The terri Schiavo Case: what did we learn from it?

By: Macceau Medozile


 
The Case History

The Theresa Schiavo case (known as Terri Schiavo case) could be referred to as a legal-ethical- sentimental battle between an inconscient life and a world of incohesiveness. Born in 1963 from a catholic family in Philadelphia, Theresa Marie Schindler grew up with her parents (Robert and Mary) and apparently dealt with a weight issue even before she graduated from High School. As any young-concerned-woman, she started to identify ways to obtain and maintain a more “acceptable-body”. While attending Bucks County Community College, she met Michael Schiavo who she married two years later (1984). In February 25, 1990, Terri’s battle for life has begun when she collapsed in her home and experienced respiratory and cardiac arrest as a result of extreme hypokalemia due to an eating disorder (Quill, 2005). She was transported to the Humana Northside Hospital, where she was intubated, ventilated and given a tracheotomy. Petsko (2005) asserts that her electro-encephalogram (EEG) was flat, an indication of the absence or quasi-absence of the higher cortical functions. Additionally, a brain scan has indicated that Terri’s neurons were dead. Terri was later diagnosed to be in a persistent vegetative state (PVS) by many physicians, including Dr. Gracia J. DeSoussa, the neurologist who cared for her at Humana Hospital. Many physicians guessed that apparently Terri was dieting by drinking liquids during the day and ice-tea at night for a longtime. According to Casarett et al. (2005),” artificial nutrition and hydration (ANH) is usually administered enterally through a nasogastric tube or a gastrostomy or jejunostomy tube, placed with fluoroscopic or endoscopic guidance. ANH may also be administered parenterally through peripheral or central venous access. Hydration alone can also be provided by subcutaneous infusion”.
In 1992 _ while Terri was transferred to the Sabal Palms Skilled Care Facility _, Michael Schiavo filed a malpractice law suit against his wife’s obstetrician, Dr. Stephen Igel, who failed to recognize and diagnose Terri’s bulimic disorder; the following year, the jury awarded them about $ 1.3 million. This award (among many other factors) has contributed to sparkle what Petsko (2005) referred to as “a legal tug-of-war with a brain-dead woman as the rope”. In 1993, Michael entered a do-not-resuscitate order for his wife _ after she contracted a urinary tract infection _, for as he mentioned throughout the battle, Terri’s will was not to live connected to a machine if becomes mentally incapacitated with no hope of improvement. However, he rescinded that order under medical pressure from those caring for Terri at Sabal Palms. In 1998, when Michael petitioned the “Sixth Circuit Court of Florida” to have Terri’s feeding tube removed, Mr. and Mrs. Schindler not only opposed to that decision but also started to raising the public awareness about the case and sought for legal and mediatic supports as well.
There were many legal appeals by the Schindlers to either remove Michael as Terri’s legal proxy or to keep her feeding tube connected. It is interesting to note that en guise of a writing advanced directives order form Terri, Robert and Mary Schindler evoked her faith and religious
values as a way to demonstrate her “pro-lifeness”. On the other hand, the relationship between Michael and the Schindlers _ broke down in 1993 _ deteriorated after his second attempt to have Terri’s feeding tube removed in 1998. Dr. Quill (2005) asserts that a wide-ranging, acrimonious legal and public opinion battles that eventually involved multiple special-interest groups developed around that case and made it a cause célèbre for their particular issues.

