|
medpundit |
||
 |
 |
|
Saturday, November 15, 2003Even though the word "unworthy" is your choice of words it makes it seem as if I actually stated that Terri Schiavo is "unworthy of living". I never stated any such opinion nor used the word "unworthy". To say that something or someone is "unworthy" implies a value judgment of one's own opinion that may stand independently of any required proof or evidence. I have never stated that Terri Schiavo should die or needs to die or does not disserve to live. What I have done over the course of three painstakingly written articles is to try and cut through all the rhetoric and misconceptions about the case and to present the clinical facts and the reasons why the Florida courts sided with Michael Schiavo in a mutual decision to remove her feeding tube. I have made no judgments as to the quality of Terri's life except to raise the possibility that most pro-lifers don't consider; if Terri is conscious then how do we know that she is not suffering? I have simply stated that the medical facts of the case point very strongly towards the fact that there is no longer a Terri inside Mrs. Schiavo's body without any evidence to the contrary. Perhaps you can correct this statement on your blog or explain why you believe that my argument implies that Terri's life is "unworthy of living". I do have a few questions since you added a link to Dr. Bradley's blog after mine where he made a comparison between Terri Schiavo and a patient with cerebral palsy. Other than for the purpose of being sarcastic, what is the logical reasoning behind many pro-lifers comparisons of Terri's case to patients with other conditions? 1. By comparing Mrs. Schiavo with other patients who have suffered brain damage such as the severely mentally retarded or stroke victims is the implication that if we start allowing PVS patients to starve to death then what is to stop us from allowing these other "undesirable" patients to die? Since these cases of PVS patients on feeding tubes started appearing 30 years ago do you have any evidence that any single case of allowing a PVS patient to die has lead to worse treatment or euthanasia of other brain damaged patients? Is this a realistic concern given the dramatic improvements in the care of mentally handicapped patients over the last few decades or is this just rhetoric on the part of the conservative right? 2. What is the purpose of comparing Mrs. Schiavo with patients who have cerebral palsy or are in catatonic states where their clinical condition appears - on the surface at least - to very closely mirror what Terri looks like in those short video clips? As physicians both you and Dr. Bradley must be aware that you are comparing apples to oranges. You must realize that this appears to be an intentional attempt to confuse the issue for the non-medical reader. The type, degree, and mechanisms of brain damage in these patients is vastly different from what happened to Terri. CP patients primarily have damage to their motor cortex but often have much of their cognition intact. The extensive brain damage evident on CAT/MRI scans of Terri's head in no way resembles anything you would see on a CAT scan of a CP patient (even in severe CP the CAT scan can be normal). Many CP patients are able to communicate in some way no matter how primitive. There is no evidence what-so-ever that Terri is conscious or attempts to communicate or interact in any way (the two physicians who side with Terri's parents can only give their opinions that they believe that she is conscious in some way. Even they have no concrete evidence). The mechanism of Terri's severe brain damage (cardiac arrest and anoxia), the CAT and MRI scans, the testimony of several neurologists, and her completely unresponsive state for over a decade have combined to convince a Florida court that Terri is no longer capable of consciousness. Do pro-lifers have any evidence to the contrary? No. Can we be sure 100%? No, but this is a dead-end argument because from a logic standpoint, a negative can't be proven. If we do accept that Terri is indeed incapable of consciousness then does this make her "unworthy to live"? I don't know. Like I said, that is a value judgment. All I know is that if we do accept that Terri is no longer conscious but we insist on keeping her body alive then we are practicing nihilistic medicine. Reading Rangel’s take, one would assume that Terri Schiavo is comatose. She isn’t. (go here and scroll down to see videos of her.) Since her brain injury, she’s been defined by what she can’t do. She can’t swallow on her own, she can’t speak, she can’t move around. But that doesn’t mean there “isn’t any Terri there.” Rangel accuses Dr. Bradley and myself of confusing the issue, medically speaking, by comparing Terri Schiavo to cerebral palsy. In fact, the Schiavo case isn’t all that different from a severe case of cerebral palsy, which is also believed to be caused by oxygen deprivation or some other insult to the brain. And there