Ethics, the Constitution, and the Dying Process

Abstract

FEDERAL AND STATE COURTS HAVE REACHED A BROAD consensus on matters of death and dying since the seminal cases of Karen Ann Quinlan in 1976 and Nancy Cruzan in 1990. So too has there been substantial consensus in the bioethics literature. Courts and scholars have affirmed a person’s right to refuse life-sustaining treatment and concluded that this right remains intact even if the person is no longer able to speak for herself. Near relatives and the courts should adopt the same course of action the person would have chosen if competent. If there is a broad judicial and scholarly consensus, then why were political leaders and the public so troubled by the heart-wrenching circumstances of Theresa Marie (Terri) Schiavo? A skeptical observer might conclude that the controversy was politically generated, fed by vivid media images of a young, vulnerable woman who appeared sentient. After all, the nation only recently experienced a presidential election in which family values, notably a culture of life, became salient. It may be that matters involving human life require fresh analysis in this new political landscape even though public opinion strongly supported the removal of Ms Schiavo’s feeding tube and opposed federal intervention. Beyond political explanations, the public expressed concern about several aspects of the case: (1) lack of factual and medical clarity—family members took divergent positions and commentators questioned the medical diagnosis; (2) withdrawal of hydration and nutrition—food and water were thought to have special moral significance; (3) the level of decision making—politicians clashed on whether intimate decisions should be made by the family or the government; and (4) the implications for the elderly and disabled, particularly the poor—concerns that the vulnerable would be abandoned and denied life-sustaining treatment. Before exploring these problems, it will be helpful to describe the remarkable facts and judicial history of the case (FIGURE). Terri Schiavo: Facts and Judicial History In 1990, fifteen years before she became a symbol of the right to life movement, Terri Schiavo, then 26, experienced cardiac arrest and sustained severe brain damage. Her plight prompted a contentious decade-long legal dispute that resulted in Ms Schiavo’s percutaneous endoscopic gastrostomy (PEG) tube being removed and reinserted twice. Shortly after Ms Schiavo’s cardiac arrest, her husband, Michael Schiavo, was appointed guardian, without objection from Ms Schiavo’s parents (Mr and Mrs Schindler). In 1992, Ms Schiavo received 2 medical malpractice awards, with most of the funds placed in trust for her care. This began a deep dispute about her treatment and the distribution of the malpractice award. The Schindlers’ attempts to remove Mr Schiavo as guardian and to keep their daughter alive began in the Florida courts in July 1993. The courts took painstaking care in finding the facts, including the appointment of 3 guardians ad litem—independent persons appointed to represent Terri Schiavo’s wishes and interests. During the next 2 decades, the District Court of Appeal of Florida rendered at least 10 decisions considering various aspects of the case; parties sought review by the Florida Supreme Court 4 times; there were several proceedings in the federal courts, including cases filed in district court and appealed to the 11th Circuit; and the US Supreme Court declined to provide relief to interested parties on 4 separate occasions. Throughout the process, the judiciary found that the husband acted appropriately and attentively, the medical diagnosis of persistent vegetative state (PVS) was reliable, and the evidence supported the husband’s conclusion that his wife would not want to live in that condition. Even the guardian ad litem appointed to report directly to the governor concurred. These findings remained constant, surviving numerous, but unsuccessful, motions including pleas for the