LEADER-Caitlyn Kambouroglos

SCRIBE-Rachel Worcester

SCRIBE-Abby Frech

EDITOR-Rachel Howard

PRESENTOR-Austin McLean

Ethics Paper

1. Define persistent vegetative state and brain death. What is the difference?

A persistent vegetative state (PVS) is a chronic condition in its permanent form after a severe
brain injury, where patients do not recover any outward manifestations or higher mental activity.
Individuals may regain eye opening, sleep-wake cycles, reflux movements (grabbing, sucking,
startled responses) with a total lack of cognitive and mental activity of any sort. Individuals have
ability to breathe unaided. The brainstem and subcortical remain intact with function, but the
cerebral cortex is not functional.

Brain death is a irreversible cessation of all brain functions--including the brain stem. It is
usually diagnosed if the following conditions are met:

1. Cerebral function must be absent. There is no behavioral or reflex responses above the
spinal cord.
2. Brain stem functions are absent. This includes unreactive pupils, absence of ocular
responses, facial sensation and motor responses, and a lack of cough and gag reflex
3. The individual must be apneic. This means the absence of spontaneous respiration in
response to a hypercarbic stimulus.

Brain death is a more serious condition where all brain functions are lost, whereas in a persistent
vegetative state, individuals can have their brainstem and subcortical regions of the brain intact,
but have a lack of cerebral cortex function.

References

Holland, S., Kitzinger, C., & Kitzinger, J. (2014). Death, treatment decisions and the permanent
vegetative state: evidence from families and experts. Medicine, health care, and philosophy, 17
(3), 413-23.

Lane, D. (2015, February 02). Brain Dead Vs. Coma Vs. Vegetative State: What's The
Difference? Retrieved from
https://blackdoctor.org/454040/brain-dead-vs-coma-vs-vegetative-state-whats-the-differe

nce/
Sullivan, J. Seem, D. L., Chabalewski, F. (1999). Determining brain death. Critical Care Nurse

19(2): 1-3.
Verheijde, J. L., Rady, M. Y., & Potts, M. (2018). Neuroscience and Brain Death Controversies:

The Elephant in the Room. Journal of religion and health, 57(5), 1745–1763. Advance online
publication. doi:10.1007/s10943-018-0654-7

2. Discuss which bioethical principles from class are involved in this case and why?

Ethical choices, minor or major, confront us daily. To help deal with the ethical issues, the
bioethical principles have been implemented over the years. The four major bioethical principles
are respect of autonomy, non malfeasance, beneficence, and justice. We decided that in the Terri
Schiavo case, non-malfeasance, beneficence and justice were present. Autonomy,

which refers to informed consent of the actual patient, was not part of Terri Schiavo’s case
because she was not in proper mental capacity to make her own decision.

With non-malfeasance, we believed that by keeping Terri alive for 15 years, there really was no
harm done to her. Her treatment was not making her condition any worse, nor any better. Some
may argue that by removing Terri’s feeding tube and hydration, harm is committed. However,
there is no evidence of joy or pain in a reproducible fashion in individuals who are considered to
be in vegetative state. There is also no real evidence that states these individuals experience
hunger, thirst, physical, psychological, social or spiritual pain. So overall, we concluded that
non-malfeasance was a bioethical principle that was involved in Terri’s case.
Another bioethical issue that was displayed in Terri’s case was beneficence. We believed that
everyone involved, her family and her husband especially, were only looking to help Terri.
Terri’s parents got second opinions and Terri was provided all the care and treatment needed to
ensure that she was given the best chance she could have been given. She had a loving
environment that provided her with support daily. In the end some might say that she was given
mercy as well with the removal of the feeding tube and hydration. There were no treatments that
were harmful to Terri and overall, everyone looked to help her in any way they could.

We also concluded that justice was a bioethical principle that was present in Terri’s case. We
decided that Terri was given a fair distribution of services and all the treatments that were given
to her over the 15 years. Society did try to step in and level the playing field with the debate
between Terri’s husband, who wished to remove Terri’s feeding tube and hydration and Terri’s
parents, who wished for the feeding tube and hydration to continue to be supplied to Terri,
ultimately not wanting her life to end. Terri was not withheld any medical treatments

during the 15 years and in the end, we said justice was brought for Terri’s husband when her
feeding tube was removed and hydration was stopped, but some might say justice was not
brought for Terri’s family. We felt that justice was brought for Terri herself.

