The furor seems to have died down. An entire nation—including Congress and the Judiciary—paused for a few days to consider the fate of Terri Schiavo. The passionate positions articulated by all sides seem to have been momentarily set aside—and life goes on for those who remain. What is the Christian to make of this heart-rending circumstance? How does one make sense of the medical, ethical, and biblical issues that are at stake?
According to the official court record, the circumstances leading up to the ultimate disposition of this case began fifteen years ago. The court record notes:
On February 25, 1990, in the early morning hours, Terri Schiavo suffered cardiac arrest, apparently due to an imbalance of potassium in her system. Michael Schiavo awakened when he heard a thump, found her lying in the hallway and called 911. He then called her brother who was living in the same apartment complex and her mother. The paramedics came, performed CPR and took her to the hospital (Circuit Court, 2000, p. 2).
She eventually was transferred to a nursing home, where she was nourished and hydrated via a feeding tube. Within two years (1992), Michael Schiavo sued the physicians who had been treating Terri prior to her cardiac arrest. The case was resolved later that year he was awarded $300,000 (“loss of consortium claim”) and guardianship of his wife, receiving net funds of $700,000 in damages. Though Mr. Schiavo and Terri’s parents (the Schindlers) had been working amicably together for three years in an attempt to provide the best possible care for Terri, when the monies were awarded by the court in February, 1993, the amicable relationship came to an end due to disagreement over the division of the money. The strife continued until Terri’s husband went to court in order to secure authority to withdraw his wife’s feeding tube.
Charges and countercharges have been bantered back and forth among the family members. It was alleged that the husband might have abused his wife and tried to kill her, or that he simply wanted the money. Both sides have argued over whether Terri, herself, would have wanted to have her feeding tube removed. Likewise, questions have been raised regarding his current relationship with another woman. Regarding this latter point, true Christianity teaches that a man is married to his wife “for as long as the both of them shall live.” A Christian husband will remain loyal and devoted to his wife—though she is seriously incapacitated. He took a vow that included the promise: “in sickness and in health.”
Regardless of these legitimate concerns, they stand distinct from the central question in this case—the sanctity of human life. Terri Schiavo was not brain dead. She was not on “life support” or being kept alive by “extraordinary measures.” She was not comatose—i.e., in “a state of profound unconsciousness from which one cannot be roused” (McDonough, 1994, p. 210). She was not connected to a ventilator, respirator, or heart machine. She was breathing on her own. The dependency she had was a feeding tube, since she was unable to feed herself. So what actions may or may not be taken with regard to such incapacitated persons? Should artificial feeding be withheld from individuals like Terri Schiavo?
SCIENTIFIC AND MEDICAL FACTORS
Terri was diagnosed as being in a persistent vegetative state (PVS). [As appeals were rejected, Terri’s family took the position that this was an incorrect diagnosis. But having read some expert testimony from at least four neurologists who examined Terri, I am inclined to agree that she was in PVS]. Oftentimes the media would use the word “coma” to describe Terri. However, Stedman’s Medical Dictionary defines coma as “a state of profound unconsciousness from which one cannot be roused” (McDonough, 1994, p. 210). Following a traumatic injury, unconscious patients are said to be in a coma. Following several days or even weeks, patients who do not recover or die often will emerge from their coma to periods of wakefulness. This was the state Terri was in (as evidenced by the videos on her family’s Web page: www.Terrisfight.org). One important difference in a comatose patient and a patient in a vegetative state is that patients in a coma do not normally go through sleep/wake cycles, and almost always have their eyes closed.
The term “persistent vegetative state” (PVS) was first described by Jennett and Plum in 1972 (1:734-737). Persons diagnosed in a vegetative state show no behavioral evidence of awareness of self or environment. There is brain damage, usually of a known cause, consistent with the diagnosis. In Terri’s case, her brain went without oxygen for too long the morning she collapsed. Most often, these patients are not on ventilators, but as was the case with Terri, they may require artificial feeding. And it was that feeding tube that caused so much controversy. Should they have removed it or left it in place?
