Terri Schiavo and diagnostic, legal, and ethical confusion

Fred Hutchison, RenewAmerica analyst

Originally published March 25, 2005

The state and federal judges who have reviewed Terri Schiavo's* case are influenced by the medical diagnosis made by a few doctors that Terri is in a "persistent vegetative state" (PVS).

The governing concept of these physicians is that the patient, with "no behavioral evidence of awareness," has PVS. A PVS patient might appear conscious in various ways such as having apparent eye contact and movement in response to nearby events, yet not be aware of external surroundings. In the case of Terri, the doctors interpreted these signs in her as reflex responses to stimuli, instead of indicators of awareness. Other doctors might have interpreted this exact set of behavioral symptoms as evidence of awareness.

Types of thought

By "awareness," the doctors mean normal waking consciousness, the lack of which does not necessarily signify a state of mental oblivion that most people think is a vegetable state of existence. It is not clear that the judges understand what the doctors mean by PVS. They might think that Terri is a vegetable with mental oblivion. "Persistent vegetative state" (PVS) is a misnomer, because the words signify something other than the intended meaning of the diagnosis. Even experts are not of one mind as to what the diagnosis means, because there are several categories of consciousness that might be diagnosed as PVS. Misunderstanding of a fuzzy diagnosis with a name that is a malapropism may well determine the outcome for the Schiavo case.

Consciousness is a tricky concept. A patient may lack "normal waking consciousness," but inhabit a semi-conscious dream state. We all experience the latter in our sleep. During a shallow dreaming sleep, we sometimes integrate external signals into our dream. Perhaps Terri is doing this. A patient may be aware of his surroundings but unable to respond to them. This is a common experience of those coming out of anesthesia. Waking consciousness can be impaired in a variety of normal and pathological ways. A normal person can tune out awareness of surroundings through intense concentration or traumatic distraction. A person with extreme sleep deprivation might be incapable of sustaining robust normal waking consciousness. A mentally ill or brain-damaged person can have abnormal waking consciousness and filter or transmogrify elements of reality in odd ways. The PVS diagnosis blurs the distinctions between the various kinds of consciousness.

Terri's parents believe that she has waking consciousness based upon her emotional and personal responses to them. On what grounds do the doctors claim to know that the parents are wrong? Well, they cite her reflexive reactions as evidence. However, both conscious and unconscious persons have reflexes. Why do reflexes necessarily define Terri as unconscious?

Dr. David Stevens, president of the Christian Medical Association, disagreed with the diagnosis of Terri. He questioned the validity of the concept of "persistent vegetative state" (PVS) and said that diagnosis of such a state is impossible. "Some patients who come out of PVS have stated that their mind was in a prison but they knew what was going on around them." (Christian Wire Service, 3/23/05) Therefore, a patient can be conscious, yet act like a person with PVS.

Consciousness and the faculty of thought must not be confused. We can be conscious of thinking — but we can also think without being aware of it. If Terri lacks waking consciousness, it does not necessarily imply that Terri has no mind and no thoughts. The doctors failed to take an MRI, so they might have been indifferent to whether Terri is thinking. All their attention was focused upon the issue of waking consciousness.

Does this clinical indifference to unconscious thought signal a presumption that the dream state is just brain static, or that unconscious thought is inferior, superfluous, and unworthy of preservation? Some of my best ideas began as unconscious thoughts or dreams. Why should not the rich realm of unconscious thought be valued? Perhaps William James' pragmatism and John Dewey's instrumentalism have conditioned our educators and doctors to devalue thoughts that cannot be immediately and profitably put into action, such as the thoughts of Terri Schiavo. But who are we to say that her thoughts have no intrinsic value? Some of the richest and most profound thoughts a person can have cannot be reduced to instant communication or put into immediate action.

To suppose that Terri's thoughts have no value is ethical presumption. A hasty decision to pull out her feeding tube amounts to speeding through a series of ethical yellow lights. Ethical reckless driving is a close kin to manslaughter, which is "the reckless indifference" to the safety of others.

