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Harvard
Annas, G.J. (1997a), 'New drugs for acute respiratory distress syndrome', New England Journal of Medicine, vol. 337, no. 6, pp. 435-439.

Maid, B.M. (2003), 'No magic answer', in M. Watts (ed.), Technology: taking the distance out of learning, Jossey-Bass, San Francisco.

Vancouver
1. Annas GJ. New drugs for acute respiratory distress syndrome. N Engl J Med. 1997;337:435-9.

2. Feinberg TE, Farah MJ, editors. Behavioural neurology and neuropsychology. 2nd ed. New York: McGraw-Hill; 1997.

3. Anderson JC. Current status of chorion villus biopsy. In: Tudenhope D, Chenoweth J, editors. Proceedings of the 4th Congress of the Australian Perinatal Society; 1986: Brisbane, Queensland: Australian Perinatal Society; 1987. p. 190-6.


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The Schiavo doctors: a response to Gordon Watts

I would like to respond to some comments made on the Terri Schiavo talk page on the subject of the doctors who examined, cared for, and/or testified about Schiavo. I’m doing it here because this discussion, while important in the sense that it informs the writing of the Wiki article, actually does not bear directly on the article itself and is likely to move away from it even further. Pursuant to the Wiki policy of discouraging use of the Talk pages to discuss the rights and wrongs of the subject of an article, I’m writing my comments here with hopes that the Schiavo Talk page is not further abused.

I begin by reproducing the relevant content of the Talk page; my remarks follow. If you would like to respond, please post your comments in the new section, below this. Do not edit this section, please.

Talk page comments on Schiavo doctors (original)

Neuroscientist and others: would this be a fair and more accurate rendition of the relevant sentence in the intro?:

This diagnosis was the center of a major dispute between her parents (Robert and Mary Schindler) and her husband (Michael Schiavo, her legal guardian by court appointment), and led to numerous court cases over the course of several years. During the time of her care, more than nine physicians are known to have examined her, including eight neurologists. All of the neurologists save one concurred in a diagnosis of PVS and six of them so testified in court—the one dissenting diagnosed a minimally conscious state. Ultimately, a Florida circuit court, presided over by Judge George W. Greer, held an evidentiary hearing, at which he heard testimony from five of the neurologists, as well as other evidence, upon which he ruled that Schiavo was in a PVS. This finding was upheld on every appeal, both in state courts and in federal courts.

Duckecho (Talk) 1 July 2005 21:13 (UTC)

The way it's worded is POV by omission bias: I'm glad that the factual accuracy is being revisited, and I'm not saying that I think this is inaccurate (not sure here), but when loads of doctors have weighed in, and the only one mentioned are primarily FOR the "PVS" diagnosis, then this is POV. I realize that many doctors didn't personally visit her, but the fact that the courts only let the "Pro-PVS" neurologists visit her (with one apparent exception above), and then we punish the article by excluding mention of the others in this section here is basically not unlike when a bully pushes a person down, and then complains when the person yells. In this analogy, I assert that Greer "pushed" the process down on the ground, by excluding many doctors who could have given input, and then when editors are criticized for trying to mention these other doctors, we must respond that it is not our fault, but the court's fault. We are doing the best with the hand dealt us. Therefore, if you include a lot of ProPVS doctors in the intro, you must include a similar (even if not equal) number of AntiPVS doctors. If you have a problem with this, then I give my "blessings" for you to include mention of which ones actually visited personally with Terri, so this is not leading the witness, or comparing "apples with oranges," ok? (PS: If you include this intro you propose, Duck, you are sure to "make the natives restless," if you know what I mean.)
Gordon, this is an excellent example of the two different standards of fact being discussed in Mediation. In fact, I'll point Ed to it. Now, your logic implys that the neurologists were hand-picked by the court (Greer), and that they went to examine Terri with prejudice. This is deeply disturbing, because it implys that these doctors are unfit to practice medicine. Further, this seems to be directly contradicted by Duck's timeline. His paragraph implys that the neurologists were not picked by the courts, and that we can assume that they examined Terri without any previous assumption of PVS. Please briefly explain to us which of these is true.
Your other assertion is that the opinions of other doctors that didn't directly observe Terri should be valued. I think Sen. Frist's mea culpa is sufficient to explain why they should not.--ghost 2 July 2005 06:02 (UTC)
"Now, your logic implys that the neurologists were hand-picked by the court (Greer), and that they went to examine Terri with prejudice." Now, I certainly do not say that the court picked all of the neurologists; I wasn't speaking on that subject, but if I were, I would have said that the court did not let very many doctors examine Terri because had they done so, there would have been a different outcome: Terri would probably have NOT been declared PVS by a majority, so they had to limit access to Terri to a "select few chosen" doctors. My original point was this in my post above: I was trying to say that including a whole bunch of ProPVS doctors in the intro section of the Schiavo article, and only 1 or 2 AntiPVS doctors was POV. The fact that loads of doctors who are trained professionals were so certain of their diagnosis that they gave the Terri's parents affidavits is not only worth mentioning, it is worth mentioning in the same intro section along with the few "special" doctors who were permitted in. "This is deeply disturbing, because it implys that these doctors are unfit to practice medicine. Further, this seems to be directly contradicted by Duck's timeline." I don't know how the timeline is relevant, unless you want to say that some doctors saw Terri first, before others submitted affidavits, and somehow use this as reason to exclude some doctors from being mentioned in the intro section. However, you seem to think I implied that some doctors are unfit to practice. Well, I won't go that far, but I think some doctors are quacks -or at least unqualified. If that is not so, then how come the 5-doctor-panel mandated by the court all disagreed with one another? Do you think it is merely coincidence that the family's doctors said Terri was NonPVS and that Mike Schiavo's doctors said that Terri WAS PVS? No way! That was not coincidence. The doctors all had biases. Why not include a load of other doctors' analyses and diagnoses, doctors who were not subject to such bias as being paid by one siad or the other to be a "hired gun?" Besides those solicited by Terri's parents (they probably didn't get paid like the first 5), and others who have opined in the news media? I'm sure we could find 20 or 30 doctors who have opined on either side, but I have heard (and I don't know if it is true or not) that MOST doctors who had knowledge of Terri said she was NOT PVS; if they are trained medical professionals, I'm sure they know when they don't have enough information, yet roughly 2-thirds of the doctors who opined one way or another said Terri WASN'T pvs, according to my meager memory. The fact that it was not a landslide one way or another mandates mention of both sides of the dispute to avoid being POV in the presentation of the events.--GordonWattsDotCom 2 July 2005 08:20 (UTC)


