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Medical, Ethical Questions Largely Decided, Experts Say

By Shankar Vedantam and Rick Weiss
Washington Po
Tuesday, March 22, 2005; Page A06

For all the political controversy over whether Terri Schiavo is in a persistent vegetative state and should be allowed to die, neurologists and ethicists said yesterday that the case presents few scientific and legal ambiguities.

Congress, President Bush and others have sought to place the case in the context of a broader ethical and political struggle to define when life ends -- with resonances for the lingering question of when it begins. But many experts said this is the wrong test case for a nation struggling with those profound questions.

Michael Schiavo has maintained that his wife, Terri, had said she would not want to receive treatment if she were ever in a situation like the one she is in. (Schindler Family Via Zuma Press)

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House Vote on Schiavo Measure
Schiavo Senate Bill
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Terri Schiavo Legal Case
The Battle for Schiavo

A look at the long legal battle over whether Floridian Terri Schiavo, 41, may be taken off life support.

Feb. 1990: Schiavo suffers brain damage from heart failure.

Feb. 2000: Circuit Judge George W. Greer rules that Schiavo’s feeding tube may be removed, as requested by her husband.

April 2001: The feeding tube is removed. Two days later, Circuit Judge Frank Quesada orders doctors to reinsert it.

June 2003: The 2nd District Court of Appeal upholds Greer’s ruling to remove the tube.

Oct.: Gov. Jeb Bush files a federal court brief urging that Schiavo be kept alive. He is denied.

Doctors remove the feeding tube. The state legislature passes a bill, called "Terri’s Law," allowing Bush to intervene. He orders the feeding tube reinserted.

Sept. 2004: Florida’s Supreme Court rules that Terri’s Law is unconstitutional.

Jan. 2005: The U.S. Supreme Court declines to hear the governor’s appeal.

Feb.: Greer grants an emergency stay blocking the removal of Schiavo’s feeding tube. He later sets March 18 as the day the tube may be removed.

Mar. 16: House passes legislation to try to block efforts to let Schiavo die.

Mar. 17: Senate passes separate legislation.

Mar. 18: House committee subpoenas Schiavo and others. Florida judge blocks the subpoenas; U.S. Supreme Court lets that ruling stand. Feeding tube is removed.

Mar. 20: Senate passes legislation giving federal courts jurisdiction in the case.

Mar. 21: House passes the same bill, sending it to President Bush for his signature.

SOURCES: Associated Press, staff reports

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The brain-damaged woman will never regain the conscious awareness she lost 15 years ago, medical experts said, and decades of case law have already dealt with the legal issues raised by people in her condition.

Patients who do not return to normal within weeks of losing conscious awareness have a very poor prognosis, studies have shown. Electrical measurements have revealed no activity in the regions of Schiavo's brain needed for such consciousness, and repeated clinical examinations have left no doubt about her future.

"She is permanently unconscious and will never again have consciousness," said Robert M. Veatch, a professor of medical ethics at the Kennedy Institute of Ethics at Georgetown University, adding that she cannot feel sensations of hunger or thirst. "She can't starve or be thirsty. Anyone who uses those words doesn't understand the condition she is in."

Schiavo's husband has said she expressed a desire not to receive treatment if she were ever in such a situation -- a claim that was repeatedly upheld in court.

Schiavo's parents, however, have argued that their daughter's condition is not as bad as doctors suggest. Schiavo sleeps and wakes, blinks, and sometimes seems to smile. Her parents and other critics of the decision to remove her feeding tube insist that she responds to the presence of friends and relatives.

Medical experts said those behaviors are the cruelest aspect of a terrible condition: Grimaces and other facial expressions give families of tens of thousands of such patients hope, but they are evidence only that Schiavo's brain stem is working, keeping alive reflexes and routine bodily functions. They do not suggest that the higher areas of brain functioning needed for her to regain conscious awareness will return, experts said.

"It's uncanny but misleading," said William Winslade, who has studied how to distinguish patients in a persistent vegetative state from those suffering from other conditions at the University of Texas Medical Branch in Galveston. "Family members . . . will interpret random eye movements as something is happening. That has to be the case with Terri Schiavo. A truckload of physicians have concluded she is in a persistent vegetative state."

Videos, such as those of Schiavo examined by Senate Majority Leader Bill Frist (R-Tenn.), a heart transplant surgeon and sponsor of legislation requiring her case to be heard in federal courts, can be particularly misleading, said a neurologist who helped develop national guidelines for determining when someone is in a persistent vegetative state.

Ronald Cranford, like other doctors who have examined Schiavo, found that she cannot respond to commands and lacks visual tracking, essential signs of consciousness. Cranford, a neurologist and medical ethicist at Hennepin County Medical Center in Minneapolis, has testified on behalf of Schiavo's husband.

"Tomorrow I will do a transplant surgery if [Frist] starts doing neurology," he said. "I have as much competence in transplant surgery as he is competent to do a neurological diagnosis on a videotape. He has no clue."

Schiavo's wish not to be kept alive should be respected regardless of whether others agree with her decision, several ethicists said.

"This case isn't about definitions of death, it's about personal autonomy," said R. Alta Charo, associate dean of law at the University of Wisconsin at Madison. "She expressed her wishes, and now people are standing in the way of her having those wishes carried out."

The struggle over Schiavo's state of consciousness echoes the long-standing controversy over defining death. Such debates have been as contentious -- if less public -- as debates over when life begins. They have changed substantially over time with the advent of new technologies and advances in scientific understanding about how the brain works.

The idea that a stopped heart determined death gave way in the late 1960s to the idea of "irreversible coma" or brain death.

Such definitions, however, have struggled to impose a bright line on what appears to be a biological gradient between life and death. A persistent vegetative state is confusing because only part of the brain is alive, even as higher centers are dead. The diagnosis can be controversial because it relies on clinical judgment and experience -- not an objective test or marker -- but experts said those ambiguities disappear when people have been unresponsive for very long periods.

Advances in imaging technology have recently raised a new round of issues, however. Some high-tech scans, for instance, show variations in blood flow in the brains of patients who are totally unresponsive, but the significance of those findings is unclear.

"Our brains are mysterious entities because you have chemical activity, electrical activity, organic activity all going on simultaneously," Winslade said. "Just because there is blood flow doesn't mean there is cognitive ability."

Because the brain performs so many functions, Veatch and others said, the ongoing challenge facing scientists and ethicists is to determine which of those functions add up to a life.

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