Thursday, March 31, 2005

Dignity by dehydration

Terri Scaivo, Dr. Cranford and the "indignity" of the feeding tube Terri Schaivo died today. Let's hope we can learn something from this terrible story. ***** One of my more outspokenly left leaning readers, Timmy the G, has taken the testimony of the doctor for Micheal Schaivo as the final word on Terri's condition and how she should be treated. It has to be noted that these are two issues, and not one. In philosophy this is the "is/ought" problem that goes back to David Hume at least. Terri might very well have been a PVS patient; I've never denied that. My concern in this case is for due process, or getting the facts right. What to do with them is trickier, but I have a few ideas about what might be reasonable in that regard too. Reading Timmy's post, one gets the impression that he and Dr. Ronald Cranford are perilously close to thinking that diagnosis dictates the treatment, which is absolutely false. Even if Cranford is right and it is PVS, that leaves very large questions open about how we respond. It is a question over which reasonable people can disagree. One reason to confuse is and ought is to avoid that very disagreement and thereby keep the discussion in an area where your credentials will be an advantage. It allows Cranford to use his medical expertise, which no one denies, to make moral and ethical claims about her treatment, and thereby advance his views on euthanasia without being questioned. Read the interview on Timmy's site; Cranford does not like being questioned. He throws facts about with venom, as if the ethical conclusion he sees are their inevitable result. This is not science; it is scientism. The dubiousness of the logical method at work on the ethics of the case are also found in the facts. Much hangs on the character of Micheal Schaivo, a man with many conflicts of interest. Can we trust him when he says that Terri did not want to live in such dire straights, and how much weight can be given those words even if she did say them? His character also affects our judgement of Terri's diagnosis and treatment. One can imagine Micheal and Terri sitting around the television and seeing, say, Christopher Reeve on TV, and somebody says "I wouldn't want to live like that." Maybe it's Micheal and Terri nods. She is in fact busy making popcorn and barely heard what Micheal said, or what he said it about. The only witnesses are close members of Micheal's family. I know this is not the actual testimony but you take my point. How much weight should we give evidence like this? Can a discussion like this be considered reasoned and informed? Then there is the fact of Micheal's second family and potential financial interest. Furthermore, he has not been generous with the money that was awarded for Terri's care. There seems to be evidence that Terri's treatment and diagnosis were not what would be hoped for. The primary witness for Micheal Schaivo was Dr. Ronald Cranford, who does indeed have a long history of dealing with the very ill and with end of life issues. It is telling, I think, that of all the specialists he could have chose, Micheal chose Dr. Cranford, who has a history of being quick to pull the trigger on patients he decides are too ill to be dignified. In this opinion piece from 1997, Dr. Cranford advocates starving (or dehydrating as he prefers to call it) Alzheimers patients:
If people really understood the reality of this dementia, I doubt they'd find it an acceptable lifestyle. Being in a state of wakeful oblivion for five to 10 years or sometimes longer is a degrading experience. The degradation is borne not so much by the patient, who may be completely unaware of him- or herself, but by the patient's family. They must endure the agony of seeing a loved one lying there year after year, often sustained only by a feeding tube... In Europe, feeding tubes are rarely seen in nursing homes. Once a patient is so severely brain-damaged that only artificial nutrition can sustain life, many doctors and families rightly ask, "What's the point?" In many civilized countries, the question wouldn't be asked -- because placing a feeding tube in someone with end-stage dementia wouldn't even be considered.
Is Cranford really saying that it is OK to kill some people because they make other people uncomfortable? Even when there is no evidence that that would be their wish? It seems so. Cranford seems unable to imagine anyone disagreeing with him. The "what's the point" attitude Cranford reveals above may have percolated through to the diagnosis and treatment that Terri received. Writing in The National Review, Robert Johansen wrote that:
