Monday, March 28, 2005

Response to Comments: The Schiavo Case

Instead of responding below comments to my post Morality vs. Legality, I decided to create a new post to provide detailed answers.
Moebius Stripper says:
For those who believe that people can choose not to be kept alive, but that Terri Schiavo's feeding tubes should be re-inserted, the only remaining moral position I can see is that the patient alone can make this choice and it must be recorded in writing (in the form of a "living will", presumably).

Where do you get this? I personally think that people can choose not to be kept alive, but that her feeding tube should be reinserted. This isn't based on a belief that only a patient can make the decision to die (like you, I'd have trouble committing to something ahead of time) - it's based on a belief that no one should die by being starved to death over a two-week period. I think that the most disturbing aspect of this case is that it's basically taken for granted that shooting Terri Shiavo in the heart or giving her a lethal injection that would kill her in seconds is murder, but that starvation over a two-week period constitutes death with dignity.

This is a good point; my original post was flawed. I presume you'd agree with what I wrote if we were discussing a similar case which didn't involve a protracted death? For completeness, when writing about the Schiavo case, I should have discussed this argument as well. If it's any comfort, MS, it hasn't been completely neglected; several websites and talk-shows have dwelt on the starvation issue and why it's cruel. Still, I don't think it makes much difference, because it doesn't seem like a tenable position, either.

The claim I've seen advanced most often is that removing the feeding tubes will cause Terri Schiavo to suffer terribly for two weeks or so. The problem is that the word starvation is loaded: our visceral reaction is to imagine patients in severe anguish for a long time. This is inaccurate; it is generally accepted that death by complete starvation/dehydration in a hospital is not particularly painful. Here are three different articles quoting several neurologists who believe that Terri Schiavo will not experience severe thirst or hunger. I'm quoting rather extensively from the best of these, an L.A. Times article devoted to this issue:
[M]edical experts say going without food and water in the last days and weeks of life is as natural as death itself. The body is equipped with its own resources to adjust to death, they say.
"What my patients have told me over the last 25 years is that when they stop eating and drinking, there's nothing unpleasant about it -- in fact it can be quite blissful and euphoric," said Dr. Perry G. Fine, vice president of medical affairs at the National Hospice and Palliative Care Organization in Arlington, Va. "It's a very smooth, graceful and elegant way to go."
"The cessation of eating and drinking is the dominant way that mammals die," said Dr. Ira Byock, director of palliative medicine at Dartmouth Hitchcock Medical Center in New Hampshire. "It is a very gentle way that nature has provided for animals to leave this life."

In a 2003 study published in the New England Journal of Medicine, 102 hospice nurses caring for terminally ill patients who refused food and drink described their patients' final days as peaceful, with less pain and suffering than those who had elected to die through physician-assisted suicide.

The average rating given by the nurses for the patients' quality of death was an 8 on a scale where 9 represented a "very good death" and 0 was a "very bad death."
[The] pain of hunger is only felt by those who subsist on small amounts of food and water -- victims of famine, for instance, or concentration-camp inmates. They become ravenous as their bodies crave more fuel, said Sullivan, a senior fellow at Duke's Center for the Study of Aging.

After 24 hours without any food, "the body goes into a different mode and you're not hungry anymore," he said. "Total starvation is not painful or uncomfortable at all.
The weakening brain releases a surge of feel-good hormones called endorphins.

Doctors also have a host of treatments to ameliorate acute problems, such as sprays and swabs to moisten dry mouths and creams to moisturize flaky skin. They can also administer morphine or other powerful painkillers.
There's also some anecdotal evidence in a comment thread at DailyKos, but you might want to take that with a grain of salt. Given that this kind of death is fairly painless, I think it's reasonable to prefer it to lethal injections or the like. (And if the nurses in that study were right, dehydration is actually the less painful alternative.)

RL's comment was longer:
I would want my family to make the best decision they could based on medical advice and the probability that I would recover.

The courts have established that it is probable that she would not have wanted to be kept alive; even if this is discounted, her husband wishes it, and if anyone has a moral right to decide, it is her spouse.

Your above two statements are very disturbing as they lead to things very very dangerous. We are living in times of Harold Shipman. I don't think civilization has reached a decisive stage where even terminal patients themselves can be given the power to decide if or not to pull the plug - leave alone a third person - however he/she be close to him/her. It is not everyday that Bush comes up with sosmething like this - but it definitely makes a lot of sense to "err on the side of life"

If that be the question - I shudder to think of the debataes that will follow. Can severely depressed men and women allowed to take their lives? What about penuriously bakrupt people? What about people in lunatic asylums? What about people imprisoned for life without a chance for parole? What about people who cannot afford to keep their loved ones on life support - though they may have a good probability of recovery in the long term?

And when you ask proponents for legislation to define that "life is sacred, and that we may never choose to let it end" - I shudder to think of the consequences. Do you think law can ever be complete ? Do we need to define everyday activities in black and white laws? We will enter a Godel's world where there will always crop cases which cannot and should not be for the courts to decide.

Life is something we havent cracked - and we cannot ever make a decision for anybody. I am a leftist liberal, but I cannot bear to bring myself to defend for everything branded as "liberal" - just for the heck of it. I believe in the sanctity of life - and I hold that above any judiciary.
He raises several issues, and I'll try to address them one by one.

To begin with, when I said, "Adherents to [the belief that we can never choose to let life end] would do well, in my opinion, to petition for legislation in their favour.", I was making a serious suggestion. This is a viewpoint I respect, and I thought (and still think) that a law would be the simplest and quickest way to ensure that it is complied with. We certainly cannot pass laws to cover every situation, but if you believe in the sanctity of life and that patients can never choose to die, legislation to that effect could easily be drafted. In the absence of legal guidelines, there will always be disputes.

As regards the liberal/conservative issue, I actually think I'm less leftist than you, RL. I'm generally liberal on social issues, but moderate to conservative on fiscal issues. Like you, I can't defend every 'liberal' cause: In fact, it's morally unacceptable to me to support any party on an issue if I disagree with their position.

And finally, while I agree that "erring on the side of life" is desirable (I don't think anyone objects to this principle), this is distinct from insisting that no-one be permitted to choose to die. My position is that people in a persistent vegetative state, with no hope of recovery, should be allowed to die if they so wish (or rather, if they had indicated this wish while still able to). In the absence of such a wish, the next-of-kin can decide. Yours, I presume, is that this decision can never be made. I think that would actually be more complicated: for one thing, the government would have to financially support such patients. On this, then, we appear to disagree.

Many of the problems you describe are not directly related to this issue. As an example, I'll pick one, the case of people who cannot afford to keep loved ones on life support even if it is likely they will recover. Consider the following problem: a member of your family will die if he/she does not undergo complex, expensive surgery. The surgery will probably succeed, but you cannot afford to pay for it. Wouldn't you agree that this is essentially the same as the previous problem? The solution has nothing to do with life-support: it would be reasonable (from a logical point of view) for the state to pay for both or neither. From an ethical perspective, I - again, like you - would rather the state paid for both. But these are issues best discussed in a separate post.

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