A Response

Gordon, with due respect, you don’t have a clue what you’re talking about and it shows.

Of the 7 neurologists who examined Schiavo and found her to be in a PVS, only two were employed by Michael as expert witnesses. The other five came to their conclusions when they were consulted on Schiavo’s neurologic health while she was in hospitals and health-care facilities (Desousa, Harrison, Karp, Barnhill) or were retained as a neutral expert (Bambakidis). It is completely bizarre to think that all these neurologists came to their conclusions because they were "biased" in what eventually became the Schiavo debacle, or were paid by Michael. Many of them in fact saw Terri way before this became a controversy of any kind. Desousa was one of the first doctors to see Terri after she suffered the cardiac arrest: he did her first EEGs and her BAER. This was back in 1990, before the Schindlers went nuts in their grief and denial. How could Desousa possibly have been involved in some kind of dark conspiracy? How could he have been "biased" in the Schiavo case, years before there ever was a case? Ditto the other guys. (BTW, this is why "the timeline" is relevant).

The statement that the courts "only let the 'ProPVS' neurologists visit her" is so crass it’s difficult to believe you're serious. You seem to have a considerable grasp of the legal proceedings that took place, so this statement worryingly suggests that you might be lying here. Do you really not know that Greer gave the Schindlers the opportunity of bringing in their experts, and Michael his? Do you really not know the number he stipulated was equal on both sides? And if indeed Greer was Head Honcho, Conspiratorial Affairs, how on earth would he have known that a given neurologist was going to be "ProPVS" before he’d examined the patient and delivered his diagnosis? Greer chose one impartial neurologist when the two sides couldn’t agree on one; did this neurologist – Greer’s sole choice – strike you as some kind of death merchant, jumping to a PVS diagnosis before his sacrificial cauldron got cold? I know what you think of Bambakidis, since you've written about his diagnosis here before, so it’d be interesting to see if you change your tune.

Then we consider the following contradiction: "Now, I certainly do not say that the court picked all of the neurologists..."

You don’t? Well, it sure sounds like you do: "...the fact that the courts only let the "Pro-PVS" neurologists visit her (with one apparent exception above)... is basically not unlike when a bully pushes a person down, and then complains when the person yells. In this analogy, I assert that Greer "pushed" the process down on the ground, by excluding many doctors who could have given input..."

You’re saying exactly what you deny saying: that Greer’s court maliciously manipulated the roll of neurologists allowed to examine Schiavo, and that Greer, for reasons only decipherable by the nutjobs who make the claim, was so intent on "murdering" Schiavo that he kept out "qualified" doctors who'd immediately have seen that Schiavo was not in a PVS.

This is nonsense, Gordon: there’s no earthly reason Greer would have such intentions, there’s not a single micron of evidence that he did, and even if he did, what he’s supposed to have done to act on those intentions plainly didn’t happen – the way the neurologists were selected is a matter of public record. I cannot understand why Schindlers’ supporters persist in shooting themselves in the foot with such stupid claims that immediately deprive them of credibility.

And the final clunker: "...I wasn't speaking on that subject, but if I were, I would have said that the court did not let very many doctors examine Terri because had they done so, there would have been a different outcome: Terri would probably have NOT been declared PVS by a majority, so they had to limit access to Terri to a "select few chosen" doctors... but I have heard (and I don't know if it is true or not) that MOST doctors who had knowledge of Terri said she was NOT PVS; if they are trained medical professionals, I'm sure they know when they don't have enough information, yet roughly 2-thirds of the doctors who opined one way or another said Terri WASN'T pvs, according to my meager memory. The fact that it was not a landslide one way or another mandates mention of both sides of the dispute to avoid being POV in the presentation of the events."

The staggering arrogance that one must have to say this is impressive.

We will leave aside the fact that the 17 or so doctors recruited by Schindler henchmen did not usually deny that Schiavo was in a PVS, they said they would have preferred more testing before they could come to a conclusion (somehow forgetting that since they had no access to the patient, her examination findings, her serial EEGs, her serial CTs, and her neurophysiological assessments, they were not making a sensible argument).

More important, Gordon, is this: you don’t have five minutes-worth of medical training, you’ve never seen Terri, much less examined her in any way that might be described as remotely medical or scientific, you wouldn’t have a clue about how to interpret the findings even if you did, and it's safe to say from your postings that you do not know any neurology – and you're pretty sure that Schiavo wasn't in a PVS? That most doctors would "NOT" have found her to be in a PVS?

Here's a clue: 7 out of 8 doctors – specialist neurologists – who examined her – her, not highly duplicitous, heavily edited footage lasting some 240-odd seconds – concluded she was in PVS.

That is a landslide, Mr. Watts.

Comments on The Schiavo doctors.

