To the Editor:

The gratuitously violent title of Paul McHugh’s article sets the tone for an unbalanced analysis of the Terri Schiavo case that typifies so much of the hyperbole and misinformation that have pervaded the public debate about it [“Annihilating Terri Schiavo,” June].

Dr. McHugh characterizes the “persistent vegetative state” (PVS) of patients like Terri Schiavo as “human life under altered neurological circumstances.” This sanitizes the permanent and devastating neurological symptoms of PVS, in which even an ostensibly awake patient is completely unaware of his environment.

Dr. McHugh then equates the cessation of unwanted life-support treatment with actions by physicians that “aim to kill.” But there is a subtle and vital distinction between ceasing treatment at a patient’s behest and, say, administering a lethal dose of morphine. This distinction was affirmed in the 1990 Cruzan case in which the Supreme Court ruled that an “incompetent” patient had the right to decline life-saving medical treatment through surrogates or through clear and convincing evidence that this had been his wish. At the time, there was no public outcry about a “culture of death.”

Most disturbingly, Dr. McHugh sets up a strawman in Michael Schiavo, implying that he viewed his wife’s condition as “life unworthy of life”—terminology Dr. McHugh borrows from pre-Nazi Germany. I do not recall seeing this despicable term applied to Terri Schiavo, but I do recall Michael Schiavo stating repeatedly that his wife had wished not to be kept alive indefinitely in a severely brain-damaged state.

Here, Dr. McHugh might have focused on an issue that deserves more attention and that can well be viewed as troubling by dispassionate critics. In the end, the basis for the removal of Terri Schiavo’s feeding tube came down to some offhanded comments she was said to have made years earlier after visiting a relative on life-support and while watching a television program about terminal illness. Whether or not the utterances of a healthy woman in her twenties should carry such legal weight is a matter for legitimate debate. But Dr. McHugh seems to call into question the entire notion of patient autonomy, suggesting that whether or not to be kept alive in a permanent state of unconsciousness is a decision best left to well-meaning physicians.

Finally, Dr. McHugh takes a swipe at bioethics. He posits the existence of two warring classes, bioethicists and medical practitioners, noting that the former are “generally shunned by doctors and nurses.” It might surprise him to learn that in many hospitals one person serves both functions. I myself have been practicing pulmonology for 32 years and have been doing bioethics consultations in my academic medical center for the last ten years.

In both capacities, I view the sanctity of life as one of the pillars of the practice of medicine. There is no “culture of death” at my hospital. But the increasing sophistication of modern medicine has meant that there frequently are difficult, gut-wrenching decisions that have to be made about the course of a patient’s treatment. In this regard, the two hats I wear are often of assistance to patients, families, fellow physicians, and nurses.

I do not share Dr. McHugh’s view of the nefarious impact of bioethics and an imagined “culture of death” on our society. The Schiavo case was a perfect storm in which a unique convergence of factors—involving medical ethics, law, family dynamics, and political alliances—produced a family tragedy and a media circus. But our country has weathered the storm.

Kenneth Prager, M.D.

Columbia College of Physicians and Surgeons

New York City

To the Editor:

Paul McHugh, a preeminent scholar and clinician in neuropsychiatry, argues that Terri Schiavo met “annihilation” at the hands of a “culture of death.” He contrasts this with the “culture of life” that is sustained by humane physicians, nurses, and hospice staff.

As a physician specializing in psychiatry, I find such Manichean divisions unhelpful. In my view, the physician’s duty is to engage in a difficult, ongoing dialectic between traditional medical ethics and the specific wishes, hopes, and directives of a particular patient. The former includes such core precepts as “First, do no harm” and “Treat the sick and injured with compassion.” The latter may extend to anything from the use of psychotropic medications during a psychotic episode to so-called living wills.

Unfortunately, physicians have only faint guideposts to lead them toward a humane resolution of this dialectic. The American Medical Association charges doctors to “respect human life and the dignity of every individual.” But does “human life” refer simply to physiochemical processes like those involved in cardiac function, or to life in the larger sense of willful, reasoning personhood? Does the “dignity” of every individual obligate the physician to preserve human life under all circumstances and irrespective of the expressed wishes of the patient, or does dignity sometimes allow for the removal of life-prolonging devices from a severely brain-damaged person who has made it clear that he would not want to be kept alive in such a state? Nobody should pretend to have easy answers to these questions.

