MEDI7231 Study Guide - Final Guide: Casuistry, Muscular Dystrophy, Terri Schiavo Case
REMOVAL OF NUTRITION AND HYDRATION (NASOGASTRIC TUBING)
Definitions
Persistent vegetative state is “a permanent and irreversible condition of unconsciousness” from which
no recovery is possible
oShewmon: ‘we cannot state categorically that vegetative state is defined by a total loss of
cortical function’
oOther studies: 12-34% patients diagnosed as ‘persistently vegetative’ are at least minimally
conscious and may respond to therapy
QoL vs SoL for Mrs Schiavo
QoL Withdrawal of nutrition and hydration permitting a natural death is appropriate in this
terminal condition, like Mrs Terri Schiavo’s case
In this limited state, she is suffering from an unacceptably minimal quality of life that
may be naturally ended by the withdrawal of hydration and nutrition; in such situations,
euthanasia is permissible & doctors should be permitted to give death a helping hand
SoL Her condition was only “end stage and terminal” once the hydration & nutrition were
removed, and her life may have continued for years had her care continued
This makes it appear as “active euthanasia”, which is neither clinically warranted nor
accepted ethically
Rejection of the argument that cessation of life support (prohibited by all other
situations) is acceptable when cognitive or physical limits are extreme
Furthermore, absence of cerebral functioning means Mrs Schavio was not suffering (so
not warranted to let her die because of undesired pain) or minimal consciousness
meant death by starvation would’ve caused suffering, which cannot be supported, thus
the doctor’s actions would be seen as malicious
Personhood
oPersonhood is not an existential attribute based upon cognitive or physical abilities, but a
communal attribute whose meaning is grounded in one’s relationship to others
oIn this construction, Mrs Schiavo was a person equal to others because her parents said she was &
her continuance had been mandated by their historically anchored, unwavering commitment to
that relationships continuance
oOliver Sacks – even the most extreme neurological conditions deny neither personhood nor the
duty to care to an individual
oStephen G Post – “even the PVS conditions does not disquality a loved one from equal moral
standing – it further suggests that the concept of QoL might be replaced by the quality of livs,
including family members”
Example: a man who lovingly maintains his persistently unconscious wife
oIt may be a sense of parenthood as a shared, rather than discrete quality, that fuelled the
extraordinary public demonstration of support for Terri Schiavo’s survival
Those protesting the withdrawal of nutrition/ hydration would have affirmed her
‘personhood’
Sanctity of life
oThe central concern of Mrs Schiavo’s supporters appears to be that physical continuance is
lexicographically a primary value violated by the discontinuation of her nutrition and hydration
Conclusion
oNobody knew what Mrs Schiavo would have wanted
No AHD
Husband vs parents
oHer absolute cognitive status was unknown – minimally conscious or permanently unconscious?
It is unknown whether she suffered from dehydration and starvation, or anything else
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Withdrawal of treatment
The withdrawal or withholding of nutritional support is one way treatment can be withdrawn
oOther methods include withdrawing ventilation, DNR (do not resuscitate), oxygen, antibiotics,
dialysis, chemotherapy & advanced care directives
Common themes of withdrawal
Best interests The best interest depends on the values of the decider (doctor, patient, next
of kin, families etc)
Case:
oNeil is a patient dying of ALS
oHe has been advised that nasogastric feeding may improve his
nutritional state and increase lifespan by 2mths
oLife is extremely effortful
oHis eldest daughter is 35wks pregnant with first grandchild
Perspectives:
oDaughter wants Neil to live to see his grandchild born (+)
oWife wants Neil’s suffering to end (-)
oNeil wants to live but hates the idea of tube feeding (undecided)
Decision: Neil will need to decide himself; doctor wants what Neil wants
Futility Feeding at end of life known to be futile in medical terms – it will not improve
nutritional state nor extend life, may even feel worse
However, there may be other meaning
oMaintain hope, familial values, time for acceptance of death, not
giving up (eg Singapore)
Who decides what is best?
oMedical view vs patient view (emotional considerations, virtue,
familial, religious)
oSuffering from hunger and thirst
oGiving up hope
Quality of life vs
sanctity of life
Primary tension: is the treatment worthwhile/ is the patient’s life worthwhile
QoL
oArgument that the patient’s life is not one worth living
oDevalue disability
oFalse assumption that patient would not want to live this way, when
they are unable to speak for themselves/ do not have an advocate
SoL
oAll life is ‘god given’ and should be preserved
oBasics of life should be afforded to all humans – food and fluid is not
medical treatment (some may argue that it is via tube)
Question: if you are devoid of cognitive function, are you experiencing life?
Autonomy Patient may have autonomy & still refuse treatment (vocally, AHD)
Patient’s without autonomy create more difficulties
oWhen patient cannot decide for themselves
oWhen decision maker’s disagree (equal decision makers in family)
oWhen the decision maker (patient or other) seems to be making a
decision not in the best interests of the patient
Pain and
suffering
Perceived pain and suffering of the patient will influence outcome
(commence or withhold feeding)
Completely related to cognitive outcome
oCognitive function present – experience pain from starvation &
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