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« Stupic Mac Tricks | Main | Et Tu, Google? »

Thrown Off The Ambulance

I've had nothing to say about the Terri Schiavo case, because I don't know that much about it. But all of the major media, including The Corner, seem determined to rectify that situation. Or rather, they seek to inundate me with information about it, if not enlightenment.

I guess it's understandable why it's become such a compelling story--it's a heady mix of themes both political and philosophical. We have the nature of marriage, the fidelity of a spouse to both his marriage and to what he claims are his wife's desires, the importance of documenting those desires prior to such an event (though one can never truly know what one's feelings will be when it actually happens), the appropriate role of the states, the federal government, and the judiciary in deciding such personal and heart-wrenching situations, the definition of "persistent vegetative state" and the uncertainties of how to determine whether it truly persists in a particular individual, the absurd hypocrisy of allowing execution without trial by passive (but not active, even though they actually are) acts, the right to live, the right to die, the value of a life bereft of cognition, even (though this is one that few talk about) whether or not such a life can even be considered fully human, and the ultimate prospects for recovery from such a condition.

I'll ignore the politics and legal issues, which will clear out quite a bit of the underbrush. I'll also ignore all of the speculation as to the husband's motives and character, about which I know little, and actually care less, at least for the purpose of this discussion.

I'd like instead to delve more deeply into what I think has been ignored--the philosophical and ethical issues involved.

Is this euthanasia? It depends on how one defines it. Obviously, the courts want to rule that it isn't because it's against the law, but what is the ethical difference between withdrawing food and water from a forty-one year old unable to feed herself, and a one-month-old unable to feed herself? (I'll ignore for now the ethical absurdity of it being acceptable to starve and dehydrate someone to death, when that is a certain outcome of one's actions, but not to painlessly euthanize them.)

It's clearly not the age, because someone who was invalid and requesting food and water would be provided it in our society, or those who failed to do so would be charged with criminal neglect, and this would be true for a person of nine months or ninety years. It can only be the potential for humanity and a life that others would consider to be of "value." A baby has a full, cognizant, sapient life ahead of it, whereas the presumption in this case is that Mrs. Schiavo apparently does not.

We are told by numerous experts (with a few dissenters) that she has no cognitive function, or awareness of either her surroundings or her own existence. I have to wonder how they can know this.

Awareness of surroundings is easy enough to identify. Assuming that their sensory apparatus--eyes, ears, skin--are functional, one can move objects to see if they follow them with their eyes, or make noises to see if they turn at the sudden sensory input. Of course, any household pet (other than a pet rock) would pass this test. So surely that can't be a test, in and of itself, either. We have granted a special privilege to creatures that share our DNA structure, though in the future, as such things become ever more manipulable, the use of DNA as a definer of humanity will come to be seen as inadequate in the face of those things that truly make us human--our cognitive abilities, our emotions, our loves and fears, our laughter and tears. I don't know to what degree Terri Schiavo still retains those features, which are what I consider essential to being a human.

But more fundamentally, is she conscious? In an ultimate philosophical sense, how can one judge that for anyone, let alone for someone with whom we are unable to communicate on even the most basic level (again, assuming that to be the case, a matter which seems also to be in some dispute).

Years ago, the famous (well, among mathematicians and computer types, anyway) pioneer of computing theory, Alan Turing, came up with something called the Turing Test. It recognizes that there's no way to know with ultimate certainty that someone is conscious or self aware--we can only know that about ourselves--but that we make the assumption with what appear to be our fellow humans that if someone acts like they are, then they are. So the question arises, if we were to develop a machine that behaves like, indeed is indistinguishable from, a human in terms of its responses to questions, and in conversation, in what sense can we say it's not conscious as well? Other, that is, than to arbitrarily (and, though I hesitate to use the term, considering that its source is Peter Singer, in a "speciesist" way) define things that are inorganic and lacking human DNA as being intrinsically incapable of consciousness?

So, is Terri Schiavo conscious? Well, she certainly seems to fail a Turing Test. But suppose (and this, of course, is the most horrifying possibility), to turn the old insult on its head, the lights aren't on--the shades are for the most part drawn--but somebody is home. Suppose that she's fully aware of her existence, in all its pain and frustration, and is physically unable to communicate that fact to us.