An ethical briar patch

Let us consider four alternative propositions about Terri's mental status. Proposition one: Terri has waking consciousness. Proposition two: Terri is in a dream state. Proposition three: Terri is unconscious, but has thoughts. Proposition four: Terri is in oblivion and has no thoughts, feelings, or intuitions. The ethics of the case partly rests upon which of the four mental states apply to Terri and the grounds that were used to make the diagnosis. Is it ethical to withdraw the feeding tube if that opinion is based on diagnostic haste, presumption, neglect, or a claim by doctors to know something they lack adequate grounds for knowing? Do the doctors have adequate grounds for diagnosing a "persistent vegetative state" without taking an MRI? Is it ethical for the doctors to ignore or rationalize away the observations of Terri's parents? Should a judge listen sympathetically to the parents? Not all doctors who are specialized in cases of severe brain damage agree that "a persistent vegetative state" (PVS) is a valid diagnosis, or that it is possible to know whether such a patient has waking consciousness. How does this medical controversy and diagnostic uncertainty affect the ethics of pulling out the feeding tube? Did Terri's husband shop for a doctor who would give him a diagnosis that would suit his intentions?

What are the ethical implications of pulling out the feeding tube on an unconscious person who is an object of love and compassion by parents who are ready and able to care for her? Is there a method of discerning if such impaired persons desire to live, such as the desire to meet people and experience new things, in contrast to the desire to withdraw and escape? Terri seemed to brighten and sometimes laughed when her parents entered the room.

Does fuzzy law trump fuzzy ethics in cases like Terri's? In what situations, if any, can the constitutional right to life and the right to due process of law bypass state law and the powers of the spouse or legal guardian in order to benefit an incompetent patient? Can ulterior motives of the guardian or spouse be used to legally declare them unfit to decide for the patient? Does cherry-picking for doctors to get the diagnosis the spouse or guardian wants to hear signify unfitness of the spouse or guardian?

Does bearing children through an adulterous affair compromise the interests of Terri's husband and call into question his fidelity, moral character, and loyalty to Terri? How can Terri's husband claim fidelity to her wishes concerning the termination of life, when he has no fidelity to the marriage vows, yet inexplicably refuses to divorce Terri? Why does he prefer divorcing her through her death rather than divorcing her through law?

The remainder of this analysis shall be confined to the esoteric question of consciousness, because the doctors and judges have made consciousness a life-or-death issue for Terri. Amazingly, a serious review of consciousness has been neglected in the public conversation.

The materialist model of consciousness

Some scientists and doctors think that man consists entirely of a physical body. Therefore, they believe that observations of superficial stimulus and response tests and empirical tests of brain activity are all that is needed and all that is admissible to diagnose a mental state. They assume the brain is the sole organ of thought and consciousness, and that medical treatment of the brain is the only valid therapy for the mind. The materialist physician believes "the brain secretes thought as the liver secretes bile." This quote originated with Dr. Pierre Cabanis, a materialist of the late French Enlightenment, and was popularized by Karl Vogt, a German Neo-Hegelian atheist/materialist philosopher of the early nineteenth century.

Edward O. Wilson, a contemporary biological determinist, says that human reason, free will, and consciousness are "epiphenomena of the brain." This means that we humans are programmed automatons — and reason, free will, and consciousness are mere illusions. Wilson expresses the view of the hard-core materialists that the mind is nothing but electro-chemical brain activity. This places us all in a passive dream state with programmed delusions of being awake and in control like the zombies of the Hollywood film "The Matrix." This implies that we are all in a dream state like Terri Schiavo, but do not realize it. (I hope they do not pull out my feeding tube until this dream of writing an essay is over.)

Materialist doctors who think like Wilson tend to follow pragmatic and instrumental values, learned from William James and John Dewey, to determine whether a handicapped dreamer is fit to live or die. These cool, calculating, amoral people might conclude that a dysfunctional, unproductive, expensive, and inconvenient dreamer — like Terri — should die. Scrooge, a Victorian utilitarian character in Dickens' famous story, said, "Let them (children in workhouses) die and reduce the surplus population." Materialist doctors are rapidly becoming masters of the "vegetable garden" where the zombies lay plugged into the matrix, dreaming their fantasy dreams. Our new masters are beginning to decide which zombies shall become surplus body parts and reduce the surplus population. Remember, to the materialist, we are all automatons, which are the rough equivalent of a zombie. The identification by doctors and the secret police of people not fit to live has already happened in Nazi Germany and the Soviet Union, because materialist rulers and doctors had the power to do it. Inconvenient people, such as religious types, were sent to insane asylums where the doctors conducted experiments on them.