Representing Theresa’s Best Interests

The Schindlers and many other entities criticized Michael as being motivated by financial greed and adversely, the Schindlers were criticized for not being able to accept that Terri’s condition was very funestral and Michael had to move on with his live. One of the dilemmas in this case was the fact that both Michael and the Schindlers were acting in the best interest of Terri. While one was trying to fulfill his wife’s will, the others, being hopeful, were trying to keep their daughter alive under any circumstances. Thus, even after a court appointed Richard Pearse as a second guardian ad litem _ and even after he concurred with Dr. Jeffrey Karp and Dr. Vincent Gambone’s PVS diagnoses _ the Schindlers, in 2000, claimed that their daughter was conscious and filed a motion to allow Terri to be fed naturally; unfortunately, Judge George Greer denied the request.
Losing hope that Terri’s condition will improve; the Schindlers challenged Michael’s guardianship based on the assumption that he was wasting the assets within their account by transferring Terri to a hospice in Florida, while they believed that she was not terminally ill. Once again, a court denied the motion to remove Michael’s guardianship and, this time, set a date (April 24, 2001) for the feeding tube to be removed. Although Robert and Mary Schindlers filed another motion for relief from the judgment, Terri’s tube was disconnected on the predicted date for the first time. Petsko (2005) argues that a great amount of energy, anger and verbiage alimented a debate about the correctness of ending a patient life, one who will never recover her cognitive functions. Dr. Quill (2005) states that Terri’s apparent alertness and movement misled Robert and Mary Schindlers about her real cognitive state and permanent inability to survive without a feeding tube.


Two days later, the feeding tube was reconnected after Judge Frank Quesada issued an injunction against its removal. Later that year, the Schindlers motioned that a new medical treatment could restore Terri’s cognitive inability in order to remain on the feeding tube; Judge Greer denied the motion. The legal battle went back and forth for over twelve years until Terri died in a hospice on March 31, 2005.

Decision Making Substitution

This case’s controversy shows how substituted decision making is likely to perturb the cohesion among stakeholders _ or simply different concerned and/or non-concerned entities _ when it comes to making the best decision (the more effective and efficient one) for an incapacitated patient. In 1998, Mr. Schiavo petitioned the life-death decision to the state for a legal assumption to be made about his wife’s will. There was a divergency between the court’s decisions and the government’s will (State and Federal governments). While the law is aimed to defend and respect one’s legal decision _ regardless if it is heartbroken or not _, the government is more focused on “moral-politics”, and therefore, is likely to be more subjective and/or authoritarian. One can see the cohesion between the courts’ decisions _ even though their rejected each other’s rulings _ in the pursued of medical and advanced directives veracity (particularly when the media and advocate groups injected themselves in the case as stakeholders). However, when the Florida Legislature passed the “Terri’s Law” and authorized Governor Jeb Bush to intervene in the case, as a pro-life politician, he ordered the feeding tube to be reinserted and used repressive force to transfer Terri from the hospice to a Rehabilitation Hospital. Dr Quill (2005) states that if the evidence is quite clear that Terri did not (or would not) want to be kept on life support with no chance of improvement, then enforcing life-prolonging treatment against her will is both unethical and illegal. In the case of Nancy Cruzan in 1990, the Supreme Court stated that the administration of artificial nutrition and hydration (ANH) without consent is an intrusion on personal liberty.

One can easily argue that the insertion of the state and federal governments in the case _ along with panoply of activists and the media _ was aimed to usurp Michaels’ legal proxy role (of carrying Terri’s wish against prolonged life) in order for the government’s desiderata to prevail. It was clear that each entity (mostly the non-concerned parties) had a different mission to accomplish in that unfortunate case. When travelled to Washington DC to sign the U.S. Senate version of the Terri’s bill, President George W. Bush was trying to seal a political victory for the Republican Party instead of morally exhorting the Schindlers and Michael Schiavo to join their legal efforts towards the implementation of Theresa’s wish (in his short speech about”culture of life”). Petsko (2005) assets that it has been suggested that Terri Schiavo case was an evidence of the hijacking of the Republican party by religious right. According to Wikipedia, recently, President Barack Obama expressed his regrets for supporting the Terri’s bill, which allowed Congress to “intrude where it shouldn’t have”.