Dr. McHugh is worried about “the increasingly assertive deprecation of medical expertise and understanding in favor of patients’ ‘autonomous’ decision-making” and about the intrusion into the medical process of “bioethicists” who lack a foundation in the everyday realities of medical practice. I share these concerns, but I do not go with him in assuming that “no document on earth can substitute for the one-on-one judgment . . . of a sensible, humane, and experienced physician.”

Consider a document like the do-not-resuscitate (DNR) order, which for Dr. McHugh is one of the “signposts of our culture of death.” Recently, I was involved in the care of a very elderly patient with severe end-stage cardiac disease. His experienced geriatrician had recommended that he sign a DNR order, explaining that at his age, cardiac resuscitation usually led to substantial cognitive impairment and a poor quality of life. The patient elected to sign, and I concurred. Had he been a twenty-year-old with no progressive disease of any kind, I am quite sure I would have recommended against his signing. One life is not “worth more” than the other, but the medical facts, prognosis, and human context differ markedly between the two scenarios.

We doctors struggle with determinations in cases like these not because we are bullied by bioethicists but because we are physicians, and because there is no “culture”—of life or of death—that can substitute for the judicious weighing of general ethical imperatives against the specific directives of an individual patient.

Ronald Pies, M.D.

Tufts University Medical Center

Boston, Massachusetts

To the Editor:

Paul McHugh’s tendentious article misstates much about Terri Schiavo’s medical condition, the care she was given, and the legal battle that surrounded her demise.

First, Dr. McHugh draws a specious analogy between Terri Schiavo’s “persistent vegetative state” (PVS) before her death and the condition of “Dr. A,” a patient he attended to some four decades ago. Though Dr. A had suffered a grievous brain injury, after which he “gave little evidence of awareness,” on one extraordinary occasion he showed that he was able to receive sensory input, process it, and articulate a coherent response. In sharp contrast, Terri Schiavo showed no signs of consciousness over the course of fifteen years, never responding to stimuli other than reflexively.

Dr. A was sentient, Terri Schiavo was not. It is wrong and seriously misleading for Dr. McHugh to describe her as “apathetic to inner needs and external events,” or to attribute her contractures to “apathy”—as though these things could have been helped. Nor can PVS patients be said to display “a lowered state of vigilance,” since any degree of vigilance, however minimal, would preclude a diagnosis of PVS.

Within five weeks of her cardiac arrest in 1990, Terri Schiavo had three CAT scans, then another in 1996, and another in 2002. These tests showed massive destruction of brain structures necessary for consciousness (as against mere reflexive opening of the eyes). Dr. McHugh finds it surprising that no functional assessment of her surviving cerebral tissue was performed. Actually, a structural MRI was done five months after her cardiac arrest, but after an experimental deep-brain stimulator was implanted later that year, no MRI of any kind could be done.

Contrary to what Dr. McHugh writes, Terri Schiavo’s electroencephalograms (EEG) were not “typical of a patient with severely impaired consciousness”; fewer than 5 percent of PVS patients have the extreme abnormality of her isoelectric (“flatline”) EEG. If Dr. McHugh knows of anyone with such structural and functional abnormalities whose condition subsequently improved significantly, he should bring it to the world’s attention. Otherwise, he should stop hinting that additional neuro-imaging might have shown that Terri Schiavo’s brain “tissue was recovering over time” and that her condition was other than permanent.

Dr. McHugh finds it troubling that in Terri Schiavo’s last days, “all—hospice staff, parents, siblings, onlookers—were forbidden by court order to give her food or drink orally,” and that her parents were not permitted “to feed her by mouth as one would any helpless person.” But the reason Terri Schiavo had to be fed through a gastric tube was that she was unable to swallow normally without risk of aspiration and pneumonia. Feeding by mouth would probably have hastened rather than postponed her death—an opinion shared by the treating doctors and by the medical examiner who performed her autopsy.

Dr. McHugh decries the fact that Terri Schiavo was “judicially prohibited” from being given “even a chip of ice to relieve the pain of a parched mouth and throat,” with “local sheriffs . . . alerted to prevent it.” But surely he knows that there can be no feeling, including the registering of pain, without sentience.

One of us examined Terri Schiavo, reporting his findings in court testimony and subsequently in a detailed article in a medical journal. Both of us believe in the paramount importance of getting the fundamental facts right, upon which all discussions of ethics and law must be predicated. The true and tragic facts of her case do not fit Dr. McHugh’s apprehension of “life under altered circumstances” being led down a slippery slope to “life unworthy of life.”

M. Louis Offen, M.D.

Rockville, Maryland

Ronald E. Cranford, M.D.