It seems to me that there are two possibilities (recognizing gradations between them).

The first possibility is that there is, in fact, someone home. If so, then the state of her mind is important. If she wants to live, despite her husband's testimony, then it would seem important to let her do so, and hopefully, few would disagree--even her husband. This is in fact her family's (with the exception of her husband) belief.

If she wants to die, perhaps because she's in indescribable pain, or simply from the frustration of being trapped helplessly in her body with no prospect for escape, then of course it's more complicated.

After all, the people who are trying to keep her alive now (and I'm not referring only to her family) would, for the most part, still be doing so even if she were expressing her desire to end her life, since for the most part they find euthanasia morally repugnant (perhaps even if it meant to consign her indefinitely to a living hell). I don't think that they would do so because they are cruel people, but because they do seem (often irrationally) to value anything that resembles human life above all else, and they can't personally know what hell they're putting her through, any more than they can know with certainty as to whether or not she's conscious.

On the other hand, many (like, for instance, me) believe that the desires of the individual in this, perhaps the most personal decision possible, should prevail, if she's an adult. So unlike them, if I knew with certainty that Terri Schiavo wanted to end her existence, I would not only allow her to do so, but I'd help her do so as quickly and painlessly as possible, particularly given how long she's been in this frustrating state.

The second possibility is the one that the courts have ruled to date is in fact the case--that she is completely uncognizant of herself or anything else--a "vegetable," albeit one composed almost entirely of protein, with few carbs. There are in turn two possibilities attached to this one. First, that this is a permanent state, irreversible. Again, this is the current position of the courts. The second, though, is that given either time, or technology (a possibility that I've heard no discussion of to date), she will at least improve, if not be talking and running and laughing again.

If we can know, with absolute certainty, that she is vegetative, and that it's persistent, then I have no problem with pulling the feeding tube, other than in fact that's a needlessly long way to go about the process of ending this (what I would consider) non-human life. In fact, it seems to me that, if there really is no one home, it doesn't matter in what manner we do so, from an ethical standpoint, other than the standpoint of human decency. We could chop off her head, bury her alive, put her through a wood chipper, leave her in the woods to let the animals feed upon her, etc. All of these would be outrages to her family and loved ones, of course (hopefully including even her maligned husband), which is why we would do none of them, but it certainly wouldn't matter to her. The point is, that we could euthanize her, and not play this bizarre philosophical game of pretending that we're not really killing her by denying her food and water--that her "dying process is continuing," as though it's something passive, with which those who (actively) removed her feeding tube have nothing to do.

But the second possibility is the one that I find most interesting, for the purposes of this (by now) long discussion.

Suppose that she is in a vegetative state, but that it can be repaired in the future, with technology not yet in existence, or perhaps currently imagined, even if she won't heal from it naturally, on her own. Those long familiar with my weblog will know where I'm going with this.

What Terri Schiavo's family is doing is asking to give her an ambulance to the future, whatever that future may hold. They want to keep her alive for the simple aphorism that where there is life, there is hope. They considered her to be in that ambulance, no matter how clunky with current medical knowledge (and perhaps given her husband's orders, for good or ill), while on the feeding tube. To remove it now is to open the back doors, and kick the patient out in the street to die, bereft of any more hope for the future.

Terri Schiavo may in fact be already dead, by the definition of cryonicists, because if her brain is as damaged as some claim, anything resembling her, in terms of personality and memories, is long gone, with no hope for return. She has suffered the ultimate, irretrievable death--information death. Even if medical technology improves in the future to repair her mind, they might restore someone to full health, who physically resembles Terri Schiavo, or Terri Schindler, but it will be a different person, with different memories, and perhaps a completely different nature. It's someone who Terri's friends and family may get to know, and come to like and even love, but it won't be Terri, and never will be Terri, no matter how strong the resemblance.

Cryonics patients, on the other hand, are trying to preserve what (if the pessimists about Terri are right) she has already lost beyond recovery. They want to preserve their memories and personality currently residing in their intact minds. Their bodies (and the number of chromosomes in their DNA) are of secondary importance (though to many, still important). A human brain frozen today cannot be repaired today, but we cannot say what the morrow brings.