The Media and the Activist Movement

Racine et al. (2008) suggest that the Media reported a variety of conflicting perspectives vis-à-vis the diagnosis and prognosis of Terri’s PVS. When analyzing over a thousand “headlines” and contents of many articles published in newspapers (and internet sources as well) throughout the nation, the investigators found that the most frequent headline themes presented the legal (31%), the end-of-life (25%) and the political (22%) aspects of the case. However, about 21% of those articles suggested that Terri Schiavo might improve and 7% leant towards the belief that she might even recover from her cognitive state. “Only 1% of the articles examined gave a definition of the "persistent vegetative state," an essential concept to understand the issues at stake” (scientificblogging.com). The refusal to inform the public about Terri’s real state was the media’s policy to keep the readers guessing and (perhaps) rallying activists around the Schindlers’ efforts to remove Michael as her primary proxy; although the Schindlers themselves believed that the media contributed to the death of their daughter.
The activists (individuals or groups) who supported the legal attempts of Robert and Mary Schindlers to prevent the State of Florida from removing their daughter’s feeding tube, and thus, dying by starvation were motivated mostly by the media and the Constitution of United States. Activists like former presidential candidate Ralph Nader suggested that a profound injustice was being inflicted on Terri Schiavo, and consequently urged the Florida courts to allow her to stay alive. Reverend Jesse Jackson pointed out the non-ethical justification of starving someone to death; while the Bronx Republican Senator, Jose Serrano, a veteran of the civil rights movement requested that the courts err on the side of giving Robert and Mary Schindler a chance to let their daughter live. The Pope himself (Jean Paul II) advocated in favor of the administration of food and water (even by artificial means) to Terri Schiavo. Despite that rally in favor of keeping Terri’s feeding tube attached, opinion polls (at that time) indicated that about 80% of Americans opposed to the involvement of Congress in that case. There is clinical evidence that ANH may improve survival among patients who are in a permanent vegetative state. These patients may live for 10 years or more with ANH but will die within weeks without nutritional support (Fleming, 1994). However, some of the activist movements were guided by the media’s headlines _ that misled them about the non-reversible cognitive state of Mrs. Schiavo (her autopsy did indicate that she was in a real PVS). The experts (neurologists and physicians) who cared for Mrs. Schiavo (and physician appointed by the court) concurred that her stage was irreversible, therefore, a feeding tube would just keep her body alive but would never be able to help revive her neurons.

Conclusion


The Theresa Schiavo case _ far from being a legal and political battle between Robert and Mary Schindler, Michael Schiavo, the State of Florida (judicial and governorship), United States Congress and former President George W. Bush _ was a conflict between science, politics and religion/faith. It was the collapse of a political and judicial system around a scientific fact that artificial nutrition and hydration is not proven to rehabilitate cognitive functions of those in permanent vegetative state. It was also a conflict of interest, for each stakeholder was trying to make a point other than what Terri’s proxy testified to be her wish: the government was trying to save the life of a daughter of the land, the judges were trying to defend and respect the constitution, the media was redefining the case, etc. Above all, both Terri’s parents and husband were trying to act on her best interest: a husband who was tired of seeing his wife suffered and mom and dad who were willing to get blood from stone to have their daughter survive that mortal stage, even if it entailed reducing her being into the least possible human dimension.

The conflict teaches us the importance of (written) advanced directives, particularly when they become handy.
This sad saga, as many people referred to it, clearly indicates that the courts might not be the last place that a patient (or proxy, parents, closed friends, etc.) would want to go to resolve those types of dilemmas (Quill, 2005), for most of the times, governments’ actions do not scope individual’s interests but the multitude (the electorate). One should learn as well that the media can be very disturbing by disseminating wrong or confusing information at time (because of lack of concurrence, verification of sources of information and/or many other factors).


 
Bibliography:

Levine, Carole. Clashing Views on Bioethical Issues. 12th ed. McGraw Hill, 2008

Pence, Gregory. Medical Ethics: Accounts of the Cases That Shaped and Difine Medical Ethics. 5th ed., McGraw Hill, 2008

The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (first of two parts). N Engl J Med 1994;330:1499-508. Scolapio JS, Fleming

Casarett,David ; Kapo Jennifer; Caplan , Arthur. Appropriate Use of Artificial Nutrition and Hydration —Fundamental Principles and Recommendations. engl j med 353;24

Didion, Joan. The Case of Theresa Schiavo. The New York Review of Books, Vol. 52, No. 10, June 9, 2005

Quill E. Timothy. A Tragedy Compounded. Perspective (cited NEJM, MED 352:16.) pp. 1630-1633, April 21, 2005)