A pattern of deception indeed. I'm also reminded of the phrase a little knowledge is a dangerous thing. In an email to a compatriot I made a lengthy comparison to a guy I used to work with who suffered the same affliction. It was both sad and entertaining. It's certainly frustrating. Someone once said "you can't argue with that kind of logic" which summarizes it perfectly. In that email I also made reference to what I call the word of the day (hereinafter referred to as WotD). It's as if he learns a new word every once in a while and yearns to work it into a post somewhere (whether apropos or not). I refer you to the Boyle's Law commentary a day or two ago. Res judica was one last week. Duckecho (Talk) 3 July 2005 19:03 (UTC)

I'm going to try to reply to some of your answers above, and quote you a bit: "Gordon, with due respect, you don’t have a clue what you’re talking about and it shows." I don't know all the details, I admit, such as exactly which doctor came from where. "The statement that the courts "only let the 'ProPVS' neurologists visit her" is so crass it’s difficult to believe you're serious. You seem to have a considerable grasp of the legal proceedings that took place, so this statement worryingly suggests that you might be lying here." I'm not going to purposely lie; However, it is a matter of record that Greer limited the proceedings to two "Schindler" doctors, two "Mike Schiavo" doctors, and one more, to be picked by mutual consent -or, if that could not be, then by the court. So, yes, there was limiting done by the court! In what many deem to be the premier case of the century, you might expect a little more then merely five doctors, but, not, Greer - who had to stop the flood gates and play God... **sigh** What was Greer afraid of when many other doctors could have offered viable feedback in the hearing in which only those five opined? I admit that I do not know the details or the circumstances of the roles of the other neurologists, but that was not a reason to limit the trial to five only, especially when it was life-or-death --and a major precedent-setter... Do you really not know that Greer gave the Schindlers the opportunity of bringing in their experts, and Michael his? Yes: Two each. That's it. Do you really not know the number he stipulated was equal on both sides? yes: that super-small number I just mentioned. And if indeed Greer was Head Honcho, Conspiratorial Affairs, how on earth would he have known that a given neurologist was going to be "ProPVS" before he’d examined the patient and delivered his diagnosis? He might not have known, but as the person picking the doctor, he could take a look at his track record and make an educated guess.

Next you say I contradicted myself, but this is not so: In the 1st quote you use, you quote me as admitting the court didn't pick ALL the neurologists. I think this is true, because I think Terri's parents picked one. Next, you quote me as saying the court limited the doctors. Yes: Greer only let in five doctors for the trial, in spite of the fact many raised objection to that. Neither fact contradicts itself, so I don't contradict myself in asserting the facts -they are NOT mutually exclusive. This is nonsense, Gordon: there’s no earthly reason Greer would have such intentions,... I can think of one: He would not want other doctors to examine Terri and find spousal abuse evidence, which would make him look like a bad judge for not having dealt with it earlier. Remember: Greer was (is) one step from impeachment, and were he to have allowed many doctors and one had found strong evidence of wife-beating (I'm not accusing anybody, only showing possible motive), and it come out Terri was beat, people would WANT GREER'S HEAD for having let Mike Schiavo slide for so long!

...the 17 or so doctors recruited by Schindler henchmen did not usually deny that Schiavo was in a PVS, they said they would have preferred more testing before they could come to a conclusion... You might be right about the numbers, however, this begs the question: Even IF most doctors by the Schindlers did not really say Terri was conscious and aware (which seems a stretch, but OK...), instead, if most doctors (as you say above) merely said Terri needed more testing, then why in the world would the judge deny further testing? Is he a doctor? From where did he get his medical degree? OK. Point made. George "wanna-be-a-doctor" Greer played doctor -and, in doing so, played God!

More important, Gordon, is this: you don’t have five minutes-worth of medical training,..." I have more than Greer, with my double major with honors in Biological and Chemical Science. ...you wouldn’t have a clue about how to interpret the findings even if you did... False: The Law Itself (case law, but law as you know it) says I do have legal knowledge to so:

Statute? Did someone say "statute?" OK: Which statute? Maybe ... uh... this Statute, which says in relevant part:

  • "§825.102(3),Fla.Stats. “(a) “Neglect of an elderly person or disabled adult” means: 1. A caregiver's failure or omission to provide an elderly person or disabled adult with the care, supervision, and services necessary to maintain the elderly person's or disabled adult's physical and mental health, including, but not limited to, food, nutrition, clothing, shelter, supervision, medicine, and medical services that a prudent person would consider essential for the well-being of the elderly person or disabled adult..." (Emphasis added for clarity; exact link on Flsenate.gov/statutes is not known as server is slow or down, but quote is correct, thank you)

Seeing as the court says that I, being at least "a person of ordinary intelligence," I can easily deduce from the statutes "what constitutes forbidden conduct," I will "deduce:" The statute in question did NOT give Greer an option regarding medical services or food; It did not say: "If it were Terri's wishes, we can violate this statute." It does not say that denying her food/necessary medical services was OK if she were "terminal," and it would not be legal to deny her even if she were "PVS" (and she might have been). The judge is not allowed to disobey the law, only interpret it; He not only violated felony law, he legislated from the bench, a separation of powers violation. (Note to Duck: This is the "new word" I learned today. "Separation of Powers," or is that several words? I can't count; give me time, lol.)

"...and it's safe to say from your postings that you do not know any neurology – and you're pretty sure that Schiavo wasn't in a PVS? That most doctors would "NOT" have found her to be in a PVS?" Let's take them one at a time: I do know a little bit about neurology; did you see my sheep skins from FSU?; Next, I am pretty sure Terri was PVS. "How," you might ask?