So from that standpoint, if Terri is as non compos mentis as the courts have ruled (again, a premise granted only for the sake of this discussion), then patients in cryonic suspension, particularly those put there more recently, under better, cell-preserving protocols, are more alive than Terri Schiavo is, even though she breathes, and needs a feeding tube, and they have no metabolism at all.

This, of course, has been a long-winded way of saying that I don't ultimately know what to do about Terri, because I don't know if (by my lights) she's alive or dead. If she's alive, and wants to remain so, she should. If she's alive and wants to die, she should be able to do that. If she's dead, then it doesn't matter. It's a hard case, and as the old saying goes, hard cases make bad law, which is why what's going on in Washington is also troubling.

What truly concerns me about this case, though, and ultimately puts me on the side of the family, is that I've seen how the courts have dealt with the rights of innocent people (cryonicists) desperate to save themselves, but who have callously been granted the equivalent of a death sentence. Sadly, courts cannot always be trusted in such matters, because judges cannot always be trusted to be scientifically literate or even amenable to simple logic. I'm concerned that Terri Schiavo hasn't gotten her day in court, or that if she did, it was a bad one, and I think that she should get one more bite at the apple, if there's any possibility at all that she has the teeth for it. Let's make sure she's really dead before we throw her off the ambulance.

Posted by Rand Simberg at March 22, 2005 08:06 AM
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Excerpt: I forgot to mention that Rand Simberg over at Transterrestrial Musings has come down on the side of hope. That, more than the "fetishizing of life" that we are accused of by the death brigade, is what this whole thing...
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Comments

I've heard a member of the team attending her at the hospital, on CNN I believe, that most of the cerebral cortex has been replaced by spinal fluid, that there is "no brain there". That highlights the difficulty of determining when human life ends. To take an extreme example, if a decapitated body was artifically sustained, could that be reasonably considered as a living human being? Personally, I think we die when our brain dies even though other organs continue, or can be made, to function.

But that begs the question of society's right to interfere in the intensely private business of an individual's decision whether or not to artificially prolong life when their condition would otherwise lead to death and from which there is no hope for recovery. (This case seems to meet both conditions.) I'm not sure such a right exists. It is unclear to me if Schiavo's parents reject her husband's assertion that she told him she did not want to be artificially sustained. But, the law defaults to the spouse in these cases, not the parents, and I'm more inclined to side with her husband than to legitimize the right of society to intervene in similar situations.

Posted by billg at March 22, 2005 11:58 AM

Your's is one of the most complete and thoughtful essays I've read on this case and I thank you for taking the time to share your thoughts with us.

I do, sadly (since everything about this case is just that, sad), disagree with your final desire. It seems to me that after weighing both the good/bad, known/unknown your essay conveyed a sense of unknowingness on your part, which I agree with fully. However, you then end it with suggesting that Terri hadn't gotten her fair day in court and, as such, should be given that. I ask you, even if true and she were given her fair day in court, would that change any of the aspects of her case as you've so eloquently articulated? I cannot for the life of me see how more court time will do this?

As such, without knowing what her "real" wishes would be, I'm left with only my own personal experience with similar people (loved ones) to draw on and in each of those instances, they all desired to cease their existence rather than live a horrid life of widening bed sores, muscles anthropy, eventual organ failure and huge emotional burdening to their loved ones.

Posted by Sailfish at March 22, 2005 01:20 PM

The only thing more court time might do is better bring to light her true condition. It may not do that, either, but I've read enough troubling things about the case to think that it's worth one more shot, after all these years. And I should add that none of the cases I've laid out justify the current process of withdrawal of food and fluids. Either kill her, or keep her alive, but don't draw it out like that.

Posted by Rand Simberg at March 22, 2005 01:29 PM

Very interesting essay. For everyone's information, there's a Dr. William Hammesfahr, a neurologist, who examined Terri for about ten hours and feels that she does have higher brain function and could improve with proper rehab.

In any case, I think she needs to be allowed to live longer while all possibilities are exhausted.

Posted by Mark R. Whittington at March 22, 2005 02:06 PM

I can think of few things worse that to be in the state this poor woman finds herself in today. She has gone from daughter to wife to patient/victim to court pawn, and now political fodder. Iím making out a living will tonight. God help us all in what we do.