Petsko, Gregory. A Matter of Life and Death. Genome Biology 2005, 6:5;109

Racine, E; Maram, R; Seider, M; Kaeczewsha, M; Illes, J. Media Coverage of the Persistent Vegetative State and End-of-Life Decision-making. Neurology 71. Sept 23, 2008. Pp. 1027-1032

Annas, J. George. Congress, Controlled Substances, and Physician-Assisted Suicide – Elephants in Mouseholes. NEJM, MED 354:10, March 9, 2006 pp. 1079-1084

www.wikepedia.com : The Terri Schiavo Case

DIALOGUE

We are very happy to announce the new series "DIALOGUE" on HAIMUSIQUE (la radio cayenne d'outre-mer). The series will run for 4 four months starting this coming Saturday night at 10 PM.

"DIALOGUE" entails to offer a free platform to Haitian scientists, philosophers, technicians/practitioners, journalists, etc. to help the haitian public (in Haiti and overseas) to comprehend the meanings of daily political, medical and social decisions taken by governments or else _ either in Haiti or abroad _ that could impact their lifes and well-beings.

To participate in that series, please contact us at haimusique@gmail.com or visit our website (www.haimusique.com ) for more details.

Thanks!

HAIMUSIQUE Annual Gospel Fest

Haimusique (la radio cayenne d'outre-mer) is proud to invite you to its
First Annual Gospel Fest this Sunday from 6PM to 10 PM (ET). Youn di lot, lets spread the words!
Just click on www.aux-cayes. com or www.haimusique. com

Happy Valentine's Day everybody! (to: Christella, Peguy, Sarah-Anne,
Garcelle & Max)

Climate change conference in Haiti

According to Amos Cincir and Michel Carlin (from Le Nouvelliste), 13 Caribbean States along with a few countries from Central America will meet in Haiti, next week, to discuss over climate changes and sustainable action plans for the Region. Mr. Jean-Marie Germain (the head of the Environmental Department) showed concerns about Haiti’s vulnerability when facing natural catastrophes; whereas, Agronomist Ronald Toussaint talked about uncontrolled (human) population growth, lack of urban planning (among others) _ as they relate to the socio-political and demographics disparity among the states of the Caribbean.

Climate change vulnerabilities, impacts and adaptation is a very complex ecological, social and political task for all nations; particularly those with limited economic/financial means and “damaged” environments (Haiti is one of them). Among all those important topics (that will be discussed), I would like to suggest three additional ones (major effects of climate changes on the environment) that require the immediate attention of our regional scientists:

* Lost of saltmarsh habitat: due to the rise of the ocean, the arbitrary deflection of stream velocity (of river and major waterbodies in the Region), coastal salubrity and farming.

* Increase of erosion on riparian buffer (due to increase of stormwater and deforestation) and riverbanks (as a result of an increase of soil friability and the quasi-elimination of the groundcover plant community).

* Control of diseases , particularly paludism and tuberculosis.


The Region’s (or Haiti) adaptation plan must entail ways to deal with those unfortunate changes and aim to minimize their effects and to (even) prevent them from taking place (too soon or ever).

L’independence d’Haiti

Premier Janvier 1804, premier Janvier 2009, deux cent cinquième année d’Indépendance d’Haiti, et la lutte socio-politique et économique continue après des guerres ensanglantées qui ont couté la vie à une masse d’esclaves, des hommes politiques, de braves gens-d’armes, d’intellectuels, de commercants; sans oublier les Francais, les Colons…

Débarqués en Amérique en 1492, Christophe Colomb et ses alliés ont détruit toute une culture, un groupe ethnique, emporté les richesses naturelles de cette Perle des Antilles. Ils ont commis la plus grande écocide de l’époque: le sol rabourré, la couche forestière détruite, la quasi-complete élimination de la population Indienne habitant sur l’ile.