One of the arguments used in the creation/evolution controversy is the law of cause and effect. Creationists correctly argue that for every material effect, there must be an adequate antecedent cause. Thus, in looking at the Universe as an effect, one must answer the question as to what caused it? It is valuable to use this same line of reasoning when considering ethical decisions. Is the person going to die naturally—as an effect of some disease or injury? Or, is their death caused by a decision a family member makes? In approaching medical situations in this manner, biblical answers become a little easier to identify. Clearly, God has appointed that each person will die (Hebrews 9:27), and thus we should not fear or shun death. After all, for faithful Christians, this is a time to rejoice as we prepare for a heavenly “homecoming” (John 14:1-3). But as loved ones get closer to that heavenly goal, we must make sure that our decisions do not become the actual cause of their deaths.
Terri was a living, breathing human being. However, because of her inability to swallow she needed a feeding tube to provide her with nutrients. In February 2000, Michael Schivao received permission from the court to remove her feeding tube. The courts have ruled that there is no difference between the termination of artificial nutrition and hydration and other forms of medical treatment, and as such, food and water can be withdrawn. I would argue strongly against such a ruling. Food and water represent standard care for any living individual (and even animals!)—they are, in fact, the sustenance of life. Stopping food and water will undoubtedly lead to death within 14 days. Plainly put, the individual will die from dehydration—not the disease or injury that caused their hospitalization. Who would intentionally withhold food and water from any loved one, regardless of age or physical condition? Jesus cautioned: “For I was hungry and you gave Me food; I was thirsty and you gave me drink” (Matthew 25:35).
Additionally, there is ample evidence today that unconscious people do suffer if they die from dehydration (see Steiner and Bruera, 1998), and yet we submit individuals (who are unable to respond) to this cruel and inhumane treatment—in an effort to “ease their suffering”? In their conclusion discussing hydration in palliative-care [reducing the severity of, or alleviating the symptoms without curing, the disease—BH/DM] patients, Nathalie Steiner and Eduardo Bruera wrote: “Clinical research has shown that dehydration can lead to potentially severe complications, altering the patient’s quality of life, including increased asthenia and accumulation of opioid metabolites with cognitive failure, generalized myoclonus, grand-mal seizures, and hyperalgesia” (14:12). Craig argued that death through dehydration is onerous for both the patient and the relatives, and that there is a powerful need to satisfy thirst (1994, 20:139). Some would argue that maintaining an individual with nutrition and hydration merely prolongs the person’s “existence,” not their life. Christians, however, must not accept or embrace any procedure that deviates from a general rule in which the sanctity of life is upheld. Joseph C. Howard rightly asserted:
We must recognize that the deliberate denial of food and water to innocent human beings in order to bring about their deaths is homicide for it is the choice to kill by starvation and dehydration. Such killing is seriously immoral and should never be legalized.... The fact that the killing is done by an act of omission makes it no less reprehensible (1994, p. 61).
We as Christians must recognize that the presence of brain activity (as Terri had) is indicative of a living person who has a right to nourishment. Having a feeding tube in place is not a “heroic measure,” nor is it providing some type of “extraordinary care,” but rather it is quite “ordinary” care. Other than to hasten the death of someone, what possible motive could someone have for removing this fundamental need? Ephesians 6:2 commands that each person is to “honor your father and mother.” According to 1 Timothy 5:8, failing to care for one’s own family is a denial of the faith, and makes one “worse than an infidel.” Just because someone is aged or vegetative, we are not to stop caring for and loving that individual. The psalmist lamented: “Cast me not off in the time of old age. Forsake me not when my strength faileth” (Psalm 71:9) Would our plea today be any different? Our decisions regarding our loved ones must take this into account, must they not? Malpractice case awards aside, Terri was living, and should have been treated as such.
AN EXAMINATION OF THE VEGETATIVE STATE
I heard on several television stations that Terri’s condition was “hopeless” and that she had no chance of recovering. One newscaster went so far as to say that the only thing that would help her out of her state was a direct miracle from God. He obviously did not have all the facts on PVS cases.
