To quote your next post, now you’re talking from your layman’s posterior!

A DNR (Do Not Resuscitate) order has nothing to do with this. It just states that the patient should not receive CPR, cardiac defibrillation (the electric paddles used to restart a fibrillating heart), or be put on a ventilator. Whether or not someone would want resuscitation is totally independent of whether or not someone would want tube feedings in a persistent vegetative state.

Also, neither side is suggesting that she’s brain dead. Brain dead in most states is dead. Brain dead means that your whole brain is dead and you can’t breathe on your own. Ms. Schiavo is breathing on her own. If one is brain dead no one goes to court. They just turn everything off and have a funeral. Terri Schiavo is brain damaged. I think her husband is alleging that she’s not interacting meaningfully with her environment.

Here is the issue: She can’t eat by chewing and swallowing. She has to be fed through a feeding tube. Lots of cases have established that tube feedings (and any other life-saving therapy) may be refused by an informed patient who understands and can weigh the consequences of her actions. So if we had a videotape of Ms. Shiavo saying “If I was ever brain damaged and couldn’t talk and couldn’t swallow and it wasn’t obvious if I was recognizing my family or not, I would certainly not want tube feeds under such circumstances, because I think that death would be preferable. I would want to be kept comfortable and allowed to pass away.” then there would be no basis for a court trial. Her tube feeds would have been stopped and she would already be dead. So it’s not always “wrong to starve a person to death” in as much as a patient has a right to refuse feedings. But what if a patient’s wishes aren’t known? Well, people who know the patient best can sometimes shed light on what the patient would want. I have stopped tube feedings of patients whose families convinced me that the patient would have told me that they didn’t want tube feedings, if only they could talk.

At issue in this case is that there are conflicting opinions about what the patient would want. The husband states that she has told him she’d never want to live like this. The parents disagree. Knowing nothing about this specific case, I can only think that there are many states of existence worse than death, and that my wife has clear instructions to make sure that I’m never being kept alive in such states. I also know the powerful walls of optimistic denial that relatives, especially parents, build when faced with a devastating diagnosis. Letting go is hard to do. Realizing that you may be keeping someone alive for your wishes and not hers is very hard to do. I feel terribly for all involved.
 

What do you make of this article which discusses a halachic (Jewish legal) perspective of this case?

On sentence I found particularly interesting:

It is important to note that Jewish law clearly distinguishes between terminal illness and progressively debilitating illness (a distinction that is often ignored in secular ethics discussions).
 

Bean,

It's tricky moral and ethical turf. From one perspective, you might make the case that the obligation to preserve life artificially (e.g. person can't feed themselves; requires tube) is limited. In fact, you might make the case (as I think you are) that it is unethical to prolong life when the quality of that life has passed a certain threshold. Defining that threshold is what becomes tricky.

From another perspective, you can make a case that it borders on torture to starve a person to death. Mrs. Schiavo was previously left for 6 days without food. IF her mental state is anything approaching that of a vertibrate, I view that as cruel; long, drawn-out starvation being one of the less desireable ways to check out.

If you don't starve the person to death, but still wish them exterminated, there are other optioins. But, to do so, you cross yet another threshold that exceeds so-called doctor-assisted suicide, and becomes doctor-assisted homicide in the absense of the patient's known wishes.

In Mrs. Schiavo's case, her wishes are not known. As you point out, the husband and the parents are at odds with each other on her wishes.

She is clearly responsive, and apparently demonstrates awareness of relatives, pain and other stimuli.

Either decision could be the wrong one. I guess my tendency would be to err on the side of life than death in this case, although I understand your argument the other direction.
 

Nomad: Love your picture!

"you might make the case (as I think you are) that it is unethical to prolong life when the quality of that life has passed a certain threshold"

Nope. I'm not saying that at all. All I'm saying is that an informed patient has a right to refuse any therapy. Perfectly healthy patients can (and do) decide to refuse potentially life saving therapy for myriad reasons (believing that the treatment is undignified, religious reasons, ...). The doctor never has to make any assessment of the patient's quality of life. The doctor just has to inform the patient of the consequences of accepting treatment and of refusing treatment and has to let the patient know that the decision is hers. The patient is the only one who, if she wants to, should assess her quality of life and decide if the treatment is worth it. Am I making sense? The doctor (or anyone else) never has to figure out "is her life worth it?" It's not society's decision. It's the patient's.

