Tuesday, March 22, 2005

"Compassionate" Cruelty

The cover story of the Spring 2005 (Vol 5, Issue 1) issue of ICU Management is ethics. N. Zamperetti makes some statements regarding end of life care "Managing a patient's refusal of vital supports: a personal position" that have broader applications outside the ICU, including the circus that has become Terri Schiavo's "life". One of the more obvious items Zamperetti points out is that dignity can have different meanings from complete autonomy to assisted care to just being alive. He notes the difference between supplying vital support when the situation is not clinically futile and support that is merely "agony prolonging" as well as the need to understand that therapy is a means to an end (clinical outcome), not a goal itself. Suggestions for a practical approach ensuring that, when a patient refuses effective therapy, it is based on an understanding and acceptance of the predictable outcome; if the predictable outcome is not in line the the patient's view of life, personal/religious beliefs, efforts should be made to encourage the patient's acceptance of known effective treatment.

In the Schiavo case, it's reasonable to believe that Terri could have said "I wouldn't want to live like that" to her husband (possibly after seeing a news story on a situation similar to her own) very seriously despite not having gone the extra step of obtaining a living will or discussing the situation with anyone else in her family. Most reasonably healthy young or middle-aged people wouldn't think a living will is something they'd even have to consider without some sort of prompting by a healthcare facility (e.g. pre-scheduled hospital admission for surgery) until much later in life (Schiavo was 26 when she suffered the initial injury).

Much has been made from "Dr." Sidney Blumenfeld's article in Worldnet Daily. The bias of his piece is clear from the first paragraph in which he accuses Michael Schiavo of murdering Terri by withdrawing support - according to Blumenfeld, Michael Schiavo is doing this in solely to marry his girlfriend and collect inheritance from Terri's estate. In the article he, incorrectly, states:
Terri Schiavo is no burden on her husband. She is being cared for by her parents who love her. The word "love" has not been used by the court in this case. As far as the judge is concerned, love is not an issue or even a consideration. Terri's parents accept her disabled state. She smiles at them. She hears them. But she cannot speak to them. And as long as they are able to maintain and support their daughter in her disabled state, why should the court deny them this expression of their love? Is not sacrifice an important manifestation of love?

As mentioned on Liberty Street, Terri is not being cared for by her parents, she is cared for by hospice workers. The Schindler's and Michael Schiavo did attempt to care for her themselves, but Terri was moved to a skilled nursing facility when the family realized they were not able to provide adequate care for her. Blumenfeld notes that as long as the Schindler's are able to accept and support her in her "disabled" state, they should not be denied the chance to do so. Does this mean this "life" that they are fighting to protect should remain as such on the basis of their whim and that, if they were to stop accepting this her life should then be terminated? I beg to differ with the statement that the Schindlers have accepted her current state, in actuality they really seem to be in complete denial of her current state. They are not making sacrifices as a proof of their love, they are requiring their daughter to make the sacrifice in order to fulfill their needs. The is the height of (well-intentioned) selfishness and an expression of more of ownership ("she is our daughter, not Michael Schiavo's wife"), than an expression of love.

According to Blumenfeld, "every time she looks into the eyes of her parents and smiles at them, she is saying, I want to continue to live, if for no other reason than to experience your love. " There is absolutely no substantiation for this statement. This is something I'm sure the Schindler's want to believe but they are treating her like a pet, not a daughter. In truth, the only appropriate response to show love would be to reply with "I love you too much to force you to continue to do this for my benefit."


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