Fwd: cruzan v schiavo what a difference a decade makes

Here is Jack's reply to my last, which went only to me as I sent only
to him, intending for the list as well. With Jack's agreement, I'm
posting both of them.

Iain.

---------- Forwarded message ----------
From: jack syme <drsyme@cablespeed.com>
Date: Thu, 24 Mar 2005 06:52:20 -0500
Subject: Re: cruzan v schiavo what a difference a decade makes
To: Iain Strachan <igd.strachan@gmail.com>

Well that is interesting, and that document surely seems credible. But
there are two points that I disagree on.

As far as the comments about minimally conscious state. She might be in
that condition. There is no way for me to know. But he seems to be
confused on the application of this to her in this case. His comment was
about her initial diagnoses of PVS and that MCS was not known at that time.
But if you look at the references for MCS, particularly the 2002 article,
one of the authors is R Cranford. And he was one of the experts testifying
FOR the husband, and R Cranford concluded that she was in a PVS. And this
article, with him as the author, was published BEFORE the trial in which he
testified that she was in a PVS. So it was not the case that this condition
was unkown prior to the November 2002 decision that she was in a PVS.

Second, I disagree with his interpretation that if she is in a MCS that it
would not be ethical to withdraw a feeding tube. I still think that given
her condition, that discontinuing her feeding tube is not unreasonable if
that is what she wanted, even if she is in something better than a
vegetative state. Like I said yesterday, whether or not she has 10% or 1%
or none of her cortex doesnt matter that much if her wishes were that she
wouldnt want to be fed by a feeding tube in such a condition. For example,
if there was a patient that had a large dominant hemisphere stroke, that
left them unable to communicate verbally, and unable to swallow so that a
feeding tube was required, and the spouse declined the feeding tube saying
"she wouldnt want that, she would never want to be a burden," I think that
even then this request should be complied with.

In Maryland interstingly enough, ( I live and practice in Marlyand) the PVS
issue is critical because a surrogate that is not appointed as the durable
power of attorney, is not authorized to withhold life sustaining treatment
unless the patient is terminally ill, or in a PVS. So the diagnosis of PVS
would be crucial in Maryland. I have read the Florida laws regarding this,
and did not see a similar restriction.

I am not advocating for allowing suicide, although there are people that
propose that as you suggest. I am just being consistent with patients
making their own decisions regarding medical decisions. To treat someone
against their wishes is immoral.

----- Original Message -----
From: "Iain Strachan" <igd.strachan@gmail.com>
To: "jack syme" <drsyme@cablespeed.com>
Sent: Thursday, March 24, 2005 6:01 AM
Subject: Re: cruzan v schiavo what a difference a decade makes