  • Statute tells me: §765.101(12)(a),Fla.Stats.: “'Persistent vegetative state' means a permanent and irreversible condition of unconsciousness in which there is: The absence of voluntary action or cognitive behavior of ANY kind.” (Emphasis added) Comment: Case law says the statute is easy enough for me to figure out, and since we saw Terri moving around on the videos, she obviously had some cognitive ability. Whatever happened in the other four hours or so is moot. It's just like a prisoner who tried to say "You've got to be mistaken: I didn't steal for over four hours, not did I kill for over four hours." Fine. But, if you stole once, you're a thief; if you killed once, you're a murderer; and, if you had any cognitive ability, per this statute, you're not PVS, because it requires the person to not have any cognitive ability. Is this morally right? Was Terri really "in there," and able to understand us? I don't know the answers to these question. If you don't like the law, change it, but it is the law, and I am qualified (per case law cited above) to understand the clear meaning of the statutes. Now, you ask if I thought that most doctors would "NOT" have found her to be in a PVS? Correct: She did not meet the legal definition, the only one that counted. Greer's opinion did not count, and neither does yours or mine. Greer was responsible with interpreting the plain language of the law, be it felony law 825.102(3) or the definitions in 765 above -not rewriting it; if you all don't like the law, talk to your lawmakers; don't complain to me...

Here's a clue: 7 out of 8 doctors – specialist neurologists – who examined her – her, not highly duplicitous, heavily edited footage lasting some 240-odd seconds – concluded she was in PVS. Oh? That is a landslide, Mr. Watts. No: It is only a "landslide" if you list each doctor, quote him, list the circumstances under which he played a part, cite your source --and, most importantly, do the same for ALL the doctors, not merely the ones you like; So what if some doctors were more credible than others? All the doctors had credentials, and each piece of information is relevant; I'm an inclusionist because I want all the facts; do you?--GordonWattsDotCom 4 July 2005 13:49 (UTC)

By the way, thank you for moving the lengthy discussion off the talk page, Neuroscientist; you're right: It's Wiki policy that the talk consist over not the issue itself but, instead, the editing of the article --andm this is a good policy; As important as these issues are, it's not right to misappropriate (waste / misspend) resources on talk for a NONedit-related item like this. You read the talk policy correctly. Good job.--GordonWattsDotCom 4 July 2005 14:10 (UTC)

What's this about you don't think I know what I'm talking about re the perfect gas law: "Graham , you're wrong. You cannot determine the efficacy of a treatment without having controls" I know that! I took classes and studied the need for controls against which to compare experimentals. (You know? Get a baseline?) I never said that Hammesfahr WAS definitely a good doctor; I merely offered a little evidence that he was (somehow) successful. I never said it was ALL his doing, but he IS an MD. Also, in case you don't know, the perfect gas law IS CORRECT. Thus, if Hammesfahr did increase volume, holding all things equal, pressure (yes! blood pressure) would drop. This is not a hard concept. Think about a piston in a car, if you are having trouble. By the way, does "PV=nRT" mean anything to you? Yes, it does sound familiar, doesn't it? Listen: Do you think I just made up all that stuff about having college classes and knowing the gas law and such? I can name most or all of my professors, and you can even look me up on the web: I went to FSU -and graduated with honors, so if you say I'm not educated, I'd respond "My dear Neuroscientist, you're talking horseshit." (If you've really got a degree in that, you know I'm not stupid; Maybe you know a few things I don't, and maybe you're even smarter than me, but that doesn't mean you have common sense. (It doesn't mean you don't either.) Thank you for your feedback, but it is not profitable for me to keep arguing; you can re-read my posts if you want to get my story. Thank you once again for listening. Have a nice day.--GordonWattsDotCom 4 July 2005 15:01 (UTC)


Balloon deflating 101

The next sound you hear will be the Greer-slanted-the-proceedings theory fliting about the room with the flatulence of ignorance accompanying its every twist. "However, it is a matter of record that Greer limited the proceedings to two 'Schindler' doctors, two 'Mike Schiavo' doctors, and one more, to be picked by mutual consent..." False to fact. Greer didn't structure the hearing. The structure of the hearing was set by 2nd DCA in Schiavo III and handed to Greer on remand. Don't give a lengthy gasbag response to this indisputable matter of record. A simple "I was wrong" will more than suffice. (sorry to butt in, NS, you can take care of the medical stuff.) Duckecho (Talk) 4 July 2005 15:59 (UTC)

"...sorry to butt in, NS, you can take care of the medical stuff." That's OK; I was wrong: The reall mob bosses violating decency here are the 2nd DCA, and that is precicely why I typically told the "petition to impeach Greer" enthusiast that they were WRONG! ...for only going after Greer, because he his "bosses" are appeals judges, or should I say "mob" bosses. (On a side note, I recall the abostract appeal lawyer lamenting the same thing; I don't see why WE must be fired if WE screw up, but a judge is like NEVER fired, no matter WHAT hooey they do... Life isn't fair.--GordonWattsDotCom 4 July 2005 21:59 (UTC)
I was wrong. That's good enough. It casts all your other claptrap in just the right light of legitimacy, and can be safely ignored. Duckecho (Talk) 4 July 2005 22:20 (UTC)
Now, now, there; don't get a big head. Putting things into perspecting: If I was wrong about Greer, then obviously (I was right that) someone else (or a group) did it: The Fla. 2nd DCA did it! It is a member of the infamous Florida District Courts of Appeal, as in "Floriduh...: Where wE CaN't CoUnT the vOtEs," he heh...--GordonWattsDotCom 5 July 2005 07:17 (UTC)

Dude! How have I deceived you?