are cases of severe cerebral palsy in which the patient is completely and totally disabled - as disabled as Terri Schiavo. Rangel's other argument is that hard science - CT scans and MRI's - prove the severity and extent of Terri's injury. There’s no way to judge from a CT scan or an MRI whether or not the essence of life has vanished. We can declare a person brain dead, but Terri Schiavo isn’t brain dead. She’s been given the diagnosis of persistent vegetative state which is a descriptive diagnosis (i.e. clinical), based on what a patient can’t do: The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations. It’s a very difficult diagnosis to make, and it’s often misdiagnosed. That’s why, in the Schiavo case, there’s been disagreement between expert witnesses about her diagnosis. In fact, ten doctors have said she isn’t in a persistent vegetative state. One of the conditions that can be confused with persistent vegetative state is locked-in syndrome (emphasis mine): The locked-in syndrome refers to a state in which consciousness and cognition are retained but movement and communication are impossible because of severe paralysis of the voluntary motor system.... Patients with this syndrome can usually establish limited communication through eye-movement signals. Diagnosis of the locked-in syndrome is established by clinical examination. Brain imaging may show isolated ventral pontine infarction, and nerve-conduction studies may demonstrate severe peripheral neuropathy. Positron-emission tomographic scans have shown higher metabolic levels in the brains of patients in the locked-in state than in patients in a persistent vegetative state. Electroencephalograms, evoked responses, and single-photon-emission computed tomograms do not distinguish reliably between the locked-in and vegetative states. Note that the only difference between a locked-in state and a persistent vegetative state that can be determined with any certainty is communication through eye movement. Take away the ability to move control eye movements, and the person who's locked-in becomes defined as persistent vegetative. A PET scan may provide some proof of higher functioning, but its use to distinguish between locked-in syndrome and persistent vegetative state is still considered investigational. We simply don’t yet know enough about PET scans, brain metabolism, and the state of being to give absolute credence to PET scan results: Questions have been raised about the validity of cerebral metabolic studies to determine whether patients in a vegetative state are conscious or can experience pain and suffering. These questions remain unanswered and require further systematic investigation. Whether patients are conscious and have the potential to experience pain and suffering can best be assessed by careful and repeated neurologic examinations. Here it’s worth noting that some of the doctors who treated Terri Schaivo and the nurses who cared for her, testified that she was responsive. But, what difference does it make, you might ask. She’s still living a lousy life, confined to a bed, unable to communicate with anyone. The difference it makes is that we don’t know what’s going on inside her head. Even if she can't blink her eyelid, it doesn't mean she isn't having thoughts or feelings. Medical science can’t tell the difference between her inner thoughts and those of, say, Jean-Dominique Bauby, the French writer who wrote a book despite being, for all intents and purposes, the same as Terri Schiavo. The only difference, as far as anyone, the greatest neurologists included, can tell is that he could move an eyelid. An ordinary day. At seven the chapel bells begin again to punctuate the passage of time, quarter hour by quarter hour. After their night's respite, my congested bronchial tubes once more begin their noisy rattle. My hands, lying curled on the yellow sheets, are hurting, although I can't tell if they are burning hot or ice cold. To fight off stiffness, I instinctively stretch, my arms and legs moving only a fraction of an inch. It is often enough to bring relief to a painful limb. My diving bell becomes less oppressive, and my mind takes flight like a butterfly. There is so much to do. You can wander off in space or in time, set out for Tierra del Fuego or for King Midas's court. You can visit the woman you love, slide down beside her and stroke her still-sleeping face. You can build castles in Spain, steal the Golden Fleece, discover Atlantis, realize your childhood dreams and adult ambitions. ... when blessed silence returns, I can listen to the butterflies that flutter inside my head. To hear them, one must be calm and pay close attention, for their wingbeats are barely audible. Loud breathing is enough to drown them out. This is astonishing: my hearing does not improve, yet I hear them better and better. I must have the ear of a butterfly. -excerpted from The Diving Bell and The Butterfly. posted by Sydney on 11/15/2003 12:10:00 AM 0 comments 0 Comments: |
|
