San José, Costa Rica, since 1956

No Right to Die Exists Here

WHEN Terri Schiavo died in the United States 13days after her feeding tube was removed, the rancorgenerated by her case did not run as deep in CostaRica, insulated not only by distance, but also by itslegal safeguards against such a fatality.The court decision regarding Schiavo, a 41-yearoldFlorida woman who survived on life support in avegetative state for 16 years, kindled a right-to-diedebate that verged on hysteria in the United States.In Costa Rica, the Catholic Church’s firm stanceon such issues, a position embedded in the nation’sConstitution, has kept discussion of whether patientshave such a right out of the public spotlight – but notout of the minds of doctors, who face life and deathissues as a matter of course.The law apparently doesn’t leave any wiggleroom, and while a doctor’s discretion may, expertssay an uphill battle faces those who wish to avoidextraordinary medical measures to keep themselvesor a family member alive in Costa Rica.ALTHOUGH a variety of laws and codes ofethics deal with the issue of life support, the basis forall such legislation is Article 21 of the Constitution,which states simply, “human life is inviolable.”Marvin Carvajal, a constitutional law professorfrom the University of Costa Rica, said human life isone of two rights described as inviolable in theConstitution. The article on the other right, property,includes exceptions, making human life the best-protectedright in Costa Rican law.This makes life support mandatory, according to Hugo Villegas, medical director of the privateCIMA Hospital in Escazú.“Euthanasia is simply not contemplatedin Costa Rican legislation,” Villegassaid. “Neither are testamentos en vida (livingwills). Legally speaking, even if thefamily members don’t want a person to beon life support, the law does not permit thatthe doctor take that person off.”In fact, even brain-dead patients had tobe kept alive until a modification in theGeneral Health Law in the early 1990smade them the only case in which doctorscan choose to take patients off life support,according to Villegas.A patient who is brain dead – alsoknown as legally dead – has no function, orelectrical activity, in any part of the brain,according to Dr. Rigoberto Monestel, withthe National Center for Control of Pain.A patient in a persistent vegetativestate, like Schiavo, has lost the higher cerebralpowers of the brain, but retains thefunctions of the brainstem, such as respirationand circulation. Such patients do notspeak or obey commands but may grimace,cry or laugh, according to Monestel.“UNFORTUNATELY, we run upagainst religious concepts (in this area),”Villegas said. “From the point of view ofthe Catholic religion, the person whodecides whether the patient survives is notthe doctor. It’s God.”The bishop of the diocese of CiudadQuesada, Ángel Sancasimiro, is of thatopinion.“We’re not owners of life,” he said.“Where life is, God is. When humanbeings do something directly opposed tothis gift, it is morally unacceptable.” InSchiavo’s case, “while she was still living,it was unjust to take away the foodthat was giving her life.”Have technological advances created anew beast – a vegetable state maintainedby machines that might be, philosophicallyspeaking, on the threshold between life anddeath?“I believe there is life while there is apulse, and while the heart beats, that life isas dignified as any of a person who can runand play and do everything. For me, all lifeis the same from the point of view of faith.From the moment of conception to themoment life ends, life is sacred,” Sancasimirosaid.DR. Isaias Salas, director of theNational Center for Pain Control, saysthere are lessons to be learned fromSchiavo’s case.“I believe in letting a person die withdignity. I ask, ‘why connect it?’ In the caseof Terri Schiavo, the thing to learn is tobetter evaluate each case before connecting(the life-support machine).“The moment you decide to put themon (life-support), you can’t take it away.First, because it’s not permitted in CostaRica by law, second because of my religiousbeliefs – you can’t do it. It would betaking the life of a person.”With the approval of the family and theconsensus of a medical team, doctors coulddecide not to connect a respirator in thefirst place, Salas said, but he is not awareof any time such a thing has happened inCosta Rica.Between 30-40 patients in Costa Ricabreathe with artificial respirators, some ofwhom also take food through a tube, andbetween 10-20 patients are fed through atube but do not need a respirator. None ofthem is unconscious, although all sufferfrom neuro-degenerative diseases and willnever recover, according to Salas.The cost of maintaining a patient insuch a condition in a public hospital is, onaverage, ¢63,000 ($135) per day.DESPITE the legal restrictions on doctors’actions, some may choose to honor apatient’s, or his or her family’s, wishes, evenwhen they run counter to the law and put thedoctor at risk, Villegas said.The primary problem such doctors faceis the possibility that a family member willfile a lawsuit against the doctor after thepatient has died, alleging the doctor did notdo everything in his or her power to prolongthe patient’s life.Villegas said such cases have certainlybeen brought before the courts, and thatany family member who disagrees with thedoctor’s decision – a cousin, a seconduncle – can file such a suit. He does notremember any cases in which doctors hadbeen found guilty of homicide, however.According to Carvajal, Costa Rica’spenal code stipulates that convictions of“homicidio por piedad,” or pity-inducedhomicide, can carry jail terms of sixmonths to three years.If a patient signs a living will or otherdocument expressing his or her wishes, itmay help doctors justify a decision to nottake extraordinary measures – but not necessarily,since such documents are notlegally valid, Carvajal said. Villegas saidthis is a particularly serious problem in thecase of foreigners who expect doctors tohonor living wills or other documents fromother countries.Over the years, legislators have consideredvarious bills that mention living wills,but “there they are, held up in the assembly,”he said. Making their way through themoral and legal quagmire “has been a constantstruggle” for doctors, he said.According to Cristina Murillo of theassembly’s archives department, however,none of the proposals currently under considerationmention such a change, althoughit is possible such proposals were discussedand then archived in the past.Carvajal said the scales of justice mightsomeday tip toward a broader interpretationof the Constitution’s dictates abouthuman life.“One must consider that even giventhese antecedents…it is possible that theinterpretation will change, to allow for awider sense of life, less strict than the onethe Sala IV has had in the past,” he said.What You Should KnowTHE experts agree: because thecountry’s laws require doctors to takeevery possible measure to prolong life,there is no way to guarantee wishes thatcontradict those laws are fulfilled.What actions should citizens or foreignresidents opposed to extraordinarylife-support measures take to improvethe chances doctors will honor theirwishes?Doctors say there are certain measuresyou can, and should, take in case of atragic occurrence. Still, there is no way toguarantee your wishes will be honored inCosta Rica. Steps you might take include:Speaking with your doctor. Make yourwishes clear. Ask for his or her opinion.If your doctor is opposed to your wishesor feels unable to comply with them,find a different health-care provider.Be sure to make the wishes of eachone of your family members clear.Visit a lawyer and ask to draw up atestamento en vida (living will) or healthcarepowers act. The latter is more specific,outlining the specific course oftreatment you request in response tovarious eventualities. While neither ofthese two documents is legally valid inCosta Rica, it may help your, or yourfamily’s, case to have a document writtenand signed in Costa Rica rather thanin your country of origin.Carry your written health-care wisheswith you whenever possible.

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