More Schiavo
By Paul J Cella Posted in User Blogs — Comments (14) / Email this page » / Leave a comment »
Here is an outstanding essay by Robert Johansen. It contains such illuminating details as this:
Terri's diagnosis was arrived at without the benefit of testing that most neurologists would consider standard for diagnosing PVS. One such test is MRI (Magnetic Resonance Imaging). MRI is widely used today, even for ailments as simple as knee injuries -- but Terri has never had one. Michael has repeatedly refused to consent to one. The neurologists I have spoken to have reacted with shock upon learning this fact. One such neurologist is Dr. Peter Morin. He is a researcher specializing in degenerative brain diseases, and has both an M.D. and a Ph.D. in biochemistry from Boston University.
In the course of my conversation with Dr. Morin, he made reference to the standard use of MRI and PET (Positron Emission Tomography) scans to diagnose the extent of brain injuries. He seemed to assume that these had been done for Terri. I stopped him and told him that these tests have never been done for her; that Michael had refused them.
There was a moment of dead silence.
"That's criminal," he said, and then asked, in a tone of utter incredulity: "How can he continue as guardian? People are deliberating over this woman's life and death and there's been no MRI or PET?" He drew a reasonable conclusion: "These people [Michael Schiavo, George Felos, and Judge Greer] don't want the information."
Or this:
Dr. Cranford was the principal medical witness brought in by Schiavo and Felos to support their position that Terri was PVS. Judge Greer was obviously impressed by Cranford's résumé: Cranford travels throughout the country testifying in cases involving PVS and brain impairment. He is widely recognized by courts as an expert in these issues, and in some circles is considered "the" expert on PVS. His clinical judgment has carried the day in many cases, so it is relevant to examine the manner in which he arrived at his judgment in Terri's case. But before that, one needs to know a little about Cranford's background and perspective: Dr. Ronald Cranford is one of the most outspoken advocates of the "right to die" movement and of physician-assisted suicide in the U.S. today.
In published articles, including a 1997 op-ed in the Minneapolis-St. Paul Star Tribune, he has advocated the starvation of Alzheimer's patients. He has described PVS patients as indistinguishable from other forms of animal life. He has said that PVS patients and others with brain impairment lack personhood and should have no constitutional rights. Perusing the case literature and articles surrounding the "right to die" and PVS, one will see Dr. Cranford's name surface again and again. In almost every case, he is the one claiming PVS, and advocating the cessation of nutrition and hydration. [. . .]
In cases where other doctors don't see it, Dr. Cranford seems to have a knack for finding PVS. Cranford also diagnosed Robert Wendland as PVS. He did so in spite of the fact that Wendland could pick up specifically colored pegs or blocks and hand them to a therapy assistant on request. He did so in spite of the fact that Wendland could operate and maneuver an ordinary wheelchair with his left hand and foot, and an electric wheelchair with a joystick, of the kind that many disabled persons (most famously Dr. Stephen Hawking) use. Dr. Cranford dismissed these abilities as meaningless. Fortunately for Wendland, the California supreme court was not persuaded by Cranford's assessment.
The refusal to allow diagnostic measures that are routine for people with mere lower back pain; the refusal to allow recommended therapeutic care; an influential expert witness who regards people who can operate wheelchairs as "persistently vegetative" -- yes this is precisely the justice system that we Conservatives just must preserve. What a melancholy day indeed! -- that such effusions of judicial wisdom might be blocked by the Congress! Oh, what horrors we will have committed against our precious federalism if the rulings and opinions of these sages are contravened by the Congress!
I am sure the physician quoted in the article above is eminent with excellent credentials, but the standard of the profession is that PVS is not diagnosed on the basis of imaging. A recent consensus guideline quoted below indicates that it is a diagnosis based on the patient's behaviors.
Why is this so? Because there is not sufficient rigorous evidence to help us interpret prognosis on the basis of imaging.
We don't even diagnose brain death--the most severe brain injury--with imaging or EEG, but simply by whether the patient breathes spontaneously off ventilator. In Ms Schiavo's case, any imaging will show some brain areas are there, and some are gone. There is so much variability in what brain damage causes clinically, that no new information will be gained useful to this debate--it will simply open up more arguments over whether the pineal gland is needed to have a soul. Behavioral criteria are more reliable.
Knowing how difficult making any diagnosis can be, I won't presume to be able to diagnose Ms Schiavo with PVS or anything else--I'm not her doctor and I haven't examined her. But I wish others would also refrain from speaking with such certainty.
The more germane questions for outside observers, it seems to me, are not whether she has PVS, but whether due process is being followed, and whether the statutes should allow those diagnosed with PVS to have feeding/hydration withheld. Ms Schiavo's is a tough case, and as other posters have aptly pointed out tough cases make bad case law, and I would add, bad statutes.
Back to the realm of the anecdotal, FWIW I can also add that in my experience working with the dying, when they are terminal and fluids are withheld I have never had a patient tell me they are subjectively starving even when lucid, and thirst is easily managed with good nursing care and mouth swabs (witholding hydration means IV, not drinks).
the judge has specifically stated that she can not be given ice chips in her mouth to help with dry mouth or hydration.