University of Minnesota

Minneapolis, Minnesota

To the Editor:

As a physician with ten years’ experience in nursing-home and hospice care, I take issue with some of Paul McHugh’s assertions. Dr. McHugh writes that “the way [Terri Schiavo] died was most unusual”; that is not so. Many hospice patients with end-stage dementia and other consciousness-impairing neurological diseases die from dehydration due to the inability or refusal to eat or drink. If the patient is provided with proper oral care, this is not an uncomfortable way to die.

Contrary to what Dr. McHugh suggests, Terri Schiavo could not have taken fluids orally after her gastric tube was removed. She would have choked and aspirated, and would have appeared to be suffering. Since successive neurologists believed that she lacked the capacity to feel pain, it is false and almost defamatory to state of her husband and his advisers that “they were willing to have her suffer pain.”

Louise Benson, M.D.

Broomfield, Colorado

To the Editor:

Paul McHugh suggests that MRI or PET scans would have demonstrated whether any neuronal activity persisted in Terri Schiavo’s brain and whether any cerebral tissue was recovering. These tools help physicians make clinical decisions when further evidence may be of value. But in Terri Schiavo’s case, the presence of neuronal activity would not have changed the fact that she had suffered a devastating brain injury, significantly altering her quality of life and leaving her in a persistent vegetative state (PVS).

At present, neither of those high-tech and expensive tests is required to predict the possibility of tissue recovery in a case like Terri Schiavo’s; once a central- nervous-system neuron is dead, it remains so permanently. As Dr. McHugh himself points out, patients in PVS “for more than eighteen months are generally unlikely to recover”; after fifteen years it is completely reasonable to come to this conclusion without the assistance of ancillary tests.

Since Dr. McHugh’s article was published, the results of Terri Schiavo’s autopsy have come out. They counter his statement that she was starved to death; according to the coroner, she died of dehydration. To be sure, neither the one nor the other sounds like a preferred way to die. But the feeling of hunger—if a neurologically devastated individual feels it at all—subsides after several hours. Medical literature also suggests that prolonged starvation leads to the release of natural substances in the bloodstream, producing a euphoric state that reduces discomfort at the end of life. If, as Dr. McHugh suggests, Terri Schiavo was indeed not provided with ice chips, moist sponges, or glycerin swabs once the decision was made to forgo assisted nutrition, then her treatment did not rise to the current standard of palliative care.

But it is not up to physicians like Dr. McHugh or myself to determine the path of care for our patients. These decisions must be made whenever possible by the patient and, barring that option, by a surrogate who adheres to the patient’s wishes. A physician’s role is to inform the decision-maker of all possible options, along with their associated risks and benefits, and then to respect the decision even if it contravenes his own beliefs. If we are unable to do so, we must step aside and allow someone who is comfortable with the chosen course to assume the patient’s care. 

Adam Rapoport, M.D.

Toronto, Canada

To the Editor:

In writing that “the overarching principle that hospice doctors and nurses strive to represent and exemplify is never to betray a patient to death,” Paul McHugh apparently does not consider that a patient can be also be “betrayed” to a life he does not want to live. Insofar as is possible, the way a person dies should be consistent with his values. Other people should respect him by doing what they can to preserve his integrity and his sense of identity. When he is beyond self-command, his agents, insofar as reason and ability allow, should fulfill his purposes according to his standards.

Dr. McHugh’s contention that nothing can substitute for the “one-on-one judgment, fallible as it may ultimately be, of a sensible, humane, and experienced physician” is more than a little self-serving. Only medical experts assure us that it is legitimate to substitute medical expertise for moral judgment. Indeed, people have entrusted me with living wills and health-care proxies precisely in order to prevent well-intentioned physicians who do not distinguish between bodies and persons from zealously keeping them alive in conditions that they scorn.

Robert Hoffman

City University of New York

Jamaica, New York

To the Editor:

One need only have read the inflammatory title of Paul McHugh’s article to know that the text would lack any pretense to objectivity. Dr. McHugh asserts that after Terri Schiavo’s gastric tube was removed, she died “within thirteen distress-filled days.” Unless Dr. McHugh was in Schiavo’s hospice room during her last days, he has no basis for this statement.

Most disturbingly, Dr. McHugh bemoans the fact that patients have become empowered to choose among their treatment options—or to choose none. He may be nostalgic for the paternalistic era when “doctor knew best,” but the explosion of interest in living wills in the wake of the Schiavo tragedy suggests that he has precious little company.

