What Was the Legal Controversy at the Center of the Terri Schiavo Case?

General Reference (not clearly pro or con)
Timothy Quill, MD, Professor of Medicine, Psychiatry, and Medical Humanities at the University of Rochester, explained the legal complexities underlying the Terri Schiavo case in his Apr. 21, 2005 article "Terri Schiavo - A Tragedy Compounded" that appeared in the New England Journal of Medicine:

"In 2002, the Florida trial court judge conducted six days of evidentiary hearings on Ms. Schiavo's condition, including evaluations by four neurologists, one radiologist, and her attending physician... The trial court judge ruled that the diagnosis of a persistent vegetative state met the legal standard of 'clear and convincing' evidence, and this decision was reviewed and upheld by the Florida Second District Court of Appeal. Subsequent appeals to the Florida Supreme Court and the U.S. Supreme Court were denied a hearing.

So what was known about Terri Schiavo's wishes and values? Since she unfortunately left no written advance directive, the next step would be to meet with her closest family members and try to understand what she would have wanted under these medical circumstances if she could have spoken for herself, drawing on the principle of 'substituted judgment'...

Here Ms. Schiavo's story gets more complex. Michael Schiavo was made her legal guardian under Florida law, which designates the spouse as the decision maker above other family members if a patient becomes irreversibly incapacitated and has not designated a health care proxy. After three years of trying traditional and experimental therapies, Mr. Schiavo accepted the neurologists' diagnosis of an irreversible persistent vegetative state. He believed that his wife would not want to be kept alive indefinitely in her condition, recalling prior statements that she had made, such as 'I don't want to be kept alive on a machine.' The Schindler family, however, did not accept the diagnosis of a persistent vegetative state, believing instead that Ms. Schiavo's condition could improve with additional rehabilitative treatment...

The right of competent patients to refuse unwanted medical treatment, including artificial hydration and nutrition, is a settled ethical and legal issue in this country — based on the right to bodily integrity... The Schiavo case raises... challenging questions about how to define family and how to proceed if members of the immediate family are not in agreement.

The relevant Florida statute requires 'clear and convincing evidence that the decision would have been the one the patient would have chosen had the patient been competent or, if there is no indication of what the patient would have chosen, that the decision is in the patient's best interest.' Since there is no societal consensus about whether a feeding tube is in the 'best interest' of a patient in a persistent vegetative state, the main legal question to be addressed was that of Terri Schiavo's wishes."

Apr. 21, 2005 - Timothy E. Quill, MD 

Rebecca Dresser, JD, Daniel Noyes Kirby Professor of Law and Professor of Ethics in Medicine at Washington University Law School, in a May-June 2005 article in the Hastings Center Report entitled "Schiavo's Legacy: The Need for an Objective Standard," explained:

"Over the past three decades, clinicians and legal authorities have constructed a basic approach to treatment decisions for incapacitated patients, but as the passions this latest case unleashed suggest, this approach is both unfinished and vulnerable to challenge. Schiavo exposed weaknesses and gaps that demand our attention...

Since Terri Schiavo had no living will, the Florida judges applied the 'substituted judgment' standard to reach a decision about her care. This standard aims to produce the decision the patient would make if able. The evidence adduced to gauge what that decision would be includes the individual's informal remarks, her religious and cultural background, and whatever is known about her attitudes toward medical care. The courts found that Ms. Schiavo's former statements constituted clear and convincing evidence that she would refuse the medical nutrition and hydration prolonging her life.

Yet the courts also recognized that the evidence was not all that strong.

Much of the opposition to the Florida court rulings was built on weaknesses in the substituted judgment standard. The testimony about Ms. Schiavo's previous statements was general enough to raise doubt about whether she would indeed have refused nutrition and hydration...

Decisions based on the substituted judgment standard can be influenced by people reporting and interpreting the evidence about patients' preferences. Many courts evaluating treatment decisions for patients diagnosed as permanently unconscious have accepted the patients' earlier general remarks as sufficient evidence of a wish to refuse treatment. But the case of Terri Schiavo demonstrates that this approach is open to attack."

May-June 2005 - Rebecca Dresser, JD 

Lindsay Hampson, a Fellow in the Department of Clinical Bioethics at the National Institutes of Health, and Ezekiel Emanuel, MD, PhD, Chair of the Department of Clinical Bioethics for the Warren G. Magnuson Clinical Center at the National Institutes of Health, explained in their July-Aug. 2005 article "The Prognosis For Changes in End-Of-Life Care After the Schiavo Case" that appeared in Health Affairs:

"The Terri Schiavo case transpired, targeting the single issue in which definitive guidance and national consensus has been lacking. First, there are no substantive criteria for when to terminate care in the case of individuals who are incompetent and have not left advance directives. Furthermore, data show that leaving the decision to patients' family members or other proxies is less than perfect because surrogate decisionmakers do not necessarily know the wishes of the patient."

July-Aug. 2005 - Ezekiel Emanuel, MD, PhD 
Lindsay Hampson 

Robert Truog, MD, Director of Clinical Ethics for the Division of Medical Ethics and the Department of Social Medicine at Harvard Medical School, and Thomas Cochrane, MD, Edmond J. Safra Faculty Fellow in Ethics at Harvard University, in their Dec. 2005 article "Refusal of Hydration and Nutrition: Irrelevance of the 'Artifical' vs 'Natural' Distinction" that appeared in the Archives of Internal Medicine, commented:

"Those who oppose the refusal of tube feedings on behalf of patients like Terri Schiavo argue that the kinds of medical interventions that may be refused should be limited to those that typically occur in medical settings and that require special medical expertise, such as mechanical ventilation or dialysis. Once a patient has had a feeding tube surgically placed in the stomach, they claim, then feeding the patient requires no special technology or expertise and therefore should not be seen as a medical intervention. As such, they claim that providing food and water to a patient through a feeding tube is not an act that can be refused by surrogates, but rather is an obligatory part of simple humane care.

On the other hand, those who support the rights of surrogates to withdraw tube feedings from these types of patients insist that tube feedings are indeed a medical intervention."

Dec. 2005 - Thomas Cochrane, MD, MBA 
Robert Truog, MD