Ils ont fait venir des esclaves d’Afrique, pas des travailleurs et/ou des engagés salaries, mais des hommes qui seront traits comme des choses, des sans-patrie, des damnés de la terre comme disait Fanon. Ces esclaves ont fait prosperer la colonie, enrichir l’Espagne et plutard, la France au détriment de leurs sueurs, leur mépris, leur décapitulation; mais dans leurs coeurs, ils ont gardé l’espoir et le désir de révolter et de mettre fin à tout cela. Certains se marronaient, d’autre se fortifiaent par des chansons et des cérémonies spirituelles.

Entre-temps, d’importantes transformations politiques et sociales s’oppéraient dans d’autres sociétés humaines en Amerique et en Europe.

En France, les révolutionnaires se préparaient à rediger la déclaration des droits de l’homme qui déclara que les droits, l’iberté et égalité sont les pylonnes des gouvernements légitimes et systems sociaux.

En Haiti, les planteurs francais, artisants, soldats et administrateurs ont suivi de très près les evenements qui se débutaient à travers l’Atlantique.

Pendant qu’ils observaient le déroulement des évènements en France, ces francais ne se rendaient pas compte qu’une révolution était en train de se former dans la colonies st. dominguoise.

Sur les plantations francaises d’haiti, les Africains-Americains subissaient les plus dures attrocités de l’esclavage. Le 22 Aout 1791, la guerre de l’indépendence commencait à prendre chair sous le leadership de Boukman quand plus de 100 milles esclaves se révoltaient ouvertement contre les francais. Contrairement aux révolutions francaise et americaine, celle d’haiti était concretement menée par des homes et femmes ayant vecu toute leur vie dans l’esclave. Ils ne desiraient pas seulement la liberté, mais aussi la vengeance. Au cours des trois prochaines semaines, toutes les plantations de canne-a-sucre etaient bruleés par les révoltés et les francais fuyaient les villes et les plantations.

Toussaint Louverture était le chef de fil de cette révolution. Ses homologues Européens lui considerait comme Georges Washington et plutard comme Napoleon Bonaparte. Quoiqu’il ne participait pas dans la destruction des plantations de cannes-a-sucre et l’éxecution des francais, Toussaint s’établissait lui-meme quand il comprenait que la révolution ne pourrait faire long feu si les esclaves ne s’organissaient pas politiquement et militairement pour faire face aux pressions exterieures; car les Espagnoles et les Anglais voulaient profiter de cette situation pour s’emparer de la perle des Antilles. Voila pourquoi Toussaint s’associait aux Francais et Haiti continuait à etre dépendante de la France.

Le 22 Juillet 1795, l'Espagne qui occupait jusque là la partie orientale de Saint Domingue (aujourd'hui, République Dominicaine), signa à Bâle un traité avec la France. Par ce traité, Saint Domingue , dans toute son étendue, devint une colonie française. Toutefois, ce traité n'atténua pas l'envie des autres nations impérialistes de l'europe sur l'ile. La France, prise dans l'engrenage des guerres en Europe, n'avait pas assez de troupes coloniales pour défendre et dût se remettre aux leaders noirs et mulâtres pour se défendre sa chère colonie.

Après la débâcle insurrectionnelle du trio Boukman, Jean-François et Biassou, Toussaint Louverture fut propulsé au devant de la scène militaire d'abord et politique ensuite. En Juillet 1801, après la proclamation de sa constitution, il devint donc le gouverneur de Saint-Domingue,et qui suscita des appréhensions chez Bonaparte, alors Premier Consul de France, appréhensions alimentés par des rumeurs faisant de Toussaint, un séparatiste. Toussaint Louverture, en fait, avait "inventé une forme constitutionnelle nouvelle, qui n'était ni l'État fédéral, ni l'État confédéré, mais l'État associé, dont on parlera beaucoup plus tard dans d'autres négociations entre colonies et métropole" (Laurent-Ropa, Denis. Haiti:une colonie française..., p. 264).

A côté de la Constitution de 1801, Toussaint réorganisa toute l'administration. Il établit des écoles, établit des bourses d'études à l'intention des jeunes de la colonie, forma une armée stable, promulgua un code rural.

