Guest Editorial for April 7, 2005
By Robert Marus
The Terri Schiavo case polarized public opinion on end-of-life issues, but for many Americans the issues are anything but clear-cut.
For example, House Republican leader Tom DeLay, who has crusaded to keep Schiavo alive, reportedly OK'd taking his father off of life support. And President Bush, while he was governor of Texas, signed a law that allows medical personnel to remove patients from life-support over the objections of the patient's family.
So how did the Schiavo case gain prominence and come to symbolize Americans' deep division on right-to-life issues? Much of it can be explained by politics, many Washington analysts say. But behind the political and cultural public-relations wars lie difficult ethical questions-for which both Christian theology and the law can offer only imprecise answers.
Terri Schiavo's parents were in a dispute with her husband for more than a decade over whether the feeding tube keeping her alive should be withdrawn, effectively causing her to starve to death.
Repeatedly, Florida courts and state-appointed medical experts found that she was in an essentially brain-dead state from which she would not recover and that, although she left no written directive or “living will,” previous statements she has made to her husband and other family members and friends indicated she would not want to be kept alive in such a condition.
Schiavo's parents disagreed on both counts. They had enlisted the help of many Christian groups and leaders, essentially turning the debate into a right-to-life issue. Partially in reaction to strong pressure from such groups, House Majority Leader DeLay (R-Texas) pushed, and President Bush signed, a law designed to give Schiavo's parents one more legal recourse in the battle to keep her alive.
At the time, Bush said the government “should have a presumption in favor of life” in cases where there are disputes over the removal of life-sustaining means. And DeLay called removing Schiavo's feeding tube-essentially dehydrating and starving her-”an act of barbarism” and “murder.”
Shortly after the subject became national news, several media outlets reported on a law that Bush signed in 1999, while he was governor of Texas. It allows physicians to overrule family members' wishes in cases where continuing life-support is deemed “futile” and the patient has no chance of recovering. On March 15, as a result of the law, 6-month-old Hudson Sun died in his mother's arms, and over her objections, at a Houston hospital.
And on March 27, the Los Angeles Times reported that DeLay agreed in 1988 with a family decision to decline “extraordinary” measures to keep alive his father, who sustained severe brain damage in a freak accident.
A spokesman for DeLay said the ethics of the two situations are quite different. Sun Hudson was removed from a respirator. The DeLay family chose not to have Charles DeLay attached to a dialysis machine after his kidneys failed.
Perhaps the first ethical question is this: Is there a moral distinction between removing a feeding tube and removing other means of life support?
“I know that I've talked to some very theologically conservative medical providers who think it's OK to remove some feeding tubes,” said David Smolin, a professor of law at Samford University, a Baptist school in Alabama. “I think that split kind of gets tossed aside in a case like this, because I think that when the case gains momentum, it comes across as a right-to-life issue.”
Smolin, who is an expert in health-care law at the Baptist school, describes himself as pro-life. The question, he said, becomes whether the removal of a feeding tube for someone who is heavily brain-damaged-but whose remaining rudimentary brain functions allow them to breathe and digest food on their own-is akin to murder.
“The fundamental underlying ethical issue is whether or not a feeding tube is something that should be similar to [normal] feeding, which should never be withheld unless the person is going to suffer from the treatment … or like something to assist breathing, like a heart-lung machine,” Smolin said. “I view that as unresolved. I think there is a definite pro-life point of view that says a feeding tube is feeding and should never be withdrawn.”
Several conservative Protestant and Catholic leaders, including the late Pope John Paul II, have advocated that argument. But some other Christian ethicists disagree.
“The idea is based on the fact, or the idea that they believe is the fact, that [tube] feeding and nutrition is natural-that is to say, it's something everybody does,” said Dixon Sutherland, a religion professor at Stetson University in Florida. “They're basically saying that this is not medical treatment, it's just feeding.”
But Dixon, who directs the Institute for Christian Ethics at the Baptist-related school, said that a feeding tube such as Schiavo's is not morally distinguishable from other means of life support. “It's no less artificial than a respirator-what would make it less artificial?” he asked.