I'm sorry, I find that to be quite cruel.
Terri's condition is not "terminal" in the sense of end stage cancer, etc... Honestly, we don't know what she is feeling.
In general I think compassionate care should include treatment of uncomfortable symptoms--whether it lengthens life or not, whether we believe the patient feels them or not.
The reason for this restriction is that oral feedings given to a patient without a swallow reflex can be aspirated, causing pneumonia.
So judge Greer is not only a better legislator than the US Congress, he is a better doctor than any one on staff with Schiavo?
Or does he just stay at Holiday Inn every night?
What are you talking about?
Judge Greer has been on this case for about a decade. He's yet to be overturned. Why do you call it judicial activism for a judge to follow existing law?
If you don't like the law, change it. But to claim judicial activism with a judge that has followed the law and been appealed and upheld numerous times, is insane.
"MRI is widely used today, even for ailments as simple as knee injuries -- but Terri has never had one."
Look, I am an MRI Physicist, I am writing a dissertation on MRI technology, with an emphasis on neuroimaging. I have also been trainedi n CT, ultrasound, and PET.
The fact that Schiavo had no MRI is the most enormous example of uninformed ignorance that I have seen in recent memory.
The CT scan alone is sufficient. The brain is liquid. Argue about miracles or cultures of life or constitutional separation of powers all you like. It doesn't matter. Keep her alive, starve her, either way her BRAIN IS LIQUID.
An MRI would tell you NOTHING than a CT scan could not at this stage. MRI is not magic. It is a method for soft-tissue contrast. A functional scan would be IMPOSSIBLE to perform because fMRI requires patient responses - you show images on a screen and you INSTRUCT THE PATIENT to PRESS BUTTONS when SPECIFIC IMAGES appear. Or do other DIRECTED ACTIVITIES upon COMMAND.
Schiavo is not capable of even participating in an fMRI scan. The result would be meaningless.
The issue is whether her BRAIN is LIQUID and for that , the Hounsfeld unit measurements of CT are obviously OBVIOUSLY more relevant. fMRI is NOT and the insistence of anyone otherwise is a revelation of their supreme, imense, awe-inspiring intellectual bankruptcy.
Really, evn pundits made even the slightes pretense of an interest in the truth rather than posturing with whatever handy prop is at hand - religion, science, whatever - to serve their agendas, there would be a lot less use for the Internet.
"Dr. Peter Morin. He is a researcher specializing in degenerative brain diseases, and has both an M.D. and a Ph.D. in biochemistry"
biochemistry? hes a chemist and he deals with brain chemstry. Not brain anatomy or function.
Get a radiologist, or an oncologist, or a neurologist, and you might have stronger standing. Assuming of course that the doctor actually PERSONALLY EXAMINED Schiavo and is not talking out the rear orifice about what his diagnosis "would" be.
Your comments about the usefulness of the MRI are interesting, butI think you are incorrect about Morin. As Cella stated, he's an MD-- it appears he's a neurologist as well as a chemist.
is not a magic degree. it means "I completed med school".
and by his own admission, he hasnt examined Schiacvo directly. Having worked with neurologists, I have some familiarity with their modus operandi. They require direct access to the patient.
My daughter, whenborn, had a (thankfully benign) condition that required us to take her to a pediatric neurologist, where I observed the basic tests that the physician performed to establish a baseline. I also see neurologists at work here at the cancer center.
Morin is speculating and is likely doing so for self-aggrandizement.
Like I said, since my opinion is that Schiavo has no brain, it doesnt matter to me whether her family suceeds in keeping her to care for or not.
Aziz-- According to this page , Morin did a residency in neurology at Harvard Medical School and as of 2001 was a pediatric neurologist in Boston. So while it may be an issue that he hasn't examined Schiavo, it seems to me that his credentials are pretty good.
I am willing to then to argue that he should be qualified to assess SChiavo's condfition. However, ONLY if he has examined her.
It is however extremely disturbing that a Harvard-trained neurologist has no idea that to conduct an fMRI scan, the patient MUST be responsive to comands.
That tells me that he doesnt practice neuro much, or is extremely ignorant of a basic, obvious fact about fMRI, analogous to a truck driver knowing that his rig requires diesel.
So, let me take a reasonably accomodating position with respect to your argument, and postulate that he is the world's best, highest-recognized expert on degenerative brain disease and neuroanatomy.
Even then it changes nothing - he has NOT EXAMINED SCHIAVO. That is the key.
Greer oders specific medical procedures done? (No ice chips?)That is beyond interfernce.
It is one thing to rule that Mr Schiavo has the right to speak for his wife to medical practicioners in her 'absence', but it seems to me to be quite another to say which procedures may be done and which may not be done.
I have been watching NBC for 16 years, but that won't ever make me a program executive.
I've often wondered this past week why her husband did not accept that million dollars to relinquish guardianship of her to her parents (and why he's denied her therapy all these years). The only conclusion I can come to is that he is afraid she will regain her abiity to speak--and then what would she say about how she got to this state in the first place?