From Quinlan to Schiavo: Medical, Ethical, and Legal Issues in Severe Brain Injury

Abstract

The battle over the life and death of Terri Schiavo was only the most recent medical ethics case to catch the public's attention. This case asked both the individuals involved and our society in general to make moral judgments about the appropriateness of a decision to maintain or withdraw life-sustaining treatment. As a practicing medical ethicist and an observer of the case, I was startled by the degree of misunderstanding about different types of brain injury and by more than a few misstatements about the medical facts of the case. Mrs. Schiavo was described at various times as comatose, brain dead, vegetative, minimally conscious, locked in, and disabled. These are mutually exclusive conditions. This failure of the media, politicians, and even some physicians who should know better to accurately describe Mrs. Schiavo's medical condition was particularly disturbing, because good medical ethics begins not with the discipline of ethics but with good clinical medicine. Appropriate moral judgments about medical treatment decisions cannot be made without first understanding the relevant clinical medicine. In this article, I review the differences between coma, brain death, the vegetative state, and other profound brain injuries. I then review the Quinlan, Cruzan, and Schiavo cases to explore various legal aspects and close with reflections on some of the ethical issues related to treatment of patients with profound brain injuries.