References
Fine R. L. (2005). From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain

injury. Proceedings (Baylor University. Medical Center), 18( 4), 303-10.

Perry J. E., Churchill L. R., Kishner H. S. (2005). The Terri Schiavo case: legal, ethical, and

medical perspectives. PubMED 143(10): 744-748.

Stone E. G. (2018). Evidence-Based Medicine and Bioethics: Implications for Health Care

Organizations, Clinicians, and Patients. The Permanente Journal, 22, 18-030.

doi:10.7812/TPP/18-030

3. What information would you give the family if asked “How long will it take her to die?
Will it be painful?”
We would tell the family that as medical professionals, if Terri Schiavo was taken off of

life support it could take a few days to a few weeks for her to die. As patients are removed from
a feeding tube, their body goes into a state of ketoacidosis where fats and amino acids are used to
make ketones to make energy in the body. During this stage, the patient will not feel any pain
because in advanced ketoacidosis the nervous system will decrease its efforts so the patient will
not feel any pain. Research actually shows that advanced stages of ketoacidosis brings a sense of
euphoria and no pain. When the body reaches a point of dehydration, urine production will stop

and the kidneys begin to fail. This causes electrolyte imbalances that affect the heart’s rhythm
and beating. Eventually the cardiovascular system will cease, but the patient will feel no
discomfort. Nurses and staff will be on hand to monitor and provide comfort by keeping the
patient under surveillance and keep up with her hygiene and environment.

References
Kitzinger, J., & Kitzinger, C. (2018). Deaths after feeding-tube withdrawal from patients in

vegetative and minimally conscious states: A qualitative study of favorite mily

experience. Palliative medicine, 32( 7), 1180-1188.

Lallanilla, M. (2005, March 18). Death from Dehydration is Usually Serene. Retrieved from

http://abcnews.go.com/Health/Schiavo/story?id=531907&page=1

4. If this case were placed before a Catholic cleric, what do you think they would support?

People who are declared in a vegetative state are still entitled to the basic patient and human
rights as those who are not in a vegetative state. Even assistance for nutrition and hygiene is part
of the “ode to care” for the vegetative state as well as warmth, cleanliness, and comfort. “To
apply this reasoning correctly, we must recognize that all human life, not only a particular kind
of life, we might consider ‘normal’ and ‘productive’, is precious and should be preserved” (The
National Catholic Bioethics Center, 2019).

On the topic of brain death, a person in a vegetative state must be declared by a medical
personnel using set neurological criteria. Proper declaration infers that the person is at a

complete cessation of all neurological activities in the areas of the brain which include the
cerebrum, cerebellum, and brain stem. According to the Catholic Church, the use of neurological
criteria to determine brain death status is legitimate if consistent with the following four signs:
coma or unresponsiveness, absence of cerebral motor responses to pain, absence of brain stem
reflexes, and apnea. Furthermore, the Church states that the Church has no understanding in
determining brain death and that it should be performed by strictly medical science.

For Terri Schiavo, not enough technology was available at the time to determine if Schiavo
would be able to be declared brain dead. In the court case, “...further indicated that Terri's
electroencephalogram was ‘flat line,’ which is very unusual in the vegetative state and
technically indicates whole brain death, even though it is clear she was not whole brain dead”
(Fine 2005). From this evidence, the Catholic Church would have supported Schiavo’s parents in
continuing medical life support because she was not declared brain dead and there was evidence
that she was not completely and whole brain dead.

It has also been noted that the Catholic Church has beliefs that nutrition and hydration are
ordinary and are a natural way to preserve life and that it is considered to be a moral obligation
under the Church.

References
Q&A from the USCCB Committee on Doctrine and Committee on Pro-Life Activities regarding
The Holy See’s Responses on Nutrition and Hydration for Patients in a “Vegetative State”.
(2007, September).

Organ Donation and Determination of Death. The National Catholic Bioethics Center. (2019).
Retrieved from

https://www.ncbcenter.org/resources/information-topic/organ-donation-and-determinatio

n-death/ncbc-faq-brain-death/
Fine R. L. (2005). From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain

injury. Proceedings (Baylor University. Medical Center), 18(4), 303-10.