En France, Cependant, Napoléon, après avoir conquéri la majeure partie de L'Europe, se retourna vers Saint Domingue avec l'intention de rétablir l'esclavage et déporter les chefs noirs. Il envoya donc une armée de 22,000 hommes sur 76 vaisseaux, sous les ordres de son beau-frère, le général Victor-Emmanuel Leclerc.

Le 1er. février 1802, cette flotte arriva devant le Cap et Leclerc somma Henri Christophe qui commandait le Nord, de lui livrer la ville dans les 24 heures. Ce dernier préféra donc réduire la ville en cendres plutôt de la livrer aux forces expéditionnaires. qui menèrent une attaque touts azimuts. Malgré la défense héroïque des noirs sous la conduite de Christophe, de Dessalines, de Lamartinière, de Maurepas, de Magny, les Français se rendirent maitre de Saint Domingue point par point. Ainsi, la première tentative d'indépendance échoua, et Leclerc profita de cet échec pour décapiter l'armée coloniale de son chef. En effet, Toussaint qui s'était retiré sur son habitation à Ennery (Département de l'Artibonite), fut attiré dans un guet-apens. Arrêté, il fut embarqué pour la France où on l'enferma au Fort-de-Joux, dans les montagnes du Jura. Il y mourut le 7 avril 1803 . (Haiti-reference.com).

A la mort de Toussaint Louverture au fort de joux en 1803, jean Jacques Dessalines a pris la relève de la révolution. Contrairement à Toussaint, Dessalines, étant fache contre les traitements qu’il subissait quand il était esclave, s’est déterminé à empecher le ré-établissement du système esclavagiste dans l’ile.

La cruauté de Leclerc et sa tentative de rétablissement de l'esclavage suscitèrent l’opposition des noirs de Saint Domingue qui avaient commencé à manifester une certaine soumission aux troupes françaises; opposition conduisant à une résistance active pratiquée à travers la guerilla d’abord, et une guerre conventionnelle sans merci ensuite, quand les affranchis mulâtres se rallièrent à la cause des noirs et entrèrent dans une alliance avec eux pour la libération. A travers des harcèlements sans répit, des embuscades en cascade, de longs sièges et aidés par une épidémie de fièvre jaune qui emporta, entre autres, le chef de l’expédition, le général Leclerc, les Haitiens finirent par forcer la capitulation des Français après l'éclatement victoire de la Crête à Pierrot. Rochambeau, qui avait succédé à Leclerc, capitula alors et s’embarqua pour la France.

Les esclaves d’hier et les affranchis mulâtres qui subissaient les vexations des colons, venaient de réaliser une geste héroïque jusque là impensable et inédite, et jusqu’ici jamais égalée dans l’histoire de l’humanité, mettant fin à une histoire des plus amères; histoire qui suscite, quand évoquée par les arrières-petit-fils de ces anciens esclaves, des sentiments de révolte, d'indignation, mais aussi de fierté (Haiti-reference.com).

Plusieurs croirent que le nombre des noirs non-combattants tués au cours de la bataille contre les troupes de Rochambeau a égalé le nombre des tués de la deuxième guerre mondiale; c’est pourquoi Dessaline a ordonné le massacre générale des Francais habitant dans la colonie.

Le 28 Novembre 1803, le Général Rochambeau a accepté la défaite et Dessalines déclarait Haiti une réublique. Il a déchiré le drapeau francais, enlevé le morceau blanc et le remis le bicolore a kathrine pour etre cousu.

Pour rendre officielle la victoire et fêter avec pompe l'indépendance, Dessalines convoqua une assemblée. Boisrond Tonnerre fut chargé de rédiger l'Acte de l'Indépendance. Les cérémonies accompagnant la proclamation de l'indépendance se déroulèrent à Gonaïves le 1er. janvier 1804. (haiti-reference.com)

ACTE DE L”INDEPENDANCE

Sources:

Haiti-reference
wsu.edu
Haiculture
Laurent-Ropa, Denis. Haiti: une colonie française 1625-1802. Paris: L'Harmattan, 1993.

Recherche, rédaction: Macceau Medozile