Posted by jjs at March 22, 2005 02:09 PM

I am skeptical of the ronin doctors willing to come forward and say she might come out of it. The issue is sufficiently politically and religiously charged that I am sure they could find someone to make that assertion, particularly because it could not be falsified.

May I suggest an alternative approach. How about if the remains be placed in cryonic suspension (the critics could pay for it)? This may offer it the best chance, at some point in the future, of again housing a conscious person. I doubt brain repair/reconstruction on the scale it apparently would require is going to be available within the natural lifespan of her remnant.

Posted by Paul Dietz at March 22, 2005 02:18 PM

In some sense, that was sort of what I was hinting at, Paul. The problem is that most of the people clamoring to save her life find cryonics (at best) weird and creepy.

Plus, as I point out, if she really is as brain damaged as the pessimists say, then you're making a double bet with cryonics--that cryonics will work, and that there's enough of her left to work with, and still get Terri Schiavo back. More likely, as I said, you'll get someone else back that looks like her, but won't have any other resemblance. It would be kind of like cloning (which many of the same suspects also find creepy), except you couldn't even count on the brain development to occur per the genetics, since the brain repair would probably be more mechanical and reconstructive in nature, rather than organic as directed by the DNA. At least most cryonicists have a functional brain before they go into the vat.

Posted by Rand Simberg at March 22, 2005 02:33 PM

I agree with anyone who thinks this is becoming political fodder. However, anyone who thinks the right/conservatives are the ones who started the rhetoric, truly needs to go look up the time line on this mess.

Its just another mess caused by a liberal activist judge.

This ladies parents have agreed to take care of her, foot the bills, and allow her husband to get a divorce.

What I don't understand is WHY this bozo won't just walk away and let it be? If she actually told her husband to let her die if she became this way, how come hubby waited 7 years to tell anyone about that little husband wife confab!!

Posted by Steve at March 22, 2005 02:56 PM

If we establish the right of society to intervene to artificially sustain the life someone who has lost, without hope for recovery, most of her brain but whom society, drien by emotions and ignorance, believes should be sustained, aren't we also establishing the right of society to intervene to end the life of someone whose brain survives but is not considered worthy of survival? Society and its politicians have no right to intervene in these situations.

Posted by billg at March 22, 2005 05:08 PM

If we establish the right of society to intervene to artificially sustain the life of someone who has lost, without hope for recovery, most of her brain but whom society, drien by emotions and ignorance, believes should be sustained, aren't we also establishing the right of society to intervene to end the life of someone whose brain survives but is not considered worthy of survival? Society and its politicians have no right to intervene in these situations.

Posted by billg at March 22, 2005 05:08 PM

What I don't understand is WHY this bozo won't just walk away and let it be? If she actually told her husband to let her die if she became this way, how come hubby waited 7 years to tell anyone about that little husband wife confab!!

Actually, from this timeline, it appears that this is the latest of many attempts by the husband to end her life in a similar way dating back to 1993. In 1993 (which is also the year that the lawsuits between the husband and her family started), he got a "do not resuscitate" order "in her medical chart" and the above site claims that he attempted to get doctors to not treat her for a couple of infections starting in August (or maybe early according to other reports) of 1993.

A number of disturbing things here. First, we have twelve years of lawsuits and acrimony. Second, it appears to have started within a few months of the settlement of the last of the malpractice lawsuits. A description of her physical state (that's Dr. William Hammesfahr's inspection mentioned above which he did in September 2002) seems to rule out the legal Florida definition of "persistent vegetative state". Also unclear is the medical problem that left her in her current state.

In this case, all parties have conflicts of interest due to the money that still remains in Terri Schiavo's trust.

Posted by Karl Hallowell at March 22, 2005 05:10 PM

Here is the timeline prepared by the GAL selected by Jeb Bush. Hardly a liberal activist judge. ;-)

http://abstractappeal.com/schiavo/WolfsonReport.pdf

Posted by Bill White at March 22, 2005 07:15 PM

Gosh, Bill, I must have missed the part of the essay where I said this had anything to do with "liberals" and "conservatives." Can you point it out?

