The above image was distributed by Michael Schiavo in March 2005; it now available from the Warriors for Truth website and from the University of Miami Ethics Program's "Schiavo Case Resources" website.

In 1990, Terri Schiavo suffered a heart attack brought on by years of bulimia.  The resulting lack of oxygen to her brain caused catastrophic brain damage, leaving Schiavo partially blind. Eight years later, her primary care physician determined her to be in an irreversible Persistent Vegetative State (PVS), a term describing patients who have severe brain damage and are in a state of what physicians call "wakefulness without awareness". PVS patients are considered by most physicians to be unconscious and unaware, although some exhibit behaviors that can be construed as arising from partial consciousness -- reflex or random behaviors such as smiling, shedding tears, grunting, moaning or screaming -- without any apparent external stimulus.

As part of a court-ordered examination in 2001, Dr. Ron Cranford, a neurologist at the University of Minnesota, assessed Terri Schiavo's brain function. Florida Today quoted him as saying that EEG (electroencephalogram) data showed no electrical activity in Schiavo's cerebral cortex, and that a CT scan showed "massive atrophy" in that region of the brain. In his opinion, the only part of the brain that appeared intact was the brain stem, which neuroscientists have found to control involuntary functions such as breathing and heartbeat -- such that Schiavo could survive if she remained on a feeding tube. "There is no medical dispute," Cranford told Florida Today. "She is in a persistent vegetative state, and she has been for 15 years."

One year later, Cranford and Michael Schiavo, Terri's husband, took an image (above left) of Schiavo's brain to serve as legal evidence that new treatments would not restore Schiavo's cognitive function -- against arguments by Schiavo's family that these treatments might help. Physician opinion served as a major source of evidence in this trial: five physicians examined Terri Schiavo's brain scans, along with her medical records, videos of Schiavo, and Schiavo herself. Their conclusions strongly diverged: a court-selected physician and the doctors selected by Michael Schiavo argued that Terri was in a PVS, while the physicians selected by Schiavo's family said that she was in a "minimally conscious state" -- in other words, that she did respond to certain external stimuli, sometimes by attempting to say "Mom" or "Dad."

Eventually, both this court and Florida's Second District Court of Appeal ruled in favor of Michael Schiavo, concluding that Terri Schiavo was in a persistent vegetative state. Yet relentless legal back-and-forth continued until January 24, 2005, when Schiavo's family appealed the trial to the Florida Supreme Court. The final ruling came on February 25, 2005, when Florida Circuit Judge George Greer ordered Schiavo's feeding tube removed.

As Terri Schiavo slowly died, both legal parties pitched camp, using various media outlets to fan the case's ethical flames. On March 29, 2005, in response to omnipresent television footage of Schiavo's apparently conscious activity, Dr. Cranford and Michael Schiavo decided to fight fire with fire. They began to distribute the above image of Terri Schiavo's 2002 CT scan alongside that of a "healthy" brain, hoping to garner medical appreciation for their side of the trial. Cranford felt that even laypersons would see the difference between the images: as he described to the Minneapolis Star Tribune, "It's pretty easy to see which is Terri's and which is not."

Picturing Schiavo

If anything, this was an understatement. The visual difference between these two images is striking.  After endless scientific blather broadcast to the American public -- including vague, uncertain, semi-scientific debates on the diagnosis and metaphysical meaning of PVS -- this image, finally, appeared to seal the deal: what could connote brain death more firmly than a partial, decomposing brain? As Joe Dumit of MIT comments in Picturing Personhood , brain scan images "invoke a sublime reaction -- 'Wow.'"

The media upped the authority of these images by publishing them alongside interviews with physicians arguing Michael Schiavo's case. On March 23, a group of Florida neurologists had viewed the above image of Schiavo's brain and voiced their responses to the South Florida Sun-Sentinal. These images, they argued, showed that "70 to 90 percent" of "her gray matter where thinking and feeling occur has died off and been replaced by watery fluid, with no chance of growing back." One physician, the chairman of neurology at the University of Miami's Miller School of Medicine, expressed his doubt that "there"s any activity going on in the higher levels of her brain," while another was more dire: "The chance that this person is going to recover is about zero." A third physician, upon seeing the scans, was openly "wow"ed: "This is as severe brain damage as I've ever seen." For them, as well as for many readers eavesdropping on their conversation in the next day's news, the Schiavo brain scan became a classic expression of pathology, a textbook image of brain damage.

Both doctors and media consumers seemed to be struck by the see-it-believe-it appeal of brain scan images -- and understandably so. These images are discrete, readable, and visually appealing. Their creation seems almost as simple and automatic as taking a snapshot, speaking directly to readers who are unlearned or disinterested in other scientific results. This apparent transparency with regard to the brain is unparalleled by numbers, graphs and scientific jargon. It is precisely these qualities that can make the images convincing to both scientists and to a popular audience -- that lend power to the images' claims. The Schiavo images were perhaps most potent for casual internet readers, who gobbled them up not only from major news sources, but also from advocacy websites and inexhaustible Schiavo blogs. Whereas many media sources dutifully provide a caption that summarizes other, less striking imaging results and explains the decisions going into the imaging process, the Schiavo scan was often distributed without any corresponding explanation.