“Mom, I love you.” According to the New England Journal of Medicine, these were the words written by the young seventeen-year-old girl more than fifteen months following a tragic car accident (Childs and Mercer, 1994, 334:24). At fifteen months, nurses started noticing rare and inconsistent responses to certain commands. Three years after the injury, she was communicating using eye blinks for yes and no. Five years after the injury she could follow conversations and was communicating by mouthing words and short phrases. The article noted: “She enjoyed pampering and her mood was usually euphoric.... She had no behavioral evidence of depression or despondency over her deficits. She enjoyed humor, making jokes and teasing her caregivers” (334:24). While she remained wheel-chair bound and totally dependent for her care, the young lady was discharged and allowed to return home 5.2 years after the injury. The importance of this story should not be overlooked, and was not missed by the authors of the article, who lamented:
More relevant is the risk of prognostic error in patients in a persistent vegetative state who survive for 12 months. The available data are insufficient to provide a trustworthy estimate of the incidence of late improvement, because of erratic follow-up, incomplete reporting, and uncertain diagnosis.... In retrospect, one could not predict the eventual improvement in our patient (334:24).
This recovery should not come as a surprise. In a 1994 Multi-Society Task Force review of the scientific literature, half of the head-injury patients who were vegetative at one month had regained consciousness after a year, as had one-third of those who were vegetative for three months. In fact, one study concluded: “The diagnosis of the permanent vegetative state cannot be absolutely certain. There is no standard test of awareness and data on prognosis are limited” (Wade, 2001, 322:352, emp. added). Persistent (or permanent) vegetative state is clinically defined as “a loss of any meaningful cognitive responsiveness, presumed lack of awareness and therefore consciousness, while there is spontaneous breathing and a range of reflex responses as well as periods of wakefulness (eyes open)” (Adams, et al., 2000, 123:1327, parenthetical item in orig.). Jennet and Plum noted that “it is often described as loss of function in the cerebral cortex while the function of the brainstem is preserved” (1997, 12:1-12).
The Multi-Society Task Force observed: “The perceptions of pain and suffering are conscious experiences; unconsciousness, by definition, precludes these experiences” (see Multi-Society...,” Part 2, p. 1576). At first glance, this explanation seems valid. Yet, look at the implications. Since animals are not self-conscious, then according to this statement, they cannot feel pain. And who, upon kicking a dog or cat, would not expect that animal to yelp or sound out in pain? As Howsepian remarked, this is “at best counterintuitive and at worst patently false” (n.d.).
As Christians, we must understand that there is a very real danger that those who have been diagnosed as being in a vegetative state will, in fact, be viewed as “vegetables” and, therefore, “subhuman.” These patients are still very much alive by all commonly accepted medical and ethical criteria. Life is life. An individual’s self-worth is not dependent on mobility and/or function. Rather, it rests in the fact that every human has been created in the “image and likeness of God.” God—not man—is the One Who establishes humanity’s significance. Another key problem with this syndrome is the name itself: persistent (or permanent) vegetative state—the notion being that the individual lying there is never going to recover to live any type of “useful” life. However, the case above (and many like it) suggest(s) otherwise.
The American Medical Association estimates that 10,000 to 25,000 adults, and 4,000 to 10,000 children, currently are living in a PVS in the United States. The vast majority do not require assistance for breathing, but many require artificial feeding. Disconnecting those people from food and water would result in the death of more than three-to-five times the number of people killed in the 2001 World Trade Center attack! Yet, given proper nutrition and care, these patients can live in this state for many years (the longest PVS case on record is 41 years)—having not improved much if any during those intervening years. The legal argument is straightforward. Patients must consent to any treatment they receive; otherwise, the doctor is liable for battery to that person. But vegetative patients are unable to provide consent; therefore, they can be treated only if it is in their best interests—something decided by a surrogate decision maker.
By definition, individuals who are in a vegetative state are living. In spite of the push to “update” the definition of death, currently, someone in PVS is neither dead nor brain dead. Biblical teaching regarding man acknowledges that he is composed of two distinct parts—the physical and the spiritual. We get an introduction to the origin of the physical portion as early as Genesis 2:7 when the text states: “Jehovah God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living soul (nephesh chayyah).” It is important to recognize both what this passage is discussing and what it is not. Genesis 2:7 is teaching that man was given physical life; it is not teaching that man was instilled with an immortal nature. The immediate (as well as the remote) context is important to a clear understanding of the intent of Moses’ statement. Both the King James and American Standard Versions translate nephesh chayyah as “living soul.” The Revised Standard Version, New American Standard Version, New International Version, and the New Jerusalem Bible all translate the phrase as “living being.” The New English Bible translates it as “living creature.”