Or are you just being partisan again?

Posted by Rand Simberg at March 22, 2005 07:25 PM

You didn't, Rand.

Steve did.

A few comments upstream.

Posted by Bill White at March 22, 2005 07:53 PM

Quote: "but what is the ethical difference between withdrawing food and water from a forty-one year old unable to feed herself, and a one-month-old unable to feed herself?"

Its my understanding that Terry can take on some food and water with a baby bottle as well. But a grown human body cannot get enough caloric intake from a baby bottle. A 10 lbs. baby doesn't need a tube inserted into the abdomen to sustain metabolism. There are birth defect where a babies can be born without a brain in essence. Ventilators and PEG tubes can keep the body alive though. I think there is about as much point to sustaining a child born without a brain as there is to sustain Terry.

Terry chose a lifestyle where she binged and purged herself to death just so she could look better. Her vain decisions deprived her body of nutrients, caused an electrolyte imbalance, and reduced her potassium levels to the point where her heart could no longer beat effectively enough to feed oxygen to her brain. It only takes a matter of minutes for cerebral necrosis to set in. Now I think its great that modern medicine was able to sustain her body and return it to a point where she is able to get all the nutrients it needs that she otherwise denied herself even. The human brain is an amazing organ system and when severely damaged is capable of rewiring itself to restore functionality. Its my understanding that 1 year is the magic number for someone to return from a persistent vegetive state. Past 1 year the patient's chart is changed from persistent vegetive state to permenant vegetive state.

Most people that get a PEG tube inserted are elderly people. Either they are so out of it that they no longer eat and drink properly or worse yet they chew on their tongue. Many of these people are coherent enough as this point though where they willingly sign their life away with a do not resuscitate order.

Before anyone has to say whether its our right to sustain life as long as possible they should spend some time in a hospital and see for themselves how life can reach a point where just letting them go is really the best thing for them. You'd be surpised how many sick and old people just reach a point where they start pulling their IV's out, pulling their PEG tubes out, even pulling their own foley catheters and rectal tubes out because they just want to die. Its about dying with dignity, not restrained to the bed living out the last days of your life with tubes coming out of you every which way.

Posted by Josh "Hefty" Reiter at March 23, 2005 07:00 AM

Rand,

Good editorial on the medical side of this argument. Many though have mentioned the political side of this argument. Should society impose its wishes in this case?

Well, I think the original question is really in play here, should the parents' or the husband's views prevail? Current laws (where society has previously imposed itself) says that the husband has guardianship.

Those laws are based on traditional understanding of marriage, in that the parents gave their daughter to a man to live with her in good times and bad; sickness and in health, til death do them part. Well, it is bad times and she is sick, but because death hasn't parted them, she is inconvient to Michael Schiavo.

I'll admit, I have respect for the man, because he's having to go through this situation. He's forced to make tough decisions. Where I run into an obstacle is understanding what is tough about returning guardianship to her parents.

Does he have to do this legally? I don't think so, by Florida law. Should he? Not if he is absolutely certain that death is what she wanted (a comment after a movie is not convincing to me). At some point though, I think he should give into the realities, and accept his new life, and let Terry's parents have the rest of her life.

Is that imposing my will? Maybe philosophically, but then I'm not actually protesting my government to get involved. On the opposite, I rather this had ended in the state courts.

Posted by Leland at March 23, 2005 07:38 AM

Euthanasia has always been a problematic issue in many countries, a question, which doesn't have the right answer... From one hand, everybody has the right to die... From another hand, how can we know he's in a sound mind when making such a decision? This is so obvious... what I think is that it's not right to prohibit euthanasia, as there's a real demand for it from the society... However, if we allow it, the law should be really strict to avoid crime.

Posted by Ambulance Nurse at July 7, 2005 04:12 AM

Euthanasia has always been a problematic issue in many countries, a question, which doesn't have the right answer... From one hand, everybody has the right to die... From another hand, how can we know he's in a sound mind when making such a decision? This is so obvious... what I think is that it's not right to prohibit euthanasia, as there's a real demand for it from the society... However, if we allow it, the law should be really strict to avoid crime.

Posted by Ambulance Nurse at July 7, 2005 04:13 AM


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