Dr. James Gebel, Jr. Issues a Report
In Response to Fr. Cekada
THE TERRI SCHIAVO CASE:
A CATHOLIC NEUROLOGIST’S PERSPECTIVE
Over the past several weeks, it has come to my attention that significant debate has developed regarding the Terri Schiavo case. I have
read various e-mail messages between Cathy Beal, Father Cekada, Father Dardis, Bishop Sanborn, and two letters appearing in the St.
Gertrude the Great Church bulletin.
Let me begin by stating that I do not feel I have either the theological expertise (mine is limited to a minor in theology at Xavier
University, a Jesuit college in Cincinnati) or moral authority to adequately address the theological aspects of this case. However, I do feel
that my background as a neurologist with additional specialized “fellowship” training in both neurological critical care (the subspecialty
of neurology which deals with patients in comas and other critical neurological illnesses) and stroke, at the Cleveland Clinic and
University of Cincinnati respectively, put me in a position to contribute some thoughts on the medical aspects of her case. Since
completing medical school, I have over 15 years of experience training, practicing, and doing research in these areas. I have also had the
opportunity as the result of my training and expertise in these areas to testify as an expert witness in such matters in medical malpractice
and pharmacological product liability lawsuits. I state the above not to be prideful, but to give you some tangible appreciation of the fact
that, simply speaking, there are few people in the country with any better training background or practical expertise to understand in
detail the scientific and medical aspects of the care of patients like Terri Schiavo, whom I deal with on literally an almost daily basis.
I have reviewed the CT scan images of Terri Schiavo’s brain, watched the video of her taken by her family members, and also reviewed
some summary comments/ excerpts regarding testimony given in deposition transcripts in her medical malpractice case. These again are
all things I do on a very frequent basis. They are, to be frank, part of how I make my living. Having clarified the context in which I share
my thoughts with you, I offer the following thoughts on this matter:
1) Terri Schiavo was NOT in a persistent vegetative state. The video taken of her clearly and unequivocally demonstrates that, at
least at times, she is in a minimally conscious state and capable of interacting in a rudimentary way with her family and environment,
which by definition excludes her from being medically classified as comatose or in a persistent vegetative state.
2) The parts of Terri Schiavo’s brain which would allow her to perceive pain, her thalami, were clearly intact and visible on her CT
scan images shown by her husband, Michael Schiavo, on national television (which I rarely watch, and by the way, I have never
voluntarily watched “Oprah”)
3) The parts of Terri Schiavo’s brain which would allow her to perform complex cognitive function, or which would enable her to
speak or understand speech, were clearly damaged.
4) The parts of Terri Schiavo’s brain which would allow her to swallow on her own were intact and, in fact, she did not suffer from
medically significant dysphagia (swallowing difficulty). If she had, she would have been dead long ago from a condition known as
aspiration pneumonia, an infection in the lungs which is the result of inhaling one’s own saliva.
5) The parts of Terri Schiavo’s brain which would allow her to move her arms and hands to feed or hydrate herself were clearly
damaged.
6) The parts of Terri Schiavo’s brain which would allow her to experience discomfort and/or pain due to hunger were undamaged.
7) Other tests were available to better clarify the full extent of Terri Schiavo’s awareness or lack thereof, such as MRI scanning of
her brain ( a more detailed picture of the brain than a CT (CAT) scan, EEG (a brainwave test), and evoked potential studies, which could
decipher the extent to which she could hear or see. These studies were refused by her husband, Michael Schiavo.
8) Terri Schiavo did not receive or require intravenous hydration or nutrition (so-called “TPN”) or total parenteral nutrition.
9) Oral or stomach tube feeding via an “NG” (nasogastric tube) (a tube put down one’s throat to the stomach) or (more commonly)
via a “G-tube” are routinely used to feed stroke victims, both temporarily and indefinitely in patients with stroke or other brain injuries
who cannot feed themselves, whether due to swallowing problems (which occur at least temporarily in most stroke victims). Such feeding
and hydration are by modern medical standards considered as ordinary and unburdensome as eating and drinking on one’s own. Such
feedings are, in fact, less expensive than what an average American spends on food and water, and are easily administered a few times a
day by a family member, requiring much less effort than cooking three meals a day. Terri Schiavo’s husband, parents, or siblings could
easily administer such feedings. They are by no logical measure extraordinary or unduly burdensome by any reasonable standard (moral,
medical, or economic).
10) Terri Schiavo could have been cared for at home with some home health care assistance at modest to at most moderate expense
which would not by any common sense standard be deemed economically burdensome.
11) Terri Schiavo’s stomach and intestines were fully functional and capable of digesting food, even normal food if it was placed in her
G-tube.