The variety of terms employed in our English translations has caused some confusion as to the exact meaning of the phrase “living soul” or “living being.” Some have suggested, for example, that Genesis 2:7 is speaking specifically of man’s receiving his immortal soul and/or spirit. This is not the case, however, as a closer examination of the immediate and remote contexts clearly indicates. For example, the apostle Paul quoted Genesis 2:7 in 1 Corinthians 15:44-45 when he wrote: “If there is a natural body, there is also a spiritual body. So also it is written, ‘The first man Adam became a living soul.’ The last Adam became a life-giving spirit.” The comparison/contrast offered by the apostle between the first Adam’s “natural body” and the last Adam (Christ) as a “life-giving spirit” is absolutely critical to an understanding of Paul’s central message (and the theme of the great “resurrection chapter” of the Bible, 1 Corinthians 15), and must not be overlooked in any examination of Moses’ statement in Genesis 2:7.
What, then, of the second part—the “spiritual”? Genesis 1:26-27 records: “And God said, Let us make man in our image, after our likeness.... And God created man in his own image, in the image of God created he him; male and female created he them.” Nowhere does the Bible state or imply that animals are created in the image of God. What is it, then, that makes man different from the animals? The answer, of course, lies in the fact that man possesses an immortal nature. Animals do not. God Himself is spirit (John 4:24). “Spirit,” by definition, “does not have flesh and bones” (Luke 24:39). In some fashion, God has placed within man a portion of His own essence—in the sense that man possesses a spirit that never will die. The prophet Zechariah spoke of Jehovah, Who “stretches out the heavens, lays the foundation of the earth, and forms the spirit (ruach) of man within him” (12:1). The Hebrew word for “forms,” yatsar, is defined as “to form, fashion, or shape (as in a potter working with clay;” Harris, et al., 1980, 1:396). The same word is used in Genesis 2:7, thereby indicating that both man’s physical body and his spiritual nature were formed, shaped, molded, or fashioned by God.
Solomon, writing in the book of Ecclesiastes, noted that “the dust will return to the earth as it was, and the spirit will return to God who gave it” (12:7, emp. added). Man’s physical body was formed of the physical dust of the Earth, and one day it will return to it. In James 2:26, James made this observation: “...the body apart from the spirit is dead.” The point, of course, was that when the spirit departs the body, death results. But there is an obvious, and important, corollary to that statement. If the body is alive, it must be the case that the spirit is present. This is a biblical principle that cannot, and must not, be ignored—especially in light of the present controversy. Is the person being cared for alive? Yes. Is the soul present? Again, according to the Bible, the answer is clearly yes.
Does God give man the right to terminate innocent life in which He has instilled a soul? No. This realization—that Christians should not prematurely terminate the life of someone in a PVS—may not be welcomed by some individuals. In fact, family members who have had to struggle with watching their loved one exist in a state far removed from their previous existence may take offense at such a suggestion. After all, they are the ones that have to bathe, feed, turn, change, and tend to the individual. They are the ones that watch bedsores come and go, and are forced to shuffle their lives, careers, and families around ICU visiting hours. Seeing their loved one so helpless has led many to subscribe to the mantra that those in a vegetative state “have no quality of life; there is not a person there.” Rather, the body is simply a “functioning corpse, not a living person.” How, then, would one explain the awakening of Gary Dockery after 7½ years in a PVS? Upon awakening, he talked eighteen hours, recalling family members’ names, names of pet horses, etc.
As evinced by Dockery’s case there are no 100% foolproof methods of determining one’s outcome. In fact, brain pathology is not even a good indication of the syndrome itself. Adams and colleagues
have considerable experience of the neuropathological abnormalities in patients who remained severely disabled but not vegetative as a result of an acute brain insult. In some of these brains there were lesions similar to those found in some of the vegetative patients, particularly the traumatic group.... It is clear...that this condition can occur in patients in whom there are no identifiable structural abnormalities in the cerebral cortex, the cerebellum or the brainstem (2000, 123:1336).
In a paper titled “Misdiagnosis of the Vegetative State: A Retrospective Study in a Rehabilitation Unit,” specialist Keith Andrews, et al. noted:
...of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed.... Most...were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues—some to a high level.... Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding (1996, 313:13-16).