I saw the comment you posted at this diff,on Duck's page about a section on Wagon's page, in which you said I was deceptive (that is, lied, I would take it). I may interpret events differently than you, but I do not lie; If I do, then tell me about it, for goodness sake. You have more credibility telling the person themselves, instead of talking behind their back. I would hope that you meant to ask me about it and became too busy. Diplomacy involves respect for obtaining first-hand another person's point of view before talking about them or forming an opinion.--GordonWattsDotCom 6 July 2005 01:52 (UTC)

Gordon, I never said you lied to me - I wasn't even around when the incidents Duck was referring to took place (nearly two months ago). This is what I wrote on his page, when we were talking about the above matters relating to the Schiavo doctors:
...Incidentally, your Talk page has been quite informative about Mr. Watts. I had no idea. A pattern of deception - I feel rather less bad about being a bit sharp with him.~ Neuroscientist July 3, 2005 17:30 (UTC)
Please do not pretend you do not understand what is being referred to: I specifically linked Duck's original post. It concerns your prior efforts at drawing attention to a minor legal role you played in the Schiavo matter, in which it would not be unfair to say you were not entirely forthcoming. If nothing else, this extraordinary episode in your recent history attests to a healthy amore propre. Now, I have no interest whatsoever in visiting this controversy once more, two months later - I can think of all sorts of painful chores I'd much rather do. If you feel Duck's denouement of your legal escapades was unfair or inaccurate, the person (and place) to take it to is him (and his Talk page). You've actually had two months to do so.
Also note that I was not at all speaking "behind your back" - I've always contacted you directly when I wrote criticisms of your views on my page. On Duck's page I made passing reference to an impressive bit of detective work on his part - and I did so in the full understanding that it was open for you to see.
Finally, note that I hope this is the absolute last time this matter is addressed on my Talk page. If our discussions are to remain cordial, I hope you'll respect my requests in re my Talk page. I will respond to your multitude of sins re the Schiavo doctors soon enough, but as far as I'm concerned your legal battles are quite uninteresting, and I'll not have this page cluttered with more nonsense than is strictly necessary. (There's already one overly verbose editor trawling this page :) ) If you post anything on this matter here, it gets deleted on sight.~ Neuroscientist | T | C July 6, 2005 03:33 (UTC)
I got your message from the diffs, and I am sorry that I misunderstood you. (I believe you when you say you posted openly and not to hide or speak behind my back; likewise, when I made comments, amore propre, about myself and advocating or defending my efforts, I hope you don't think I was trying to hide the facts or trick you or talk behind the court's back and pretend I did something I didn't do.
It is OK with me if you delete my comment immediately -because a comment is less important than a person. You are right on target with your comment that your talk page is becoming cluttered (all pages seem to be cluttered too much, lol), and, in fact I may not participate much in Wiki in the future, and if that is so, I hope I have not offended you. Take care,--GordonWattsDotCom 6 July 2005 06:20 (UTC)
Gordon, do not be concerned about what I think about the issue, please. It had little to do with me. I am also rather difficult to offend. I consider this matter now closed. Regards,~ Neuroscientist | T | C July 6, 2005 06:45 (UTC)

Cheshire, MCS, and patient autonomy

I just finished reading Cheshire's affidavit. I had glanced through it once before, but I now had some time to pore over it in depth. I am troubled. I'm not troubled by was a mistake made—was a sentient being mistakenly put to death. I don't have the training or experience to make such a judgement in even the remotest sense. My personal beliefs seem to be congruent with yours—at least seven good doctors with rich CVs concluded she was in a PVS. I cannot imagine that they were wrong. No, what troubles me is the question Cheshire raises that I would label the ethical equivalent of Catch-22 and I would describe thusly: if Terri (and any other PVS patient) is truly in a PVS then there is no question that she should be afforded the opportunity for a dignified and ethically correct death (given that was her wish—a separate argument that I'm satisfied was concluded). However, if she were across that extremely hazy line (as I see it) of minimally conscious state, where she may experience pain, and she may have awareness of her circumstances, the ethical position of Cheshire mandates a continuation of the life prolonging intervention even though her wishes have not changed (I'm speaking to the ethical question here—we'll have to leave the statutory one alone for this discussion). And under those circumstances of potential yet limited cognition, she might at some level be aware not only of her circumstances but that her wishes weren't being honored. Now I'm aware of the slippery ethical slope that some might argue to avoid at all costs (how far into the MCS zone do we make exceptions, for example), but it still troubles me. I know you respect Cheshire, but it really strikes me that he permitted some personal agenda to add some nuance to either his observations or conclusions or both. Anyway, am I missing something?

Attention other readers: NS and I haven't the luxury of private email exchanges at this time. I am not interested in other's commentary, observations, arguments, or other interaction to my post to NS and I presume neither is he. Please stay out of it. Duckecho (Talk) 3 July 2005 21:27 (UTC)

Duck, excellent questions and thoughts. I'll reply at some point tonight - I'm just going to put this under a separate section if you don't mind, and leave the above to Mr. Watts and anyone else who might have something to say re the earlier post (yes, I'm the nit-picky, organized type). For now I'll leave you with the tantalizing thought that no, you're not missing anything.~ Neuroscientist July 3, 2005 21:58 (UTC)
While I was away doing some remodeling another thought came to mind (I call those lawn mower conversations—which reminds me, I've been meaning to memorialize that concept in an essay for posting on my website), I would almost characterize Cheshire's (and others of his apparent ethical inclination) position as subverting the wishes of the patient for the maintenance of his own personal views. Incidentally, I would also characterize the Schindlers the same way. Although I believe they may fundamentally be nice people, I'm quite harsh in my assessment of both their handling of this case and their expressed views of it. More on that, someday, privately. (I'm nit-picky the same way—witness what I did with the Legal disputes section today.) Duckecho (Talk) 3 July 2005 23:28 (UTC)


