When President Bush and Congress intervened in the long and tragic public ordeal of Terri Schiavo, it reignited widespread concerns among many healthcare providers about the potentially explosive clash of medicine and politics.
"Is this a precedent, where Congress intervenes again and again in these types of medical decisionmaking?" asked Ilena Blicker, a neurologist from Glendale, Calif., who has dealt with wrenching end-of-life decisions involving her own patients on many occasions. "Our concern is that this wasn't based on a true wish to deal with this very difficult situation, but, unfortunately, it is simply a political football."
Blicker was one of about 700 physicians who were attending the California Medical Association's annual meeting when Congress passed the legislation. At the meeting, the physicians passed their own legislation of sorts: a near-unanimous resolution expressing "outrage" over the federal lawmakers' intervention.
The law, which allowed Schiavo's parents to file suit in federal court to contest the removal of the severely brain-damaged woman's feeding tube, is not designed as a precedent for lawmakers to step into every difficult case involving terminally ill patients, White House officials said.
In the end, the emergency legislation by Congress had little effect on the 41-year- old Florida woman. Her parents' pleas were rejected by both state and federal courts last week. The U.S. Supreme Court, in a terse, one-page opinion, also refused to hear the case. Her feeding tube was removed March 18.
"I think it's tragic that Congress got involved in this case," said David Bernd, chief executive officer of six-hospital Sentara Healthcare, Norfolk, Va., and the immediate past chairman of the American Hospital Association's board of trustees. "I understand the emotional aspects of this case, but these kinds of life-and-death decisions are made every day in hospitals across the United States. Most are handled the way they should be, privately, with the family and doctors."
The Schiavo case has raised troubling questions before about ethics and healthcare. Concerns about the intrusion of politics in this case and other bioethical dilemmas were raised in a Modern Healthcare cover story almost a year and a half ago, when Florida Gov. Jeb Bush, the president's brother, used a newly passed state law to order doctors to resume Schiavo's life support (Oct. 27, 2003, p. 4). Since then, the bitter family dispute over her fate has been taken to new levels, encompassing all of the broader, politically charged elements of an emotional issue that has galvanized right-to-life activists.
"I am incredibly apprehensive about the government stepping in with additional rules and regulations, taking these decisions away from families and medical ethics committees," said Jim Martin, a San Antonio physician who served last year as board chairman of the 94,000-member American College of Family Physicians. "It'll make me second-guess what I do."
Bernd said he was relieved that the decision-at least as of late last week-had been made by courts rather than politicians. "Courts have come back, again and again, to support the rights of the husband," he said. If anything, he added, the attention focused on this case will foster more dialogue about bioscience, ethics, the quality of life and the need for advanced directives. "The only bright side," he said, "is that (these issues have) become an everyday topic of conversation."
Patrick Clary, a physician who is president of the board of directors of the New Hampshire Hospice and Palliative Care Organization and medical director of the Seacoast Hospice, said end-of-life decisions should be "patient-centered, and it's hard to be patient-centered if you're in Washington, D.C., and the patient is in Florida."
Clary, who deals with the issue almost daily, added, "State courts have made a very reasoned approach to what this patient would want. And they have decided that she would not want to be in this meaningless, terminal existence. ... This patient is living in a hospice. What is a hospice, but a place where you go to die?"
Even though the congressional legislation was tailored exclusively to Schiavo, who has remained in a persistent vegetative state since 1990 when a heart attack temporarily cut off oxygen to her brain, lawmakers did include a recommendation that Congress consider broader legislation in the future to address such contentious right-to-die cases. Last week, Bush spokesman Scott McClellan refused to rule out the president's signing of broader legislation.
One expert on the medical ethics of death and dying, Norman Cantor, a law professor at Rutgers University School of Law in Newark, said Congress' action does nothing to "dictate new laws" or even to change the eventual course taken by courts in this case, but physicians and hospitals aren't the only ones concerned about the political move.
In a CBS News poll taken last week, 82% of Americans said Bush and Congress should stay out of the Schiavo case, while 66% said Schiavo's feeding tube should not be reinserted.
"I think everybody in healthcare is worried that (the intervention by Bush and Congress) is going to make a situation already fraught with stress even more chaotic," Clary said.