5. If you were Terri, what would you want done?

In the position of Terri Schiavo, we concluded as a group that we would have decided to end our
life and pull the feeding tubes. Our main focus was on the quality of life we would be facing. If
we could not perform everyday activities and needed assistance, then we felt as it would have
been a burden on our family and loved ones. Without clear and whole cognitive function, it
would have been difficult to express reactions and expressions to the surroundings.

The doctors that reviewed her files and conducted her tests believed that she would never be able
to emerge from her comatose state or even regain any percentage of her consciousness again.
“An autopsy definitely settled that question. Her brain was severely atrophied, weighing less
than half of what it should have. No treatment then or now could have reversed the brain damage
she suffered. She was not conscious for all those years and never would be again” (Caplan 2015).
If we were put in that state of vegetation, we collectively decided that if there was no chance of
recovery or even the possibility of regaining some part of consciousness, then we would not want
to put our loved ones through the burden of taking care of us or have to live with the constant
medical attention without having some sort of quality of life.
References
Caplan, A. (2015, March 31). Ten years after Terri Schiavo, death debates still divide us:

Bioethicist. nbcNEWS. Retrieved from

https://www.nbcnews.com/health/health-news/bioethicist-tk-n333536.
Marshall R. C., Steele S., Eisenberg J. B., Felos G. J., Perrelli T. J., Portman R. M. Mach D.,

Bennett I., Jueds V. H., Pulham T. G., Robbins D. B. (2005). Respondent Michael Schiavo’s
opposition to application for injunction. Retrieved from
https://euthanasia.procon.org/sourcefiles/MichaelSchiavoOpposition.pdf

6. How would you argue in favor of the husband?

One expert chosen by Terri’s parents was William Hamasfar and MD and board-certified
neurologist who worked for the St. Petersburg Medical Clinic. He was an advocate for a
vasodilator therapy for cerebral ischemia that he had created. 105 commands and 61 questions
were asked to Terri. Some questions were even asked by her mom. Judge Greer who was on
Terri’s case, after watching 12 hours of tape, decided that only a few of the actions that Terri
made could be deemed responsive. This would support her husband’s view that her lack of
responsiveness caused her condition and quality of life to not be the standards as Terri wanted.

It can also be argued that Terri’s condition was not getting better and there was no chance for
improvement in the future. In 2002, Terri’s CT scans indicated that she lost a large percentage of
her brain tissue. This further proves that her diffuse cortical injury was adding to

her vegetative state. Since she had no living will and no written proof of her medical wishes,
Terri’s husband fought for her dignity and respected her wishes based on what she told him when
she was still alive. He looked at the medical facts in Terri’s case and argued how she would have
wanted to end the life support if there was no chance of improvement.

In the beginning he was hopeful and devoted his time to taking care of her and actually moved
into her parents house soon after she had her collapse to be with her and work with her family to
care for her. He then continued to make regular visits when Terri was moved to the nursing home
and demand that Terri received the best care possible. But Terri’s husband also had the claim
that Terri would have not wanted to live in that quality of life and wanted to respect her with the
decision he fought for.

References
Fine R. L. (2005). From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain

injury. Proceedings (Baylor University. Medical Center), 18(4), 303-10.

Newsweek Staff. (2003, November 2). Who has the right to die? Newsweek. Retrieved from
https://www.newsweek.com/who-has-right-die-133705.
Staff, N. (2010, March 13). Who Has The Right To Die? Retrieved from

https://www.newsweek.com/who-has-right-die-133705

Weijer C. (2005). A death in the family: reflections on the Terri Schiavo case. CMAJ : Canadian
Medical Association journal = journal de l'Association medicale canadienne, 172(9), 1197-8.

7. How would you argue in favor of the parents?

In terms of Terri Schiavo’s parents, they fought to keep Terri alive. Terri could breath, swallow,
maintain a heart rate and blood pressure on her own. Terri had head movements and at times
would make different expressions and vocalizations which appeared to be purposeful reactions.
Her parents felt that she had flickers of consciousness that might lead to rehabilitation. One
person wrote, “...I never imagined Terri would be so active, curious, and purposeful. She
watched people intently, obviously was attempting to communicate with each in various ways
and with various facial expressions and sounds. For me, watching Terri Schiavo in the website
videos, it was difficult not to feel I was seeing a person interacting with with others and aware of
her surroundings” (Farah, 2006).