Comments from A ghost

NS, thank you for your kind words on both Templates for deletion and Intelligent design. On one thing, Uncle Ed and I agree unconditionally: We (the editors) should be more kind to each other. And that gets hard with the unending hurricane that is Misplaced Pages. But when we can rise above that, it is truely breathtaking to see.--ghost 5 July 2005 14:25 (UTC)

...And not all the editors play well with others. - I thought you'd like that. ;-) --ghost 5 July 2005 16:33 (UTC)
Lol. Yeah. Perhaps it's inevitable on Schiavo, ghost; the same beliefs and emotions that made it controversial in life make it controversial on Misplaced Pages. In thinking about the editors working on the article, it occurs to me that the only one who might manage a sympathetic ear from all sides is you (i.e., I think you're the only editor who can raise an issue with "opponents" without automatically drawing up their guard). The views of the rest of us rise and fall only on the strength of our reasoning. Where you try to persuade the Other, most of us (on all sides) seem to force the Other (i.e., to see that his view is indefensible). Part of this is predicated on the perception of how open to rational persuasion the Other is. I think it's great there are pedians out there who work hard at their approach (or simply have a talent for it). I would too, but Gordo has forced my hand with the horse droppings, and made it impossible for me not to reveal the power of the Dark Side. ;-)~ Neuroscientist | T | C July 6, 2005 03:33 (UTC)

Edits (Sources in Schiavo)

Chuckle. I saw you de-capitalized the Eric Zorn link and the Living Wills link. I had looked to do that once a month or so ago, however I remember checking the Zorn link specifically (and probably checked the other, too), and the title of his article is in all caps. Consequently I left our link alone. I am sure strong styilistic and attributional arguments can be made for either. By the way, I couldn't stand Eric Zorn when I was living in Chicagoland and the choices for newspaper reading were the Tribune, the Chicago Enquirer (Sun-Times), or the local rag—Aurora Be Confused (Beacon-News)—which is a Sripps-Howard publication even further right than the Trib. Unfortunately, he got on the correct side of a couple of issues so I occasionally had to swallow a bitter pill whenever he wrote on those issues. Duckecho (Talk) 5 July 2005 21:09 (UTC)

Don't you just hate it when the folks you love to hate say something you can't? Spoils all the fun. Re the de-capitalization, I ignored it for as long as I could, but the discrepant style eventually proved too grating for my nit-picky sensibilities :)~ Neuroscientist | T | C July 6, 2005 03:33 (UTC)


Another question (MCS)

Let me know if you're going to start charging me for these. I just read a couple of MCS articles; one, the report from the Aspen Neurobehavioral Consensus Conference, and the other, Bernat's Questions remaining... . I gather that the MCS category has only been around since '96 (both of those articles were apparently published in '02). One of the bleaters on the Talk page (actually a couple of them—they both get their material from the blogosphere) has made what I consider the utterly specious claim that the legal definitions of terminal condition and life prolonging procedure (which included the feeding tube) weren't in the statutes in 1990, thus don't apply to her. It strikes me that we could counter that claim by citing that the MCS diagnosis wasn't available in 1990 and thus doesn't apply to her, either. Any good? I don't do emoticons, but if I did, one would be here. Duckecho (Talk) 7 July 2005 02:08 (UTC)

