Doctors are simply ignored

By Marc Siegel

Terri Schiavo has lingered for 15 years in what many neurologists call a persistent vegetative state. Because the public has seen her plight largely through a political prism — right to life vs. right to die — core medical issues have been overlooked and distorted.

Regardless of where one stands on this issue, as a physician, I'm disturbed that the medicine of this case has become an afterthought. Doctors have become the medical marionettes as the courts and attorneys pull the strings.

Though most end-of-life specialists are willing to remove feeding tubes, many of the rest of us — physicians who treat severely disabled patients — are not. The only consensus in the medical community on this issue is that we should be consulted, not expected to blindly follow judicial decrees.

Much has been made about the fact that Schiavo's life lacks quality, but this assertion is not a permission slip to end it. The pathway to death should not be inhumane just because more humane choices, such as physician-assisted suicide, are not legal. Because she breathes on her own and is not in apparent pain, there is no quick or rational way to end her life. Until there is, we should let her live.

Most neurologists would contend that Schiavo cannot feel anything, even pain or thirst. The problem with this assertion is that no one has come back from such a state of neurological impairment to verify or dispute this contention. She reportedly lacks upper brain function, meaning her thinking centers are still, but it cannot be proved that the lower brain would not allow her to feel discomfort.

I recall one brain-damaged patient in my hospital practice, not quite as sick as Terri, who did wake up. Initially, his eyes were open, but he didn't respond. For months, he was fed through a tube, until the day when his heart rate began to subtly increase whenever his family visited. A few months later, he was conversing and eventually was discharged to resume his life as a waiter in a restaurant where he had been the chef.

Could Terri be blessed with such an outcome? There's no indication from the court-appointed physicians that she could. Even so, the contrast is a useful reminder that each case should be weighed on its own merits — the medical ones, not solely the legal ones.

Drawing a line in which one life has quality and another doesn't is contentious enough, but extending this to an initiative to withdraw nutrition is a legal move that doesn't adequately consider the medicine. Even if Terri had a living will, many physicians would still not feel comfortable executing it in this manner. It shouldn't be assumed that doctors can simply be ordered to starve their patients.

It is generally accepted that a physician's role in health care is to prolong life or relieve undue suffering. The only time a true medical debate emerges is when these two roles come into conflict. The Schiavo case is not such a time. It is difficult to argue for euthanasia because she does not appear to be suffering. Working to prolong her life simply means providing nutrition, which physicians usually do without endless debate.

The case of a terminal cancer patient, for instance, is quite different because, by increasing morphine, a physician may legitimately choose relieving suffering over prolonging life. Treating cancer, a doctor can sometimes justify ending a pain-wracked life.

The most disturbing aspect of the Schiavo case is that the doctors are portrayed as those who will simply abide by the final decision and either put the tube back in or keep it out — a job for a medical yo-yo rather than a professional. But doctors are not court-appointed mechanics. Our own code of ethics and standards must drive us. Removing feeding tubes is not part of my job description. It should not be part of a physician's job at a Florida hospice either.

This doesn't mean that I'm against hastening death to reduce suffering. In certain cases — use of pain medications to treat the terminally ill, for instance — such actions might be warranted. But the end in any case would be rapid and controlled by medication.

In the Schiavo case, a physician removing a feeding tube of a patient who does not appear to be suffering could lead to a protracted, uncomfortable death. This would undermine a physician's basic role — first, do no harm — as suggested by the Hippocratic Oath.

Marc Siegel is a clinical associate professor of medicine at New York University.

http://www.usatoday.com/news/opinion/editorials/2005-03-22-schiavo-medicine_x.htm