12) Terri Schiavo could have received sequential neurostimulation therapy to her throat muscles, which may have further improved
her swallowing function to the point that she may have been able to chew or swallow at least some types of normal food and/or liquid if
placed in her mouth. This and other similar available measures were denied to her by her husband.
13) Terri Schiavo’s brain, while severely damaged, had not “failed”. When someone’s brain “fails,” i.e. is irreparably and totally
damaged, they are, by definition, dead. While we can keep people alive when other vital organs such as the liver, kidneys, lungs, and even
heart fail (via dialysis, organ transplantation, etc.), not even 2005 era medicine can keep one alive if one’s brain has failed, because all
other organs shut down within 5 days when this occurs, even when every maximal effort possible is made.
14) Terri Schiavo did not require, nor to the best of my knowledge did she ever receive intravenous nutrition (TPN), as was suggested
in one of Father Cekada’s e-mail messages. Lifelong TPN, in contrast to tube feeds, is widely considered to be an extraordinary,
burdensome, and expensive means of prolonging life, and are comparable to a respirator in that regard.
15) Terri Schiavo’s doctors did, in my opinion, probably commit malpractice by failing to order routine pre- procedure labs which
would have disclosed severe electrolyte disturbances secondary to her bulimia.
16) Medical malpractice care awards/settlements are often grossly overinflated due to plaintiff’s attorneys hiring so-called “life care
planners” who add up every conceivable convenience and treatment imaginable as “necessary” for the rest of the patient’s life. Their
overestimates are typically further compounded by overestimating the patient’s life expectancy. Furthermore, all the money is paid in
advance at today’s dollars, meaning the real money value of the award is much higher than the actual cost of such care in the vast majority
of such cases. Terri Schiavo’s true care needs would certainly be far less than 750,000 or 1,000,000 dollars.
17) Attorneys representing patients and defendants in medical malpractice and other medicolegal matters often “shop around” for
expert witnesses until they find experts who will give an opinion which suits their client’s needs. Thus, it is no surprise that George
Felos, a well-connected euthanasia advocate, was able to find three physicians to testify that Mrs. Schiavo was in a persistent vegetative
state. In fairness, likewise it is no surprise that Terri Schiavo’s parents and siblings’ attorneys found expert witnesses who testified that
she was not. One should certainly be suspect of the testimony of an expert witness who has spoken to the Hemlock Society and
concludes that Terri Schiavo is in a persistent vegetative state.
18) Terri Schiavo died of dehydration, not starvation. Dehydration kills one much faster than starvation, barring the exception of
extreme malnourishment, which was not the case here.
19) Terri Schiavo had an average life expectancy despite her brain injury, and would not have died were it not for her being deprived of
nutrition and hydration. The proximate legal and medical cause of her death in my opinion was dehydration.
20) Laws regarding who has legal authority over health care decisions vary greatly by state. In Pennsylvania, for instance, children and
siblings have as much right to make medical decisions as spouses, unless a pre-specified durable power of attorney designating one of
them pre- exists the illness, or unless a living will was written by the patient. Other states require a durable power of attorney to be
obtained no matter what. Ex- spouses, unless they are made durable power of attorney, have no legal right to make medical care decisions
in any state.
21) Discontinuation of tube feeds or any form of food in general causes intense hunger pains for 2-3 days, which Terri Schiavo would
have had the capacity to feel and suffer.
22) Death by dehydration occurs slowly, eventually causing hyperosmolarity often resulting in shriveling, cracking, and bleeding of
the mucous membranes. This causes pain, nosebleeds, and as consciousness begins to wane, patients often begin aspirating blood from
the nosebleeds, thickened, mucus or saliva, or both, causing aspiration pneumonitis. The aspiration along with accumulation of unsecreted
organic acids results in progressive shortness of breath which further compounds the mucus membrane injury. Observing this struggling
to breath and choking is often very disconcerting to family members as well as potentially painful and discomforting to the patient. This
is why such patients are often administered morphine, which both relieves pain and suppresses this so- called “air hunger.” This is also I
suspect why the judge in the Terri Schiavo case barred pictures or video of her being taken while she dehydrated and starved. Much as
those who are pro- abortion most detest the one thing which actually shows people what happens in the case of abortion (pictures of
aborted babies), euthanasia advocates do not want people to see the visible suffering which often occurs in cases like Terri Schiavo’s.
23) Cases like Terri Schiavo’s are, thankfully, rare. This is why when they occur and ultimately result in legal battles, we hear about
them on the media. Collectively, even if one were to assume each and every one of them were to result in a lifetime of tube feedings,
would be far less of an economic burden on society than a new football stadium.
