Where’s the Outrage?*
April 2005

Pope John Paul II has died. I believe the passing of this extraordinary man of God is an opportune moment for all people, including a Methodist like me, to reflect on his life, his actions and his faith. John Paul made the papacy relevant once more on the world stage. He was truly a world leader. He helped to inspire changes in his native country that led to Polish independence. He spurred similar developments in Chile (1). Some historians have even given Pope John Paul credit for the fall of the Soviet Union. Besides having a hand in political events, the pontiff was a champion for the poorest and most oppressed souls on our planet, an inspiring friend to young people, and a serious environmentalist. But, paradoxically, he chose to turn his back on women, and he discouraged activist priests. Worst of all, he did not act quickly to rid the American Catholic church of child-molesting priests or their apologist-protectors such as Cardinal Law of Boston. Why didn’t he say, “If you molest a child, we will defrock you immediately and make sure you go to jail?” For these reasons, I am a bit bewildered by this great man. But I hope and pray that he rests in peace.
On March 31, 2005, Terry Schiavo died after a gut-wrenching public battle—one that was legal, medical, and moral. While the medical community has little data on what patients like Mrs. Schiavo go through during the last days of life, the one thing that we do know is that she was not in pain. Although the press covered this case ad nauseam, they didn’t write much about this; there were other ways in which the press failed in its coverage of this story. First, as a doctor, I firmly believe that this case was never (as many disabled Americans have feared) about disabilities. It was about how we view “next of kin” and spokesmanship. To be specific, it was about this question: who should we empower to speak for those who cannot speak for themselves? In the case of adult patients, should it be the spouse, as both Biblical and English common law have long maintained? A majority of states—thirty two to be precise– say yes (2). In medical school, I was taught that the patient should have the final say in all treatment decisions. When patients are unable to speak for themselves, physicians are trained to talk with family members. This can be a very long and difficult process. When a loved one is at death’s door, families are inundated with many conflicting feelings and thoughts—their own as well as those they believe the patient might feel or think. The skillful physician can usually help family members put their own feelings aside, so they can concentrate on what they believe the patient might want. It is astonishing how people who find themselves violently thrust into crisis and who face heart-breaking and often irreversible decisions can and do make rational decisions. When they can’t—or when they can’t all agree—then we have cases like Terry Schiavo’s. The only answer must be a nationwide movement to make living wills a commonplace—if not a law. Besides making a case for some kind of comprehensive living will policy in this country, the Schiavo case also raises a question that modern medicine has made increasingly more pressing: When is enough enough? With modern technology and medical therapies we can keep many people “alive” long after their brains have stopped functioning. Brain death is defined as no brain function. There is no debate over these patients. Instead debate exists over those patients with severely depressed brain function like Terry Schiavo, who was in a persistent vegetative state. In this state the patient has lower brain function–breathing, heart rate, eye opening, etc.–but no higher brain function. These patients do not have the ability to do any voluntary functions such as blinking or moving a finger or a toe on command (3). They can look around spontaneously, but their eyes wander rather than focusing upon specific objects. Despite reports to the contrary, they do not have the ability to look at the family they once loved or to understand what is said to them or to communicate in return. From an ethical and moral standpoint, what do we do for these unfortunate people? One consideration that must be taken into account—alas—is cost. Our modern health care system, with all its miracles, comes at a price. Costing between $80,000 to $100,000 per patient (in a persistent vegetative state) per year, we are talking about a great deal of money. Where will this money come from? President Bush has proposed cuts to Medicare in his 2006 budget, so the Republican’s don’t seem to be a likely source. Many private citizens already have to choose between medicines or groceries. Clearly the Schiavo case raises many questions, ones that we are going to have to discuss and solve in the coming decade.
Congressional leaders aren’t much help, though. Recently they have stooped so low on so many levels it is hard to know how to comment. They spent many hours and tax dollars passing a law to help Mrs. Schiavo’s parents find a judge who might help them wrest control of their daughter’s situation from her husband? What about the others? Between 30,000 and 40,000 Americans are in a similar predicament (persistent vegetative state). Will Congress take their cases on one by one, too? And how ironic it is that Congress did see fit to pass a law making it harder for citizens to shop around for judges who might help them sue a potentially negligent corporation (Class-Action Fairness Act of 2005).
Finally, as a physician, I must rebuke the other doctors who chose to step into the limelight and offer diagnoses of Mrs. Schiavo’s case without ever examining her. Many aspects of this case are worthy of physicians’ comment, but Mrs. Schiavo’s diagnosis is not one of them. It is totally unconscionable for them to offer a diagnosis based on a couple of minutes of videotape, when multiple court-appointed, independent neurologists examined Ms. Schiavo and they all came to the same conclusion: Terri Schiavo was in a persistent vegetative state. For another physician to question this diagnosis without examining the patient is arrogant, unprofessional, and cruelly meddlesome.
President Bush and his point man Senate Finance Committee Chairman Charles Grassley (R.-Iowa) continue to hammer away at Social Security with their plan for personal retirement accounts. The concept is to give us free access to our money because they believe, in true Republican laissez faire fashion, that private citizens can manage their money more efficiently than the government. Maybe. Currently all the money that we pay into Social Security sits in an account somewhere that we really can’t get to. But if you have a private account, when you get in a bind, you may tap your retirement money as collateral for a loan, or as funding for a new car. I fear that private accounts will present most of us with an irresistible temptation to borrow money that most of us cannot afford to pay back. In the end, we will have nothing but debt when retirement comes around. If the question is how do we make Social Security solvent, the answer is not private accounts. Our first priority should be to guarantee Social Security solvency. No one wants to pay any more in taxes, therefore the answer is obvious. Benefits must be decreased and/or the retirement age must be raised. Of course, the president’s tax cuts could be reversed.
Recent news:

