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The Terri Schiavo Case

Understanding Terri Schiavo

By CURTIS KRUEGER, Times Staff Writer
Published October 28, 2003

Terri Schiavo smiles. She laughs, cries and moans. Her eyes appear to follow a balloon around the room. When a cotton swab slips into her mouth, she grimaces. Those images, from video clips on television and a Web site created by Schiavo's family, have helped fuel the national debate over whether to remove the feeding tube that has kept the brain-damaged Pinellas County woman alive for 13 years.

To her parents, Bob and Mary Schindler, and some doctors who have observed her, those reactions show that the 39-year-old woman is aware and responding to the outside world.

But her husband, Michael, a number of doctors and courts that have heard medical testimony say she is in a persistent vegetative state. That diagnosis means means that, though awake, she is not conscious or capable of responding to others except by reflex.

By order of an appeals court, five doctors examined Schiavo in 2002. Two were chosen by the Schindlers, two by Michael Schiavo and one by the court. Three of the five, the ones chosen by Michael Schiavo and the court, said Terri Schiavo was in a persistent or permanent vegetative state.

Here is a look at Terri Schiavo's physical behavior and what both sides say about it.

-- CURTIS KRUEGER


THE BALLOON

A videotape of Schiavo from 2002 (available at www.terrisfight.org) shows her eyes as she appears to follow the movement of a balloon around the room.

The Schindlers' position: Schiavo is aware of the balloon's movement and can track it with her eyes.

Dr. William Maxfield, a radiologist, examined Schiavo in May 2002. He said he stood to one side in the room while a family member brought in a balloon and bounced it around. "She was actually following the balloon with her eyes, with turning her head to the side," Maxfield said. Her ability to follow the movements exceeded what someone could do by reflex, he said. He spoke about his opinion Friday, after a news conference organized by family members who oppose removing Schiavo's feeding tube.

For that and other reasons, Maxfield concluded, and testified in court, that Schiavo is not in a persistent vegetative state. He says the actions he witnessed showed Schiavo to be conscious, though she clearly has suffered brain damage.

Michael Schiavo's position: Schiavo's eye movements are random.

Dr. Ron Cranford, a Minneapolis neurologist, examined Schiavo after an appellate court in 2001 ordered additional medical review. He said she was not able to follow movement with her eyes. "Terri doesn't do any of that. She has no sustained visual pursuit. And that's the hallmark of the vegetative state," he said by telephone on Monday.

In fact, Cranford said, Schiavo's inability to follow objects or people with her eyes was one of the main reasons he concluded that she is in a persistent vegetative state. He testified so in court.

"This diagnosis is so straightforward in her case," Cranford said.

He has reviewed the videotape that purports to show Schiavo following the balloon with her eyes, and says "these are random eye movements."

More extensive video footage shows Schiavo as unresponsive, and the videotapes are merely snippets of that, he said.

"The videotapes tell the truth but you can't have excerpts of the truth," said Cranford, who is on the neurology faculty at the University of Minnesota.


THE GRIMACE

Another videotape from 2002 shows a doctor putting swab in her mouth. She grimaces and turns away.

The Schindlers' position: Schiavo has enough awareness to feel discomfort.

The Terri Schindler-Schiavo Foundation says that in this clip, "Terri shows CLEAR annoyance with being tickled with a cotton swab."

At the family's news conference last week, one woman who has visited Schiavo to pray with her, said she thinks Schiavo feels pain. She said she has seen Schiavo groan when she is in pain, or uncomfortable, such as when she is congested.

Michael Schiavo's position: Schiavo is not conscious of discomfort.

Was Terri Schiavo consciously deciding to turn away from the swab? Not necessarily, says Dr. Walter G. Bradley, chairman of the department of neurology at the University of Miami School of Medicine.

"There are a lot of complex actions that can be taken by the nervous system that are reflexes," Bradley said. People in a persistent vegetative state are not conscious, even though they can maintain normal sleep cycles, blink, change facial expressions and make sounds. "These are are all reflexive manifestations. They are not the person spontaneously saying, "I want to have some food, I love you, I want to get out of this bed.' "

Bradley, who has not examined Schiavo, did not attempt to say whether she is in a persistent vegetative state. But he said that for someone who is in this state, "there is no conscious perception of pain."

Bradley had not seen the videotape. But asked about the cotton swab, he said this could be an example of something called the gag reflex.

"Why is it called the gag reflex? Because it's a reflex."


THE SMILE

In another videotape, taken on Aug. 11 2001 and released by her family, Schiavo smiles as her mother gives her a kiss on the cheek.

The Schindlers' position: Schiavo is happy to see her mother and responds to her attention.

Here again, the question is whether Schiavo is consciously showing pleasure or changing her expression by reflex.