Terri's diagnosis was arrived at without the benefit of testing that most neurologists would consider standard for diagnosing PVS. One such test is MRI (Magnetic Resonance Imaging). MRI is widely used today, even for ailments as simple as knee injuries but Terri has never had one. Michael has repeatedly refused to consent to one. The neurologists I have spoken to have reacted with shock upon learning this fact. One such neurologist is Dr. Peter Morin. He is a researcher specializing in degenerative brain diseases, and has both an M.D. and a Ph.D. in biochemistry from Boston University. In the course of my conversation with Dr. Morin, he made reference to the standard use of MRI and PET (Positron Emission Tomography) scans to diagnose the extent of brain injuries. He seemed to assume that these had been done for Terri. I stopped him and told him that these tests have never been done for her; that Michael had refused them. There was a moment of dead silence. That's criminal, he said, and then asked, in a tone of utter incredulity: How can he continue as guardian? People are deliberating over this woman life and death and there's been no MRI or PET? He drew a reasonable conclusion: These people [Michael Schiavo, George Felos, and Judge Greer] don't want the information. Dr. Morin explained that he would feel obligated to obtain the information in these tests before making a diagnosis with life and death consequences. I told him that CT (Computer-Aided Tomography) scans had been done, and were partly the basis for the finding of PVS. The doctor retorted, Spare no expense, eh? I asked him to explain the comment; he said that a CT scan is a much less expensive test than an MRI, but it only gives you a tenth of the information an MRI does. He added, CT scan is useful only in pretty severe cases, such as trauma, and also during the few days after an anoxic (lack of oxygen) brain injury. It's useful in an emergency-room setting. But if the question is ischemic injury [brain damage caused by lack of blood/oxygen to part of the brain] you want an MRI and PET. For subsequent evaluation of brain injury, the CT is pretty useless unless there has been a massive stroke.
In the transcript of Cranford's interview on Scarborough Country that Timmy refers to, Cranford rushes right by the MRI question. He never answers it:
DANIELS: Doctor, was a CAT scan -- Doctor, your critics would ask you, was a CAT scan used? Was an MRI taken? Were any of these tests taken? CRANFORD: You don't know the answer to that? The CAT scan was done in 1996, 2002. We spent a lot of time in court showing the irreversible -- you don't have copies of those CAT scans? How can you say that? The CAT scans are out there, distributed to other people. You have got to look at the facts. The CAT scan is out there. It shows severe atrophy of the brain. The autopsy is going to show severe atrophy of the brain. And you're asking me if a CAT scan was done? How could you possibly be so stupid?
One of Cranford's earlier patients, Nancy Curzon, was euthanized even though she was able to feed from a spoon. Cranford reportedly felt that was also "treatment" that could be withdrawn. You can learn more about the very relevant Curzon case here. In that case, the courts ruled that there was not enough evidence that Curzon would have consented to the removal of her feeding tube, despite her parents' wishes. It recognized that we cannot allow people to die merely to placate interested parties. The court also, however, said that it could hear evidence on what the patient herself would have wanted. On that point I agree with justice Renquist more than the National Review's Mathew J. Frank. Applying this ruling to Schaivo, however, I think that there is insufficient proof as to what Terri would have wanted. In the absence of that high quality proof, the court should have denied Micheal's petition. It also should have ruled that third parties do not have the right to deny food and water, since they are not extraordinary medical interventions. "Substituted judgment" should be reserved for more aggressive treatments. As justice Scalia put it, in his dissent on the Curzon case: "the intelligent line does not fall between action [e.g. the gun] and inaction [the withdrawal of a feeding tube] but between those forms of inaction that consist of abstaining from 'ordinary' care and those that consist of abstaining from 'excessive' or 'heroic' measures." Terri was not dying before the tube was removed, and she did not die during her accident. She was severely handicapped, nothing more, and nothing less. None of us deserves to tell her she is too undignified to live. This is not to say that Terri, had she been able to tell us directly what she wanted, should have been forced to undergo the feeding tube. If she could clearly indicate that she refused it, then I think we ought to respect her. That would be a sad and unlikely decision, I think, but I can't imagine forcing the issue. I also doubt very much that anyone would choose dehydration, or if they did, that they would pursue it to the end. Most people would concede that point, I suspect, which makes all of the talk about Terri's passing "peacefully" and with her favourite teddy bear a macabre bit of public relations theatre for the euthanasia crowd.

No comments: