Editor:

The case of Terri Schiavo is tragic. The fervent political tug-of-war surrounding this tragedy only compounds the ordeal suffered by those who love her. This political clash raises several important issues about the care of severely disabled persons, the definition of “meaningful life,” and the paramount question of who should make critical medical decisions for those who cannot speak for themselves. Unfortunately, the bizarre and fanatically accusatory letter by James Snow, “A skewed perspective on life” (Oct. 30), fails to elucidate any of these matters.

Terri Schiavo sustained massive brain damage when her body was deprived of oxygen following a cardiac arrest. She progressed from a comatose state to what many now argue is a “persistent vegetative state.” Terri’s husband has argued that such a “vegetative” condition is not what Terri would have wanted and is not a “meaningful” existence. Some doctors have supported Michael’s contention and they believe that withdrawing tube feeding, which would result in Terri’s death, is ethical and even compassionate because Terri is incapable of meaningfully interacting with the world around her. Many others, however, most notably Terri’s parents, argue instead that Terri is alert, interactive and does not want to die. In other words, for them, Terri is emphatically not “vegetative.”

Snow offers no real insight into whether Terri is vegetative or not. He instead seems to think that all of this arguing is simply a matter of semantics. Snow charges Michael Schiavo with a “demonic reconstruction of our language” where “mentally disabled quadriplegics or paraplegics are now considered to be in a persistent vegetative state.” He then writes that “if Terri Schiavo was truly in an authoritative and verifiable persistent vegetative state, then no amount of comfort care could prevent a person without functioning nervous and cardiopulmonary systems from dying.” This statement is manifestly false and betrays a fundamental lack of understanding about human physiology, brain death and clinical death.

Many people, including the passionate but ill-informed Snow, seem confused about the term “vegetative.” This word has a specific clinical definition that has nothing at all to do with whether someone is quadriplegic, mentally disabled, or has a functioning nervous or cardiopulmonary system. The crux of the issue is Terri’s awareness of her surroundings and her ability to interact in such a way that an unbiased observer would conclude that her actions have “meaning.” Can she follow even rudimentary commands? Can she communicate her wishes in a consistent fashion? Can she respond to stimuli utilizing the higher functions of her brain and not simply by basic, hard-wired reflexes? Many of those who have recently observed Terri, including various doctors, do not agree on the answers to these questions. Some argue that she does communicate, while others claim her actions are without meaning.

Interestingly, Snow ignores these questions and instead constructs his argument in a way that upholds his zealous and uncritical support of the principle of “life.” In his simple view, because Terri Schiavo has “life,” she inevitably must not be vegetative. Because she “has a functioning nervous and cardiopulmonary system,” she indisputably must not be unaware and unresponsive. Yet the harsh truth is that electrical activity in the heart does not necessarily imply a vital mind. Perhaps the most cruel aspect of hypoxic brain injury is that it often destroys higher functions of the central nervous system that allow reason, memory and emotion while preserving the rudimentary, mechanistic functions of the autonomic nervous system that allow the heart to continuing beating and the lungs to continue respiring.

Snow goes so far as to state that Michael Schiavo and “his agents of death” have defined “vegetative” in a manner that “would include the physical and vocal ability of a Stephen Hawking, Terri Wallis or Christopher Reeve.” In a striking breakdown of logic, Snow fails to include in his comparison the mental ability of these people-the one crucial factor that altogether distinguishes them from Terri Schiavo. As already stated, the term “vegetative” has little to do with physical ability and everything to do with higher thought processes. The comparison to Hawking and Reeve is so utterly wrongheaded that it defies all reason. No person with even a basic understanding of medicine would conclude that these men are vegetables. In fact, the entire tragic battle over Terri’s life and death continues because she cannot speak for herself. If you are wondering whether Christopher Reeve wants to continue living in his present condition, just ask him. See the difference? If Terri Schiavo is truly vegetative, then all the “physical therapy, mobility devices and communication devices” in the world won’t make any difference in allowing her to make choices and communicate her wishes to others.

I don’t know if Terri Schiavo is vegetative. Even some of the doctors who have evaluated her don’t agree. What scares me is that so many people have made their decisions based on political battle lines that they drew long before hearing of this case. In Terri’s circumstances alone, numerous doctors, family members, lawyers, judges, state legislators, and even the governor have chosen their respective sides. As I write this, the debate continues with no clear answer to the question, “Who should make this decision?” I have communicated my wishes to my wife if I were in a similar situation as Terri Schiavo. What I have seen in this case offers me little comfort that my wishes will be respected. For those of you who think that a living will is the answer, think again. Those documents are routinely subject to the same semantic manipulations that are being bandied about between both sides in this case. In fact, because of the innumerable ambiguities encountered in living wills (do you really think you can anticipate every possible medical contingency?), medical decisions are often deferred to family members even in the presence of a living will. And after witnessing the actions of the Florida government, it is clear that some political forces avidly defending the term “life” may very well impose their beliefs on any of us. The question of who should ultimately make such a decision is complex. I’m not sure I have the answer. I can say, however, that it should not be James Snow, or Jeb Bush or anyone else who favors an unyielding and fervent dedication to the ideal of “life” without the reason or knowledge to accept the complexities of death.

Timothy Schaat

M.D. Alumnus