Schiavo's parents say their daughter shows clear pleasure when family members come into her room and start talking to her. Her brother, Bob Schindler Jr., said he told her that he got to meet rock star Bruce Springsteen and, "There was a smile on her face to light up the room. She showed elation."

Maxfield, the doctor who spoke on behalf of the Schindlers at their news conference, said that when he examined Schiavo, he tried to get her to respond to him. She wouldn't. But when her family members came in, it was a different story. Then she smiled and appeared happy, he said.

Michael Schiavo's position: Schiavo does not consciously respond to others. Smiles and other movements are random.

Smiling does not necessarily mean consciousness, said Dr. Peter B. Dunne, chairman of the department of neurology at the University of South Florida, who has not examined Schiavo.

"Oh, my gosh, they may smile, they may frown, they may cry, but it's not related to any particular stimulus," Dunne said.

If someone is in a persistent vegetative state, Dunne said, "it looks as though the person knows what's going on, but they're really not... they can smile, frown, etc., but it's really not related to any kind of stimulus. It may just be a reflex."

This is what makes persistent vegetative state so agonizing for family members, said Cranford, the Minnesota neurologist.

"All persistent vegetative state patients have the appearance of interaction with their environment," he said. "It's a scary, scary, scary syndrome."


Awake, but is she aware

Much of the debate over Terri Schiavo centers on her state of consciousness. Many doctors say she is in a persistent vegetative state with no hope of recovery, while her parents disagree. Here are descriptions of various states of consciousness:

COMAS:

"A coma is a profound or deep state of unconsciousness. An individual in a state of coma is alive but unable to move or respond to his or her environment," according to the National Institute of Neurological Disorders and Stroke. Comas can be the result of illnesses or injuries.

PERSISTENT VEGETATIVE STATE:

Some people in comas lapse into a persistent vegetative state. The NINDS says: "Individuals in such a state have lost their thinking abilities and awareness of their surroundings, but retain noncognitive function and normal sleep patterns. Even though those in a persistent vegetative state lose their higher brain functions, other key functions such as breathing and circulation remain relatively intact. Spontaneous movements may occur, and the eyes may open in response to external stimuli. They may even occasionally grimace, cry or laugh. Although individuals in a persistent vegetative state may appear somewhat normal, they do not speak and they are unable to respond to commands."

MINIMALLY CONSCIOUS:

A group of neurologists has proposed a new category called "the minimally conscious state." People in this state are impaired, but have some capabilities. Time magazine recently described them this way: "Patients may reach for and grasp things, track movingobjects, locate sounds, process and respond to words. Patients may inconsistently verbalize or gesture to communicate. Patients may gain full consciousness."


What's been said

"I go in there regularly and Terri appropriately responds to whatever it is we're talking about. There's times when I go in and as soon as she hears my voice she just breaks out in a huge smile and begins to vocalize.... It's very hard for me and I know the family to sit back and listen to people who haven't seen Terri, judges or whomever, say that Terri is in a persistent vegetative state and that she's unresponsive with a reflexive movement.
-- Suzanne Carr, Schiavo's sister, on Friday.

"Doctors aren't gods. They don't know."
-- Mary Schindler, Terri Schiavo's mother, in 2000.

"There's no treatment, no cure. Nothing known to science will help this woman."
-- Dr. James Barnhill, in 2000, testifying in Pinellas-Pasco Circuit Court.

"...despite the irrefutable evidence that her cerebral cortex has sustained the most severe of irreparable injuries, we understand why a parent who had raised and nurtured a child from conception would hold out hope that some level of cognitive function remained. If Mrs. Schiavo were our own daughter, we could not but hold to such a faith.

But in the end, this case is not about the aspirations that loving parents have for their children. It is about Theresa Schiavo's right to make her own decision, independent of her parents and independent of her husband."
-- The 2nd District Court of Appeal, June 2003


How the brain works

Cognitive and physical functions are divided among several parts of the brain. When a person is said to be 'brain damaged', it may take several forms.

Times Graphic -- Curtis Kreuger and Steve Cavendish


What the courts say about Schiavo's brain

In a June 6 opinion that rouched on the medical evidence in the Schiavo case, the 2nd District Court of Appeal wrote" "Although the physicians were not in complete agreement concerning the extent of the daughter's brain damage, they all agreed that the brain scans showed extensive permanent damage to her brain. They only debate between the doctors was whether she had a small amount of isolated living tissue in her cerebral cortex or whether she had no living tissue in her cerebral cortex."

Sources: "Keep Your Brain Alive," by Lawrence Katz and Manning Rubin; KRT; court testimony; howstuffworks.com; Bay News 9; Associated Press

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