Most severe brain damage does result in a coma but not always. A subgroup of patients who suffer severe brain damage enter what is called a vegetative state which is defined as wakefulness without any signs of consciousness. This state is considered persistent if it lasts beyond three months. How can this happen?

Believe it or not wakefulness is just another brain function that is controlled by small areas (nuclei) in the deeper structures of the brain near the brain stem (the hypothalamus). These areas coordinate with the circadian rhythm to wake up a person after their sleep cycle is complete. Wakefulness as activated by these brain areas is essential for consciousness as afforded by the higher centers of the brain. But in the event that these higher centers (cerebral cortex) are severely damaged or destroyed it is possible for the undamaged hypothalamus to cause a state of wakefulness without awareness. In other words, the patient appears to be awake but all the apparent actions of such a patient (open eyes, movement, swallowing, or even emotional outbursts) are totally automatic and randomly occurring reflexes.

Wakefulness does not necessarily imply conscious awareness and in this case where Mrs. Schiavo’s cerebral cortex has been almost completely destroyed (by a lack of oxygen from her cardiac arrest in 1990) there can be no consciousness. Think of this like a car without an engine but with a functioning battery and electrical system. The lights and air condition come on (wakefulness) but the car will not go anywhere under it’s own power (no consciousness). To put it crassly, the lights are on but no one is home.

How do we know that Mrs. Schiavo’s “engine” of consciousness has been removed? She has had CAT scans of the brain which show the severe damage to her cerebral cortex and these scans have figured prominently in the initial lower Florida court decisions to remove her feeding tube. The University of Miami web site has a link that it identifies as Mrs. Schiavo’s CAT scan of the head.

(Comparison image stolen from Alas).

To the medically trained person this scan appears grossly abnormal and sickening. The blue areas are remaining brain tissue but most of the scan shows black areas which are essentially fluid (cerebrospinal fluid). The normal body reaction to irreversibly damaged tissue is to replace it with fluid and this is clearly what has happened after Mrs. Schiavo suffered severe anoxic damage to her cerebral cortex . Most of what remains of her brain is essentially a fluid filled sac surrounded by a thin shell of brain tissue rather then the solid structure we normally associate with a brain. The deeper parts of her brain including the hypothalamus and brain stem (not shown in the scan) remain intact and these continue to function to cause wakefulness and regulate other automatic body functions. These deeper areas are more resistant to anoxic damage and so were for the most part uninjured from her cardiac arrest.

While a CAT scan cannot detect brain function, further evaluation such as the use of a PET scan (Positron emission tomography) is not indicated. Advocates of further testing appear unaware of the paradox of calling for the evaluation of something (Mrs. Schiavo’s cerebral cortex) that is clearly not present on the CAT scan. A PET scan will not suddenly reveal a functional cerebral cortex in Mrs. Schiavo’s cranium as if it had been hiding behind her cerebellum all this time. Calling for a PET scan makes as much sense as calling for an X-ray of a leg that had been amputated. An MRI scan (magnetic resonance imaging) is not indicated either since the CAT scan is more than adequately sensitive enough to detect the presence or absence of a cerebral cortex.

This inability to understand or accept that Mrs. Schiavo can be awake but devoid of consciousness was clearly evident in the (once again) hypocritical actions of House majority leader Tom Delay who was instrumental in getting Congress involved in this case. As it turns out, Mr. Delay and his family made the decision in 1988 to take his own father off life-support and allow him to die after he received severe brain trauma in a freak accident. Despite the trauma the brain damage to Mr. Delay’s father was in no way as severe as what appears on Mrs. Schiavo’s CAT scan and rather then waiting 15 years to see if he would wake up the family waited a mere 27 days before pulling the plug.

No estranged family members took Delay’s case to court to prevent the death. No government legislatures passed laws to take away their rights as next of kin. No hysterical crowds of right-to-lifers picketed outside the hospital back in 1988 nor made death threats against those family members wishing to see an end to the suffering of their father. Why does Delay believe that the government has a right to intrude in this case and deny the Schiavos such rights and privacy as his family was afforded back in 1988?

Delay advisors claim that his father’s case is different in that he required a ventilator and was facing dialysis in order to live but the real difference is that he was in a coma and to conservatives Mrs. Schiavo appears to be awake and aware despite her vegetative state. It is this salient fact that misleads Delay and the other conservatives. It is simply easier for the intellectually limited or lazy to consider a brain damaged comatose patient to be incapable of consciousness than to understand the apparent paradox of the persistent vegetative patient.

The contention of Delay and others that allowing Mrs. Schiavo to starve (actually die of dehydration) is morally different from disconnecting a comatose patient from a ventilator has no logical basis. The two are actually morally equivalent. Both are artificial ways to sustain the life of a patient. While a ventilator is needed for a patient’s inability to breath, a feeding tube is needed because of a patient’s inability to obtain food. Both supplement functional deficiencies. While disconnecting a feeding tube causes the patient to stave to death, disconnecting a ventilator causes a patient to essentially die from suffocation.

The real issues at stake.

The truly ironic thing about this case is that even though the controversy over treatment of patients in persistent vegetative states is not new and continues to be hotly debated, there has been plenty of precedent set, both legal and ethical, about how we go about determining whether medical treatment should continue in patients who are permanently unconscious. The most widely accepted set of rules was adopted by many states as well as the American Medical Association.

“Physicians should honor the patient’s previously expressed desires regarding the use of life support. Thus, if the patient has chosen to forego life-sustaining measures, they should be withheld or withdrawn. However, in many cases, the patient will not have indicated his or her desires before becoming permanently unconscious. In such cases, the decision whether to use life support should be based on the patient’s perceived preferences and values, and the decision should be made by the family or legal representative. If the patient’s preferences or values are not ascertainable, the family or legal representative should decide on the basis of the patient’s best interests.”

Despite what many believe, this case is neither about “right-to-life” nor about the ethical issues surrounding the discontinuation of life support. It is about defending the principles of patient autonomy and the medical decision making ability of next of kin as firmly established by common law and state statutes against an increasingly vocal and radical religious right wing minority who seek to usurp these rights and have them transferred to government authorities. It does not help that in the last few years the ruling Republican Party at the state and Federal levels has begun to prostitute itself to every right-wing religious cause that comes around. The action of the GOP in this matter are inexcusable.

The case of Terry Schiavo is unique only for the publicity and media circus that surrounds it (as masterfully orchestrated by Mrs. Schiavo’s parents). Every single year in this country thousands upon thousands of unconscious patients are taken off of life support by their families and allowed to die. Most have far less brain damage than Mrs. Schiavo and most have far more of a theoretical chance at recovering consciousness than Mrs. Schiavo does (without a cerebral cortex her chance is essentially zero). Families take these actions to prevent unnecessary suffering in a loved one who is not expected to recover from their illness. They take these actions to honor the wishes of their loved ones.

The actions of Schiavo’s parents and of the religious right no matter how well intentioned threaten the commonly held American/libertarian principles of government noninterference in private matters. Not surprisingly the vast majority of Americans oppose government interference in this case (these poll numbers must stun those GOP politicians like Bush and Delay who have their lips firmly planted on the posteriors of the religious right).

In the U.S. we have the rule of law and of the courts. The actions of the religious right in this matter amount to little more than the rule of the mob in attempting to garnish as much popular support before imposing their own moral value system upon private citizens in a very tragic but private matter. As an average citizen and one who wants to have control over the fates of my family members I am very concerned about these developments and so should you be.