The Terri Schiavo dilemma: an ethics report card with a few surprises.

Terri Schiavo lived for 15 years in a persistent vegetative state. Her legacy includes a healthy national interest in living wills and euthanasia. However, end-of-life issues are just the tip of the ethics iceberg in this complex scenario.

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Let's take a look at an ethics report card that reflects the frank views of students in a university ethics class.

What's an ethics report card?

Even if you never had a formal ethics course, you can easily learn to create ethics report cards. The purpose is to learn more about yourself and those with whom you interact in personal life, business, and government.

As a class teaching exercise, my students in a university ethics course graded the behavior of some key participants in the tragic life and death of Schiavo, including her husband, her parents, Republican government leaders and conservative Christians.

As you read the report card, note that the students clearly understand two critical differences between ethics and morality in today's world.

First, there are two kinds of judgment. Judging in the ethical sense means drawing conclusions from a combination of observation, critical thinking, and a sense of right and wrong. On the other hand, judging in the moral sense means lauding people as angelic or declaring them evil.

Secondly, ethicists judge situations and underlying ideas; moralists judge people. Because of these differences, an ethics report card exercise is useful because it requires thinking so can result in self-improvement whereas an exercise in moral judgment is a self-righteous display of firm preconceived notions.

The story

Schiavo was an obese, shy child with severe self-image problems. During her adolescent years she lost over 60 pounds. In retrospect, she was diagnosed as having bulimia, a condition in which people feel guilty about eating so induce vomiting right after eating thus becoming malnourished.

In 1990, while allegedly on a diet of 10 to 15 glasses of iced tea a day and little additional intake, Schiavo suffered cardiac arrest that caused irreversible brain damage. The cause of her collapse was never proven beyond a doubt, but most likely was due to hypokalemia (low serum potassium), a result of her eating habits.

Ironically, for 15 years in a persistent vegetative state (no human brain function), Schiavo was kept alive with tube feedings. On March 15, 2005, after a long and bitter legal battle involving her husband, her parents, government leaders, and religious activists, Schiavo's feeding tube was removed. She died of dehydration on March 31, 2005.

Ethics on display

Schiavo met her future husband, Michael Schiavo, while both were students at Bucks County Community College in Newton, Pa. They were married November 10, 1984. After Schiavo's brain damage occurred, Michael Schiavo studied nursing so he could care for her. He encouraged implantation of a thalamic stimulator, a brain stimulating treatment that did not work.

Until 1993, Michael Schiavo and Schiavo's parents, Bob and Mary Schindler, had a good relationship. Then, Michael Schiavo accepted what he believed was the inevitable. He gave up hope for his wife's recovery and focused on whether or not she would want to be kept alive in her persistent vegetative state. He recalled conversations with her that suggested she would rather die. Unfortunately, she did not leave instructions in a living will.

Michael Schiavo's interpretation of her wishes, and his right as his wife's surrogate decision maker, were confirmed in court cases. Michael's motives were suspect, however, because he was now living with another woman with whom he had two children. In addition, Michael had won a million dollar malpractice suit because physicians did not timely diagnose his wife's bulimia.

Student views

Michael Schiavo: The students did not attempt to judge Michael Schiavo's motivation. Rather, they focused on his observable behavior. They applauded his concern and action as long as there was any hope of his wife's recovery. They applauded the fact that he arrived at a point of accepting the inevitable. (1)

Furthermore, they felt that Michael Schiavo's wait before developing a relationship with another woman was long enough. Speaking directly, as students often do, they felt it was expecting too much of a man to avoid female companionship when irreversibly robbed of consortium with his wife.

Ethical grade: B

Bob and Mary Schindler: The Schindler's turned against Michael Schiavo for accepting Schiavo's condition as irreversible, attempting to discredit him and the doctors. They made a video that they said proved their daughter's ability to function at a cerebral level. An autopsy showed the doctor's diagnosis was correct. Schiavo's brain was tiny and shriveled; her skull was filled primarily with fluid. (2) Schiavo's responses were all reflexes mediated at the brain stem level or in her spinal cord.

The students criticized the Schindlers for a self-serving parenting ethic, for being unwilling or unable to face reality, and for adhering stubbornly to religious views that ignored their daughter's best interest. Ethical grade: D

Republican politicians: Florida Governor Jeb Bush had the Florida legislature pass a law giving the governor permission to order that Schiavo's feeding tube not be removed. The courts declared this law invalid. President George Bush and congressional leaders Tom Delay (R, Texas) and Senator Bill Frist (R, Tennessee) attempted to intervene with new federal legislation.

The students saw the Republicans' actions as attempts to please a critical part of their power base. Indeed, they were appalled at this exploitation of Schiavo's condition and the family and religious conflict it engendered. However, the students did not dwell on issues of electioneering politics. Rather, having just studied a portion of John Locke's Second Treatise on Civil Government, (3) a work from which our forefathers borrowed heavily, the students focused on the purposes of government.

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These include limiting the freedom of individuals to assure that each individual can freely exercise natural and human rights (Locke declared that "liberty is not license"), providing services to the people, funding these services, and developing relationships with other nations. (3)

The students felt that Republican leaders should have been exerting leadership in pursuit of these purposes vis a vis domestic and international issues rather than spending their time and the taxpayers' money playing politics. Their word for the behavior of these government leaders was "despicable."

Ethical Grade: F

Conservative Christians: The class reflected the nation's divided opinion about whether a beating heart and automatic respirations without any human brain function constitute meaningful life. However, they were not divided in their view of the effort by conservative Christians to wrap a social agenda and political power plays in the mantle of God in an attempt to make opposition to conservative Christian views appear to be ungodly behavior. Ethical Grade: D

Do you agree with the students' analysis or not? Put yourself in the place of Michael Schiavo, Bob and Mary Schindler, the politicians and the conservative Christians. What would you have done? What do your answers tell you about your own personal beliefs and behavioral guidelines at work and at home?

Richard E. Thompson, MD, is author of Think Before You Believe: Modern Day Myths, Questionable Claims and Uncommon Sense, Xlibris, Philadelphia, 2004. He teaches ethics at Missouri State University. Springfield, Mo. and can be reached at [e-mail]

References

1. Kubler-Ross, E. On Death and Dying. New York: Macmillan, 1969.

2. Autopsy report. www.abstractappeal.com/schiavo/autopsyreport.pdf

3. The Second Treatise on Civil Government (first published in: Two Treatises of Government [1690]), Buffalo, NY: Prometheus Books, 1986.

4. Thompson, RE. Think Before You Believe. Philadelphia: Xlibris, 2004.

By Richard E. Thompson, MD