In an argument for Terri’s parents, they also proposed the idea that Terri was a devout Catholic
for most of her young life. Her parents argued that Terri would not want to die in a manner that
was not accepted “in the light of the recent proclamations by the Roman Catholic Church”
(Reynolds, 2004). In March 2004, Pope John Paul II made an address where he states that giving
food and hydration will always represent “a natural means to preserving life” and he states the
food and hydration should be ordinary and proportionate as a moral obligation (Reynolds, 2004).
Thus, Terri would never willingly defy the the Catholic church and the Holy Father’s teachings
by giving her consent to conduct that is considered to be morally forbidden by the church. It was
noted by several doctors that Terri could benefit from certain therapies that her husband actually
refused.
Terri’s parents also could propose the argument that Mr. Schiavo had abused his wife prior to her
collapse, and that he should be removed as her guardian, especially due to the fact

that Mr. Schiavo was living with another woman who he openly referred to as his fiancée and
had two children with in the past decade of Terri’s trial. Mr. Schiavo refused to divorce Terri,
giving the impression to the Terri’s parents that Michael just wanted to inherit Terri’s trust fund.
Terri’s parents also had great personal views and emotional feelings with Terri being their
daughter that also impacted their fight to keep her alive.

References
Farah, M. (2005, March 23). Terri Schiavo’s Brain: A Neuroethicist Clarifies her Condition.

Retrieved from

http://www.bioethics.net/2005/03/terri-schiavos-brain-a-neuroethicist-clarifies-her/

Reynolds, Dave. (2004, September 4). Terri Schiavo Would Not Want To Go Against Catholic
Church, Her Parents Argue. Retrieved from http://mn.gov/mnddc/news/inclusion-
daily/2004/09/091504fladvschiavo.htm

Staff, N. (2010, March 13). Who Has The Right To Die? Retrieved from
https://www.newsweek.com/who-has-right-die-133705

8. What decision did the courts hand down?

The courts ruled in favor of Terri Schindler-Schiavo’s husband, Michael Schiavo. The court
resolved that Michael could make the decision to have his wife’s feeding tube removed, which
was keeping her alive. This decision was made based on the argument that Terri did not have any
cognitive abilities, conscious responsiveness, and that her condition was permanent with no
chance of improvement. Thus, being said after years of dispute, the court ruled in favor for
Michael Schiavo.

In 2001, Terri Schiavo was removed from her tube feedings for the first time after the Florida
courts ruled in favor of Michael Schiavo and stated that Terri Schiavo would have chosen not to
prolong her life-treatment. The tube was re-inserted a few days later after an appeal. In 2003, the
courts decided once again to remove the tube and Florida’s legislature created “Terri’s Law” and
her tube was inserted again to keep her on. Her tube was removed for a third time, an
“emergency measure” that the President signed into effect that forced the courts to review the
case and to re-inserted her tube. After the fourth time of removing her tube feeding, Terri
Schiavo died on March 31st, 2005. This was 13 days after her feeding tube was removed for the
last time.

References
Quill T. E. (2005). Terri Schiavo: A tragedy compounded. New England Journal of Medicine
352, 1630-1633. Doi: 10.1056/NEJMp058062
Timeline of Events: Terri Schindler Schiavo (n.d.). Robert Powell Center for Medical Ethics at

the National Right to Life Committee. Retrieved from

https://nrlc.org/archive/MedEthics/TimelineTerri.html

9. Should the government be involved in these decisions?

Even though the government cannot declare death or what decision someone would make in a
case of a medically-induced death, they are able to set definitions and limitations to the statute.
By clarifying who may have legal right to make medical decisions (if the patient is

unresponsive or not able) in terms of living wills and forms, the government can help define
what terms may be chosen in a decision and what permissions are allowed.