Withdrawing food but not fluids causes starvation which takes weeks to months. I have never known this to be the way in which someone is allowed to die. When tube feedings are stopped, the fluids provided through the feeding tube are stopped also. The cause of death is dehydration, not starvation. This typically takes a few days to a week and is not a miserable experience. A person with a normal brain would experience thirst for a few days, but at any evidence of suffering (moaning or grimacing) morphine would be given which would take away the sense of thirst and make the person sedated and comfortable. After a small number (2 - 3) days the person loses consciousness. With appropriate end-of-life care (i.e. treatment of any signs of suffering with a narcotic like morpine) the end is usually very comfortable. I've seen this (I've ordered this) a gazillion times. It's not a bad way to die.

Ralphie: that's a really long answer. I'll work on it later today. I haven't read the article you link to, but I will.

Short teaser heretic answer: there are important differences between Jewish and secular medical ethics. I do secular medical ethics. [cue lightning strike]
 

I generally agree with Bean's comments. My experiences have been similar.

There is definitely a huge difference between Jewish ethics and secular ethics, and the difference is not always what you think. The big distinction is whether Jewish law recognizes "quality of life" and "patient autonomy" as issues. By Jewish law, you cannot take your own life or decide to refuse basic lifesaving treatment (food).

Secular law prevents the active taking of your own life (suicide) but allows you to refuse treatment (feeding tubes). A curious distinction.

One issue is how we, as religious doctors, resolve conflicts. I've been involved in many cases like this, and my philosophy is that I'm the patient's doctor, not their rabbi or priest.
 

But, as I understood you to say, in the absense of the patient's known wishes, family can surrogate?

--Just to be clear, I'm totally cool with somebody of sound mind refusing care. His/her life. His/her choice--

But -- and I guess this may really be the issue here -- we don't know Mrs. Schiavo's wishes. Additionally, in the presence of a pending cash settlement, we can't be sure of the motives for the family member's assertions.

Given the different inputs, and given Mrs. Schiavo's responsiveness, do you agree with me that it is better to err on the side of keeping Mrs. Schiavo alive?

Also, could you explain the surrogate privledge/responsibility a bit more to me? Obviously, there must be a line drawn between when a patient is in control of his/her fate, and when a spouse or other family member is. But, I wouldn't be comfortable if the line is simply the patient's inability to communicate. You hear stories of coma survivors being cognizant of events that took place bedside while they were otherwise incapacitated. A stroke victim may lose the ability to communicate, but still be quite mentally sound (although I presume this may be demonstrable through means other than speech).

I just see a lot of room for abuse, particularly where big insurance settlements, or other selfish motivations may be involved. Obviously, the rules in Florida are vague, which is why this is being shuffled between courts at the moment. Who oversees decisions in California?
 

Ralphie: I finally found some time to read the article to which you link and to formulate a response (by neglecting my children and my patients, but that’s OK, no?). I apologize for the hideous length of this.

The article has a few factual and logical problems. Factual problems first:

“Her [Terri Schiavo’s] impairment is cognitive and Judaism does not recognize any less of a right to treatment for one cognitively impaired than one mentally astute.”

No. She’s not simply demented. She can’t swallow or walk or talk. She has severe motor, cognitive and sensory problems. A persistent vegetative state isn’t just a cognitive problem. She’s not just a very poor chess player. She actually has no brain function apart from that needed to maintain life – breathing.

“While Judaism does recognize quality of life in certain circumstances (such as the incurable terminally ill patient in intractable pain mentioned above), the Torah does not sanction euthanasia in any situation. To remove the feeding tube from a patient whose only impairment is cognitive is simply murder.”

