Maintain or Withdraw the Life Support System – Medical Ethics Example

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"Maintain or Withdraw the Life Support System? "  is an engrossing example of a paper on medical ethics.   The case of Ms. Terri Schiavo attracted nationwide and worldwide attention and support due to the very unusual circumstances of her case. Although there were other previous comatose cases like hers such as that of Karen Ann Quinlan, her case was unique enough in that her family and husband fought each other all the way up to the United States Supreme Court over a custody issue as to who has the final say to make the decision in her behalf.

Her case even involved Pres. George W. Bush who saw it fit to also intervene on moral and ethical issues as well as political. A person or patient who falls into a coma presents a serious quandary and painful dilemma for family members, who need to decide when is the right time to pull the plug (Interlandi, 2011, p. 1) because the comatose patient can be kept alive indefinitely although the brain is now dead. A further complication is that a comatose person, if he or she ever wakes up, rarely regains normal bodily functions but instead ends up in a permanent vegetative state (PVS); euthanasia is almost consequent consideration as other matters come up such as the expenses and costs of continuing medical care, the quality of life or dying a dignified death.

It is a moral dilemma for the medical practitioners as well who are confronted with euthanasia in severe cases if the family requests it (Keown, 2002, p. 9). Besides legal complications, a comatose patient may wake up but in a state that is slightly better than PVS, a state called as minimal consciousness wherein the patient can understand some basic commands and respond to them at certain times, but in general unable to talk, walk or even hold his head upright.

Some of these patients eventually respond to medication and end up leading the normal life they had before they became comatose, further complicating when is the right time to take away artificial life support when there is always the possibility of recovery. This paper examines and discusses the Terri Schiavo case to the parties involved.   Discussion Coma can be caused by oxygen deprivation (a near-drowning, choking or strangulation) or due to blunt trauma (a blow to the head, a vehicular accident, falling from stairs, etc. ) and in the first case, the vegetative state becomes permanent three months after the injury while in the latter instance, it becomes permanent after a lapse of one year if there is no spontaneous recovery (Interlandi, 2011, p.

1). In the case of Terri Schiavo, she spent a total of 16 years being comatose, from the day she had a cardiac seizure from extreme dieting resulting in an electrolyte imbalance up to the day she died when life support was withdrawn (from 1990 to 2005) and not even once did she stir or showed the slightest sign of ever waking up.

In other words, she was well beyond the period a spontaneous recovery can be reasonably expected despite all the odds and forced her husband Michael to make the ultimate decision in her behalf (Caplan, McCartney & Sisti, 2006, p. 94); even the Catholic Church intervened, deeming life support as excessive or burdensome. Should care be withdrawn or maintained?

- the moral consideration is always side with life, that whenever there are still vital signs, the response is to maintain all medical care and life support. All the major religions forbade the taking of life (whether it is another person's life or one's own life because suicide is deemed a cardinal sin) and based on this, she has all the right to live and continue to receive care despite her deteriorating condition (Dennis, 2008, p. 40). Who has the right to make end-of-life decisions – Terri Schiavo was technically married to her husband as they were not divorced.

As such, Michael has the spousal right to decide on her behalf, unlike the case of Nancy Cruzan, whose husband divorced her and relinquished his rights back to her parents (Bartee, 2006, p. 244). Terri's parents signed a waiver in favor of Michael.   Financial considerations in end-of-life care - this is quite a sticky issue but it is one that needs to be discussed thoroughly among family members. Health care is expensive and not all the families can afford prolonged care, especially in the case of Terri where there were no definite or clear-cut results as to when it is appropriate to continue or not.

The economics of end-of-life care dictate it should be considered although doing so may seem impolite, insensitive or heartless but it is an uncomfortable topic that cannot be avoided by anyone (Morhaim, 2011, p. 251), although patient's wishes should always come first and financial considerations are only secondary. The case for maintenance of life support – Terri's case took so many twists and turns because her parents intervened on her behalf.

They contended she still wanted to live despite her condition and argued she was conscious, although perhaps in the state of minimal consciousness. Her case attracted attention from the media, politicians and life-advocacy groups such that it took seven years to finally resolve by the Supreme Court. Terri's parents fought her husband in courts although, under Florida laws, Michael is considered her guardian and surrogate decision-maker as he is the legal spouse (Votroubek & Tabacco, 2010, p.

