Terri Schiavo lies in a Florida hospice, subject to a judge's order that will cause her to die of starvation and dehydration commencing this Friday, March 18, at 1:00 P.M. Her parents, Bob and Mary Schindler, have fought for over a decade to prevent her death. They have repeatedly gone to court in their efforts to stop Terri's husband, Michael, from removing the tube that provides her with food and water.
The court battle has gone largely against the Schindlers. Last week, Pinellas County Circuit Court judge George Greer issued a steady stream of rulings denying almost every motion the Schindlers raised. He denied some of them summarily, without hearing arguments or evidence. Among the motions Judge Greer denied was a request for new testing and examination of Terri by independent and qualified specialists. David Gibbs, attorney for the Schindlers, submitted 33 affidavits from doctors and other medical professionals contending that Terri's condition should be reevaluated. About 15 of these affidavits are from board-certified neurologists. Some of these doctors also say that Terri could benefit from therapy. Judge Greer was unmoved.
Many people believe that Terri Schiavo has had "the best of care," and that everything has been tried by way of rehabilitation. This belief is false. In fact, Terri has had no attempts at therapy or rehabilitation since 1992, and very little had been done up to that point. Terri has not even had the physical therapy most doctors would regard as normative for someone in her condition. The result is that Terri suffers from severe muscle contractures, which have caused her body to become contorted. Physical therapy could remedy this, but husband Michael has refused to provide it.
Terri has also suffered from what many professionals would regard as neglect. She had to have several teeth extracted last year because of severe decay. This decay was caused by a lack of basic dental hygiene, such as tooth-brushing. She also developed decubitus (skin) ulcers on her buttocks and thighs. These ulcers can be prevented by a simple regimen of regular turning: a basic nursing task that any certified nurse's aide can perform. The presence of these easily preventable ulcers is a classic sign of neglect. Bob and Mary Schindler have repeatedly complained of Terri's neglect, and have sought to remove Michael as guardian on that basis. Judge Greer was unmoved by those complaints as well.
And, quite apart from the question of Terri's therapy and care, it is entirely likely that Terri has never been properly diagnosed. Terri is usually described as being in a Persistent Vegetative State (PVS), and indeed Judge Greer ruled as a finding of fact that she is PVS; but this diagnosis and finding were arrived at in a way that has many neurologists expressing surprise and dismay.
I have spent the past ten days recruiting and interviewing neurologists who are willing to come forward and offer affidavits or declarations concerning new testing and examinations for Terri. In addition to the 15 neurologists' affidavits Gibbs had in time to present in court, I have commitments from over 30 others who are willing to testify that Terri should have new and additional testing, and new examinations by unbiased neurologists. Almost 50 neurologists all say the same thing: Terri should be reevaluated, Terri should be reexamined, and there are grave doubts as to the accuracy of Terri's diagnosis of PVS. All of these neurologists are board-certified; a number of them are fellows of the prestigious American Academy of Neurology; several are professors of neurology at major medical schools.
So how can Judge Greer ignore the opinions of so many qualified neurologists, some of whom are leaders in the field? The answer is that Michael Schiavo, his attorney George Felos, and Judge Greer already have the diagnosis they want.
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."
Dr. Morin explained that he would feel obligated to obtain the information in these tests before making a diagnosis with life and death consequences. I told him that CT (Computer-Aided Tomography) scans had been done, and were partly the basis for the finding of PVS. The doctor retorted, "Spare no expense, eh?" I asked him to explain the comment; he said that a CT scan is a much less expensive test than an MRI, but it "only gives you a tenth of the information an MRI does." He added, "A CT scan is useful only in pretty severe cases, such as trauma, and also during the few days after an anoxic (lack of oxygen) brain injury. It's useful in an emergency-room setting. But if the question is ischemic injury [brain damage caused by lack of blood/oxygen to part of the brain] you want an MRI and PET. For subsequent evaluation of brain injury, the CT is pretty useless unless there has been a massive stroke."
But in spite of the lack of advanced testing, such as an MRI, attorney George Felos has claimed that Terri's cerebral cortex has "liquefied," and doctors for Michael Schiavo have claimed, on the basis of the CT scans, that parts of Terri's cerebral cortex "have been replaced by fluid." The problem with such contentions is that the available evidence can't support them. Dr. Zabiega explained that "a CT scan can't resolve the kind of detail needed" to make such a pronouncement: "A CT scan is like a blurry photograph." Dr. William Bell, a professor of neurology at Wake Forest University Medical School, agrees: "A CT scan doesn't give much detail. In order to see it on a CT, you have to have massive damage." Is it possible that Terri has that sort of "massive" brain damage? According to Dr. Bell, that isn't likely. Sometimes, he said, even patients who are PVS have a "normal or near normal" MRI.
