The Case of Terri Schiavo: When Does Dignity End?

In the American west in April 1879, a superior court rejected, thankfully, a District Attorneys claim that a local Indian leader was not a person "within the meaning of the law." A month later Standing Bears brother, Big Snake, tried to leave the reservation. The Army General in command explained to Big Snake that the court decision granting his brother personhood applied only to Standing Bear, not to him. Big Snake didnt understand, and was shot to death while resisting arrest.¹

Exactly what human qualities constitute personhood have been debated for centuries, perhaps beginning in earnest in the sixteenth century with the discovery of Africa and South America by Portuguese and Spanish explorers. Their subsequent enslavement of portions of the native population led to intense philosophical debate within the Church. One side argued that the natives primitive culture and habits testified to their subhuman nature, justifying their enslavement by the more culturally advanced Europeans. The other side, the winning side in the end, stressed that primitive habits and lack of education were not sufficiently egregious shortcomings to disqualify the natives from the human rights due all men made in Gods image and likeness.

This debate was the match that lit a slow fuse of thought that burned its way through the centuries. The explosion it eventually ignited blew slavery to bits, gave women the right to vote, and humanized factory-working conditions, among many other accomplishments. Its supreme achievement resulted in the universal recognition of inalienable human rights in the Christian countries of the West, rights guaranteed in law.

Unfortunately, these rights, thought to be "self evident" and "inalienable" by the writers of the Declaration of Independence, are proving more difficult to define and defend only slightly more than two centuries after their manifest nature was so famously proclaimed. The massive legal seawall protecting human rights is eroding at its base.

The sixteenth-century debate over personhood and human dignity discussed whether incest, lack of a written language, nakedness, human sacrifice, child abandonment, and other primitive habits disqualified a tribe from the human community and its corresponding legal protections. The current debate over personhood concerns no such matters of behavior or custom. Todays debate over dignity concerns matters of dependency.

There is a growing tendency to justify an attack on any life that exists in a condition of radical dependency. Pro-abortionists, for example, no longer quibble over whether preborn life is human life or not, since sophisticated imaging technology has removed that weapon from their arsenal. Yet they can argue that the childs state of complete dependence on its mother excludes it from the circle of legal protection afforded autonomous persons.

The real and theoretical achievements of the sixteenth-century debate are thus being slowly unraveled. The bonds tying personhood to human life are being snipped cord by cord. So while a pro-abortionist will acknowledge that the baby in the womb is a human life, that acknowledgement itself is insufficient to guarantee that same baby the right to life. In other words, just because someone is alive does not therefore mean that he is a person. Only autonomous human life thus rises to the level of personhood and its legal protections. Dependent human life, however, because of its need for outside aids to maintain itself, does not qualify for personhood. We are thus left with a new category of individual: the human non-person.² That this sounds ridiculous does not preclude people from believing it. Just ask Big Snake of the Poncas.

Terri Schiavos situation

Moving on from the abortion debate, the argument that human non persons have no rights is now being applied to those on the other end of lifes spectrum, to the elderly and terminally ill. The withdrawal of artificially delivered nutrition and hydration from the terminally ill is the next battleground in the struggle to defend the dignity of marginalized human life. The circumstances of Floridian Terri Schiavo highlight the difficulty of discerning whether certain medical procedures violate or promote human dignity. While hard cases dont make good law, Schiavos circumstance crystallizes all the major issues surrounding care for the terminally ill, and provides an opportunity for priests to preach and educate our people about human rights, the inherent dignity of all human life, and the limits of medical treatment.

The general principles of Catholic Health Care and their practical applications are explained in the Ethical and Religious Directives for Catholic Health Care Services (the ERDs.) Written by the Committee on Doctrine of the USCCB and approved by the Vatican, these Directives are normative for Catholic Health Care in the U.S. They do not attempt the impossible by trying to solve every conceivable health care dilemma. They do, though, provide enough authoritative guidance to help untangle the twisted knot of concerns which difficult end of life situations present.

In general, the Churchs position on artificial nutrition and hydration (AN/H) is summed up in Directive # 58: "There should be a presumption in favor of providing nutrition and hydration to all patients, including patients who require medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the burdens involved to the patient." Leaving aside the question of benefits and burdens for the moment, the Churchs position basically means that when a patient can no longer swallow food and water, it is presumed that nutrition and hydration will be delivered to that patient artificially.

There are two important exceptions to this general position, summarized in the Introduction to Part Five of the Directives: "hydration and nutrition are not morally obligatory when they bring no comfort to a person who is imminently dying or when they cannot be assimilated by a persons body."

According to the first exception, when death is imminent AN/H can be withdrawn, provided it is giving no comfort to the patient. In such circumstances the lack of nutrition and hydration does not cause death. The disease process runs its course before the lack of nutrition and hydration has the chance to adversely affect the body. The only difficulty with this exception is that doctors skills at predicting death are overrated. Nonetheless, to the extent that an imminent death is foreseeable, AN/H need not be continued if it gives the patient no comfort.

