The Schiavo Case and Death by Dehydration

On March 31, 2005 Terri Schindler-Schiavo died of dehydration in a Florida hospice. Heroic efforts to save her life failed to halt Judge George Greer’s cruel order that Terri be denied all food and water until dead.

Are you familiar with this case?

• In 1990, Terri Schiavo, mysteriously collapsed and stopped breathing for a period of time, causing severe brain damage.
• In a medical malpractice suit, Michael Schiavo, Terri’s husband, told the jury that he wanted to take care of her for the rest of her life. Reports vary on the amount, but Michael was awarded somewhere around $700,000 for Terri’s ongoing medical care and $300,000 to him for loss of companionship.
• Michael—Terri’s guardian—denied her rehabilitation, as well as ordinary medical care (such as antibiotics to treat infections) and dental care. When she did not die from neglect, he sought to have her feeding tube removed.
• The case went to court when her family objected. Her parents sought guardianship as they wanted to care for her.
• Michael was allowed to continue as Terri’s court-appointed guardian in spite of the fact that he began living with another woman and fathered two children by her.
• Contrary to media reports (“brain dead,” “comatose”, “in a persistent vegetative state”) Terri was responsive and could feel pain.
• While a few doctors testified in court that Terri was in persistent vegetative state—PVS—many others submitted affidavits that she was not.
• On March 17, 2005, after a long, highly publicized and highly controversial legal battle, Terri’s feeding tube was removed at the order of County Circuit Court Judge George Greer.
• It took her two weeks to die without fluids or food.

Note: Disability rights groups protested Terri’s “death sentence.” Many religious leaders—Catholic, Jewish, Protestant—spoke out against withdrawing and withholding food and fluids from Terri and other disabled persons. Pope John Paul II, addressed the 2004 International Congress on “Life-Sustaining Treatments and Vegetative State,” making it clear that:

• The administration of water and food, even when provided by artificial means is “ordinary and proportionate, and as such morally obligatory,” so long as they achieve their purpose, which is to provide nourishment or alleviate the patient’s suffering.
• “Death by starvation and dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”

Setting the stage for Terri Schiavo’s court-ordered death, there were a great number of court cases in various states that ruled in favor of death by dehydration (stopping tube-feeding) for disabled patients. A few were mentioned earlier—e.g. Nancy Cruzan.

1986: The Massachusetts Supreme Judicial Court decided the matter of Brophy v. New England Sinai Hospital. It was the first U.S. case resulting in the court-authorized discontinuation of artificially supplied nutrition and hydration.

• Paul Brophy was a Massachusetts firefighter. In March 1983, an aneurysm ruptured in his brain resulting in severe brain damage. Told that he would never get better, his wife wanted his tube-feeding stopped in order to end his life.
• Mr. Brophy died on Oct. 23, 1986 from dehydration, eight days after medical personnel stopped his tube-feedings.

DEATH BY DEHYDRATON

Judge Lynch, dissenting from the majority opinion in Brophy, argued that death by dehydration was “cruel and violent” because:

• The mouth would dry out and become caked or coated with thick material.
• The lips would become parched and cracked.
• The tongue would swell, and might crack.
• The eyes would recede back into their orbits and the cheeks would become hollow.
• The lining of the nose might crack and cause the nose to bleed.
• The skin would hang loose on the body and become dry and scaly.
• The urine would become highly concentrated, leading to burning of the bladder.
• The lining of the stomach would dry out and the sufferer would experience dry heaves and vomiting.
• The body temperature would become very high.
• The brain cells would dry out, causing convulsions.
• The respiratory tract would dry out, and the thick secretions that would result could plug the lungs and cause death.
• At some point within five days to three weeks, the major organs, including the lungs, heart, and brain, would give out and the patient would die.

• The court ruled that Paul Brophy’s feeding tube could either be removed or clamped. Neither was done. When he began to have seizures, anticonvulsant medication was given through the tube. Antacids to prevent bleeding in his stomach and laxatives to “make him more comfortable” were also given via tube.
• The feeding tube itself was not considered burdensome. Apparently it was Mr. Brophy’s life that was considered the burden – so they killed him.