So why hasn't an MRI been done for Terri? That question has never been satisfactorily answered. George Felos has argued that an MRI can't be done because of thalamic implants that were placed in Terri's skull during the last attempt at therapy, dating back to 1992. But Felos's contention ignores the fact that these implants could be removed. Indeed, the doctor who put them in instructed Michael to have them removed. Michael has never done so.
The most obvious possible explanation for what would otherwise be inexplicable behavior is that Michael Schiavo, George Felos, and Judge Greer don't want to admit any information that would upset the diagnosis they already have. Dr. Morin, when told that Michael had refused an MRI, and that Judge Greer had confirmed the decision, said: "He refused a non-invasive test? People trying to do the right thing want the best and most complete information available. We don't have that in Terri's case." Dr. Bell agreed with this assessment, saying, "It seems as though they're fearful of any additional information."
Doctors for Michael Schiavo have said that an MRI and PET are not necessary for Terri because PVS is primarily a "clinical" diagnosis, that is, one arrived at on the basis of examination of the patient, rather than by relying on tests. And the neurologists I have spoken to agree on the clinical nature of the diagnosis, while insisting that advanced tests nonetheless are a necessary part of it. But the star medical witness for Michael Schiavo, Dr. Ronald Cranford of the University of Minnesota, has repeatedly dismissed calls for MRI testing, and his opinion has prevailed.
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 the cases of Paul Brophy, Nancy Jobes, Nancy Cruzan, and Christine Busalucci, Cranford was the doctor behind the efforts to end their lives. Each of these people was brain-damaged but not dying; nonetheless, he advocated death for all, by dehydration and starvation. Nancy Cruzan did not even require a feeding tube: She could be spoon-fed. But Cranford advocated denying even that, saying that even spoon-feeding constituted "medical treatment" that could be licitly withdrawn.
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.
Expert witnesses in court are supposed to be unbiased: disinterested in the outcome of the case. Part of the procedure in qualifying expert witnesses is establishing that they are objective and unbiased. But given Dr. Cranford's history of advocacy in the "right to die" and euthanasia movements, and given his track record of almost always coming down on the side of PVS and removal of nutrition and hydration, one might question his objectivity. Indeed, the Schindlers' attorneys attempted to do so in the 2002 evidentiary hearing at which Cranford testified, but went unheard. Organizations such as the International Task Force on Euthanasia and Assisted Suicide submitted amicus curiae (friend of the court) briefs in the appellate proceedings in Terri's case, demonstrating Cranford's bias in detail. But these arguments also seemed to fall on deaf ears.
Some neurologists who also consult in legal cases were not surprised at the handling of Dr. Cranford's expert testimony. In theory, they said, the expert witness is supposed to be objective, but, as Dr. Bell explained, "the way it really works is that an attorney carefully selects an expert that will give him the outcome he desires." He related that he has been asked by attorneys to serve as an expert. "I have looked over medical records," he said, "and told attorneys what I thought." But on occasion, he said, his opinion was "obviously not what they wanted to hear" and "they moved on to another expert." Bell acknowledged that Cranford is "a highly accomplished and experienced speaker," but said that in him the court "likely found a highly prejudiced expert."
Neurologists who are familiar with diagnosing and treating PVS and other brain injuries have told me that PVS is a notoriously difficult diagnosis to make. It requires a great deal of time spent with the patient over several days or weeks. The reason for this, as Dr. Bell explained, is that brain-injured patients have severely disrupted sleep/wake cycles. Dr. Mack Jones, a neurologist in Ft. Walton Beach, Fla., added that patients with severe brain injury will have greatly varying levels of alertness: "Two independent examiners may get an entirely different impression depending on when and how long he/she has spent performing the examination. For example, one examiner may unknowingly attempt to evaluate the patient during a stage of sleep. Another examiner, by chance, may find a more responsive patient simply because [the patient is] now more aroused." Dr. Morin concurred, saying that in his experience "the attention of brain-injured patients is very erratic," and that because of this he has "seen inadequate assessments even by experienced neurologists." Because of these difficulties, the American Academy of Neurology has made it clear that it can take months for a physician to establish with confidence the diagnosis of PVS. A 1996 British Medical Journal study, conducted at England's Royal Hospital for Neurodisability, concluded that there was a 43-percent error rate in the diagnosis of PVS. Inadequate time spent by specialists evaluating patients was listed as a contributing factor for the high incidence of errors.
