During the time of the Holocaust the Nazi SS sadistically punished rebellious prisoners by simply putting them in a cell without food or water. The hapless victim would be driven insane with hunger and thirst and would die a horrific, excruciating death. This would serve as an example to the other victims of the utter hopelessness of their condition. The man-made laws of Nazi Germany enabled the legal murder of millions. Likewise, the distorted logic of the American legal system has allowed a patient to be condemned to death in the cruelest fashion imaginable.
As a board certified attending neurologist, I would immediately question the constant refrain during this tragedy that "Terri didn't feel a thing" during her forced starvation. I would contend that the opposite is much more likely. Terri was brutally trapped in the worst of all worlds. Widespread laminar necrosis of the cerebral cortex is typically found after the anoxic encephalopathy that Terri initially suffered. However, the more primitive areas of Terri's brain: the hypothalamus, amygdala and brain stem remained intact. As Terri was starved, the primitive factors that regulate food intake such as blood glucose and amino acid concentrations set off the physiologic equivalent of an air raid siren in the feeding center of the hypothalamus screaming "feed me." However, the cortical area of her brain which would have allowed for a cognitive comprehension of this dilemma was dysfunctional. Likewise, a massive transmission of pain signals flooded into her hindbrain and thalamus without a subsequent cognitive interpretation. In order to begin to disprove my conviction that Terri suffered during her forced starvation her doctors would have had to perform an (1) EEG (electroencephalogram) showing cortical brainwave activity (2) PET (Positron Emission Tomography) Scan to show a reduction in cerebral metabolism (3) SSEP (Somatosensory Evoked Potential) to show brainstem neurophysiologic functioning and (4) MRI scan of her brain to show anatomical disruption. I understand that either these tests had not been performed in years or were never done in the first place. Although Terri was judicially condemned to death, she met almost none of the standard Harvard criteria for brain death.
Around the time that I first started practicing as a neurologist I was called by my hospital's emergency room doctor to see a comatose patient. He was apologetic in asking me to come in to see a patient with the absolute worst type of malignant brain tumor, a Glioblastoma multiforme. When I arrived in the ER I was met by the patient's former wife, who between loud sobs, pleaded with me to "save" her ex-husband. At that point, I wouldn't have given this 63-year-old profoundly comatose patient a thousand to one odds for remaining alive another hour, let alone having any future life. Reluctantly, I went through the motions of putting the patient in the ICU and putting him on steroids in a cookbook fashion. Miraculously, the man slowly improved, left the hospital and lived another eight years, during which time he joined a number of local clubs. Likewise, even when considering Terri's purported diagnosis of a persistent vegetative state (in my opinion, not properly supported by the above elucidated tests) "The occurrence of rare instances of very late recovery in adults must be acknowledged." (Adam and Victor's Principles of Neurology, Seventh Edition, p. 370). Even more disturbing, in this standard teaching textbook of neurology, is the statement on the same page, "At no time after the onset of coma was it possible to distinguish patients who would remain in a vegetative state from those who would die." Killing Terri destroyed the hope for any possible future potential therapeutic modality such as stem cells, hyperbaric oxygenation or neurotransmitter treatment. There have been at least four confirmed cases of patients with persistent vegetative state who have recovered some neurologic functioning. Dr. Ronald Cranford, the neurologist who diagnosed Ms. Schiavo's condition, was the attending physician in one of those cases. Dr. Cranford later admitted, "Yes, I made a mistake and to this day no one can explain these cases." Isn't it obvious that this could be yet another "mistake"? The most basic principal in medicine, based on the Hippocratic Oath is to "do no harm." I would tend to believe that actively killing one's patient violates this most basic principal.
The forced death of Terri by our judicial system sets a horrific precedent. Should we now begin starving anyone with a neurodegenerative condition? That would include patients with Alzheimer's Disease, Multiple Sclerosis, Parkinson's Disease, ALS, Tay-Sachs Disease, Canavan's Disease, and the list goes on and on.
Ultimately, a society must be judged by the manner in which it treats its most vulnerable members. Like the one and one-half million children slaughtered by the Nazis, Terri Schiavo was totally helpless and vulnerable. The tragedy of her needlessly imposed death greatly lessens us all.
March 31, 2005