Lonny Benamy

Brooklyn, New York

To the Editor:

Paul McHugh has written an insightful and poignant essay about our culture’s attitudes toward life and death. I share his disgust with the legal wrangling over Terri Schiavo’s fate. How did we reach this point where we are so fascinated with death, or look at it so cheaply, that no solution short of ensuring a slow death could be found within the law? Perhaps this is a simplistic or superficial answer, but I trace our society’s callous view of death to the Holocaust, when the techniques of modern science were first applied to the death process.

I take issue with one point that Dr. McHugh raises. He asserts that it is the sensible, humane, and experienced physician—and not the ethicist—who possesses the “one-on-one judgment, fallible as it may ultimately be,” to care for a patient at crucial moments in the dying process. But how many doctors nowadays have the kind of relationship with their patients that would generate the proper insight and understanding? Besides, the doctors closest to a person at the end of life tend to be specialists only recently called to the scene, with no sense of who a patient was prior to his final illness.

David Lentz

West Orange, New Jersey

To the Editor:

Language is at our disposal, but it also disposes of us; the way we talk creates the setting in which we conduct our moral calculus. Paul McHugh’s analysis of the Terri Schiavo illustrates this in a number of ways.

First and foremost, Dr. McHugh’s dramatic personal testimony about the submerged remains of consciousness in a patient with a condition not unlike Terri Schiavo’s is important both clinically and ethically. Second, his dissection of the term “persistent vegetative state” is a warning about how a single formula can be clinically accurate and at the same time subtly stretch moral possibilities. Finally, by calling attention to the chilling historical parallels between the Schiavo case and the bizarre, oxymoronic title of the 1920 German work Die Greigabe der Vernichtung Lebensunwertes Leben (“Lifting Constraints from the Annihilation of Life Unworthy of Life”), Dr. McHugh helps restore our own medical-moral talk to its first function as truth-telling.

Of course, the case of Terri Schiavo is awful and complex. But the understandable fear of the living that their minds could end up trapped and silenced inside a damaged body should not be what determines the outcome of cases like hers. Here is where the story of Dr. McHugh’s patient is important. In response to Dr. McHugh’s own voice at his bedside, this man with a damaged brain uttered a perfectly precise sentence—and then never spoke again. This is a cautionary tale. It makes us skeptical about what are still crude scientific measurements of human consciousness. It suggests that, rather than impose the gruesome imagination of the living upon those in “altered neurological states” (“I wouldn’t want to be in that condition and have all that attention and expense!”), doctors, family members, and the law should strive as much as possible to follow the Hippocratic Oath.

At what point do we judge that a person is no longer present in his or her body? Cases of severe dementia, last-stage Alzheimer’s, and massive brain injuries raise difficult questions. These are still unsettled issues. Yet we do know a person is someone with a history (even if plaque in the brain has destroyed his own access to it), someone who has been in relationships with others (even if he can no longer communicate with them), and someone who is alive (even if only by the aid of a machine). Beyond this, a person is a living entity to whom we accord certain kinds of respect and treatment. For a long time, Terri Schiavo was accorded the care that implied she was a person. Once she was cortically de-personalized, she could be dehydrated and starved to death.

Dr. McHugh has done caregivers for future Terri Schiavos—and all of us—a very humane service.

Robert F. Leavitt, S.S.

St. Mary’s Seminary and University

Baltimore, Maryland

To the Editor:

As one who recently lost a beloved companion to cancer after fending off periodic attempts by third parties to end her life, and who would have gladly given years of his own life to see hers prolonged—if only for a few days, and even in her final, semi-vegetative state— I was deeply upset by the Terri Schiavo case.

Things have really gone topsy-turvy when a government that purports to act in defense of human life, and with due respect for rational will, in fact does the opposite. In the case of a mentally sound person who wishes to die—such as one suffering from persistent pain or just pervaded by tedium vitae—government not only ignores his will but endeavors actively to block its implementation. Yet when it came to Terri Schiavo, who found herself as defenseless as any human being can possibly be, government not only failed to protect her but actively participated in taking her life.

Oh, yes, Terri Schiavo is said to have expressed her will to die rather than live in a vegetative state. But this justification reflects a deep misunderstanding of the nature and expression of rational will. The courts knew of Terri Schiavo’s will only through her husband’s uncorroborated statements. With a human life at stake, one would expect a third party’s assertions to be subjected to the most stringent scrutiny and denied any weight absent incontrovertible supporting evidence. Yet the courts were prepared to find cause for the imposition of a death sentence in such naked assertions.