What are the grounds for thinking that we are automatons driven by mindless bodies? A tight clique of French Enlightenment philosophers of the eighteenth century became atheists and embraced philosophies of hard materialism as their intellectual rationale for atheism. They cleverly linked the empirical philosophy of John Locke and David Hume with materialism, atheism, and empirical science, something that the empirical Locke and the skeptical Hume never did.

Empirical science is based upon the observation and measurement of matter. The French intellectuals drew the conclusion that all we can really know is sensory, empirical, and scientific — and every other kind of knowledge is mere conjecture and fantasy. The French "philosophes" made a further leap of speculation and said that what we cannot know through science does not exist, but there is nothing that does exist that science cannot eventually learn. Therefore, only science has a right to speak with authority, and science has no limits to its jurisdiction. Our new master will be the science establishment. The philosophes asserted that science necessarily supports materialism and atheism. But are these sweeping generalizations true? Or are they a myth of the cult of scientism?

I would like to ask Edward O. Wilson how a material automaton, for whom reason and consciousness are illusions, can know anything about science or matter. Such an automaton can only run mental programs like a computer. If the materialist scientists are themselves programmed automatons, all their claims to sole authority about knowledge, unlimited jurisdiction over knowledge, and unlimited potency in learning all knowledge, are grandiose delusions. These fantasies are mere epiphenomena of their brains. Right, Dr. Wilson? Materialist philosophy is self-contradictory nonsense. The mind cannot possibly consist only of brain activity, or else this life is the mere illusion of dreaming fantasy.

If science can only know about matter and energy, how can it say anything whatever about a non-material realm? If scientists think that we can only have authentic knowledge through material science, how does this imply that non-material realms beyond our knowledge do not exist? But if such realms do exist, why cannot humans possess mental and spiritual faculties for knowing something about these realms?

Laboratory links between mental activity and brain activity have been convincingly established. Does the establishment of clear links between the brain and the mind automatically rule out the possibility that the mind also has a non-material component? Many scientists from a hard-materialist background are making this leap, yet asserting at the same time that the mind can be nothing more than brain activity. But this is a logical fallacy. It is like saying, "Learning takes place in school. Therefore, learning can only take place in school, and nowhere else." This is the fallacy of exclusive authoritative jurisdiction. "The only case worth listening to is the authoritative case made by a staff of experts." This is close to the "God complex," which scientists and doctors who have institutional authority and mastery of a specialty are sometimes susceptible to. A doctor with a God complex feels that he can judge who should live and who should die.

Materialists who would laugh at the God complex and the fallacy of exclusive authoritative jurisdiction will say without blushing, "There are links between the brain and the mind, and therefore brain activity is the only source of mental activity." This is the kind of educated simpleton's fallacy that is behind statements like, "Terri has physical reflexes to stimuli, and therefore all her outward reactions are physical reflexes." Only a highly educated, specialized mind can be trained to be this stupid.

Since materialists believe reason and consciousness are illusions, does that account for medical carelessness in diagnosis of the mind? If we are all automatons, as materialists think, what difference does it make whether Terri is a dreamer, an automaton, or a vegetable? To the materialist, those distinctions are much ado about nothing. Why exercise due professional care when not much is at stake?

The spiritual-material mind

The remainder of this analysis of consciousness is for readers who are open to the idea that the mind consists of both material and nonmaterial components. Scientists know that there is a link between brain activity and mental activity, but have no idea of how brain activity is converted into thoughts. This opens the door to the possibility that a nonmaterial or spiritual agent is at work that assists the brain in formulating thoughts.

If the mind is nothing but the brain, it is a closed system, and everything that happens in the system is determined by the system. That is why Edwin O. Wilson believed no independent reason could subsist within brain activity. However, a spiritual faculty cannot be trapped in a material prison. If the mind is a brain-spirit hybrid, the spiritual part can rise above the neural system. This makes it possible for human reason to rise to independence and for the will to break free of deterministic forces and truly become free will. If we are to assume that we are not automatons, and that reason, free will, and consciousness are not mere illusions, we must also believe that the mind has nonmaterial components.

If the mind is a hybrid of matter and spirit, the nonmaterial part of the mind might continue to operate, possibly in impaired form, after the brain is severely damaged. This means that no matter how much Terri's brain was damaged, she still possesses a spiritual mind. That mind, of course, can only communicate to the outside world to the extent it can connect with what is left of the brain that has nerve links to the body. Because this is true, a doctor who makes a PVS diagnosis has no clue about this, or is unethical.