De-myth-ifying artificially provided nutrition and hydration

• Food and fluids do not become medical treatment simply because they are put through a tube anymore than penicillin or Pepto-Bismol become food when taken by mouth. However, legally, tube-feeding is now considered medical treatment.
• Tube-feeding is not “new” or “high-tech.” The 1896 Annals of the Kentucky Medical Association had two articles talking about how common gastrostomy-tube (g-tube) feeding was. That was over 110 years ago.
• Thousands of people need to be tube-fed for various reasons (birth defects, blockages, injuries, swallowing problems, etc.). Lots of these people go to school or work every day, play sports (even swim), etc. But we usually hear only about those who are profoundly disabled, like Terri Schiavo.
• There are three main types of tube-feeding.
  1. Nasogastric intubation: a medical process involving the insertion of a plastic tube (ng-tube) through the nose, past the throat, down the esophagus and into the stomach. Used for short-term tube-feeding.
  2. Gastrostomy tube, also called a percutaneous endoscopic gastrostomy (PEG) tube: a surgical opening is made through the abdominal wall to the stomach and a port is put in place. A plastic tube (g-tube) is attached to the port when it is meal time. This is the most common type of feeding tube. The surgical procedure takes about 20 minutes.
  3. Jejeunostomy: a surgical opening is made through the abdominal wall into the small intestine (j-tube). Generally used if the patient is a high risk for aspiration (reflux causes stomach contents to be breathed into the lungs)
• Tube-feeding costs about the same as a regular diet.
• Once the tube is in place, tube-feeding does not require skilled nursing care. However, the patient may need nursing care for other reasons.

How did this change in medicine and law come about? It was engineered by “right to die” advocates.

The following is just one example of “right to die” advocates’ tactics and an example of how “right to life” advocates save lives:

In 1984, 92-year-old Mary Hier had lived in a state hospital in Massachusetts for more than fifty-seven years. Demented, but happy, she thought she was the Queen of England. Mary was not terminally ill, but had needed a feeding tube for many years. When her g-tube became dislodged, the hospital sought court permission to have it surgically replaced. (Mary was a ward of the state, so court permission was necessary.)

“Right to die” proponents watch for such cases in order to change the law and set precedents. Their “medical experts” sought standing to intervene and were granted it. They told the judge that this surgery would be cruel and invasive, “a major medical procedure” with a “relatively high risk” due to her age. The judge, on this basis, denied the hospital’s request to reinsert Mary’s feeding tube.

Just as this case was being reported, a friend of mine who was a pro-life doctor and a pro-life attorney were having lunch together, checking out the latest news. In the same newspaper that carried the story about Mary Hier’s “right to die” case was another story about a 94-year-old woman who was doing well after “minor surgery to correct a nutritional problem.” The surgery, performed under local anesthesia on an outpatient basis, was the insertion of a gastrostomy tube. The woman was Rose Kennedy, matriarch of the rich and powerful Kennedy clan.

The physician and lawyer went to the judge and pointed out the inequity. The judge reversed his order. Mary Hier’s life would have been prematurely ended without this last minute intervention and this fair-minded judge. Mary’s tube was replaced; she went on happily signing her name “Mary Hier, Queen of England” for many more years.

In too many instances, whether inserting a feeding tube is considered a “major” or “minor” medical procedure depends upon whether the person is viewed as expendable or valuable.

Withholding or withdrawing food and water leads only to death. Death by starvation and dehydration is a very undignified and inhumane death. It demeans the patient. The patient’s mouth dries out and becomes coated with thick material. Lips become parched and cracked. The tongue swells and might crack. The eyes sink back into their orbits. The lining of the nose may crack and bleed. The skin becomes loose, dry and scaly. The urine concentrates, then decreases until there is no urine. The stomach lining dries, causing dry heaves. The respiratory tract dries out, giving rise to thick secretions which could plug the lungs and cause death. Eventually, major organs fail, including the lungs, heart and brain.

Methods of administering food and water include the customary method of self-feeding with utensils or fingers, and being fed or given a drink with a glass, a spoon or a straw. When a person has difficulty with swallowing, including an inability to swallow and/or the possibility of aspirating food into the airway, a nasogastric tube (plastic or rubber tube passed through the nose into the stomach) or gastrostomy (a tube going through the abdominal wall into the stomach, which can be done nowadays in a patient’s room with minimal discomfort) is used to administer food and water. While a nasogastric tube uses an opening that is present naturally, it can be safer and easier for patients prone to aspiration to have a gastrostomy tube. Water and nutrition can be given directly into a blood vessel when medically indicated. The moral obligation to supply hydration and nutrition, even artificially if necessary, remains intact even when caring for patients in a coma or so-called “persistent vegetative state.” Mental incapacitation does not relieve this responsibility.

Withholding or withdrawing food and water is active euthanasia apart from the exceptional case where the method of administering food and water is gravely burdensome or requires heroic virtue, i.e., the method in itself is gravely burdensome in excess of the burdens already being experienced by the patient, or it renders the whole medical situation gravely burdensome. There is no moral obligation to obtain or to continue treatment that is gravely burdensome or would require heroic virtue.