THE battle between Terri Schiavo's husband and parents over whether the Florida woman wanted to die or remain alive while hooked up to a feeding tube has led to suggestions here that it may be time to make living wills legally binding documents in Jamaica.

CAMPBELL-FORRESTER. time for the Medical Association of Jamaica to formulate an official position on the issue

Some medical, legal and religious leaders have come out strongly in support of the use of these documents, through which individuals can clearly outline how far they are willing to go to remain alive.
"I think it is something that we certainly should take a look at," said health minister John Junor.

And while the minister stressed that any such move would be secondary to other measures to save lives - such as taming a crime level that left almost 1,500 people dead in Jamaica last year - Public Defender Howard Hamilton was among those who argued that the Schiavo case had given new urgency to the need to tackle the issue of living wills.

"With the new developments in which we can keep people alive with modern technology, perhaps it's time that we looked at giving meaning, or force, to some form of legislation along those lines. Presently we don't have it," said Hamilton, who is a lawyer.

The well-known image of Terri Schiavo's mother, Mary Schindler, at her daughter's beside.

"For my part, I am not in favour of the taking of life, generally. That's where I start from. But circumstances can always alter cases and the situation like the Schiavo case is clearly an exceptional one which requires new thinking on the subject," he suggested.
President of the Jamaican Bar Association (JBA) Arlene Harrison-Henry said the JBA has not yet discussed or arrived at an official position on living wills or the broader issues involved in the Terri Schiavo case.

But JBA vice-president Clayton Morgan is among those who personally agree that the time has come for local laws to give teeth to what is now an informal process through which patients can have a say about how they spend their last days, or hours.
"I think the time has come for parliament to legislate on it so if a case like (Terri Schiavo's) comes up in Jamaica it would be clear who should make what decision," he said.

Legally giving another person power-of-attorney and the go-ahead to make decisions on financial issues does not cover life or death decisions such as when to remove a feeding tube, he explained.
"The law is not clear in saying who has any decision over life and death, so unless you give somebody specific instructions during your lifetime you might run into problems like in the Schiavo case," Morgan warned.

Dr Sheila Campbell-Forrester, the Regional Director in the Western Regional Health Authority and who has almost 30 years' experience in the medical profession, believes it is time for the umbrella group, the Medical Association of Jamaica (MAJ), to formulate an official position on the issue.

HAMILTON. Schiavo case had given new urgency to the need to tackle the issue of living wills

"One way to overcome a situation like what happened in the Schiavo case is for medical science and civil society to come together and develop policies that are very clear on how you operate in that kind of situation," she said.

"I think the time has come for us to look at it seriously because we are strongly influenced by the world around us. We are living in a global environment and. health care is also part of that global environment."
The MAJ, she said, should at least attempt to find out what society's thinking is on the issue.

"I think that this is a role for the MAJ to play, to get the views of the community, civil society and the medical fraternity," Campbell-Forrester said. "And there are going to be divergent views, but a least we should be able to come to a common point of deciding on what might be the best way forward."

Issues that would need to be explored when formulating a position, she said, would include how to protect the medical fraternity from litigation by family members who disagree with the course of action taken as outlined in the living will.

MORGAN. I think the time has come for parliament to legislate the issue of living wills

Litigation played a major role in the Terri Schiavo case, with her husband Michael and her parents Robert and Mary Schindler duelling as far as the Federal level as each side tried to convince the courts that they knew what the 41 year-old woman would have wanted.

Schiavo's husband steadily insisted that she had verbally indicated that she would not want to live in a persistent vegetative state, a condition which the American Academy of Neurology said currently afflicts between 10,000 and 25,000 adult Americans and somewhere between 6,000 and 10,000 children.

While awake, a person who is in a persistent vegetative state shows no evidence of a working mind.
Terri Schiavo died on March 31, almost two weeks after her feeding tube was removed at the end of a bitter court battle that spurred political, ethical and religious debates across America and around the world. Her parents and their supporters have described the conditions under which she died as inhumane, saying she was literally starved to death.

One of the major reasons why the Schiavo case dragged on for years was because there was no written evidence of her wishes. Since her death, there has been a renewed push, in several US states, to pass legislation to encourage more Americans to make living wills, a concept that is still unfamiliar to most Jamaicans.

