On Death & Dying & Terri Schiavo
By Timothy P. Collins | July/August 2005
Timothy P. Collins, M.D., is Board Certified in Anatomic and Clinical Pathology, and a Fellow of the College of American Pathologists. He, his wife, and four children live in Chesapeake, Virginia.
I was performing an autopsy when Terri Schiavo died.
I am a pathologist. Not a forensic pathologist, so I don’t get involved legal cases. I’m just a general pathologist working in a hospital laboratory, signing out cases, interpreting lab data and, occasionally, doing what are known as “medical” (as opposed to forensic) autopsies. In this case the patient — we’ll call him Mr. Goodpasture — was an elderly gentleman who had suffered from kidney disease and severe emphysema for many years. He had been admitted to my hospital about a month previously with severe worsening of his kidneys to the point where they shut down completely and he went on dialysis. In addition, his emphysema — which already required supplemental oxygen — got worse; he stopped being able to breathe on his own, and he had to be intubated and put on a ventilator. Mr. Goodpasture spent a month in the intensive care unit, on a ventilator, getting dialysis as well as a host of other aggressive high-tech therapies in the hopes that he would regain some kidney function, and regain enough lung function to be taken off the ventilator and breathe on his own. Throughout this time he was obtunded and unresponsive. After a month of very aggressive therapy it became clear that Mr. Goodpasture was not going to improve, ever get off the vent, or even regain consciousness, and his children requested that his ventilator be turned off. His physicians concurred. The vent was disconnected and he was put on “blow by” oxygen only. He died shortly thereafter. His immediate cause of death was respiratory failure due to severe chronic obstructive pulmonary disease, exacerbated by end-stage renal failure. His manner of death was natural.
The Catholic Church does not teach now, and has never taught, that every heroic and extraordinary measure must be taken to preserve life for as long as humanly possible. Pope John Paul II did not teach that in his March 2004 address, “On Life-Sustaining Treatments and the Vegetative State.” The Catechism does not teach it; in paragraph 2278, the Catechism states, “Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate…. One does not will to cause death; one’s ability to impede it is merely accepted.” In 1981 the Congregation for the Doctrine of the Faith promulgated its Declaration on Euthanasia, which reaffirmed the traditional Church teaching distinguishing between “ordinary” and “extraordinary” means of prolonging life. This can at times be a difficult distinction, and evaluating different treatments with different risks, hazards, pains, costs, and so forth, can be a fairly technical task, requiring the help of physicians.
In lethal illnesses, the crucial thing to consider is the treatment’s burdensomeness and its potential usefulness. While distinguishing between ordinary and extraordinary means of prolonging life — laying out how families and physicians can make correct moral choices as to whether this or that treatment is futile — the Declarationreaffirms the magisterial teaching that absolutely proscribes the intentional killing of an innocent human being: It is never right to kill a patient, or to allow him to die by withholding legitimate medical care, even because of the alleged poor quality of his life. Pope Pius XII, in a 1957 address to a congress of anesthesiologists, said, “normally one is held to use only ordinary means [to prolong life]…, means that do not involve any grave burden for oneself or another [the Pope is here assuming that the patient himself is the one deciding on a treatment]. A stricter obligation would be too burdensome for most men…. Life, health, all temporal activities are in fact subordinated to spiritual ends.” The Pope is addressing the issues of the burdensomeness of a treatment. What he is doing is giving the faithful Catholic at the end of his life the permission to say, We’ve done enough. Now I will go to stand in Judgment. This scenario is not suicide; the patient does not desire death. He is accepting the inability to further impede death.
These situations arise in every hospital, every day. I have been involved with them many times as a physician in my former activities as a Family Practitioner, trying to guide a patient or a family through the profoundly difficult maze of what is, and what is not, futile, in a given situation. I have also been called, twice, to be the one to make the decision regarding termination of medical therapy on my own immediate family members. And, in this situation, lawyers and judges and politicians have no place whatsoever, assuming right intentions on the part of patient, family, and physicians. It is an intensely private matter.
All of the preceding discussion applies to the case of Mr. Goodpasture. Though I was not part of the decision, in my opinion, the family and physicians made the correct choice. Further treatment was futile. Attempting to maintain him on the vent and dialysis was futile and excessively burdensome. There existed no reasonable ability to further impede death. He was comatose. Turning off the vent allowed him to die peacefully and fairly rapidly. I have no moral concerns regarding Mr. Goodpasture. Conversely, virtually none of the preceding discussion applies to the Terri Schiavo case. She was not near death, or even acutely ill. Indeed, the fact that it took two weeks to starve and dehydrate her to death testifies to her underlying “good protoplasm.” She was not, and apparently never had been, on “life support” as our corrupt media and our corrupt pollsters continually bleated. She required no mechanical assistance to breathe. She apparently was able to swallow (she swallowed her secretions; she did not drool) and so it seems quite possible that she could have been fed. However, apparently she never had a formal feeding evaluation. The fact that she was fed through a gastrostomy tube means nothing: There are patients who have had radical surgeries for cancers of the mouth and neck, who can no longer eat normally. They have G-tubes discreetly tucked under their shirts, easy to get at to pour the Ensure down. None of us in the public domain knows what Mrs. Schiavo’s true level of consciousness was, though there is more than enough evidence available for even the casual observer to seriously question whether she was in a “persistent vegetative state.” But here’s the main point: Even if she really was in one of the several related neurologic conditions where the individual is deprived of consciousness or cognitive ability, that doesn’t justify starving her to death.
It is true that there are a handful of Catholic priest/theologians who have argued that starving a patient in a persistent vegetative state (PVS) to death can be considered morally licit because PVS is excessively burdensome. PVS patients can live for a long time if fed. Some of these theologians may have even been trotted out and put on the telly during the Schiavo fiasco to give the “Catholic viewpoint.” However, the position isn’t valid, and has been well refuted. The Pope, as mentioned earlier, devoted an entire address to the topic in 2004. In his address he objects to the term vegetative: “A man, even if seriously ill or disabled in the exercise of his highest functions, is and always will be a man, and he will never become a ‘vegetable’ or an ‘animal.’” John Paul continues, “The sick person in the vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to his confinement to bed. He also has the right to appropriate rehabilitative care and to be monitored for clinical signs of eventual recovery.” His Holiness then goes on to point out that food and water, even when provided by artificial means are a natural means of preserving life, not a medical act. They come under the heading of “minimal care.” John Paul concludes the section with the following observation: “The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation of minimal care for the patient, including nutrition and hydration. Death by starvation or 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.” Terri Schiavo’s cause of death was starvation and dehydration. Her manner of death was euthanasia. If I were to euthanize my cat the way Mrs. Schiavo was euthanized, PETA would try to have me put in jail.
The Pope and Catholic teaching do not deny that medical treatment can become futile. The entire Magisterium does say that one can never withhold basic necessities of life to someone who is not dying, who is capable of assimilating the nourishment, and who requires nothing beyond such basic sustenance and care. Further, the Magisterium absolutely prohibits euthanasia, as well as suicide.
When I wrote this, the day after Mrs. Schiavo’s death, John Paul II was in extremis, succumbing to heart failure and sepsis as complications of his longstanding and progressively worsening medical problems. Though there were physicians at his bedside, the Pope did not go back to the hospital. Instead, he died in his own bed, having fought the good fight, and run the race, but also realizing his time on earth had come to an end. Like Mr. Goodpasture, like John Paul II, there will come a time for each and every one of us when trying to further impede death is futile. But what we cannot do, what we must never do, is kill ourselves or those who are dependent on us for their care.