The GOP Candidates and Terri Schiavo

In a recent debate in Florida, the GOP presidential candidates--all quite possessed with desire to secure the evangelical and Catholic vote--had a chance to take a swipe at end of life issues, via a question regarding the case of Terri Schiavo. Florida is the state where Schiavo resided until her death in 2005 and where a district court judge (appointed by a Republican) told the Attorney General, the sitting president, and Rick Santorum to bugger off.

While much of the media commentary after the debate simply recorded what the candidates said, few have debunked the meaning or intention of their statements.

Rick Santorum told the audience:

"I called for a judicial hearing by an impartial judge at the federal level to review a case in which you had parents and a spouse on different sides of the issue," said Rick Santorum, a U.S. senator at the time. "And these were constituents of mine. The parents happen to live in Pennsylvania, and they came to me and made a very strong case that they would like to see some other pair of eyes, judicial eyes, look at it.

"And I agreed to advocate for those constituents because I believe that we should give respect and dignity for all human life, irrespective of their condition," Santorum said.

Rick Santorum was very involved in the Schiavo case. Schiavo's parents did petition Santorum for support. They also initiated a media blitz that is still widely recalled today. The then-Pennsylvania senator was strongly behind government intervention into the case, despite his down-playing of that during the debate (most likely because the Republicans have ludicrously put the "keep government out of health care" on the Obama Administration's health care bill).

A "pro-life" Catholic who received the ultra-conservative FAMiLY LEADER endorsement in Iowa, has been vocal about his support for Vatican-led efforts to end abortion even in cases of rape and incest and to end the legalization of aid in dying. In keeping with the Schindler family's belief that Schiavo was "disabled," Santorum would most likely push efforts to support these beliefs because, as he has stated, his version of God's law defines human rights. Santorum's version of religious freedom--and that of all the candidate with the questionable exception of Ron Paul--allows for the "pro-life" motivated regulation of medical procedures.

Gingrich got a couple of issues mixed up. He compared the rights of civil patients to those of death row prisoners:

"Well, look," Newt Gingrich said. "I think that we go to extraordinary lengths, for example, for people who are on murderer's row. They have extraordinary rights of appeal. . . .

"It strikes me that having a bias in favor of life, and at least going to a federal hearing, which would be automatic if it was a criminal on death row, that it's not too much to say in some circumstances your rights as an American citizen ought to be respected," Gingrich said. "And there ought to be at least a judicial review of whether or not in that circumstance you should be allowed to die."

Gingrich mistakenly focused on the judicial proceeding in the Schiavo case. By the time Santorum and Republican lawmakers got involved, the judicial cases had been decided. What kept them going was the Schindler's and their allies unwillingness to comply. They kept appealing, then went to federal lawmakers and the media.

Paul answered:

I find it so unfortunate, so unusual, too. That situation doesn't come up very often. It should teach us all a lesson to have living wills or a good conversation with a spouse. I would want my spouse to make the decision.

Apparently Paul doesn't read Thaddeus Pope's blog where related cases are constantly featured. I also suspect that Paul doesn't know that there are an estimated 100,000 persistent vegetative state patients in the US at any given time. But his answer essentially repudiates what happened with Terri Schiavo.

Perhaps fully understanding that public opinion is in favor of patients' right to medical self-determination (polls in 2005 showed that the Schiavo fiasco was highly unfavorable to most Americans), legal services companies didn't lose the chance to offer their assistance with advanced directives and living wills in the wake of the GOP debate. Republican presidential candidates should pay attention to what end of life issues does to their polling numbers, particularly because their constituents tend to be old and white, the very same demographic willing to pay close attention to these issues. Choice at the end of life isn't as laden with issues of sex, guilt and shame that reproductive choice is.

For more on the debate and candidate's answers about end of life issues, go to GeriPal blog. I've written directly or indirectly about the Terri Schiavo case here and here.

Is It Legal? Catholic Mandate for Patient Care.

Bob Egelko at the San Francisco Chronicle has an article today that gets most things right.

