Running head: LEGAL CASE STUDY: TERRI SCHIAVO CASE

Legal Case Study: The Terri Shiavo Case
University of Phoenix
Legal Case Study: Terri Schiavo Case Terri Schiavo sustained a permanent brain injury on February 25, 1990. She did not have a living will or a durable power of attorney. Her husband, Michael Shiavo, was appointed her legal guardian. Because Ms. Shiavo was unable to swallow, a feeding tube kept her alive and nourished. Later that year, she was determined to be in a persistent vegetative state (PVS). Throughout the early 1990’s, Mr. Shiavo worked hard with his wife’s health care team, providing her with extensive rehabilitation, which included physical, occupational, and speech therapies. Despite this effort, Ms. Shiavo’s condition did not improve. After he accepted his wife’s prognosis, he worked to follow through with what he stated were her beliefs that she would not want to continue to be kept alive through the means of artificial life support. Her parents disagreed with his convictions of what his wife would want, and subsequently the most watched ethical dilemma played out for the world to see. (Perry, Churchill, & Kirshner, 2005). This case has been the focus of medical, legal, theological, ethical, political, and social controversy nationwide. The case alone threatened to undo thirty years of ethical and legal progress enabling individuals to control and limit medical interventions performed on them. (Hook & Mueller, 2005). This paper will discuss the ethical importance of the case and its effect on future practice, the legal proceedings and the results, the ethical principles that were violated, and the effect on the standards of practice. The ethical framework for this case includes the issues of the sanctity of life, discrimination towards the disabled community, and the moral character of the people with the power to make decisions. Many consider this case to be a struggle between the sanctity of life versus quality of life. The political question in the Schiavo case is who decides what is “right” in the public eye? The Progressive ideology is the answer is the individual’s morality. For the conservative, the answer is the one true morality dictated, revealed, or discovered by an appropriate higher authority (Klugman, 2006). The law must preserve and support the rights to act according to one personal morality. That said, living wills and durable powers of attorney are the blatant driving forces of autonomy, yet by removing the issues of autonomy and liberty from the equation, it is the courts that are left to make decisions in the best interest of the individual according to their own values, even if they no longer have the ability to communicate for themselves (Perry, Churchill, & Kirshner, 2005). Removing Ms. Shiavo’s artificial nutrition and hydration resulted in an ethical dilemma. There was much concern over the potential cascading effect that would result if people who are disabled may be perceived to have a poor quality of life and felt disregarded. While there is no general policy for what should be done to and for people living in a persistent vegetative state, the notion of liberty ought to be stressed as the fundamental issue involved, that all individuals will be able to choose for themselves and that their living wills, if in existence, will be honored (Perry, Churchill, & Kirshner, 2005). Another important ethical issue in this case centers on the husband, Michael Schiavo, and whether he should have had a voice in the decisions made for his wife. It was argued that he should not have had a say concerning decisions made for her because over the fifteen-year period of caring for her, he developed a relationship with another woman. Regardless of his romantic life after Ms. Shiavo’s injury, his aggressive attempts to rehabilitate her cannot be ignored. Yet attempts were made to take the focus off of the decision itself and discredit the individual making the decision (Perry, Churchill, & Kirshner, 2005). There are three complicated terms one must be familiar with in the Terri Schiavo case. The first is persistent vegetative state (PSV) occurs after a coma; a patient loses cognition and can only perform certain, involuntary actions on his or her own. While some describe those in a persistent vegetative state as "brain dead," in fact, the lower brain stem in PVS patients retains some reflexes and the ability to breath. The second term is “whole brain death” refers to no brain activity at all and the last term is “higher brain death”. Higher brain death is the cessation of functioning in the parts of the brain responsible for consciousness and higher reasoning. Terri Schiavo suffered higher brain death (Wijdicks, 