This is to state the blindingly obvious, and of course you know this, but these morons really should be clued in to the fact that the statute "argument" is easily met on its own terms. Schiavo may have entered PVS and gotten her PEG in 1990, when there was no statute; but she was still in PVS and still PEGed in 2005, when there was. So it applies.
Now, turning the MCS argument on them might seem a mischievous way of getting back - and it is - but ironically there is actually some heft to the argument. This is in two parts.
Firstly, yes, MCS is a recent description. (More precisely, the entity understood today to be MCS is a very recent description). This is not to say that instances of it (or entities similar to it) were not studied and described; Joe Giacino, the big name in MCS (1st author of the paper you're calling the Aspen report) has been doing work in this area since the 1980s, for example. But the first attempt at a careful syndromic description only got published in 2002 (Aspen), and the literature in this area is absolutely tiny. There are a lot of problems with the diagnosis - since you also read the Bernat editorial you are aware of some of the important ones. The issue of the upper boundary for example is important, but with Schiavo it was the lower boundary that mattered. How accurately can behaviors said to be MCS be differentiated from some of the reflex phenomena of PVS? If the line is so fine, really, is there a significantly different neuroanatomic correlate? PVS is neuropathologically enormously heterogeneous - where does MCS fit in to the spectrum? Is there a real pathologic difference that will make a difference with therapies? It must be remembered with Schiavo that even if she was in MCS, she was sitting on the line or very close to the line. Nothing we have now, and nothing we'll have for the next twenty years, would make a mite of a difference to her cognition. We just can't regenerate brains yet.
MCS as it stands is really a research diagnosis, IMO. There is too much that is not understood about it, and the meaningfulness of even defining it (the way it's currently defined), for it to be very useful clinically. I know some rehab specialists will take a different tack, but the questions are there and they're unanswered.
Secondly, and most importantly, there is the ethical issue. Somehow no one seemed to consider this much. Whether or not she was PVS or boderline MCS actually did not matter as much as people seemed to think. The crucial clinical issue was that she was 1. incompetent - permanently incompetent - to make informed decisions about her health and her future, and 2. had permanently and irretrievably lost, if not all the characteristics that we associate with the human experience, virtually all of it.
However, being incompetent does not relieve one of one's rights. The right to bodily autonomy, the right to not have futile medical treatment foisted on you, the right to refuse interventions aimed merely at prolonging death and a meaningless existence. Our society deals with this issue through surrogate decision-making. There are clear and specific requirements for the SDM to fulfill. If Michael and the other 18 folks had given Judge Greer evidence that Schiavo would have wished to exist as a hollow repository of bacteria and liquifying bones for the benefit of parents stuck in a grotesque form of denial, weirdly feeding her body through a tube cut into her stomach, for 15 years after her departure, then nothing short of absolute brain death could have led to the removal of the PEG. But that wasn't the case. Credible evidence showed she would not have wanted this - a decision which is far more likely to be right than wrong, as even pro-Schindlers have to agree (ever noticed how even the staunchest always prefaced their diatribes with, "You know, if I were Terri, I would not want to continue like that, but...)~ Neuroscientist | T | C July 7, 2005 04:33 (UTC)
…for the benefit of parents stuck in a grotesque form of denial, weirdly feeding her body through a tube cut into her stomach… Don't forget the willingness to authorize up to quadruple amputation if necessary. She was their trophy child. I don't know whether it was for pity points or they truly needed the actual protoplasm. On another note, did you see on the Talk page that Cranford sent me a copy of Facts, Lies & Videotapes? It's a PDF of the article in the June Journal of Law, Medicine & Ethics. Duckecho (Talk) 7 July 2005 05:16 (UTC)
Awesome. As I noted some time ago, he was bringing it out in one of the biomed ethics journals, although I didn't know it was in June - it hasn't been indexed by the Nat Lib of Medicine's Medline, which is odd if it has already been published. Are you sure it wasn't electronic early release? I'll check the journal web site. NB. You might want to reference the paper at various junctures in the article, Duck. Incidentally, I've been thinking about the article, and I've decided we're giving an ahistorical perspective. More soon.~ Neuroscientist | T | C July 7, 2005 05:35 (UTC)
It may very well be an electronic release. The JMLE was in the footer of each page, though, but it probably would be electronically, too. It's not yet on the journal website (as of yesterday). The latest edition there is #1 of the current volume. The only concern I have with citing it is the brouhaha that's sure to arise when we do, due to Cranford's alleged POV. He is, after all, one of the blogosphere's biggest villains. Secondly, I don't think it's yet on the web anywhere. In a follow up note to me, Cranford said, "he articles I write, I want to be cited freely." In a private email to both FW and Ghost I suggested we ought to put him together with Matt Conigliaro (with whom I've also exchanged email—you really should consider joining this elite group…) for its inclusion at Abstract Appeal. I'm not sure what you mean by ahistorical perspective, but I'm interested in your thoughts. Regards. Duckecho (Talk) 7 July 2005 16:05 (UTC)


Fox1 on Schiavo article

Bottom line, this article is destined be a mediocre battleground piece with visibly substandard construction until such time as the editors are allowed to write concise prose in a structured framework that makes sense, instead of each and every sentence being obfuscated by its own weight in weasel words, insinuations, rebuttals to anticipated inferrals, and seven other kinds of unneccesary additions designed for a fictional reader whose first and only exposure to this issue will be this article. It's worth noting that even if this person exists, this article is still not being written for them, but for a highly impressionable mental construct of this fictional individual who, if not sheperded carefully by certain editors, may come away with "the wrong idea" (horrors!). Holy Cthulu, describing conduct on this $*%& is like writing science fiction. Fox1 6 July 2005 15:40 (UTC)

~ Neuroscientist | T | C July 7, 2005 21:36 (UTC)

Molehills → Mountains

Thank you. I was beginning to wonder if anyone was getting it. Duckecho (Talk) 23:33, 10 July 2005 (UTC)

It may be useful to simply cut and paste the following at the 3RR page, in the exceedingly unlikely event that Slim Virgin does not see through Watts.
  • Page edit by Duck: 03:52, 10 July 2005. This was an edit, in which a change that was thought to be useful was introduced for the first time.
  • Gordon disagrees, says numbers are too small, and reverts Duck's edit to a previous version: 05:57, July 10, 2005
~ Neuroscientist | T | C 01:38, July 11, 2005 (UTC)
Thanks. I posted essentially the same argument on the 3RR page, but nowhere near as concisely and succintly as you. See below. I suspect someone's off their meds. Duckecho (Talk) 01:52, 11 July 2005 (UTC)
Skewed and glued. Thanks. Duckecho (Talk) 02:06, 11 July 2005 (UTC)

In re   In tro

I guess I'm a little confused. I thought I was headed in the right direction, particularly with regard to size, by getting it down to <240 characters. That seems to be just about the lower limit that I can see, yet still be able to convey ticklers of the salient points, which I believe the function of the intro to be. I know that was certainly a goal of both of us, and irrespective of the defensive posture FuelWagon maintains, his long term goal, as well.

Your edit (and please take this with the least of offense as it is not my intent to give same) seems to expand in areas I didn't think were beneficial, and in fact in one respect (although it has an elegant side effect) is downright repetitive.

Now (and please excuse my obvious ego, but I'm nearly 60 and I've learned a few things about myself over the years), although I have some college writing experience, admittedly it was more battle with the professor over my own developed style than learn things to make my writing better that I already knew instinctively—I have a native skill. My point is I'm not classically trained at technical writing as you are. And although I know I write eminently readable stuff, I have to yield to a large extent to those so trained.

Not the least of my difficulties is the sense of parochialism in having crafted two significant edits that, while receiving general acclaim (and I'm not fishing for compliments), yet still apparently fall short of the mark—a mark I had felt I came pretty near hitting. But, as I said, I'm man enough to recognize when to swallow the pill and continue to work with other capable writers toward a common goal (yada, yada, yada).