The article's title, "New Catholic Mandate on Comatose Patients," is misleading. The mandate, Directive #58, applies not just to comatose patients but to all patients who are deemed by the church in need of the introduction of artificial nutrition and hydration (ANH) or who wish to have ANH removed, whether they be victims of a terminal disease, a tragic accident or old age. The Directive qualifies ANH, applied by a surgical procedure, to be "obligatory" care, regardless of the "do not resuscitate," advance directive or living will desires of the patient.

Egelko asks, "A Legal Conflict?" As we've seen with other patients' rights at Catholic hospitals, particularly women's reproductive rights, the church is shielded by a webwork of laws (provider refusals or so-called "conscience clauses") that allow not only individuals but institutions (even those with tax-exempt status, serving diverse communities and 50% funded by the federal government) to deny patient's their rights by either not informing them of common procedures, not referring them for such procedures, or simply not performing those procedures.

The conscience clause enacted by Bush 13 months ago is up in the air as the Obama administration reviews it. Fierce lobbying by (unregistered, unreported) Christian lobbying groups, such as the USCCB, which has a staff of 350 in Washington, are working around the clock to ensure that their health care entities are not regulated by the federal government - and can subsequently shape health care as they see fit. Beyond segmented patients' advocacy groups for elder and terminal rights, gay rights, and women's rights, there are few powerful entities within society that can stand up to the entrenched, well-funded, and influential medical or Christian lobbies.

Religiously-inspired conscience clauses have been challenged unsuccessfully in the courts but only on privacy grounds, not on Establishment, Equal Protection, or separation of church and state grounds. The courts, including the Supreme Court, have famously shied away from engaging "separation of church and state" arguments with regard to health care. The patients' rights movement has struggled for decades against the powerful medical industry and fundamental Christian forces. As patients' rights stand now, medical institutions and the Catholic Church enjoy much more protection and many more rights than the patient.

The solution that Lori Dangberg of Alliance for Catholic Health Care disingenuously offers is that patients who encounter a conflict with the Catholic institution where they are being cared for can be transferred. But anyone who has experienced the wasting and death of a loved one knows that Coombs Lee is right when she states, "[Patients and families are] very vulnerable to the kind of duress and shame that a policy like this would inflict."

We've seen the church use this tactic before with abortion, sterilization and other "shameful" women's services. Over the past 30 years women have been shamed out of hospitals, become accustomed to traveling for the services they need, or required to comply with the dictates of the Church because they lack the resources to go elsewhere. A network of clinics and independent reproductive service centers has risen up to serve those neglected by the Catholic and other discriminating hospital networks.

The end of life is a trying period for both patient and family. Because few Catholic hospitals readily provide patients with informed consent - and because the general population doesn't understand that Catholic hospitals restrict their care services according to doctrine - many patients and families find themselves in a situation where the advance directive is ignored and death is prolonged or futile care is applied when the patient doesn't want it.

It is nearly impossible for patients and their families to be savvy when they are typically encountering the Catholic medical system - or any medical system - for the first time. Doctors and medical institutions operate from a position of authority and vulnerable and distraught patients and families are often cowed into complying with such authority, against their wishes. For many, this experience of death is their first and they go into it without understanding how we die, what medical procedures are standard or necessary, and what a patients' rights are. Going against hospital policy takes tremendous knowledge and effort when in such a traumatic situation.

I'm tickled to see Egelko's article now. I hope it is a sign that the media is beginning to recognize the current discrimination in health care delivery. And I hope that it raises pressure on the church, the state, and the medical industry to better serve citizens.

The nation's Catholic hospitals, including three in the Bay Area, face a new religious mandate in the new year: to provide life-sustaining food, water and medicine to comatose patients who have no hope of recovery

The U.S. Conference of Catholic Bishops issued the directive Nov. 17 to the more than 1,000 church-affiliated hospitals and nursing homes in the United States and to all Catholic doctors and nurses. Invoking a 2004 speech by Pope John Paul II, the bishops said Catholics must provide nutritional assistance to patients with "presumably irreversible conditions ... who can reasonably be expected to live indefinitely if given such care."

A previous directive let Catholic hospitals and doctors decide whether the burdens on the patient outweighed the benefits of prolonging life. The bishops said the new policy was guided by "Catholic teaching against euthanasia" and by John Paul's observation that providing food and water "always represents a natural means of preserving life, not a medical act."