Given that diagnoses can be difficult, and knowing that the person is alive, Christians are left with a singular option. They must ensure the sanctity of life, and comfort their loved one through this traumatic period. We must ask: Are we trying to end our loved one’s suffering, or our own?
God’s Word tells us that death is a fact of life for all humans (Hebrews 9:27). Ecclesiastes 3:2 points out that there is, “a time to be born, and a time to die.” The Bible also is clear that no man has the right to hasten another’s death—with exceptions being instances such as capital punishment (Exodus 20:13; Romans 13:9). For the “arm-chair” reader, the issues may seem abundantly clear. But to individuals like Michael Schiavo, the Schindlers, and hundreds of others who face the loss of a wife of many years, or the parents faced with the decision of quitting their jobs and going on welfare in order to stay home and care for their invalid son or daughter, the matter is far less esoteric. In an age where our values often follow our pocketbooks, we are finding more and more excuses to free up hospital beds. Thus, it appears that the best “treatment” for individuals suffering from Lou Gehrig’s disease (ALS), Parkinson’s, Alzheimer’s multiple sclerosis, and traumatic injury is—death!
When we hear about cases such as Terri’s, or when we ourselves face such ethical dilemma’s—as many of us will—our decisions must be centered on God’s Word. Our instincts and insights are of no use, since they often are clouded by pain or emotion. Likewise, the laws of man are of little use, since what is legal may not be what is right in the eyes of God. Therefore, we must prayerfully request wisdom, which God promises to those who ask (James 1:5). Of all the times in our lives when we need to search earnestly for a “thus saith the Lord,” or for the principles contained within the “perfect law of liberty” (James 1:25), surely these are such times.
Adams, J. Hume, D.I. Graham, and Bryan Jennett (2000), “The Neuropathology of the Vegetative State After an Acute Brain Insult,” Brain, 123:1327-1338.
Andrews Keith, L. Murphy, R. Munday, C. Littlewood (1996), “Misdiagnosis of the Vegetative State: Retrospective Study in a Rehabilitation Unit,” British Medical Journal, 313:13-16.
Childs, Nancy L. and Walt N. Mercer (1996), “Late Improvement in Consciousness After Post-Traumatic Vegetative State,” The New England Journal of Medicine, 334:24-25, January 4.
Circuit Court (2000), “In Re: The Guardianship of Theresa Marie Schiavo,” [On-line], URL: http://abstractappeal.com/schiavo/trialctorder02-00.pdf.
Craig, G.M. (1994), “On Withholding Nutrition in the Terminally Ill: Has Palliative Medicine Gone Too Far?,” Journal of Medical Ethics, 20:139-43.
Fox, Gary D. (2003), “The Lost Lesson of Terri Schiavo,” St. Petersburg Times, October 26, [On-line], http://www.sptimes.com/2003/10/26/Floridian/The_lost_lesson_of_Te.shtml.
Harris, R. Laird, Gleason Archer, Jr. and Bruce Waltke, eds. (1980), Theological Wordbook of the Old Testament (Chicago, IL: Moody).
Howard, Joseph C. (1994), Linacre Quarterly, pp. 60-61.
Howsepian A.A. (no date), The Multi-Society Task Force Consensus Statement on the Persistent Vegetative State: A Critical Analysis.
Jennett, Bryan and Fred Plum (1972), “Persistent Vegetative State after Brain Damage: A Syndrome in Search of a Name,” Lancet, 1:734-737.
McDonough, James T. Jr., ed. (1994), Stedman’s Concise Medical Dictionary (Philadelphia, PA: Williams & Wilkins), second edition.
Multi-Society Task Force On PVS (1994), “Statement on Medical Aspects of the Persistent Vegetative State,” The New England Journal of Medicine, 330:1499-1508, May 26.
Steiner, Nathalie and Eduardo Bruera (1998), “Methods of Hydration in Palliative Care Patients,” Journal of Palliative Care, 14:6-13.
Wade, Derick T. (2001), “Ethical Issues in Diagnosis and Management of Patients in the Permanent Vegetative State,” British Medical Journal, 322:352-354, February 10.
Wolfson, Jay (2003), “A Report To Governor Jeb Bush and the 6th Judicial Circuit in the Matter of Theresa Marie Schiavo,” [On-line], URL: http://abstractappeal.com/schiavo/WolfsonReport.pdf.
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