Under the Texas Advance Directives Act, several laws are joined together to ultimately decide
on how end-of-life decisions should be handled. In cases where the patient is responsive, they
may be able to reject or request treatment in the face of an irreversible condition. However, if the
patient is incompetent and unable to make that decision, as in the Terri Schiavo case, the
decision falls on the surrogates acting on behalf of the patient. Patients in a vegetative state with
irreversible illnesses are minimally covered under this law but ethics committees can be
consulted if circumstances arise in disagreements. “The futility of treatment, however, depends
on the situation...Texas law does not use the term ‘medical futility’ but rather the term ‘medically
inappropriate’ when discussing whether or not a treatment may be withheld or withdrawn from a
patient” (Fine 2000).

The government should not have had any involvement in this case since it was based in
medicine, but as a group we understand why they had to be involved. With the huge
disagreement and debate over whether it was ethically right or morally wrong to end Schiavo’s
life, the government needed to step in. Riots and protests were occurring and without
government interference, the outbreaks could have drastically been worse. From the standpoint
of medicine, there was no reason why the government should be involved in cases similar to
Terri Schiavo. However, since the family and her husband went to court that eventually led to a
try for a case in the Supreme Court with the public actively engaged, the government was
involved.

References
Fine R. L. (2005). From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain

injury. Proceedings (Baylor University. Medical Center), 18(4), 303-10.

Fine R. L. (2000). Medical futility and the Texas Advance Directives Act of 1999. Proceedings

(Baylor University. Medical Center), 13(2), 144-7.

10. What is the position of the professional association the group chooses regarding
withholding/withdrawing nutrition and hydration?

The Academy of Nutrition and Dietetics (AND) position statement regarding

withholding/withdrawing nutrition and hydration says that individuals have the right to request
or refuse nutrition and hydration as medical treatment. All healthcare professionals have an
ethical obligation to practice the bioethical principles. They have a duty to protect the lives of
their patients to the best of their ability and to relieve suffering whenever possible. Autonomy,
nonmaleficence, beneficence, and justice are governing principles for Registered Dietitians as
well as other health care professionals according to the Academy of Nutrition and Dietetics. In
order to ensure the highest quality of care health care professionals should work
interprofessionally. Two providers from different backgrounds working together can deliver a
better quality of care.

When it comes to medical-ethical decision making, as in the case of withholding/withdrawing

nutrition and hydration, the AND supports self-determination of the individual. This would take
precedence over the views of the health care professional. This is because all persons have
different wishes and approaches to end of life decisions due to factors

such as culture and religion. AND also encourages the Hippocratic writings that seek to to
understand when medicine no longer becomes useful at the end of one’s life. In this case the
medicine being nutrition and hydration. So the major question that must be asked is, “ When is
there a moral obligation to provide nutrition and when it morally optional?” The first thing that
should be done to answer this question is to determine the consequences. Nutrition and hydration
are a means of maintaining life; however, they can no reinstate consciousness in a human being
or stop inevitable death. The Registered Dietitian has two roles in this medical-ethical decision
making process. First,they must be a part of the ethical deliberation and provide input when
working on interpersonal teams. Second, the RD must always understand what is wanted by the
individual, whenever possible.
It is the position of the Academy of Nutrition and Dietetics that Registered Dietitians (RDs) have
the responsibility of providing education to the patient and their family pertaining to end of life
nutrition. The RD should ask the patient and their loved ones if it is okay for them to talk about
what nutrition at the end stages of life looks like. The dietitian should educate the patient and
loved ones on the risks and benefits of providing nutrition through the end stage of life such as a
tube feeding for an older adult with dementia. The RD should explain that a loss of appetite and
thirst are part of the natural dying process and that the patient is not starving. Lastly, the RD
should emphasize how it is important to honor the patient’s wishes after they have received
education on the matter.

References
Dodd, K. M. (2017, March). End-of-Life Care - Understanding the RD's Role - Today's Dietitian

Magazine. Retrieved March 13, 2019, from

https://www.todaysdietitian.com/newarchives/0317p36.shtml#
Maillet, J. O., Schwartz, D. B., & Posthauer, M. E. (2013). Position of the Academy of Nutrition

and Dietetics: Ethical and Legal Issues in Feeding and Hydration. Journal of the Academy of
Nutrition and Dietetics,113(6), 828-833. doi:10.1016/j.jand.2013.03.020