The idea that it is morally natural to keep someone alive by sustenance that they would not otherwise be able to give themselves-Schiavo, according to court-appointed doctors, could not feed herself, chew or swallow-is “pretty bankrupt,” Dixon said.
Such situations happen all the time in America, Dixon noted, though the dramatic and highly publicized disagreements within Schiavo's family pushed the case to the national news pages. The courts have long recognized the legality of such feeding-tube removal if those advocating it can produce “clear and convincing” evidence that the disabled party would not have wanted to be kept alive in such a way.
Why then the furor over Schiavo's feeding tube?
“I think what you have here is a symbol going on, and I understand that. The symbolic nature of feeding or not feeding is kind of intuitively repugnant to us,” Sutherland said. But, he added, the idea of life historically has been closely associated with the ability to breathe. Once someone loses the capacity to do that on their own, they often are considered dead.
But, given our modern medical understandings, that may be an outmoded way to understand the threshold of life, he said.
“With all the capacities we have now, we don't normally associate life with breath, but with brain function-or, at least, heart function. All those things had ceased with Terri Schiavo; they were artificially reinstated. So, to argue that she was doing anything naturally is kind of vacuous, ethically,” Sutherland said.
“You can't artificially resuscitate people and make them live artificially for 15 years and they are not even aware of their own existence and then argue that we are doing something artificial or extraordinary” by removing feeding.
But Smolin said that could be a legally slippery argument. “I've heard of cases where somebody said that giving an antibiotic to treat pneumonia was not necessary, making it was ‘extraordinary care,' ” he said.
Smolin said another difficulty the Schiavo case presented is whether individuals-whether through written documents or, as the courts determined in Schiavo's case, through oral commitments-can morally make end-of-life decisions for themselves when they are in healthy states.
“I am extraordinarily skeptical of the ‘what Terri would want' argumentation on either side,” he said. “There are two fundamental problems: One, the ability of us,
when we're healthy, to imagine what we'd want when we're sick. … Once you're in that position and your choice is to be alive in that position or dead, it's different.”
The modern bioethics movement focuses on safeguarding “the autonomy of the patients,” Smolin noted. “The problem is, obviously, that model doesn't work terribly well when you have incompetent patients.”
Whatever the ethical legitimacy of the advocates for sustaining Schiavo's life, Sutherland said, it raises an important question for Christians: Do churches do enough to minister to those facing the end of their lives, or those of their loved ones?
“I think it is a great disservice that the church has not pursued end-of-life issues,” he said. “The church in general-and I'm not saying every church
-but I know very few churches that have taken this on as a serious issue that they educate parishioners about and make it a part of their ministry.”
Sutherland noted that 100 years ago in America, most Christians were more in touch with the idea of death as a natural part of life.
“Look at the churches historically-they were surrounded by cemeteries,” he said. “Why aren't churches building hospices?”
Sutherland said churches should utilize experts, such as physicians and nurses who are members, to educate congregations about end-of-life issues like living wills.
What churches should not do, he argued, is advocate for sustaining life the way Terri Schiavo's parents and their supporters did.
“They're not erring on the side of life here; they're erring on the side of death defiance. They're seeking immortality instead of talking about the resurrected life,” he said. “Terri Schiavo was dead a long time ago; it's just a matter of being clinically dead that was the issue here. And a position that holds that the sacredness of life extends until clinical death occurs is bankrupt.”
But some who supported keeping Schiavo alive view it as an obligation to defend the weakest and most vulnerable members of society. In a March 24 opinion piece written for New York's Newsday before Schiavo died, Cathy Cleaver Ruse, an attorney with the United States Conference of Catholic Bishops, said the law should presume to defend the lives of those who can't defend themselves.
“Schiavo cannot speak on her own behalf. She is totally defenseless and dependent on others. But she retains every ounce of her human dignity and deserves respect and care.” Ruse wrote. “Her plight dramatizes one of the most critical questions we face: To be a truly human society, how should we care for those who cannot care for themselves? Ultimately what happens to Terri Schiavo will say more about us than it does about her.”
Associated Baptist Press
Robert Marus is chief of ABP's Washington bureau.