The directive plunges the bishops into another health care controversy, on the heels of their lobbying for tight restrictions on abortion coverage in health legislation pending in Congress.

Catholic hospital officials say the November decree isn't rigid and leaves room for accommodating patients' wishes. But the bishops' language appears to conflict with a hospital's legal duty to follow a patient's instructions to withdraw life support, as expressed in an advance written directive or by a close relative or friend who knows the patient's intentions.

Courts have ordered hospitals to disconnect feeding tubes when an unconscious patient's wishes were clearly established. The best-known case involved Terri Schiavo, the Florida woman who died in 2005 after 15 years in a coma and unsuccessful attempts by her parents and Republicans in Congress to keep her alive.

A legal conflict?

The bishops' order "fails to respect settled law that empowers patients with the right to refuse or direct the withdrawal of life-prolonging care," said Barbara Coombs Lee, president of Compassion & Choices, which advocates for the right of terminally ill patients to make life-or-death decisions.

"It will apply irrespective of your religious faith, your stated wishes in an advance directive, or the instructions of your family."

That's not how the bishops' decree will be carried out, Catholic hospital organizations insist.

The decree itself does not require life-sustaining care that would be "excessively burdensome for the patient" or would cause "significant physical discomfort." If those exemptions don't apply, a hospital will send a patient elsewhere rather than violate his or her expressed wishes, the organizations said.

"If it was unresolvable ... we would transfer them or find some other means to accommodate them," said Lori Dangberg, spokeswoman for the Alliance of Catholic Health Care, which represents California's 55 Catholic hospitals.

The hospitals include St. Francis and St. Mary's in San Francisco and Sequoia Hospital in Redwood City, all owned by the Catholic Healthcare West chain. Dangberg noted, however, that such situations usually arise in nursing homes and other long-term facilities, rather than in acute-care hospitals.

Ethics considerations

The Catholic Health Association of the United States, which represents both hospitals and nursing homes, said a facility's ethics committee would probably meet with the doctor and the patient's representative to "explore the alternatives" whenever a patient's decision to withdraw life support clashed with Catholic doctrine.

"In some instances, this might include the transfer of the patient to another facility," the association said.

That's not an adequate option, even when non-Catholic health facilities are nearby and available, said Lee, of Compassion & Choices.

"These decisions are hard on the family," she said. "They have to muster their will and their courage to do what they know Mom would want or what the advance directive says.

"They're very vulnerable to the kind of duress and shame that a policy like this would inflict."

Debunking Republican and "Pro-Life" Talk on End of Life Consultations.

Robert Parham, Executive Director for the Baptist Center for Ethics, takes apart in a column for the WashingtonPost the "kill granny" meme that Republicans have been pushing regarding the current health care bill.

No political deception this year has been more shameful than that of Sarah Palin, the Christian Right and many Republicans who have tried to sabotage health care reform with the canard of "death panels." Even after many myth-debunking articles and reports, the anti-health care reform crowd still crows about death panels.

Only a few weeks ago, the Southern Baptist Convention's chief lobbyist told students at New Orleans Baptist Theological Seminary that a Senate bill would reinstate "death panels."

The myth-that-will-not-die distorts the provision for voluntary counseling by doctors with patients once every five years related to the care patients want at the end of life--paid for by Medicare.

Rather than affirm the cherished value of the doctor-patient relationship, the right sees a conspiracy of the federal government pulling the plug on grandma.

Part of the right's fear is rooted in its anti-government DNA. Part of it is embedded in the belief that our culture hates life and is slipping down the pro-death slope toward active euthanasia for the aged and terminally ill.

For years, "right to life" groups have opposed living wills. They see such legal documents as a stalking horse for the "right to die" movement accused of advocating mercy killings and assisted suicide. They distrust the courts and legislatures, charging them with having a presumption against life, of favoring a "quality of life" ethic. They urge their supporters to sign "wills to live," documents that request treatment to include food and fluids when the patient cannot speak for themselves, as opposed to being allegedly starved to death. They often warn that without a will to live what happened to Terri Schiavo might happen to them and their family members.