> Jack,
>
> I'll freely admit I've wavered between both sides of the argument. At
> first sight, I sided with those who want to save Terri - it seemed
> cruel and inhumane - I was too easily persuaded by the emotional side
> of the argument.
>
> Then as I worked my way through the thread, I was beginning to be
> persuaded by your arguments.
>
> Then on reading the lawyer's testimony, I started to swing back the
> other way. I agree with you that you don't know how much of what the
> Schindlers' attorney said was accurate - and she is not an expert.
>
> However, I came across this one today:
>
> http://www.terrisfight.net/documents/032305cheshire.pdf
>
> ... again admittedly from a propaganda site, but this time from a
> practising neurologist. Unfortunately the quality of the pdf is poor.
> He argues that very often relatives of PVF patients have false hopes
> because of the occasional responses they see. However, he argues that
> from his observations (much as the Schindler's attorney argued, and I
> have said here as well), of consistent emotional responses to loved
> ones, expressions of delight (e.g. when listening to music) etc, that
> a more valid diagnosis would be a "Minimially conscious state", rather
> than PVS, and that as a result, Terri can feel pain, and very likely
> also experience pleasure. He also argues that the last time Terri had
> a neurological examination, the "minimally conscious" diagnosis had
> not emerged as a separate condition, but that medical science had
> advanced since then.
>
> I suppose part of my gut feel here is influenced by some of my own
> voluntary work which involves talking to people who are suicidal, and
> often suffering from suicidal depression. When severe, and in a
> suicidal state, such people have lost the ability to experience
> pleasure and to see anything at all positive about life. The
> organization ( UK Samaritans) actually supports peoples' right to
> commit suicide ( something that I have some difficulty with), but in
> the Schiavo case, I see, on the face of it, and now with the opinion
> of a neurologist, a person capable of experiencing pleasure and pain,
> who is having the decision to commit suicide made for her (her partner
> decides that she would not want to live on in this state - I would
> take "not wanting to live on" as a suicidal desire). If she were
> without doubt PVS, then (as the neurologist in the above article has
> said also), there would be no problem IMO in withdrawing the feeding
> tube. But it seems to me there is reasonable room for doubt. After
> all the experts weren't unanimous - it was only 3 out of 5. I don't
> know why the judge chose to think the other two weren't valid - maybe
> because they were chosen by the Schindlers?, but then you could
> equally say it's suspicious that the two exports chosen by Michael
> Schiavo were in favour of the PVS diagnosis.
>
> I hope no one minds my dragging this up again.
>
> Iain
>
> On Wed, 23 Mar 2005 20:01:03 -0500, jack syme <drsyme@cablespeed.com>
> wrote:
>> oops i meant to post that to the entire list.
>>
>> But that is what I mean. How much of that observation in accurate?
>> There
>> is no way to know. I do know the qualifications of the people that
>> examined
>> her. So I am taking the testimony of three professionals over this
>> anecdote. There are things that I have heard that would be inconsistent
>> with PVS, but I have not examined her. I doubt that the 3 individuals
>> have
>> an ulterior motive, and I doubt that the judge has an ulterior motive
>> when
>> he thought the other two were not as credible.
>>
>> On the other hand, does it make that much difference if she has 1% or
>> 10%
>> or 50% of her cortex vs zero? I think that if her condition is such that
>> her appropriate surrogate thinks that she would not want to continue in
>> that
>> condition, then I think withdrawing is appropriate.
>> ----- Original Message -----
>> From: "Iain Strachan" <igd.strachan@gmail.com>
>> To: "jack syme" <drsyme@cablespeed.com>
>> Sent: Wednesday, March 23, 2005 7:16 PM
>> Subject: Re: cruzan v schiavo what a difference a decade makes
>>
>> > Jack,
>> >
>> > Thanks for taking the time to write this explanation. My only
>> > connection with things neural is my research into Artificial Neural
>> > Networks, which only tangientially pay lip service to the biology.
>> >
>> > It's clear the article is written in a way to manipulate you into one
>> > way of thinking, as I said in the post. However, there is one point
>> > I'd take issue with. You stated:
>> >
>> > But the cortical functions are lost with the death of cortical neurons,
>> > the
>> > ability to speak, understand, remember, think, plan, comprehend ones
>> > self,
>> > recognize loved ones, any of those functions that you associate with a
>> > person, and with thinking. So a person in a PVS opens their eyes, has
>> > reflex grimacing and smiling, wakes up, goes to sleep, breaths without
>> > a
>> > machine. But cannot swallow, use their limbs, or interact with the
>> > environment in any consistent or meaningful way.
>> >
>> > ... but it seems to me that some of what the article was describing,
>> > e.g. the following ritual with the "lemon face" when Dad went to kiss
>> > her with his mustache, was evidence of remembering, recognizing a
>> > loved one and being consistent.
>> >
>> > ---
>> > When her father greets her, he always does the same thing. He
>> > says, "here comes the hug" and hugs her. He then says, "you know
>> > what's coming next---the kiss." Her father has a scratchy mustache and
>> > both times when he went through this little joke routine with her, she
>> > laughed in a way she did not do with anyone else. When her father is
>> > ready to plant the kiss on her cheek, she immediately makes a face her
>> > family calls the "lemon face." She puckers her lips, screws up her
>> > whole face, and turns away from him, as if making ready for the
>> > scratchy assault on her cheek that she knows is coming. She did the
>> > exact same thing both times that her father initiated this little
>> > routine joke between the two of them.
>> > ----
>> >
>> > This doesn't seem to agree with your definition of PVS. On the face
>> > of it, this looks like a remembered joke, rather than a random reflex
>> > that only has the appearence of purposefulness. That's why I posted
>> > the article ... despite the emotionalism, and manipulation of the
>> > reader, there seemed to me to be some real observations of behaviour
>> > that differed from what one might expect.
>> >
>> > Iain.
>>
>>
>
>
> --
> -----------
> There are 3 types of people in the world.
> Those who can count and those who can't.
> -----------

-- 
-----------
There are 3 types of people in the world.
Those who can count and those who can't.
-----------