Who are you? -- March 25, 2005

Carlton Vogt's

Enterprise Ethics

Volume 3 Number 9 March 25, 2005

Who are you?

Personhood lies at the center of the Schiavo case

Let's do a mind experiment. Suppose that medical science had perfected a brain transplant, and doctors could place a healthy brain inside a body where the original brain had been damaged or diseased.

Now suppose that you and I were in a terrible automobile accident. Your body was horribly torn apart, but your brain was perfectly intact and could be kept on life support. Now further suppose that my condition was the exact opposite. My brain, pierced by a jagged chunk of metal, was irretrievably damaged, but my body was miraculously intact. Kept on life support, it would survive for a short time.

Now finally suppose that the doctors did perform a brain transplant, putting your brain in my body. And suppose the operation was successful. When the day came to wake up, who would wake up? Whose memories, personality, hopes, dreams, aspirations, likes and dislikes, and spiritual beliefs would be lying in the bed? Why you, of course, even though the body in the bed looked like me. I would be dead.

What's the point of this exercise? It's to show where "you" are located. "You" are not your body. "You" are not even your face or any other physical attributes. "You" are precisely the psychological continuity residing within your brain tissue that, over a period of time, has made you what you are. It is your personality. It is your "person." When those mental functions disappear, as they did in my case in our mind experiment, then "you" are gone -- departed. My body would have been there, but I would have gone away.

This is a crucial element of the Terri Schiavo case. According to what I have read in the last few weeks, the preponderance of medical evaluations say Ms. Schiavo is operating almost solely on brain stem activity. This means that the lower part of her brain, the part that controls basic functions and reflex actions, is functioning, although it has suffered some damage as well. But the higher brain functions -- memory, rationality, self-awareness, communication, emotion -- are gone, and permanently so. The brain tissue that supports these functions has deteriorated and the space filled with fluid.

There are a few dissenters to this evaluation, but they tend to be people with a pre-existing religious/political agenda or people on the payroll of other people with such an agenda -- and a couple of self-promoters with a patent cure to peddle, thrown in for good measure.

For Ms. Schiavo, there is no memory, there are no aspirations, and there is no rational self-awareness. I resist the impulse to compare her current condition to the lower order of animals, because such a comparison is demeaning to someone who was once a vibrant, active person, but nonetheless, the comparison is accurate.

Perhaps, as is pointed out by the activists who want to force feed her to keep her body alive, she can track objects with her eyes. The question is whether that action has any meaning behind it, or it is just a reflex shared by most other beings with a rudimentary brain operating.

So, if the preponderance of independent medical opinion is correct -- and I'm making an assumption that it is, mostly because it's so consistent -- "Terri Schiavo," the person, has already died. The body that she once occupied still persists, aided by artificial and minimally invasive nutrition. Some have tried to compare her to a disabled person, but that is terribly inept, because no "person" exists to be disabled. The body is disabled, but not the person.

One of the things we consider when determining whether invasive procedures on the incapacitated are warranted is whether the benefit outweighs the invasiveness. In this case, it seems doubtful. Although the invasion is minimal, the benefit just isn't there. If the person of Ms. Schiavo is, as I concluded, already dead, then there is no one to benefit from the extended persistence of her body, except perhaps her parents and those with a crass political interest in the case.

On the other hand, if Terri Schiavo, the person, has died, then someone could argue there is no one to harm in forcing the continued existence of the body. Or is there? At some point, no matter how much the mind -- and the person it once created -- has deteriorated, there is still the matter of dignity, of respect to the person who once existed. This is why we conduct funerals with more or less solemn rites. This is why we just don't leave the bodies of our loved ones on the street corner with the weekly refuse.

We all have wishes -- no matter how simple -- for how we wish our remains to be treated after we die. And those wishes carry some weight. Even for those who donate their bodies to be cut up by medical students we demand some dignity. And, we become appalled when we hear of bodies being mistreated by an undertaker or at a crematorium.

And, therefore, I could argue that this campaign to continue force-feeding Terri Schiavo to score some political or religious "victory" is a loss of dignity for her. It violates one of the cardinal principles of ethics. It uses Terri Schiavo's body as a means, rather than an end. There is no way she will benefit from the continued existence of her body. The only ones who will benefit are the political and religious opportunists who see this as a way to promote their various agendas.

Even the media are confused over this. My, admittedly right-wing, local newspaper had a screaming headline today "Time Running Out to Save Terri Schiavo." I'm not sure whether this was done out of ignorance or deceit, but there is no Terri Schiavo to "save." Doctors may be able to pump food and drugs into the body and continue its existence for perhaps years, but Terri Schiavo cannot be "saved." She died, along with the higher functions of her brain, 15 years ago.

From where I sit, the real harm being done in this case could be to her parents. Very often, in similar cases, families have a difficult time letting go -- especially when the patient has facial expressions and makes movements that they can interpret as meaningful. They see what they want to see.

There's a common expression in medical ethics that there comes a time when you stop treating the patient and start treating the family -- getting them to realize that further treatment, while possible, is futile and that it's time to let go. Sometimes that is easy, and sometimes it is tremendously difficult. It takes patience, education, and support.

Unfortunately, in the case of Terri Schiavo's parents, there is no support, and any attempts at education are being thwarted by the peddlers of false hope -- from opportunistic politicians, physicians with an axe to grind, the so-called "pro-life" activists who see this as a chance to further their political agenda, and an assortment of people who act out of ignorance. In difficult cases such as this, where family members have a hard time coming to grips with reality, the people resisting will always grasp at whatever straws of hope come their way. Unfortunately, Terri Schiavo's parents are being thrown an overdose of such straws and are grasping to them firmly. The straws are real. The hope is false.

If any of these people truly cared for either Terri Schiavo or her parents, they would help the parents see that everything that can be done for Terri has been done -- a long time ago. Keeping her body alive no longer serves any legitimate purpose.

I hadn't intended to write this much about the Schiavo case when I started several weeks ago. However, like previous landmark cases, it will be discussed for years to come. And it has provided a great opportunity for educating people about some difficult issues in medical ethics. The sad and unfortunate thing is that the ethical issues were settled -- or at least we all thought they were -- a long time ago. This case has been marked -- and marred -- by the intense political and religious fundamentalist maneuvering, neither of which bodes well for sound medical ethics.

I may write more as conditions warrant, but I hope that this can come to a more or less peaceful solution -- although I doubt it.

* * * * * * * * * * *

Before I finish I'd like to raise a completely different issue, and sound out your opinion on something.

The question involves job openings where the organization doing the hiring is required to post and advertise the job, and to consider candidates, but the hiring manager already has a candidate who -- barring some unforeseen tragedy -- will get the job. It doesn't really matter how good other applicants are and how well they do in interviews, tests, or in what credentials or references the present. As long as the predestined candidate can abstain from being arrested for drug dealing or child molestation, that person has the job and all other applicants be damned.

I've been on the short end of this procedure several times in my career and once, I suspect, recently. The prime offenders are public agencies and union shops, where openings are required to be posted.

So, my question to you is: Should people who are hiring be required to tell you that there is a preferred candidate for the job -- actually more than "preferred;" "lead-pipe cinch" -- and that you are pretty much wasting your time? I ask this because the last time it happened to me -- or so I suspect -- the application process was so lengthy and complicated, as well as expensive, that I considered it unethical to put me through it if I didn't at least have a fighting chance. In this case, had I been told that there was a preferred candidate, I wouldn't have bothered spending the time and money to apply.