2001). Ms. Shiavo’s brain was severely damaged due to lack of oxygen. She demonstrated some gross motor movement and could breathe on her own, indicating some brain stem activity. Having residual reflexes provides one with the ability to open their eyes on breathe on their own. For this reason many argue that she had brain function. The definition of brain death is absolute unresponsiveness to stimuli, the absence of spontaneous muscle activity that includes respiration. Brain death is also known as irreversible coma and cerebral death (Fritz, 2005). In this debate, however, both organizations took a conservative position, relying on more traditional approaches. According to traditional standards of whole-brain death, Terri was still fully “alive” and thus should not have her feeding tube removed. Terri Schiavo suffered from a “higher brain injury. Primal responses remained resulting in quality of life issues. The Schiavo case involved repeated appeals, motions, petitions, and hearings in the courts at all levels. The media added to the problem by exploiting individuals using the case as a platform for their religious, political, or cultural views. Activism from the pro-life and disability rights groups grew and both sides bellowed their beliefs. The case was reviewed both by state and federal courts, and numerous judges examined the issues surrounding the question of whether a severely brain damaged woman’s feeding tube ought to be removed. The question is not about what the husband, parents, congress or the President of the United States wants. The legal question is not even about what Terri Shiavo wanted. It is about whether due process was denied and whether the courts gave due consideration to all of the issues in this case (Dresser & Kirby, 2005). The law did not fail Terri Schiavo. This case is historic in the United States as it has provided excellent evidence, legal scrutiny, and judicial attention. Ms. Schiavo was in a persistent vegetative state since 1990 diagnosis verified by numerous doctors. After eight years of rehabilitation Terri’s husband petitions to have Terri Schiavo’s feeding tube removed. The first attempt to remove the feeding tube occurred in February 2000. Terri Shiva’s parents win a motion to resume tube feedings. The legal system in the state of Florida ruled for the second time the removal of the feeding tube on October 15, 2003. Five days later the Florida Legislature enacted an action allowing Florida Governor Jeb Bush to override withholding nutrition and hydration from a patient. This was later deemed unconstitutional and Mr. Schiavo, the guardian, challenged this and the court ruled in his favor (Dresser & Kirby, 2005). On March 18, 2005, Judge George Greer ordered the removal of the feeding tube. The Supreme Court refused to hear the case causing the third removal of the feeding tube. There were numerous attempts by Ms. Schiavo’s parents to feed Terri, which were denied by Judge Greer. Following Judge Greer’s order, Governor Bush and Congress passed the “Palm Sunday Compromise”, which transferred the Schiavo case to federal jurisdiction. President Bush flew to Washington to sign it. The United States Supreme Court declined to grant the motion that ended the dispute, allowing Terri to die (Dresser & Kirby, 2005). This case is a convincing example of the decisions that the government makes that can lead to dire social consequences. Therefore, it is more desirable to obtain a statement or legal document stating the individual's wishes. A living will takes the difficult and guilt-ridden life-ending decisions out of family members' hands. A living will specifies what the individual's wishes are if they become incapacitated. The individual will be given peace of mind knowing that their family members will not be placed in such a situation (Dresser & Kirby, 2005). Healthcare professionals use ethical principles and ethical theories to guide clinical practice. Examples of ethical principals include autonomy, beneficence and nonmaleficence, veracity, fidelity, paternalism, justice, and respect for others. Although these principles are important to understand and strive to meet in daily practice nurses need to have a deeper basis to help them guide their practice. (Guido, 2010). Several ethical principals were violated during this case. By not granting her wish of not wanting to live in a PVS, the courts and members of her family violated her autonomy. Terri Schiavo’s wishes expressed to her family and friends before her injury were not respected. Beneficence was another principal that was violated because instead of doing her any good, they harmed her by not respecting her wishes and keeping her alive with no quality