  • Did you notice that we just sold F-16 fighter jets to Pakistan? I thought we were promoting democracy throughout the world? Didn’t our president mention that in a state of the Union address? Didn’t President Pervez Musharraf of Pakistan come to power in a military coup? Well on the good side, Pakistan is the largest and longest surviving democracy in the area… oops, that’s India. Pakistan, our partner in the War on Terror, did help to seal the border with Afghanistan to prevent the escape of Osama bin Laden through the Torah Bora Mountains. Wrong. They didn’t do that either. So, why did we sell them F-16’s?
  • When are we going to spend the money to make our school children safe? How many more crazed, disaffected youth need to attack our schools before we act? The events in Red Lake, Minnesota sadden me to the core. As I write this newsletter, a football coach is fighting for his life in my hospital. He is the victim of a school shooting at one of the high schools in my own community. The videotaped reports I watched on the national news made it clear that this is a school that has spent a lot money on its building and grounds—what will it cost to make our schools not only beautiful, but also safe for students and teachers?
  • Michael Jackson. I was a huge Michael Jackson fan. I have seen him in concert three times. I have albums and CD’s. I loved his fabulous videos and was glad when his albums went platinum. Today, his story is just tawdry. I’m tired of seeing him on my TV screen. I do not know if Michael Jackson molested his (latest) accuser. I just hope that justice is served and served quickly. 
  • Congress decided to hold hearings to discuss steroid abuse in baseball. Why? Imagine that you are a minor league baseball player. You make almost nothing in salary. If you take steroids you may have the power to muscle one or two more fast balls out of the park. You might be able to catch up to a few more fast balls. You might be able to throw a little farther or run the bases a little faster. That difference could mean the difference between the minor leagues and the major leagues. You can take steroids and possibly make millions in the majors or you can wear yourself out in the minors. What would you decide? There will always be athletes who are willing to push the envelope, believing that they will not develop any of the physical complications of steroids. Who will pay the price of their bad decisions?
  • Paul Wolfowitz as chairman of the World Bank? Why? What has this man done in the last four years to convince anyone that he is a competent leader or an internationalist? (Does it seem like the administration is just shuffling around the same five or ten people to you, too?)
  • The latest economic figures reveal that wages continue to be stagnant and job growth continues to be anemic. When is somebody going to stand up and say the President’s economic and job stimulus package has not worked? It has not created a significant number of new jobs and the average worker is no better off today than he was four years ago. I feel as though I’m stuck in an episode of Hogan’s Heroes. For those of you who don’t know the program, Hogan was the dashing American POW who always outsmarted Colonel Klink, the incompetent German commander of Stalag 13, and Sargent Schultz, the bumbling guard whose tag lines were “I see nothing. I know nothing.” But I’m wondering: where is Hogan? Is Congress playing Klink? And are the rest of us see-nothing/know nothings?

* with writing and editing assistance of Catherine Ross, PhD.
1. Wayne Svoboda, “Chile Bearer of Unwelcome Tiding,” Time, April 13, 1987.
http://www.time.com/time/archive/preview/0,10987,963998,00.html Accessed on April 30, 2005.
2. Daniel Eisenberg, “Lessons of the Schiavo Battle,” Time, April 4, 2005.
3. George J. Annas, JD, MPH, “’Culture of Life’ Politics at the Bedside – The Case of Terri Schiavo,” New England Journal of Medicine, March 22, 2005.

© 2005 Errington C. Thompson, MD All Rights Reserved.