Secular medical ethics also doesn’t sanction euthanasia in any situation, which makes me wonder if the author knows what euthanasia means. Euthanasia is the intentional killing of someone through the administration of a lethal dose of a medicine. It is not withdrawal of care or treatment.

Now to the general philosophical differences between Jewish and secular medical ethics.

First of all, I’m a little uncomfortable criticizing a branch of Jewish religious thought in an audience of both non-Jews and Jews without explaining that I’m a religious Jew criticizing a small part of a religion to which I am loyal. My agenda is not to publicly criticize Judaism or Jewish law in general.

The principle of autonomy is a major guide in secular medical ethics. It basically states that people have a right to self-determination, but in medical ethics it is usually limited to mean that an informed patient has a right to refuse any therapy. Note that this says nothing about the patient’s quality of life or the presence of a terminal illness or anything else. I can refuse life saving surgery because I’m dying of cancer, or because my arthritis pain is so bad that I’d rather die, or because I worship Soltar The Magnificent who forbids it, as long as I understand my choice.

Not so in Jewish medical ethics. At root the difference stems from a difference in understanding to Whom our lives belong. In secular medical ethics, our lives are ours. In Jewish medical ethics our lives belong to our Creator. A question of Jewish medical ethics never asks “Can a patient chose such and such” but always just asks “What is the right thing to do (according to Jewish law) in this situation”. The wishes of the patient, or the doctor, or anyone else are not factors.

Another big difference is that in secular medical ethics there is no difference from withholding a certain treatment and withdrawing the treatment after it has been started. Meaning, it’s OK to remove someone from a ventilator in any occasion in which it’s OK not to have put someone on the ventilator in the first place.

In Jewish medical ethics there’s a big difference between withholding and withdrawing care. There are instances in which it is permissible to withhold life saving therapy (meaning not to put someone on the ventilator or not starting tube feedings). But once such therapy is applied, withdrawing it is usually forbidden.

My objection to Jewish medical ethics, both as a doctor and as a patient, is that in practice, it is unworkable. What is a doctor to do with a patient that refuses care? Batter the patient by forcing a treatment on him that he’s refusing? Also, the way I’ve seen the ban against withdrawal of care play out in real life is something like this: a gravely ill patient is on a ventilator. No one thinks that this patient has a meaningful chance of recovery, but he could live for weeks unconscious on the ventilator. Faced with this information, the family wishes (or the patient’s previously stated wishes) to discontinue the ventilator and let the patient die. The doctor is a religious Jew (not me) who explains that he is not permitted to do that, so he transfers the care to another physician (also not me) who complies with the family’s wishes. What is gained here? The family simply sees that a religious Jew was commanded to wash his hands of the patient’s care in his last hours. That’s not the message I want the world to hear.

In Ms. Shiavo’s case the tormenting decision is: what would she want if she could tell us? I have no idea. We have courts to sort that out, and that’s what they’re trying to do.
 

Hey Bean, I'm pretty sure I said the exact same thing as you but it only took me 11 lines. ;-)

BTW, there are some very thoughtful Rabbis out there who do try to be more than literal with this.

My Rebbi, who is a famous Chassidic Rebbi (I'm not a Chossid BTW) consulted me frequently about the case of his son-in-law, who was an incredibly charismatic Rosh Yeshiva in Lakewood.

Unfortunately, he was injured in a bus accident in Israel and was left in a persistent vegetative state for almost a year.

Then he suffered a brain hemorrhage and became brain-dead on a vent, with pressors, fluids and tube feeds.

The rebbe called me frantically from NY on several occasions, as did his daughter. There were more right wing elements of the family who refused to let go.

I had to tell him that there was no way that higher brain function would ever recover (barring miracles, but we don't rely on those), and that in all likelihood, he would die no matter what we did. It would just take a little longer.

I urged him to stop the pressors, food, IV, and try to get the vent pulled as well.

Having been through many cases with me in the past, he knew I was right. But there were many social, religious, and emotional forces at play here. He eventually passed a few days later.

This case was cut and dry, but there are many more grey cases out there, and Schiavo's is one of them.

