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Monday, March 28, 2005  

Commentary: Schiavo neurologist is convincing

The first thing a thoughtful person thinks while observing the reprehensible behavior surrounding the Terri Schiavo cases is not 'There are some intelligent people with useful information involved in this.' No. One thinks: Congress has no role in this kind of personal decision-making. Florida Gov. Jeb Bush's plan to send police officers under his command to take possession of Ms. Schiavo by force raises questions about his sanity. President George W. Bush, Sen. Tom DeLay and Rep. J. Dennis Hastert dropped the Schiavo situation as if it were on fire after polls showed more than 80 percent of Americans opposed their intervention. Intelligent people? Useful information? Bear with me. It's true.

By now you probably know the name Ronald Cranford. He is the highly respected neurologist and medical ethicist the trial court appointed to test and evaluate Ms. Schiavo two-and-a-half years ago. His findings -- that she is in a persistent vegetative state -- confirmed those of other neurologists who had examined her. The New York Times recently talkedto Cranford (pictured) about the Schiavo cases.

Dr. Ronald Cranford, a Minnesota neurologist who examined her in 2002 as part of a previous court case, said a CT scan of her brain showed very little but scar tissue and spinal fluid. An electroencephalogram measuring electrical activity in the thinking parts of her brain showed no evidence of continued function, he said.

"It's totally flat - nothing," Dr. Cranford said, "and this is very unusual. The vast majority of people in a persistent vegetative state show about 5 percent of normal brain activity."

In some cases, patients with severe brain injuries may indeed reach or pass through a state of minimal consciousness, where they are intermittently able to respond or move with purpose, say by reaching for a glass. In a study published earlier this year, neuroscientists in New York reported that on brain scans these patients do show evidence of some conscious awareness.

But after a year in a persistent vegetative state, patients who have traumatic brain injuries from blows to the head rarely regain even minimal awareness. And those in Ms. Schiavo's category, whose brain damage was from lack of oxygen, almost never recover after three months.

Despite the high esteem he is held in by those in his profession, Right to Life activists and Right Wing bloggers have relentlessly maligned Dr. Cranford. No one has been charged with intending to murder him yet, as has occurred with Michael Schiavo and Judge George Greer. But, it may occur. One of the reasons they condemn Dr. Cranford is that he has said we should consider not administering food and water to late term Alzheimer's patients artificially. I've looked into his opinion on the matter and find it offers clarity not only in regard to those patients, but the issue of whether long-term reliance on feeding tubes for patients with no hope of recovery in general is defensible. The Star-Tribune published an op-ed article on the topic by Dr. Cranford in 1997.

Medical organizations, courts and other groups generally agree that there are some important distinctions between stopping treatment and acting to cause a patient's death. By insisting that withdrawing a feeding tube is akin to euthanasia, these special interest groups are undermining their credibility.

And they're creating unnecessary confusion for the growing numbers of families losing a loved one to Alzheimer's. Vegetative state cases are not nearly as numerous as cases of Alzheimer's. But both kinds of cases force families to mull over the same question: When the human brain is so badly damaged that its owner can no longer think or even eat, what should be done?

This is a question families should feel free to answer for themselves -- without fearing intrusion from outsiders. And when you really think about it, the idea of placing a feeding tube in a patient with advanced Alzheimer's disease makes no sense at all, medically or morally. It borders on barbaric and cruel. It's just the kind of dehumanizing medical intervention that the public finds so distasteful. It's the sort of practice that undermines confidence that doctors have the best interests of patients and families at heart.

I appreciate Dr. Cranford articulating what the interests actually are. Removing the feeding tube returns the patient to her natural state. Defining removal as ghastly intervention doesn't make sense. But for the feeding tube, nature would have taken its course within two weeks of the injury. So, the intervention is keeping the tube, not taking it away. The intervention is not benign in an end of life Alzheimer's case (or Ms. Schiavo's) because it can only maintain the patient in a hopeless condition. Therefore, it is reasonable to remove the feeding tube. (Cf: A feeding tube for a moderate burn patient whose throat was effected would be benign intervention because the patient is likely to recover.)

As Baby Boomers continue to age, more and more families will be faced with the question of whether to continue life support in the form of a feeding tube. The number of Alzheimer's patients far out number those in a persistent vegetative state and that population will grow. I find Dr. Cranford's position convincing. If the person has deteriorated to the point that she has lost most of her faculties, and, can no longer eat by normal means, insertion of a feeding tube to extend her life serves no defensible purpose.

Reasonably related

Though the far Right followers who have behaved so bizarrely in regard to the death of Terri Schiavo seem unable to understand them, the reasons Robert and Mary Schindler lost in their efforts to continue life support are simple:

•There was oral testimony that established Ms. Schiavo's intent that she not be kept alive by artificial means. In the absence of a living will, oral testimony is acceptable evidence.

•All credible expert medical testimony, which included more than 40 medical personnel over a 15-year period, agreed that Ms. Schiavo is in a persistent vegetative state. Persons wishing to read a summary of neurologists' opinions should read all of the NYT article cited above.

10:30 PM