I ate my wafer...

3/20/2005

Schiavo

I've been putting this post off for weeks. Perhaps Talcott is correct and the silence has gotten deafening in the HBC on the topic. In any case, since I've already insinuated my position in Jake's comments, here goes:

I'm NOT campaigning to kill her, the whole mess is tragic, and I feel horrible for her family. I just think that she isn't a good candidate for martyrdom and extraordinary measures.

1. Legal Issues.

The evidentiary hearings seem remarkably through and extensive. This puts my mind almost completely at ease with regards to David's (an many others) concern that this will lead to a slippery slope of euthanizing the disabled. The precedent from this case is that a vast area of high quality brain scans, combined with a very solid majority of qualified neurologist testimony convinced a competent legal trier of fact. The hearing commentary and opinions seem brutally clear that if Terri had even a remote chance of recovery the outcome would be wildly different. Courts make life or death decisions all the time, and if one is comfortable with capital punishment, especially in states that historically screw it up, I don't see why one cannot trust this precedent.

2. Medical issues.

I REALLY hate the taped clips one sees on the news. I think they are wildly misleading, and cherry picked for emotional manipulation. As others have said, one has to either argue that the CAT scans are faulty, or that consciousness can occur without a cerebral cortex to make a argument for any actual thought or mental activity AT ALL. If a strong argument can be made for the first, I would be interested to hear it, and change my position on this topic entirely. If an argument can be made for the second, I would be dumbfounded.


Similarly, I dislike comparisons to cases where people miraculously awake from comas, "locked-in syndrome" and various neurological conditions. Those folks had a cerebral cortex of some sort. People seem to be using "miraculous" when they really mean "extremly unlikely but physically possible within the known laws of science".

3. Ethical Issues

Euthanasia.

I can respect, and find it logically coherent that some people believe in a sanctity of life approach that makes any attempt to remove life support, ever, unacceptable. (I do find some slight incoherence in objecting to the legal system making determinations in end of life issues while supporting capital punishment.) I don't happen to believe that myself, and to be brutally honest, I have several family members who have personally participated in what could be harshly called physician assisted suicide. I am NOT talking about Kevorkian like stuff, more the very, very rare prescribing of a on demand Demerol drip that crossed LD-50 but would still be inadequate to cover severe, terminal, cancer pain after discussing the issue with a conscious, and rational and coherent patient. I'm OK, if not comfortable with that, and very much OK with living will=removal of support situations.

Miracles.

There is no doubt that Terriā€™s family, and a great number of Americans are holding out for a miracle. God could make it happen. Her brain could regenerate overnight, and poof, she wakes up asking for a McGriddle. The same could be said for the cancer patient discussed above though or for anyone on life-support. I'm personally willing to let some chances for such miracles pass in the interests of preventing suffering. With all possible respect for people's opinions, I find it logically incoherent to believe that Terri should be kept alive at all costs hoping for a miracle if one doesn't do the same thing across the board with ALL end of life issues. From my perspective, if the CAT scans/interpretation is solid, a miraculous recovery is no more likely than it is that she'll live for 40 years without feeding.


4. Final Thought

I hate the whole business. I hate that millions of Americans have seen the tapes, and are emotionally pushed to positions they don't really want to hold. That's true on both sides, since a large number of us who make the no cerebral cortex=braindead connection are more or less forced to argue for killing her. I hate that I cavalierly discussed the odds of miracles above. I hate that by posting this, I will inevitably become classified as some sort of cold, utilitarian, progressive liberal. I hate the fact that Michael Schiavo may indeed be an evil asshole and completely made up everything about Terri's wishes. I hate the fact that her parents, IHMO, have been given a great deal of false hope. I hate that this seems to bring out everyone's irrational sides, mine included (yes, the tapes can make me emotionally react "oh crap, she's trapped in there"). I hate that some really, really bad law is likely to come out of this. I hate that a pretty decent sounding judge is being completely demonized. I am VERY willing to say that the world would be a better place if Michael Schiavo had been less stubborn or more greedy and simply took the cash and ran. Not because of ethical or medical reasons, merely so the whole damn mess would stop.



10 Comments:

  • What about the Pandora's box scenario? Some republicans would rather pay to keep this woman (and the thousands like her) alive than to open the floodgates of euthanaisia as seen in some liberal/socialist (Neth.) and some despotic countries.

    Some are fighting this fight to keep the box shut. Can you blame them?