Even if we accept at face value Michael Schiavo’s characterization of his wife’s will, no person’s decision about the termination of his own life can be called rational when it is made at an undetermined distance from the moment it will actually be implemented—and if, at that moment, it cannot be revoked. Let us consider a circumstance like that in which Terri Schiavo was said to have expressed her “will.” Seeing on television a person fed by tubes, or carried miserably in a wheelchair, the viewer says, “I’d never want to live like that.” He might even be moved to express this in writing. How can he know that he will have the same attitude at a moment when his neurological state is radically different?

Dismally, the courts fail to accord this obvious paradox anything approaching the importance it merits. Yet it is the subject of a simple story penned a century ago by the Nobel laureate Luigi Pirandello. A man strolling in the park with his wife sees a stroke victim being led around in a wheelchair, and says: “I would never want to live in that condition.” A year later, he himself is felled by a stroke. As he is led in a wheelchair to the park in his vegetative state, he begins to feel—without being able to manifest it—the wonder of life, which he appreciates even more than he did in health and which he now clings to desperately. Fortunately for him, his society neither offered living wills nor dangled before his wife the possibility of securing his state-sanctioned annihilation.

Mauro Lucentini

New York City

To the Editor:

Paul McHugh’s cool and reasoned reading of the Terri Schiavo case is a welcome relief from the political hue and cry that has surrounded this sad story. I wish to point out one small, inconsequential mistake in his article, perhaps a mere typographical error. He writes: “No functional assessment of her surviving cerebral tissue was performed by means of magnetic-resonance imaging (MRI) or proton-emission tomography (PET).” Proton? Protons are perfectly stable particles; were they to be emitted from our bodies, we would all disappear in short order. Dr. McHugh is referring to positrons, the antiparticles of the more familiar electrons. Positrons are positively charged, and they disappear in a flash when encountering (negatively charged) electrons because the latter are so much more abundant in the cosmos.

Positron-emission tomography is itself a bit of a misnomer, leading to the common belief, even in the medical profession, that positrons are emitted inside the body and detected by outside instruments. Actually, positrons so rapidly encounter electrons that they travel no more than about two millimeters inside the human body before being annihilated, thereby emitting highly energetic gamma rays. The gamma radiation is what the medical devices detect. The term “positron-emission tomography” was coined because the words “annihilation” and “gamma rays” were too frightening to patients. The same sort of euphemistic substitution is responsible for the “MRI,” which refers to a procedure that used to be known as NMR, or nuclear-magnetic resonance.

Didier de Fontaine

University of California

Berkeley, California

Paul McHugh writes:

An impressive feature of the Terri Schiavo case was the zealous public support that gathered behind her husband’s wish that she die. Some of my correspondents’ letters reflect that zeal; they deserve careful examination for the light they shed on the increasingly intrusive fact that ending a life, like living a life, has more than a purely private meaning.

Kenneth Prager’s letter is rather confusing. He seems at first to be of the opinion that Terri Schiavo was getting “unwanted” treatment; then he acknowledges that his basis for holding that opinion—namely, a number of “offhand” comments allegedly uttered by the young Terri Schiavo—is “a matter for legitimate debate.” Indeed: that debate is at the heart of the matter.

Dr. Prager also denies there was any “aim to kill” behind the efforts to deny food and drink to Terri Schiavo. But if that was not the aim, why were sheriffs brought in to guarantee that she got no fluids? In a spirit of compromise, I am willing to amend my statement and say that the aim was to make sure Terri Schiavo died. Is that a distinction with a difference?

More interesting to me is that Dr. Prager describes his work as “wearing two hats.” Here is my question to him and to others who play this double role: can they show that their second hat, that of the bioethics consultant, improves the fit of the first, that of the doctor? Until that question is settled by means of something more persuasive than testimonials, I would advise them to stick to being doctors.

Equally confusing is Ronald Pies. He wants to start with the principle of doing no harm. Fine; but how does he square that principle with the way in which Terri Schiavo’s life was disposed of? Wrestling with the concept of human life in the presence of debilitating disease or injury, Dr. Pies resists the effort to think through the implications of the term “life under altered circumstances,” a standard medical idea since Claude Bernard in the 19th century. He also mistakes as a “concern” of mine what is merely an observation: namely, the “increasingly assertive deprecation of medical expertise and understanding in favor of patients’ autonomous decision-making.”