The other main exception to the presumption of providing AN/H concerns those patients suffering from stomach cancer, liver or kidney problems, and other pathologies in the abdominal cavity. As their diseases progress it becomes impossible for them to assimilate any nutrition or hydration whatsoever, even if artificially delivered. In such cases nutrition and hydration is considered futile care since it provides no nourishment. Because it goes undigested, it can also hasten the patients death by causing bloating and other complications.

Terri Schiavo suffered severe brain damage after cardiac arrest deprived her brain of oxygen for ten minutes in 1990. Since that time she has never been on a ventilator, yet she is unable to swallow food and water naturally. Applying the principles and exceptions stated in the ERDs allows us to come to some conclusions about her situation.

Terri Schiavos death is not imminent. She is not on a ventilator, dialysis, or other life sustaining equipment. She is not awaiting a transplant or other major surgery. She is not in pain. She has two parents and siblings who love and care for her. She has access to good health care. If given basic care and food and water her life will continue in more or less its present state. The very fact that her present state is pretty miserable is precisely why some think she should die.

The Church does not advocate the use of life sustaining technology at all costs, but is against the withdrawal of technology for the express purpose of causing death (ERDs, Intro. Part V.) Those advocating Terri Schiavos death, including her husband, are not making their case on medical grounds, but on Terris radical condition of dependency and low quality of life.

As John Paul II points out in Evangelium Vitae, the meaning of death is closely tied to the meaning of life. If a culture erodes the meaning of life its no wonder that changes in the meaning of death follow close behind. "When the prevailing tendency is to value life only to the extent that it brings pleasure and well being, suffering seems like an unbearable setback, something from which one must be freed at all costs. Death is considered senseless if it suddenly interrupts a life still open to a future of new and interesting experiences. But it becomes a "rightful liberation" once life is held to be no longer meaningful because it is filled with pain and inexorably doomed to even greater suffering." (#64)

Because Terri Schiavo cannot speak, express much emotion, enjoy what life has to offer, or have a life "still open to a future of new and interesting experiences" some consider her life expendable. Terri has never said "Put me out of my misery." It is more likely that her continued survival bothers the consciences of those who find the emotional and practical demands of caring for her too much. She has become a drain on their quality of life. They, in a sense, want to put her out of their misery. This is a far cry from the ideals of Evangelium Vitae: "True compassion leads to sharing anothers pain; it does not kill the person whose suffering we cannot bear." (#66)

The Terri Schiavo case presents a teaching moment for the Church, which translates into a learning moment for our parishioners. In sum: we defend human life in all its forms, regardless of its condition of dependency; medical technology is to be used to sustain life unless that technologys burdens outweigh its benefits; no one is obligated to use extraordinarily expensive, painful, ineffective, and risky technologies to sustain life; and AN/H is generally not considered extraordinary treatment.

A summary and talking points

• Food and water is not medicine. When were hungry we dont say "Im starving, lets go to McDonalds and pick up some medicine."
  
  
• Artificial nutrition and hydration should not be categorized as medical treatment. Its medical care, not medical treatment. It is on a par with the clean sheets, warm room, and bed care given even the most terminal patients.
  
  
• Artificial nutrition and hydration is not extraordinary care. At times, though, it can be futile care.
  
  
• There is a huge difference between keeping a patient on a ventilator and artificially delivering food and water. A ventilator is expensive, requires medical supervision, leads to infection, cannot be used for more than a few weeks, is extremely uncomfortable, and replaces a major body function breathing. It is clearly extraordinary care, unlike artificial nutrition and hydration.
  
  
• The technology used to deliver artificial food and hydration is not excessively burdensome. It is not very expensive, painful, rare, difficult to use, or compromising of human dignity.
  
  
• Not being able to swallow is not a fatal pathology.
  
  
• What is the familys intention when removing food and water? Is the intention to cause death?
  
  
• "What is grandma dying of? Is she dying of her disease process? Or is she dying of a lack of food and water?"
  
  
• Does human dignity decline along with the ability to enjoy life? Doesnt imperfect human life show in a more tangible and powerful way our truly dependent nature before God?
  
  
• Food serves the same purpose in a terminally ill person as it does in a healthy person. It keeps him alive. If a healthy person is denied food and water, hell die. If a sick person is denied food and water, hell die.
  
  
• The Church focuses more on the inherent value of life than on the relative quality of life. Human life is not merely an instrumental good, but an inherent good. It is a good of the person, not just for the person.

Endnotes:

1. Raymond Dennehy, Anti-Abortionist at Large, (Trafford Publishing, Victoria BC, 2002) Pg. 146. Dennehy is quoting from an essay by Germain Grisez entitled "When Do People Begin."
   
   
2. For a summary of the philosophical roots of the "human non person," see Torchia, Joseph, Postmodernism and the Persistent Vegetative State, The National Catholic Bioethics Quarterly, summer 2002. Pg. 263.