Cases like Terri Schiavo’s understandably evoke a wide range of emotional responses and theological arguments. Unfortunately, the
Catholic Church, theologians, and bioethicists in general lag far behind in their scientific understanding of the rapid and increasingly
complex advances in medical care, which often occur literally even prior to our ever having the opportunity to contemplate their moral
and theological implications. It is in the spirit of attempting to help simplify and clarify some of the medical aspects of the Schiavo case
that I share the above thoughts with those who are inclined to read them. Finally, I would advise each and every person to prepare a
living will as you would a normal will so that your families might be spared the pain and anguish of having to decide what care measures
you would want should a grave or terminal illness occur. Had Terri Schiavo done so, her family and many others would have been spared
from the bitter, divisive, and expensive series of legal battles which followed, which were the real extraordinary burden to society in her
case.
Respectfully,
James M. Gebel, Jr., M.D., M.S., F.A.H.A.
Fr. Cekada Makes Retort to Dr. Gebel
About a week after Dr. Gebel’s report was first posted, Rev. Cekada issued a response. That reply appeared (without the text of Dr.
Gebel’s report) in the St. Gertrude Church Sunday bulletin. Here is that response:
Dear Dr. Gebel,
Someone forwarded to me your comments about my articles on the Schiavo case..
A number of other people involved in health care have written to me about the medical aspects of the case.
I not qualified to decide whether your medical opinion or other conflicting medical opinions about PVS, therapy, etc. are more in
accord with the principles of medical science.
But common sense tells me that the method you used to arrive at your opinion -- reviewing CT images, watching a video and
reviewing summary/excerpts regarding testimony given in deposition transcripts -- is no substitute for examining a live patient.
Unlike other doctors directly involved in the case, moreover, you have not been cross-examined on either your methods or your
conclusions.
Be that as it may, I am qualified to speak about the moral issues in the case, and indeed, I am also obliged to do so.
If what you seem to be claiming is true and Terri Schiavo was somehow able to eat and drink by natural means, there is no dispute that
those who cared for her would have been obliged to provide her with food and drink. To have withheld these would have been a mortal
sin (unjust direct homicide) against the Fifth Commandment.
However, my writings on the Schiavo case centered on something else: the principles that Catholic moral theology would apply to
removing a feeding tube.
I do not want my parishioners to be left with the impression -- due to the high emotions and bitter controversy fanned by the morally
bankrupt media and by various lay and clerical grandstanders -- that something is a mortal sin when it is not.
Who knows when any one of my flock may be called upon to deal with the issue of a feeding tube for himself or a family member?
Here, put very bluntly, are the two essential questions in moral theology that I have sought to resolve:
(1) Does the Fifth Commandment under pain of mortal sin always require a sick person who is unable to eat or drink by natural means
to have a doctor shove a tube into his nose or poke a hole into his stomach in order to provide food and water?
(2) Does the Fifth Commandment under pain of mortal sin then always forbid such a person to have these tubes removed, no matter
what grave burdens -- pain, revulsion, depression, expense, etc. -- their continued use may impose on him or another?
The answer to both questions is no.
Having a hole poked in you, a tube shoved in and then having to eat and drink that way would be burdensome for any normal man.
Like the IV drip mentioned by the moral theologian McFadden (whom I quoted elsewhere), one could maintain this procedure would
be morally compulsory “as a temporary means of carrying a person through a critical period.”
“Surely,” however, “any effort to sustain life permanently in this fashion would constitute a grave hardship.” (Medical Ethics, 1958, p.
269.)
(Perhaps some priest, layman or doctor who rejects this conclusion could get his own feeding tube inserted, live that way for fifteen
years, and let us all know in 2020 whether the experience was a grave hardship or not. Any takers?)
Insisting (as some have done in the Schiavo case) that one is bound to this under pain of mortal sin (otherwise, euthanasia! murder!)
contradicts Pius XII’s teaching that one is bound only to use “ordinary means,” which he defined as those “that do not involve any grave
burdens for oneself or another.”
Imposing “a more strict obligation,” the pontiff warned, “would be too burdensome for most people and would render the attainment
of a higher, more important good too difficult.”
So, even though as a doctor you may well consider poking holes into people and inserting permanent feeding tubes “by no logical
measure extraordinary or unduly burdensome by any reasonable standard, moral, medical or economic,” Catholics must nevertheless draw
their understanding of extraordinary means from the Church’s moral teachings -- rather than from the practices and pronouncements of
the medical-industrial complex.
In sum, by the standards of Catholic moral theology, the permanent use of a feeding tube constitutes extraordinary means and is
therefore not obligatory. Like all such means, one is free to use it, “as long as one does not fail in some more serious duty.” (Pius XII)
But one cannot maintain that a Catholic is always bound to use a feeding tube under pain of mortal sin – still less, that the refusal to do
so constitutes “murder.”
Don’t try to invent a mortal sin where there is none.
In Christ,
The Rev. Anthony Cekada
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