Does she have a meaningful existence? I don't think so. But if all she needs to live is food and water, I don't know if at least by Jewish Law, we have a right to deny that.
 

According to standard Jewish medial ethics it is not permissable to withdraw care, and it is not permissable to withhold food/hydration from a patient. So, from the standard Jewish medical ethics point of view, the decision in the Schiavo case is a no brainer(sorry for the pun), because it is quite obvious that withdrawing food is not allowed. Also, I challenge the viewpoint that she has no brain function aside from breathing. From purely anatomical point of view, it is impossible for only the respiratory centers to be functional, and nothing else. It may be that there is nothing else obviously working, but that does not mean that she is one breath away from being brain dead. The situation of brain death is quite different.

I would also take issue with Dr. Bean on the topic of how Jewish ethics interacts with patient care. My practice is guided by Jewish medical ethics. My patients are not obliged to follow my ethics, and I am not obliged to follow theirs. However, if they ask me to do somthing that is contrary to my ethics, ie, violate a religious tenet, I let them know. I have been in many situations involving terminal stages of life. I do not withhold information, or couch my discussion so that they will agree with my ethical point of view. However, if they choose something that violates what I consider to be the dictates of my religion, I do not feel obligated to follow that. I very carefully explain to them that someone else will fullfill their wishes. They know I am around, and still sitting with them. They see a committed Jew with a kippah on his head spending lots of time and effort to take care of his patient, and also that I am committed to my religion, and not compromising what I believe in. And in all cases, they have more respect for me, not less. I am still there, holding their hands, explaining what is going on, its not that I have abandoned them, and they understand that. That is the mesasge that the world needs to hear: that a committed Jew can take care of his patients, is not imposing his world view on non-Jews, and remains committed to his ideals and values, and is not letting them shift in the wind just for expediency or because to proclaim one's values is not politically correct.
 

dilbert: Welcome. I appreciate your comments. It sounds like you are a sensitive and thoughtful physician and I’m happy that you are mindful that your behavior reflects on physicians in general and religious Jews in general.

I never said that Ms. Schiavo is one breath away from brain death. I retract the sentence “She actually has no brain function apart from that needed to maintain life – breathing.” But I maintain my disagreement with the article to which Ralphie links. Her deficits are far more than just cognitive.

Allow me to ask you a few questions to try to understand how Jewish medical ethics actually integrates into your practice. If you think a more private forum (like email) would be more appropriate let me know.

Of course your patients can’t compel you to do anything you wish not to do. Let’s pick a specific example. A family asks that a ventilator-dependent patient be extubated. You explain that you are religiously not permitted to do that but that there are other doctors who will comply with their wishes. The family wishes you to involve a physician that will withdraw the ventilator. Is your description of your attentive care with the family (“They know I am around, and still sitting with them. ... I am still there, holding their hands, explaining what is going on, its not that I have abandoned them, and they understand that.”) what happens after another physician has assumed the patient’s care? Meaning, have you signed off the case but you still come back every day to be with the family while the new physician carries out the family’s wishes? Or is the attentive hand-holding what happens only if the family decides to follow a path that you can follow as well? Does it make a difference if the family asking you to do this is a religious Jewish family?
 

If I have a relationship with a family, I will continue to see them, talk to them, see the patient, etc, even if someone else is taking over management of the patient. However, usually I dont have to turn over management to someone else. The reality as you know is that if a patient is in the ICU and on a ventillator there are many physicians taking care of the patient, internal medicine, ICU/pulmonary, neurology, etc, and any one of them can fulfill the family's wishes, most of the time it doesn't have to be me. I have not been in a situation where it has been a religious Jewish family(I have an affinity for Catholic medical institutions for reasons that I cannot comprehend). If a Jewish family is involved, I try to make sure they have access to rabbinical advice. If it is a religious family, and I thought they were making a choice inconsistant with Halacha, I would, with the family's permission, get the family rabbi involved and let him decide if and what persuasion is appropriate.
 

translation for whoever needs it: Halacha = Jewish law.

dilbert: many thanks for your answers. I'll have to give what you said some thought.