Dr Carolyn Gomes, the executive director of the rights group Jamaicans for Justice and a medical doctor who is all too familiar with cases of family members arguing over what is the best route to take when faced with an obviously-suffering terminally-ill patient, is among those who believe that living wills are vital.

"I think it's important that you have living wills," she said. "(Making tough decisions about a patient's final care) is a dilemma that people face, though not very frequently, in this country; but we still face it. Doctors face it, patients' families face it and it's important that your wishes are known."

Providing just the right level of support for patients and their family members as they struggle with tough decisions that literally mean life and death is difficult, she said.
"It's difficult for everybody - for the family, for the doctors," said Gomes. "These are decisions we make every day in hospitals, do we turn off the machine after the patient has been on the ventilator for a week?"

It is the physician's job, she said, to provide patients and their family members with enough information for them to come to a decision.

"You talk to the family and assess the chances of recovery, and then they come to a decision privately," she said. "We look at cases of elderly persons with bad cancer and in a lot of pain, who are having trouble breathing and swallowing (and the question is) do I give them extra morphine. These decisions are made every day throughout the island by doctors and families. It's difficult."

Dr Derrick Aarons, a former member of the MAJ's ethics committee, is familiar with the struggles that patients and their families face. He had one patient, he said, who refused a round of treatment for leukemia and died at age 28 after finding it difficult to cope with the side effects of the medication. Most patients, he said, preferred to avoid prolonged suffering.

"If the patient is conscious and aware, he often opts for least suffering, and does not want to add life (with the aid of medical technology) if there is going to be suffering involved," said Aarons. "The family, however, is emotionally involved and wants to do everything to keep him alive (for their own sake)."

Proponents of living wills say it is situations like those that legally binding documents would address.
Jehovah's Witnesses have used living wills for years, and it is a part of the religious group's doctrine.

"Jehovah's Witnesses carry on their person a legal document that sets forth the individual's treatment instructions regarding end-of-life matters," said Luther Georges from the local branch of the church's Watch Tower Bible and Tract Society of Pennsylvania.

"It is helpful for copies of such a document to be supplied to a trusted, close relative, one's physician, and the person designated to speak on (the patient's) behalf if he is unconscious."

The Roman Catholic Church's Archbishop Lawrence Burke was unavailable for comment, but Monsignor Richard Albert said the decision about making a living will should be left up to each person.
"It's up to the individuals to make their choices or to certainly let their close family members know what they would like done," he said.

However, Seventh-day Adventists have clearly defined guidelines on caring for the dying in a world where modern medical advances may mean significant differences in the quality of care offered from one year to the next.

In a statement of consensus on care for the dying that was approved by the general conference on Seventh-day Adventists' executive committee at the annual council session on October 9, 1992, that religious group said it was best if the wishes of the individual were put in writing and in agreement with existing legal requirements.

"When a dying person is unable to give consent or express preferences regarding medical intervention, such decisions should be made by someone chosen by the dying person. If no one has been chosen, someone close to the dying person should make the determination," said the statement.

"Except in extraordinary circumstances, medical or legal professionals should defer decisions about medical interventions for a dying person to those closest to that individual. Wishes or decisions of the individual are best made in writing and should be in agreement with existing legal requirements."

As the Terri Schiavo case has shown, the mere act of saying a patient has made his wishes known is not enough. In the absence of any legally binding written instructions, Gomes said, family members and some local doctors may simply ignore the patient's wishes.

"You certainly can set out your wishes on paper, (but) whether your family will follow it is another matter," she said, adding that "the religious beliefs and practices of the practitioner" may also be a factor in determining whether, for example, a terminally ill patient's request not to be resuscitated once his health has deteriorated to a certain point is respected.

Another issue that may come into play, Gomes said, is the interpretation of any written instructions supplied by the patient.
"Even though the wishes may have been 'don't keep me alive artificially', what does that mean?" she asked.

"Does it mean giving me an extra shot of morphine because I'm in pain, even though it might stop my breathing? Does it mean only natural food in a shake? Saying something like 'don't keep me alive artificially' means different things to different people."

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