of life, putting her at risk for bed sores, infections, and contractures. Paternalism was also violated when the courts ruled for her instead of allowing her husband and legal guardian to make medical decisions for her (Guido, 2010). Ethical theories and principles are used on a daily bases in the medical industry. It is important to understand these principles as they assist in decision making when dealing with ethical dilemmas. Nurses are often the mediator between the family members and the rest of the healthcare team, when it comes to making the best decision for the patients needs (Guido, 2010). This case mirrored a perfect example of conflicts arising from end of life decision-making. The effects of the case include hospitals continuing to rely on clinical ethicists, ethics committees, or mediators to help in the resolution of conflicts between family members or health care providers. When conflicts arise such as in the case of Terri Shiavo, these resources can be accessed to aid in decision making for the individual in question. While this case became the center of all media outlets, ethical dilemmas similar to hers are being worked out. Clearly due to the heavy media influence on the case, Ms. Shiavo’s right to die with dignity and privacy was violated (Erban, Sullivan, Ney, & Weijer, 2006). Medicine has seen immense changes such as organ transplants, implantable defibulators, and permanent gastric tubes. The technology lengthens life but the payoff is seen in numerous social and moral issues. This has resulted in modern medicine merging with legislation, ethics, and politics (Cline, 2010). Quality of life must be considered as the life expectancy increases in the 20th century. Today, people are being kept alive in the most unthinkable situations. Life support, breathing ventilators, and heavy doses of medication keep patients alive for as long as possible. Health care providers must continue to respect their patient’s wishes, and allow them to die on their terms and with dignity (Klugman, 2006). Ms. Shiavo’s story and other similar cases are well publicized in the media. Activists, religious groups, and politically driven groups use the cases for their own agenda. The lengthy Schriavo case was dragged out over years while the public witnessed behavior and decisions made that were not in her best interest. As the world watched her fate unfold on national television, a new interest arose in living wills and health care surrogates. Living wills include the use of physician orders for life-sustaining treatments (Cordes, 2005). Since the Terry Shiavo case, decisional improvements have been made regarding end of life issues. In order for the nurse to provide appropriate care for her patients with brain injuries or brain death, medicine must have a clear understanding of the criteria for brain death and the misconceptions associated with it. Accurate information can provide a sound basis for talking to families to assist them in coping with the devastating loss (Cordes, 2005). While Ms. Shiavo is gone, she remains the center of controversy nationwide. Her case stresses the need for more attention to be placed on ethical principles and the legal system when dealing with an end of life issue. Even though the case threatened to undo years of ethical and legal progress that enabled individuals to control their own medical care, it did not succeed. Ms. Shiavo has inspired many people to consider their own beliefs about end of life and living wills (Hook & Mueller, 2005).

References
Dresser, R., & Kirby, D. N. (2005). Schiavo Legacy: The Need for an Objective Standard. Hasting Center Report, 35(4), 225-29.
Erban, J., Sullivan, W. J., Ney, P. G., & Weijer, C. (2006). Terri Shiavo: Rest in peace. Canadian Medical Association Journal, 175, 621-622.
Fritz, G. (2005). Brain death: clear definitions and terminology. Intensive Care Medicine, 27, 947-7.
Guido, G. W. (2010). Legal and Ethical Issues in Nursing (5th ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall.
Hook, C. C., & Mueller, P. S. (2005). The Terri Shiavo Saga: The making of a tragedy and Lessons learned. Mayo Clinic Proceedings, 80, 1449-1460.
C. M. Klugman: Reframing Terri Schiavo: One Family's Story of Morality, Ethics, & Politics. The Internet Journal of Law, Healthcare and Ethics. 2006 Volume 4 Number 1. Retrieved August 2, 2010, from, http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijlhe/vol4n1/schiavo.xml
Perry, J. E., Churchill, L. R., & Kirshner, H. S. (2005). The Terri shiavo case: Legal, ethical, and medical perspectives. Annals of Internal Medicine, 143, 744-748.
Wijdicks, E. F. (2001). The diagnosis of brain death. New England Journal of Medicine, 344(16), 1215-21.