Some of my other correspondents confirm the reality of this phenomenon. What actually concerns me, however, is that many doctors have grown wary of offering clinical guidance because they think patients distrust their judgment. Dr. Pies seems to be among those who believe this distrust is warranted; he himself would place his reliance on a document like a do-not-resuscitate (DNR) order. I am dumbfounded by this attitude.

Of all the new practices tied to the effort to support patient “autonomy,” DNR orders are probably the most injurious, and known to be so. Evidence from nursing journals is particularly telling here, documenting how patients on DNR orders are customarily moved to less accessible places in the hospital and shamefully neglected, becoming in effect non-persons. In short, DNR often translates into “do not care.” These documents represent a bad experiment, and should be junked.

M. Louis Offen and Ronald E. Cranford claim that, being closer than I to the Terri Schiavo case, they were better able to “get the fundamental facts right.” But they do not deny the most essential facts on which my argument rested. They do not deny that she slept and awoke on schedule, grimaced and groaned with pain, and turned responsively to sounds and touches. Nor, on the other hand, do they report that she was incapable of managing her oral secretions, which apparently she could swallow without difficulty. Nevertheless, they assert that she would have been incapable of swallowing nutrient fluids, and would have injured her lungs in the attempt.

Let us be real. The doctors did not want her fed because they worried about her lungs, but because they believed she was better off in the grave than living in the hospice. Everything else in this letter is simply science-bluffing in lieu of care-giving, and can be safely ignored.

Louise Benson similarly claims that Terri Schiavo could not have taken fluids orally. Was it, then, to avoid aspiration pneumonia that the courts sent police to guarantee that no innocuous ice chips could reach her mouth? I have had even more years of experience than Dr. Benson, but never have I seen a neuropsychiatric patient done to death by government order. Unless Colorado is different from most other states, I doubt that Dr. Benson has, either. Hence my claim that this death in a hospice was “most unusual.”

Adam Rapoport and I may seem at first to be engaged in a verbal quibble. I specifically stated that Terri Schiavo “died of dehydration”; he agrees that aspects of her treatment did not rise to “the current standard of palliative care.” But we part company definitively when, in his final paragraph, he describes a physician’s role as that of “inform[ing] the decision-maker,” thereby relinquishing the doctor’s tutelary responsibilities.

Patients are not doctors, and they need more than facts, which they can find readily enough on the Internet. What they seek is help in living with the facts, help in the form of guidance, counsel, and support from a person of experience and matured judgment—especially one who will see the problem through with them. If doctors, in response to culture-driven concerns over “paternalism,” deny this help to patients, they will leave them naked to their worst fears. Given the overall tenor of Dr. Rapoport’s letter, I would like to think that he could be brought to agree with me about this.

Although Robert Hoffman sees me as “self-serving,” I clearly stated that medical judgment is fallible. Does he, in turn, concur that clinical decisions provoked by “living wills” are also fallible? If we could get that far, we might then draw closer to the source of these respective fallibilities. With doctors, fallibility arises from lack of experience and/or lack of close attention to telling life details. With living wills, fallibility arises from their legalized rigidity even as life situations change, and attitudes along with them. If we agreed on that point, my next question would be: how can patient care be better improved, by concentrating on the education of doctors or by adding endless new codicils to living wills? I’d bet on the doctors, and I’d expect—hope—to see living wills eventually discredited.

Which brings me to Lonny Benamy, who notes correctly that the media reporting on Terri Schiavo prompted many fearful people to write living wills. That, indeed, was one of the reasons that prompted me to write my own counterreport, which I undertook not out of any nostalgia for the day when “doctor knew best” but out of a hope that readers might talk more with, and learn more from, their doctors—and that they would look for doctors who want to care for them through thick and thin.

In his very thoughtful response, David Lentz observes that such doctors are now hard to find, and that most people go from specialist to specialist in the course of their illnesses, particularly their terminal ones. Needless to say, I deplore this state of affairs, which perhaps more than any other has opened the door to new and chilly specialists in ending life. I can only say that I know many doctors—neuropsychiatrists and oncologists especially, but many others as well—who provide exactly the kind of long-term care I describe, and I hope that if he or someone close to him needs such a physician, we will always be able to find one for him.

Father Robert F. Leavitt and Mauro Lucentini could obviously have written better than I on this whole subject. It is clear that they understood my essay from the ground up, and I thank them for their efforts to enlarge upon its message. I also thank Didier de Fontaine for his kind comments and for his clear demonstration of how the use of abbreviations can often lead to embarrassment. I have sat through hour-long lectures on PET’s and MRI’s and learned less than what he taught in 238 words.