The immaterial spirit part of the mind may continue its existence after death. Only material bodies die. Therefore, in the next life, we are not cut off from that part of our earthly mind that was immaterial. When Terri Schiavo dies, her spirit mind will continue to exist and will continue to have consciousness. A babe in the womb has a spirit mind and consciousness even before his brain is functional. The women who think they are aborting a lump of protoplasm are deceived.

The mystery of consciousness

Those who believe that the mind has two components of matter and spirit are of three opinions about consciousness. The Cartesian dualist (who follows the theory of Rene Descartes) believes that there is a higher mind completely separated from brain activity and that consciousness is a faculty of the higher mind. This view has logical problems. How does the higher mind communicate with the brain and thus command bodily activity? This is the Cartesian dilemma and the problem of all forms of dualism. How is the dualist to explain the links that scientists have discovered between thought and brain activity? The discovery of these links is almost a fatal blow for dualism.

Some of those who see the mind as a blended hybrid of matter and spirit believe that consciousness and conscience come from the spiritual elements of the mind. This is a valid conception, but with one difficulty. If the spiritual activity of the mind is mingled with the brain activity, how can the spiritual part abstract itself in order to observe the thoughts of the mind? We all have conscious thoughts and unconscious thoughts. Sometimes, when we become conscious of our thoughts, we can observe our minds at work like an detached observer. Who is the observer that is observing the mind?

I am forced to conclude that two entities exist — an observer who is aware of the mind at work and the mind itself. How does the detached observer communicate his will to the mind? Dualists have no answer. But if the mind is a hybrid of matter and spirit and the observer is an incorporeal spirit (disembodied spirit), then the spirit observer can communicate from the spiritual part of the mind. The spiritual element in the mind can communicate with the brain. The brain communicates with the body through the nervous system. Thus, the spirit observer can signal to the body via the mind as its intermediary.

The spirit observer is not God. Theologians tell us that the spirit (pneuma) is the part of man that knows God, who is Himself a spirit. Therefore, the person who knows God subsists in the spirit. The soul (psyche), which contains the mind, is formed from earthly materials and becomes a living soul when the breath (pneuma) of God blows upon it. These concepts of soul and spirit were discovered in the Bible by early twentieth-century theologian Watchman Nee.

Consciousness must subsist in the incorporeal spirit, because it is the only detached platform from which to view the mind and the body, and from which one can also observe other people and recognize them as persons. Terri can do all these things precisely because she is more than a physical body.

Some may say that Terri was a person with a bubbly personality, but that person is gone. I agree that the old personality is gone, but I insist that the person herself is not gone. Personhood is expressed to the world through personality. Terri's personhood vested in the spirit was once expressed through the mind and body as an original personality. Terri's personhood is now expressed through a damaged mind and body as a different personality, but the same person underlies the new personality. Her parents insist that they perceive expressions of Terri's new and unique personality every time they visit her. The doctors are blind to her personality and dismiss the symptoms of personality as "reflex action." Even her smiles, laughter, and personalized responses to her parents are rationalized away as mere "reflexes."

Some of my readers might wonder, how I can be so sure that the person subsists in the spirit. After my mother's brain was destroyed by Alzheimer's and strokes, her personality was still recognizable to an astonishing degree. She retained her spiritual gift of discernment. She could not remember my name, but I still could not fool her. She saw right through my games, as always, and knew foolery when she saw it. She was flawless in her judgment of who to trust. She continued to pray until the end.

The conscience is invested in the incorporeal spirit. God often touches our conscience as his first movement towards us, and it is always a personal experience because both conscience and the person subsist in incorporeal spirit. Momma could accurately discern between good people and evil people after her mind was ruined, because her conscience was in her spirit, not her mind.

In conclusion, Terri Schiavo still [as of this writing] has consciousness and a conscience. But do those who are in haste to pull out her tubes still possess an active conscience? If the pleas of the conscience are ignored long enough, the conscience can become comatose. Do the doctors and the judges have consciences that are in a "persistent vegetative state"?

* Schiavo: pronounced in Italian as "Skee - ah - voh." Pronounced in American news lingo as "Shy - voh," sounding like the word Shiloh.

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© Fred Hutchison