    Your thoughts? on this . . .

    Madness!!!

    By Anonymous Jake Allen, at 9:51 PM  

  • I honestly think that fears of this case as a legal precedent for Netherlands-style euthanasia are wildly exagerated, the evidentiary hearings were pretty fair and rigorous. (I.E. its a precedent that would not allow the euthaniasia of, oh, say, a person with parkinson or ALS.) It is not as if there will be vast numbers of idenical, no cerebral cortex cases, and the judicial holdings are pretty narrow. Remember that the whole mess is basically only precedent in a small chunk of florida. From your point of view, I'd think that the concept of getting it into federal court as a habeus corpus appeal or whatever would be terrifying, because then you have to worry about a national precedent.

    To summarize all of that, I don't think it is entirely rational to say that pandora's box opens on THIS case.

    The fact that people (I don't think its fair to say republicans only, this issue should muddle party lines) would pay for contiuned lifesupport is nice, and noble. I don't think that its particularly relevant other than as an optional item. That is, I cannot see a federal law REQUIRING people to be kept on lifesupport if donors can be found. In fact I'd venture to say that with the typical support of "death with dignity" laws, most americans would have issues with that concept.

    Finally, if I had to propose a solution for the whole mess, it would be to require, as a condition of getting a drivers license/filling out a FASFA/or recieving any governement benifits at all that everyone fill out a standardized living will/advance directive type form. Note that I would have the forms sealed, openable only under court order to reduce privacy right concerns. Your thoughts?

    By Blogger Bob, at 12:11 AM  

  • Don't we already have to worry about this as a national precedent?

    Sure, this is a Florida-court case, but we've seen other socially charged issues cross state lines (ie gay marriage). Would Florida become the place to go to euthanize relatives?

    I really don't want to sound like Chicken Little, and perhaps you are right, that this does not open up a doorway to wider euthanasia.

    This publicity probably will spur many to write living wills. But does a new government program really solve this?

    Thanks for your thoughts; I am still wrestling through this.

    By Anonymous Jake Allen, at 9:02 AM  

  • Bob,

    Have been following this thought on the hillsdale blogs and wanted to see what you thought of the medical evidence concerning the fact that Terri Schiavo has had no MRI or PET scan. Only a CT scan has led some neurologists to conclude that her cerebral cortex has liquefied; other neurologists dispute the possibility of reliably making that inference from CT scans. Many of the initial determinations of fact under Judge Greer relied mainly on the testimony of Dr. Ronald Cranford. He is certainly a medical expert; but he is also a right-to-die zealot who advocates the removal of feeding tubes for patients with Alzheimer's dementia.

    Also take a look at this article: (http://www.nationalreview.com/comment/johansen200503160848.asp( Gives a broad overview but caused me to pause.

    JRein

    By Blogger Jeremy, at 10:56 AM  

  • Something I should add on the "chicken little" issues is that nearly identical cases HAVE been state level precedent elsewhere for ~10 years. Specidically I'm thinking of

    In re Tavel:

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11648308&dopt=Abstract

    Ten minutes on Lexis shows TN and KY have similar cases too...and there maybe others, those just happen to be states that cite In re Tavel.


    Some people, notably , in the HBC, talcott have asserted that the current mess would be the first time, etc, removal of support was permitted in this type of situation...which simply isn't true.

    It is my oppinion that schiavo differs from those cases merely because of the videos. The human tendancy to anthropomorize, and assume conciousness is never stronger than when looking at another human.

    Do you think that the "focus on the family" and AFA massive emails (yes I subscribe to BOTH of their listservs) have been entirely fair in never mentioning the cerebral cortex issue, or discussing the brain anatomy involved? Certainly they haven't mentioned that a monkey vivisected to remove everything but the bare minimum of brain stem would show the same sort of responses to stimulation. (I happen to REALLY dislike vivisection, but am glad to benifit from 150+ years of knowlege from it http://www.cerebromente.org.br/n01/frenolog/frenloc.htm ) I tend to think that the reliance on the tape clips, and comparisions to wildly neurologically different cases tends to degrade the credibility of the pro-life side in this case. Does that make sense to you? It just seems to border on intellectual dishonesty to me.


    Oh, new thought on the living will business, make it a section on all federal 1040 forms...optional, but worth a $20 credit or similar?