31) and Terri had left no living will or any advance directives. The courts decided against the parents based on documented evidence from Michael and also testimonies from other people that Terri did not want to be a burden to anyone as she had expressed in conversations while she was still healthy. Michael Schiavo had a spousal right to decide as stated in Florida statutes and case law (Spielman, 2007, p. 20) and these are the laws governing termination of any life-prolonging procedures. Florida had specified in its laws a person incapacitated to make a personal decision (due to being a comatose or mental illness like Alzheimer's) that a surrogate is designated (Masters, 2009, p. 235) to meet strict legal standards.   The case for withdrawal of artificial life support – the husband of Terri Schiavo found it appropriate and justified his action based on his legal rights as the spouse and her legal surrogate to make the decision in her behalf, in what is termed as substituted judgment, that presumed the best decision of a comatose patient's life wishes if he or she were competent to make the decision (Schaller, 2008, p.

167). Michael Schiavo cannot be faulted if he made this decision, as care for Terri already took an immense toll on his emotional, financial and physical well-being but more importantly, his legal struggles to let Terri die a dignified death than lead a very meaningless life (Schiavo & Hirsh, 2006, p. xvi) and alternatively, respect her right to die too. His being the legal surrogate for Terri entailed taking over her rights of patient autonomy and self-determination. Conclusion It is appropriate that financial considerations be discussed during critical moments in a person's life, such as palliative or end-of-life care because health care today is so very expensive and puts a heavy burden on surviving family members.

It is morbid to think about it but this is a  reality and an issue nobody can really avoid. Early Greek philosophers had discussed this issue quite extensively, including euthanasia (Mystakidou, 2005, p. 98) and a way to prevent the legal complications is to have advance directives like a DNR or do-not-resuscitate (Chen, 2010, p. 1).   Utilitarian ethics would dictate letting Terri die a dignified death was the best course of action.

A deeper examination of the legal case of Terri Schiavo will show that the relationship between her parents and Michael Schiavo had become poisoned due to the monies involved. The malpractice suit filed in favor Terri against her doctors has a potential award of $1.2 million and then another $1.5 million for Michael for the “ loss of consort” privileges he suffered as a result of her coma.    

References

Bartee, A. F. (2006). Privacy rights: Cases lost and causes won before the Supreme Court. Lanham, MD, USA: Rowman and Littlefield.

Caplan, A. L., McCartney, J. J. & Sisti, D. A. (2006). The case of Terri Schiavo: Ethics at the end of life. Amherst, NY, USA: Prometheus Books.

Chen, P. W. (2010, April 15). “Making Your Wishes Known at the End of Life.” The New York Times. Retrieved from http://www.nytimes.com/2010/04/16/health/15chen.html?_r=1

Dennis, D. (2008). Living, dying, and grieving. Sudbury, MA, USA: Jones and Bartlett Publishers.

Interlandi, J. (2011, December 1). “A Drug that Wakes the Near Dead.” The New York Times. Retrieved from http://www.nytimes.com/2011/12/04/magazine/can-ambien-wake-minimally-conscious.html?pagewanted=all

Keown, J. (2002). Euthanasia, Ethics and Public Policy: An Argument Against Legalization. Cambridge, UK: Cambridge University Press.

Masters, K. (2009). Role development in professional nursing practice. Sudbury, MA, USA: Jones and Bartlett Publishers.

Morhaim, D. (2011). The better end: Surviving (and dying) on your own terms in today's modern medical world. Baltimore, MD, USA: Johns Hopkins University Press.

Mystakidou, K. (Winter 2005). The Evolution of Euthanasia and its Perceptions in Greek Culture and Civilization. Perspectives in Biology and Medicine, 48(1), 95-104.

Schaller, B. R. (2008). Understanding bioethics and the law: The promises and perils of the brave new world of biotechnology. Santa Barbara, CA, USA: Greenwood Publishing Group.

Schiavo, M. & Hirsh, M. (2006). Terri: The truth. New York, NY, USA: Penguin Group.

Spielman, B. (2007). Bioethics in law. New York, NY, USA: Humana Press.

Votroubek, W. & Tabacco, A. (2010). Pediatric home care for nurses: A family-centered approach. Sudbury, MA, USA: Jones and Bartlett Publishers.

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