So, did Dr. Cranford, or any of the doctors testifying for Michael Schiavo, spend months evaluating Terri? No. To be fair, none of the doctors appearing for the Schindlers spent months with Terri either. But it is hardly coincidental that the doctors who spent the most time with Terri came to the conclusion that she is not PVS. The doctors brought in by the Schindlers spent approximately 14 hours examining Terri over more than two weeks; their conclusion was that Terri is not PVS, and that she may benefit from therapy.
In marked contrast, Dr. Cranford examined Terri on one occasion, for approximately 45 minutes. Another doctor for Michael Schiavo, Dr. Peter Bambikidis of the Cleveland Clinic Foundation in Ohio, examined Terri for about half an hour. When Dr. Bell learned of the cursory nature of these exams, he said: "You can't do this. To make a diagnosis of PVS based on one examination is fallacious." In Cranford's examination, described by one witness as "brutal," he discounted evidence under his own eyes of Terri's responsiveness. At one point, Dr. Cranford struck Terri very hard on the forehead between her eyes. Terri recoiled and moaned, seemingly in pain. In his court testimony, Cranford dismissed the reaction and moan as a "reflex."
"I asked Dr. Bell if he thought a moan uttered after a painful blow could be a reflex. "It's highly unlikely," he replied. He qualified his answer by noting that he had not actually seen the video of the exam, but he believes that the description of Terri's reaction is not consistent with a reflex. "A moan is not a reflex," Bell said. "A wince or grimace is not a reflex."
By the very definition of Persistent Vegetative State, the patient must exhibit no "evidence of awareness of self or environment" or "ability to interact with others." As one neurologist put it, if a patient shows "any response to the outside world, the patient isn't in a PVS." All it takes, according to Dr. Jones, is "only one examiner to discover the presence of higher brain function and the naysayers' opinions are, by the very definition of PVS, null and void."
Given the difficulty of diagnosing PVS, the high rate of error, the obvious bias of the doctor whose judgment forms the basis of the judge's ruling that Terri is PVS, and the growing outcry from the neurological community, how is it that Judge Greer's ruling has been sustained? The answer is that in our legal system, once a judge has ruled on a matter of fact, it is very difficult to revisit such a ruling. The lawyers' rule of thumb is that trial courts hear and rule on questions of fact, and appellate courts rule on questions of law; it's unusual for an appellate court to overturn a lower court's ruling because of an issue of fact.
That's why, at every turn in this case, the Schindlers have had to try to undo the faulty rulings of fact previously issued by Judge Greer. They've had to go back before Judge Greer himself and try to convince him that he was wrong, and should undo his own rulings. Judge Greer has proven unwilling to do so. The higher courts, unwilling to overturn a trial judge's rulings of fact, have no interest in granting new hearings. Michael Schiavo and George Felos have no interest in revisiting Terri's diagnosis, as that ruling provides the whole legal basis of their ability to end her life. Dr. Cranford has no interest in seeing his own diagnosis called into question. Dr. Bell lamented that at this point, "medical realities are no longer governing this case." He added that it seemed to him that medical issues concerning the care of the patient had been subsumed by legal issues. In our courts, he added, "once a decision is made they don't want additional information."
The whole history of Terri's case over the past few years can be summed up as the efforts of the Schindlers, and those who value Terri's life, to try to introduce additional information before the courts and other authorities. Some of this information consists of facts and arguments that were ignored or dismissed without adequate consideration; some has been the result of advances in the diagnosis and treatment of brain injuries over the last five years. On the side of Michael Schiavo, George Felos, and Judge Greer, their efforts have consisted almost entirely in trying to prevent any new information from being presented or considered.
The legal system's willful blindness to facts cannot succeed forever. The truth has a way of coming out. But will it do so in time to save Terri Schiavo? Dr. Morin said to me, towards the end of our conversation, that "the law can find a way to do the right thing if it wants to." The problem so far is that those who have the power to do the right thing seem to have no desire or inclination to do so.