Wednesday, June 08, 2005

Neuroplasticity

One my my favouite essayists, Joan Didion, has taken on the Terri Schaivo story. I've respected Didion ever since I read Slouching Towards Bethlehem for an essay course as an undergrad (no, it's not a religious book). She's no religiois nut, and she does well with the story. On PVS:
No one who has had even a passing exposure to brain injury can think of neurology as a field in which all questions are answerable. The "prognosis" is arrived at only clinically, after the fact, by observation of what happens. Vegetative patients whose brain injury was traumatic (a fall, an accident, an external mechanical event) are more likely to recover response than those, like Theresa Schiavo, whose injury resulted from a lack of oxygen to the brain. No one knows why. Patients who emerge from coma and show some response can later drop into a less responsive state. Again, no one knows why. Neurologists can pinpoint the precise location of injured areas, know exactly what the functions of those areas are supposed to be, and still have no idea what actual deficits the patient will or will not experience: every brain, I was told by a neuroscientist at UCLA, is wired differently. The injured brain, moreover, can rewire itself. Neuroplasticity, to a greater or lesser but in each case unpredictable extent, can allow the construction of new circuits, new synapses. Undamaged areas of the brain can assume some of the functions of injured neurons. Whether or not this will occur can be known, again, only by observation of whether or not it does occur.
On the beginings of this case:
the suggestion (no diagnosis exists) of an "eating disorder" appears to have been entirely assumptive, based on no evidence beyond the unexceptional facts that she had some years before gained weight, gone on a diet, and lost the weight. We do know that on Theresa Schiavo's initial testing the level of serum potassium was 2.0, not only well below the "normal" range, which is 3.5 to 5.0, but also below the level, 3.0, at which cardiac effects may be expected. Bulimia, or any vomiting at all, can cause potassium deficiency. Since other common causes include kidney disorders, colon polyps, and the ingestion of diuretics, laxatives, asthma medications, certain penicillins, or even large amounts of licorice, the lowered serum potassium level on its own does not tell us what led to the deficiency that is believed to have triggered the cardiac arrest.
On the generally poor quality of the debate in the media:
On each side of the debate, the convictions that the Schiavo case was seen to validate were prior convictions, old stories, rendering the discussion déjà vu, a hermetic reiteration of familiar griefs with and outrages of our political process. What might have seemed a central argument in this case—the ethical argument, the argument about whether, when it comes to life and death, any of us can justifiably claim the ability or the right to judge the value of any other being's life—remained largely unexpressed, mentioned, when at all, only to be dismissed...
On the the most likley short term legacy of the whole sordid story, with which we are now burdened:
Living wills, it was frequently said, could be "Terri's legacy." There was considerable fuzziness here, not least in the reverence accorded the "living will," which seemed increasingly to be another of those well-meant and seemingly unassailable ideas that do not quite work the way we are encouraged to think they work. The chances of being admitted conscious to a hospital without being pressed to produce a living will have become virtually nil, yet any "living will" prepared in advance (as in "advance directive," exactly the document we are pressed to produce) requires us to make specific medical decisions about situations we cannot conceivably anticipate. According to studies cited last year in the Hastings Center Report by a medical researcher and a law professor at the University of Michigan, Angela Fagerlin and Carl E. Schneider, almost a third of such decisions, after periods as short as two years, no longer reflect the wishes of those who made them. The "health care proxy" or durable power of attorney, through which we assign someone we trust to make the decisions we can no longer make, is the better document, but it optimistically presupposes that we will each have with us at end of life "someone we trust." The further problem with such directives is that they can be construed as coercive: no one wants to be a "burden." Few of us want to be perceived as considering our own lives more important than the ongoing life and prosperity of the family. Few of us will sit with a husband or wife or child in a lawyer's office or a doctor's office and hesitate to sign the piece of paper that will mean, when the day goes downhill, the least trouble for all concerned. For all the emphasis on the importance of "choice," the only choice generally approved by the culture is to sign the piece of paper, "not be a burden," die.
And then there's this, which drives home the zeal with which the final court order was executed:
There was an insensitivity in the timing of the removal of the feeding tube, which took place on the Friday before Palm Sunday, meaning that the gradual process of dying coincided with a week that for Christians has specifically to do with sacrificial suffering and death. "Oh come on," someone said when this was mentioned on a cable show. There was a further insensitivity in the fact that the tube was removed at all. If the sole intention is to terminate feeding and hydration, there is no need to remove a gastric feeding tube. All anyone need do is stop plunging the formula into the tube. Hospitals routinely leave gastric tubes in place long after patients have progressed to oral feeding, because any later need to replace the tube (after the incision has begun to heal and scar tissue to form) can be difficult and require surgery. In this case, in the absence of some unusual circumstance that remained unreported, the sole purpose of actual removal would seem to have been to make any legally ordered resumption of feeding difficult to implement.
What's the word for 'plasticity of conscience'?

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