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Quinlan, Cruzan, Schiavo_1

Quinlan, Cruzan, Schiavo_1 - Copyright 2005 Baylor...

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Copyright © 2005, Baylor University Medical Center From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury Robert L. Fine, MD From the Office of Clinical Ethics, Baylor Health Care System, and Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas. The battle over the life and death of Terri Schiavo was only the most recent medical ethics case to catch the public's attention. This case asked both the individuals involved and our society in general to make moral judgments about the appropriateness of a decision to maintain or withdraw life-sustaining treatment. As a practicing medical ethicist and an observer of the case, I was startled by the degree of misunderstanding about different types of brain injury and by more than a few misstatements about the medical facts of the case. Mrs. Schiavo was described at various times as comatose, brain dead, vegetative, minimally conscious, locked in, and disabled. These are mutually exclusive conditions. This failure of the media, politicians, and even some physicians who should know better to accurately describe Mrs. Schiavo's medical condition was particularly disturbing, because good medical ethics begins not with the discipline of ethics but with good clinical medicine. Appropriate moral judgments about medical treatment decisions cannot be made without first understanding the relevant clinical medicine. In this article, I review the differences between coma, brain death, the vegetative state, and other profound brain injuries. I then review the Quinlan, Cruzan, and Schiavo cases to explore various legal aspects and close with reflections on some of the ethical issues related to treatment of patients with profound brain injuries. TYPES OF BRAIN INJURY
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Coma Most serious brain injuries begin with a coma, which is best thought of as an “eyes-closed unconsciousness.” It is as if the patient is sleeping but cannot be roused. Coma is usually not permanent. Some patients go on to become brain dead; others enter the vegetative stage, become “locked in,” or enter the minimally conscious state; still others recover completely. Patients who recover may be normal or may have a functional deficit such as paralysis, weakness, or cognitive impairment. Brain death Brain death …, is the irreversible loss of the clinical function of the whole brain: the cortex (responsible for motor and cognitive function), the midbrain (which might be thought of as integrating higher and lower centers in the brain), and the brain stem (responsible for vegetative functions such as sleep-wake cycles and breathing). Brain death is a product of modern technology, made possible by mechanical ventilators and cardiopulmonary resuscitation. It was first described in the medical literature in 1959 by two French neuropsychologists who referred to le coma depasse, or a state beyond coma (1). In America, we often refer to the Harvard Medical School definition of irreversible coma as the definition for brain death. This definition
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Quinlan, Cruzan, Schiavo_1 - Copyright 2005 Baylor...

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