However, CT scans are not 20-20 visions of the human mind -- or even of the brain -- nor are they constructed and distributed solely by computers. Scientists make decisions about the images in experimental setup, during the scanning process and afterward.  Scanners are programmed to collect certain data, and then a computer algorithmically reconstructs the data into a three-dimensional map of activity based on researchers' assumptions about the scanner and brain activity. The result is a dataset of the individual's brain activity, which researchers transform and normalize based on prior CT scans. To make these "brainsets" visible, researchers substitute colors for numbers to highlight some differences at the expense of others, and select specific colored brainsets to be produced and published. Each of these steps is hotly debated, and each requires assumptions about human nature, anatomy, and physiology. The ambiguity and theory behind each image greatly influence the visual result. 

Without a caption explaining this ambiguity, CT scans can become immensely convincing for the average media consumer who, in any case, has no patience for lengthy scientific explanation. Worse, certain media sources structured entire articles around the images alone; as Roland Barthes remarked, "The image no longer illustrates the words; it is the words which, structurally, are parasitic on the image." Dumit issues a warning about this trend: CT images "are consciously selected to enhance the textual argument. They are crafted to undergird, teach, and illustrate the process of discursive and statistical persuasion." The Schiavo brain scan should never have been represented, captionless, as singular evidence of her physical state -- even though the average reader might simply gloss over an added caption.

The Anonymous Normal

To focus only on Schiavo's image above, however, is to overlook another recent trend in science media: the ubiquitous image of a "healthy" brain, a "normal" brain. Again, without a caption underlying the brain scans paired above, a casual readership may gather more from the images than the images deserve. The "healthy" brain above was selected for comparison despite having a different skull shape than Schiavo's, heightening the seemingly obvious differences between the two images. The color selected for each scan was different, further amplifying contrast between them. Of course, significant visual differences exist in the two patterns of brain matter, but the casual reader could not be asked to evaluate these differences without further information or knowledge of brain anatomy. It seems that Cranford's stylistic choices were intended to substitute for further scientific explanation.

Brain scans presented in the media often offer simple comparisons between brains: a schizophrenic brain versus a depressed brain, addict versus non-addict. But "rationally," Joe Dumit writes, "We may still remember that this is a category mistake, a substitution of a small set of scan differences for the universal assumption of differences in kind."

The "healthy" brain scan presents a highly specific problem: who, if anyone, counts as having a healthy or normal brain? French philosopher Georges Canguilhem argued in The Normal and the Pathological that the "normal" can be defined in many ways -- as an average in a population, as a typical member of that population, or as an ideal type of person. In the case of the Schiavo/Healthy image, "healthy" most importantly (to a reader) means not-Schiavo, not-brain-dead, and not-unconscious -- and in this respect, nearly any image of a conscious person's brain could have taken its place.

Without a reference to the origin of this second image (neither Cranford nor any media sources provide one), we can only guess at why Cranford chose this specific image to represent the "healthy" brain. It was doubtless tough to do so. Certain "trait characteristics" (like gender and ethnicity) are controllable in sampling, but "state characteristics" remain: has the subject recently consumed caffeine, nicotine, vitamins, other drugs? What time of day was the experiment conducted? Many scientists consider it impossible to represent a truly standard, truly healthy, truly normal brain. They cope either by merging scans from many diagnostically "healthy" individuals, or simply by selecting and comparing the most obviously different scans from "diseased" and "healthy" individuals under their care.

Nevertheless, the final image makes it to the media with one label, implying that there exists a kind of person, a healthy kind of person. Presented this way, the images easily become de-individualized, idealized, and distant. Editors of American media sources will inevitably prefer the caption, "Healthy," to "White American Right-Handed Caffeine-Free Female with No Prior Familial or Medical History of Head or Psychological Trauma, 4:17pm."

A Stubborn Viewership

Of course, not every American media consumer saw the Schiavo image as evidence that, as the physician said above, "There's [no] activity going on in the higher levels of her brain." Many Americans felt that no image or statistic could represent Schiavo's actual experience, that her first-person reality could not be summarized by third-person data. Others believed that despite Schiavo's dubious consciousness, her soul remained intact -- or that, counter to the conclusions of materialists, the mind does not equal the brain. Therefore, while certain many media consumers just needed a proper dose of "evidence" to be convinced that an empty Schiavo brain meant an empty Schiavo, there were nevertheless countless viewers for whom no image of Schiavo's brain could have budged their original sense of the case.

We can look to their apparent stubbornness for a good reason to distrust CT images: a brain scan represents a visualized data set describing brain activity, but the connection between brain activity and the mind is a subjective jump that only certain American viewers were willing to make. 

Brain scans have clearly become important diagnostic tools within some areas of medical science. But in Schiavo's highly visible case, her CT scan was an effort to lend scientific support to one side of a relentlessly debated, popularized ethical issue. Few critics questioned what place these "objective" images had in an ethical debate -- or whether they had any place at all. Indeed, in this case, science only begat more science: Schiavo's popularized CT scan prompted demands for PET scans and MRI's, as if another scientific tool might reveal some extra hidden truth about Schiavo's inner state. 

Months after Terri Schiavo's death on March 31, the Schiavo media blitz remains strictly polarized over whether scientists can quantify conscious experience. But between battle lines, there lies a fertile middle ground: the media could examine the relevance of science to Schiavo's case, and how science has made claims about Schiavo's conscious experience. Engrossed with noxious two-party debate, the media has so far missed a golden opportunity to educate the larger public on ambiguities behind newly widespread medical technologies. Perhaps, after Wednesday's autopsy revitalized the Schiavo coverage, reporters will pick up some of this slack.

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