Commentary: Six Years Later and Katrina Still Engenders Bioethical Debate
What Has Culture Really Decided about Emergencies and Euthanasia?
During August 2005, the Gulf Coast experienced the most expensive natural disaster in history. The remarkable devastation would be painfully remembered simply as Hurricane Katrina. Amidst the hue and cry of lives lost, levees that failed—and alleged FEMA incompetence—Hurricane Katrina’s darkest moments, especially for medicine, continue to reverberate. It must never be forgotten that after the initial shock from the powerful storm had dissipated, forty-five corpses were retrieved from one New Orleans hospital under suspicious circumstances. 1 A subsequent article reporting the events was trenchant enough to receive a Pulitzer Prize.2 At the time, it was alleged that some of these forty-five individuals were injected with sedatives such as morphine to relieve either their suffering or to deliberately hasten their deaths.3 Therein lays the rub of the principle of double effect. The Louisiana Attorney General and prominent forensic scientists labeled what happened homicide.4 The local coroner later testified in agreement with this claim and provided evidence of the drug levels to demonstrate what should have been a lethal cause and effect. Also critical to the ensuing debate, several of these persons whose death may have been hastened did not have a Do Not Resuscitate order. There was no evidence that any of the individuals consented to assisted suicide. One case study may provide insight.5
A sixty-one year-old man was at this New Orleans hospital awaiting colon surgery. He was a paraplegic, described as an individual with “a good sense of humor and a rich family life, (who) rarely complained.”6 He did not have a Do Not Resuscitate order. Katrina ravaged the hospital, with temperatures reaching 110 degrees from a loss of power and was further complicated by an absence of running water. While evacuation efforts intensified, he said to his nurse, “Don’t let them leave me behind.”7 However, this man’s evacuation was problematic from a logistical perspective—he weighed 380 pounds. Despite his explicit wishes, his life was ended by the administration of drugs. Were those medications given for his obvious suffering or to promote his death? Despite investigative efforts, that question still has not been answered.8
The disturbing discoveries would finally meet cultural realities. Although noted bioethicist Arthur Caplan observed that the drug administrations were “not consistent with the ethical standards of palliative care that prevail in the United States,” and furthermore that “the death of a patient cannot be the goal of a doctor’s treatment,”9 what followed was relevant to what has become evolving ethical debate about what happened in that hospital. New Orleans was barely and haltingly recovering from a terrible disaster. If the doctors were found guilty, it was presumed that an already depleted doctor corps would bolt the city or refuse to help in future emergencies. The decisions could have far-reaching national repercussions in the conduct of future emergencies. Those involved, one physician and two nurses, were not indicted by a grand jury. A 50,000-page file of discovery material regarding the aforementioned events remains in the hands of the Louisiana Supreme Court. It has not been released.
Much has been written regarding the rightness or wrongness of the acts themselves as well as the grand jury’s determination. It is time for a retrospective reframing of a critical discussion that should not be permitted to expire unexplored.
The news regarding these events has been reported through several frames. Let’s look at some of them. One interpretation was that these medical professionals were altruistic. Unlike others, they chose to stay despite substantial risks. Do not punish them for decisions made under uniquely trying circumstances. Secondly, there should be no question; it is critical to relieve suffering, so there could never have been any intent to hasten death. Another was that there were no rules to guide them—this was a one-of-a-kind emergency—and they were forced by circumstances out of their control to ad lib in some degree. I suggest another frame needs to be considered. Has society, that is, both the medical community and the culture at large, evaluated the important ethical issues embedded in this controversy? Undoubtedly, there will be more emergencies. Have we adequately considered the ethical dimensions of such situations in order to be prepared to respond morally?
In a disturbing number of online reports and ensuing comments, a majority of the electronic respondents did not see any wrong in what transpired. Some, in fact, hoped that even the families of the dead would be prevented from pursuing civil suits on behalf of their loved ones. Many have made the professionals in question heroes. There must be more to this cultural ethos than natural disasters, relief of suffering, and perceptions implying a paucity of guidelines.
Has the Christian-Hippocratic template for practice really disappeared? Recent scholarship has suggested that there are “several competing forms of professionalism at work.”10 In fact, there are seven, including an entrepreneurial model that considers altruism to be the least important aspect of a physician’s character. The same holds for a lifestyle definition of professionalism. In the same paper, the mandate that doctors do no harm is now identified as nostalgic. Is it not surprising then that what may have been unadulterated killing has become trivialized, even by medical professionals? Or, that lay culture cannot see the distinction between relieving suffering and killing when physicians accomplish the acts in question? There were neither guidelines nor controversy once culture-at-large denied the binding precept that doctors do not kill.
History has repeatedly recorded the reprehensible deeds of physicians who crossed the line between white (life) and black (death) medicine. A moral society should shudder. However, new Louisiana laws will be enacted to supervise emergency physician practices in the future. In the words of the physician implicated in the post-Katrina events, “I think what happened to the three of us could really hurt volunteering across the nation.”11 Implied in this statement is admission of unethical behavior. So a physician oversight panel will decide if triage and death hastening during emergency medical response to disasters is to be embraced. Which of the burgeoning models for professionalism’s particular definition of relieving suffering will become normative? If the response to the events that complicated Katrina is any guide, the line they draw between relief of suffering and killing will not be directed by a Christian-Hippocratic compass. Katrina took the blame this time. We should beg to differ. The hurricane was merely a convenient scapegoat for an entire culture that has blurred the lines between relief of suffering and killing. As one evacuated patient stated, “How can you say euthanasia is better than evacuation? Let God make that decision.”12
10 Hafferty, Frederic W., and Brian Castellani. “The Increasing Complexities of Professionalism.” Journal of the Association of American Medical Colleges 85, no. 2 (February 2010), http://journals.lww.com/academicmedicine/Fulltext/2010/02000/The_Impact_... (accessed April 4, 2010).
11 Foster, Mary. “New Legislation Pleases Doctor Accused of Murder.” Committee for Disaster Medicine Reform. http://www.cdmr.org/ (accessed April 7, 2011).
12 Fink, Sheri. “Strained by Katrina, a Hospital Faced Deadly Choices.” The New York Times, August 30, 2009, http://www.nytimes.com/2009/08/30/magazine/30doctors.html?scp=1&sq=stran... (accessed April 7, 2011).
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