Friday, December 18, 2009

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” ( 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.


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).


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 : The Terri Schiavo Case