Persistent Vegetative States: Legal and Political Ramifications

Law_Politics.jpgOne controversial area where the brain, politics, and law collide is in cases where people suffer severe brain damage and are in a persistent vegetative state (this is more accurately termed complete vegetative state). In this state, the higher cortical functions of the brain are essentially wiped out. The person’s brain stem is often still intact so breathing, swallowing, eye-blink, and other basic functions still can occur. However, without the neocortex (cortex that is not brainstem), the person cannot really see, hear, speak, or think.

People in persistent vegetative states usually cannot survive on their own and have to have a feeding tube. They do not, usually, have to be on full life support because the brainstem is intact. This differs from brain death (not technically a medical term — it’s a legal term) where the brain and brainstem also have no activity; people in this state have to be on full life support. While many people can spontaneously recover from a persistent vegetative state, it is possible that those who do so were misdiagnosed to start.

TreePolitics comes into play because some people clash over how to deal with people in persistent vegetative states. In 2005 the Terri Schiavo case brought national media attention to this condition. Terri’s husband finally prevailed and Terri’s feeding tube was removed. She died within two weeks. A CT scan of hers is readily available online. It shows considerably enlarged lateral ventricles and marked cortical atrophy. Her pathology report indicated severe loss of cortical neurons in nearly every part of the cortex. There was no chance that she could ever recover functioning.

Ms. Schiavo had been in the vegetative state for 15 years at the time of her death. Some people still consider her death a court-sanctioned murder (these generally are people without any knowledge of the functioning of the brain). Her brain was in such poor condition that it was likely very similar to what would happen if all the white matter connecting brain regions together was severed and most cortical and many subcortical neurons destroyed, leaving her brainstem mostly intact. The political-legal conflict occurred in part because her parents kept hoping beyond hope for a miracle while her husband stated that Terri wouldn’t want to live how she was living.

Again, my belief is that people who spontaneously recover from persistent vegetative states were misdiagnosed to begin with. In any case, as time goes on recovery from a vegetative state becomes more unlikely with greater cognitive deficits. Schiavo was in a state where even if she had recovered she would have had very little cognitive abilities. One of the positive outcomes of Schiavo’s case was the scrutiny of vegetative states, with neurologists seeking for clearer definitions and more sensitive tests.

  • John Sipos

    Vegetables can’t scream on immediate interactive cue (see Google Video). Ms. Schiavo was NOT in a persistent vegetative state.

    This was to have been a very easy more than a million dollars payday for very friendly friends of the court hired to kill an inconvenient wife. You do not know the medical and judicial fraud at the heart of this brutal killing. It may take a generation to prove, but when the record is examined by person or persons not tainted by self serving agenda, Ms. Schiavo’s death will be reclassified, “judicial murder.”

  • B Schatt, MS, MBA

    The tragedy here is that Shiavo’s only goals were (1) money and (2) to deny his wife her life. He kept her in sensory deprivation for at least 12 years. He enjoyed the fruits of adulterous behavior. He outright stole from the public via the Medicare system (that is you and me). After dehydrating for 13 days I guess her brain and everything else shrunk.

    Teri had people who loved her and wanted nothing more than to take her home and care for her at their expense. A probate judge of nefarious repute and totally illegal behavior raped her as surely as did her husband. He definitely committed homicide as if by his own hand.

    Also, please note that Shiavo has been under investigation by state and federal agencies, his TeriPac was a total sham and he behaved very badly, neither he nor Felos are smelling too good on the lecture circuit, and Greer should be disbarred. Sadly, among the losers are Shiavo’s kids, they will forever be known as the spawn of a murderer and it will haunt them.

    The Shindlers on the other hand are supporting people world wide and offering comfort to those in need. The lecture circuit vigorously pursues them. They used a terrible loss to bring a great compassion to this world. They are good Christians and Catholics.

  • With ALL DUE RESPECT, I am not just stating my opinion with nothing to back it up. In 2001 I spent 14 long miserable weeks with my wife in the same condition as Mrs. Shiavo. Her eyes were open, she looked right at me, but couldn’t see me. She couldn’t see anything — her brain was basically GONE after a massive stroke. (My wife was 39 years old at the time.) We were luckier than the Shiavos — my wife died on her own after the 14 weeks. I LOVED MY WIFE MORE THAN LIFE ITSELF and will never be OK, but do you think it would have been better for her to live like that.

    People who say that Mrs. Shiavo should have been kept alive HAVE NEVER BEEN IN THAT POSITION. Would you like to be kept alive like that? We toted my wife around during that time between 4 hospitals and 2 nursing homes all because of legal red tape. What kind of a life is that? I begged my higher power to spare my wife’s life — I didn’t get it. But you know what, we are all better off especially my wife who is in a much better place than being warehoused just to live out her days like that.

    I’m really tired of hearing these people’s opinions who have never been in that situation!

    Scott Becker

  • Chris Fan, M.D.

    People in PVS can and do exhibit many subcortical responses: laughing, moaning, crying, facial movements, orienting to sound or visual cues, screaming, nociception, even talking, etc. The key is whether they do so in a constant and consistent fashion on command. The video that shows Terri screaming “on command” in no way negates PVS as a diagnosis. It may have simply been coincidence. Unless one can demonstrate constant and consistent responses to commands, PVS is the default diagnosis.

    Dehydration has little to no effect on brain weight. The cerebrospinal fluid acts as a buffer. The CSF volume will shrink before the brain loses water weight. If one looks at Thogmartin’s report, the weight of CSF was roughly double the brain weight, which tells us how atrophied the brain was. Even with maximum CSF depletion, it was still double the brain tissue. Moreover, the neuropathological findings all showed the classic changes from chronic anoxic damage — NOT acute changes from dehydration. Likewise, starvation has little to no effect on brain weight. If body weight/fat were a determinant, then obese people would have larger brains than lean people. In point of fact, the lipid rich content of the brain is sructural in the way of myelin sheathes, and therefore is unavailable as energy substrate. This is similar to the fat pads of the eyelids, fingertips, thenar eminence, etc. Even people who have died from starvation will have sparing of those areas, and their brains are no lighter than people who died from other means.

Jared Tanner, PhD

Jared Tanner has a Ph.D. in clinical psychology with an emphasis in neuropsychology. His interests are mainly neuroimaging and neuroanatomy. He spends his research time looking at the structure of gray and white matter in the brains of people with Alzheimer’s disease and Parkinson’s disease. With a focus on neuropsychology, he is also interested in how normal and abnormal brain structure relates to cognitive and behavioral functioning.

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