    By Blogger Bob, at 11:03 AM  

  • JRein:

    First, I don't think there's much room to suggest flaky intrepretation in the scans, from what we know at the moment. There has been a, well overwhelming silence on that issue from the Schindlers, and from outside experts with the exception of Hammesfahr. The CT scans were, I beleive entered as evidence in at least a few of the court hearings, so its not as if Greer and Co. were ONLY listening to expert testimony.


    I AM curious about the imaging involved, and frankly would LOVE to see the scans myself. However, my understanding is that the CT scanning done was high-resolution and likely more than precise enough.

    I happen to have seen LOTS of brain imagery growing up of the various types, since my mom was diagnosed with M.S. in the late 1970's, and has had a series of imaging done with the various technologies. A good illustration of the progress in CT imaging is here:

    http://imaginis.com/ct-scan/history.asp

    If its possible to see tiny M.S. lesions clearly on a high resolution CT, I cannot imagine that PVS/cerebral cortex loss would be hard to see. Exactly how much, down to a milimeter, and the exact compostion of the fluid, sure, that's MRI/PET fodder.

    The oft repeated blog assertion that one cannot tell the difference between fluid and brain tissue with CT scanning, is...B.S. want to see it? Here: http://www.health.adelaide.edu.au/paed-neuro/hydr2.jpg

    The black part in the center it cerebral-spinal fluid. The grey part is brain. That's not even a particularly high resolution CT.

    My understanding, possibly faulty, from rangeMD is that MRI scanning was done as well, and if it was helpful, sure as anything, the Schindlers would have been using that:


    http://www.rangelmd.com/2004/09/florida-supreme-court-strikes-down.html
    http://www.rangelmd.com/2003/11/playing-god.html
    http://www.rangelmd.com/2003/11/terri-part-iv.html


    A related topic that interests me a GREAT deal is the (two?) eeg(s) that Hammesfahr dismisses out of hand due to a restless patient. He was not at least based on any sources I've seen, present for the scan, and restless patient eeg is possible.

    By Blogger Bob, at 12:36 PM  

  • I've been trying to find a complete, not cherry-picked copy of the 2000 trial transcript for several days now, with no luck, BUT, careful reading of Judge Greer's 2000 order:

    http://abstractappeal.com/schiavo/trialctorder02-00.pdf

    Shows that the CT scans were in evidence and compared to scans of one of the expert witnesses. Like I tried to point out in my last comment, even a lay person, like Greer should have no problem seeing, if the scans show "to a large extent her brain has been replaced with spinal fluid" (page 6 of the Greer order).

    By Blogger Bob, at 12:57 PM  

  • Liquefactive necrosis (cerebral cortex liquefied) is not hydrocephalus (pic Bob has demonstrating the difference b/w CSF and Brain. Liquefactive necrosis is illustrated here:

    http://www.szote.u-szeged.hu/radio/neuro1/a1neur9a.htm

    The swelling (edema) is between the brain cells (actually the brain cells are dead and being degraded) in liquifactive necrosis versus the hydrocephalus where the fluid is illustated by the enlarged ventricles. MRI are nicer (more fun to look at) but CT are useful. The the court order saying, "brain damage and to a large extent her brain has been replaced by spinal fluid," doesn't really say anything descriptive radiologically. It would be helpful if the report mentioned which reflexes Ms. Schiavo has as then we could say better what is/is not intact in her brain. Without anything more useful published (the actual CT, neurologist reports) I can't in good conscious say that the decision is a good one or bad. The only thing anyone can do is trust the testimony of Drs. Garnhill and Gambone mentioned in Greer 2000 order and the fact that apparently Mr. Schiavo was his wife's most frequent visitor.

    dtmiller

    By Anonymous Anonymous, at 8:59 PM  

  • This is purported to be THE CT scan. Reliable? I dunno.

    http://www.dailykos.com/story/2005/3/18/162547/578

    By Blogger Bob, at 9:51 PM  

  • Bob,

    Thanks for the imaging scans, interesting stuff. While I am interested in the scans, I am also interested in how they are being used to undermine the idea of a culture of life. The scans do give evidence of liquification of the cerebral cortex. However, when can one choose to say that a person if "brain dead." When 51% of the cerebral cortex is liquefied, 90% who is to say? For all of current medical knowledge of neurology, the brain is still an amazing and complex organ of which we know very little. It worries me that people are condemning congress and specific republican senators for attempting to emphasize a culture of life. Also there is a big difference between life-support and a feeding tube.

    By Blogger Jeremy, at 10:30 AM  

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