My thoughts (in future discussions could we number them 1 through whatever including the lead sentence, even though we're done with it?):

  • It appears we're in agreement in the lead sentence. I think we can put that to bed.
  • #1 is okay, although I've been forced to dig in my heels on certain verbiage, and it's hard to let go of it. That's why I worded my second paragraph 1 the way I did. The only thing I thought needed work was the evolved into which I inferred from something you wrote, yet wasn't able to correspond with you to massage it.
  • #2 to me just seems bloated beyond what it needs to be. Bob & Mary and Michael can be easily excised, I believe, because their identities are readily found in the very first part of the main article. I kept asking myself when I was hacking away, "how does this sell Terri's story?" Bob & Mary and Michael don't—'rents and DH do (Darling Husband, if you're not up on women's groups netspeak—I have a 31 year old, 'net savvy daughter). I do like some form of acrimony in there. But otherwise, I feel it rambles rather than hammering facts into hooks.
  • #3 I intensely dislike one sentence paragraphs. It seems to me we should either find a way to meld it into another paragraph, expand it (bloat—ugh!), or drop it altogether.
  • #4 As written is a two subject paragraph. I thought we had a much more powerful closer when we had the case of the litigated feeding tube, the date of its final removal, and the denouement of her expiration.

That ought to keep you busy for, what, five minutes? Regards. Duckecho (Talk) 01:49, 11 July 2005 (UTC)

They call me Mister Echo

Prepare for onslaught of utterly off topic personal vignette.

"(I can't believe I'm calling a gentleman almost twice my age that. I have an urge to begin each correspondence with you henceforth with, "Mr. Duckecho, sir, if you please...")" What's this gentleman crap? I figured you to be younger than me, but not my kids' age!! Actually, I am quite uncomfortable with being called Mr. anything. When I was younger it became my observation that my father was someone who commanded respect from all he met. Nothing he overtly said or did; people just naturally treated him with deference.

I recall when he and I would go out to the golf club and pick up another couple of guys for a foursome we would all introduce ourselves, "hi, I'm Les; I'm Bill; I'm Fred; I'm Duck." For the rest of the round, invariably it would be Bill, Fred, Duck, and Mr. Echo (Dad, for me, obviously). It almost embarrassed me because I felt we were in a decidedly casual social setting and that he should make an extra effort at setting the others at ease by reminding them of Les at their first transgression. He said he had never noticed.

Now, he was a school principal and worked in an environment wherein everyone was Mr. This and Mrs. or Miss That (back in the day, there was no Ms.). And one of his pasttimes was as a Boy Scout leader, where naturally all the Scouts would address him as Mr. Echo. So I could see him being so accustomed to it.

As for me, I got interested in amateur radio as a teen and once licensed was on an immediate first name basis with everyone, 8 to 80, as is the custom. Then I went to work for the FAA and everyone there was on a first name basis. The facility chief was someone who had probably been your radar man only a couple of years earlier. It was impossible to give up that informality just because the paycheck got bigger. So, I've been on a first name basis, both gotten and given, virtually all of my adult life. The first time I was actually addressed as Mr. Echo, even though it was by a youngster, I actually, physically cringed. Years later, it's still not something I seek nor am comfortable with.

Your environment is entirely different and I am aware that physicians are extremely proprietary about their titles (remember I mentioned SWMBO's background). I would have to guess that your experience might be almost the opposite of mine, in that I'll bet there are informal settings with other physicians, but outside the work environment, wherein it's not necessarily easy to use first names.

So, please, it's Duck (or Duckecho). And sometime if you ever do want to exchange email, you'll learn what Les' son's name really is. Didn't know you were going to get an essay, did you? Duckecho (Talk) 03:41, 11 July 2005 (UTC)

LOL. No, I didn't. FAA, eh? Immensely Cool. I'm not proprietary about receiving the Dr. bit, although I've always had a habit of addressing my professors with the title. Around colleagues my age we're all on first names. I have a natural deference toward those older to me - probably my upbringing. All my elderly patients are Mr.___ or sir, or M(r)s.___ or Ma'am (unless they absolutely insist on first names). They never do. :) (They will also never address me without Dr. ____, even when we know each other very well). It's the generation. I do know one erudite wit who's peeved I have scientist in my handle though. I must be doing something right.~ Neuroscientist | T | C 05:22, July 11, 2005 (UTC)
If you think the casual mention of FAA is cool, let me give you the actual CV: I did 30 years as an air traffic controller. I spent the first five years in the Jacksonville ARTCC (FL), and the last 25 in Chicago—mostly ARTCC, but I had some time at ORD, too. And to put things about the ARTCC in perspective, 75% of the operations at the Center (ARTCC) involve inbounds to and outbounds from ORD. I've been retired since I was 51. That explains how I'm able to be here so much.
Are you a pilot, by any chance? One of the classic stereotypes in aviation is a doctor in a Bonanza. Duckecho (Talk) 15:14, 11 July 2005 (UTC)
51! Holy cow. I expect to have to be going at it even at 65. No, not a pilot, sorry, no bonanza. MudPhud. Currently on lab rotation, with a computer that's always on next to my bench. Which should explain something.~ Neuroscientist | T | C → 15:29, July 11, 2005 (UTC)

MIA

In re Ghost. I don't know. The last email I got from him was on the 7th. I've written at least one since (and another just now) that should have garnered a response, but didn't. Must be one of those life things you and FW mentioned. Duckecho (Talk) 15:14, 11 July 2005 (UTC)

Deserving of special mention

I really appreciate the support. Duckecho (Talk) 15:14, 11 July 2005 (UTC)