Katrina, Doctor Pou, and the Ethics of Killing and Letting Die
Is it ethically acceptable to give terminally ill patients pain relieving medications with the knowledge that they might hasten death?
Is it ethically acceptable to give terminally ill patients pain relieving medications with the knowledge that they might hasten death? Going further than this, can it be morally permissible intentionally and directly to kill such patients?
These are two of the many questions that swiftly come to mind when we review what happened at Memorial Medical Center at New Orleans, Louisiana on September 1, 2005, just days after Hurricane Katrina.
“A small staff struggled to care for critically ill patients in a dark building with no electrical power, no fresh water, a flooded first floor, a nonfunctional sanitation system, and interior temperature above 100 [degrees Fahrenheit],” wrote Susan Okie, M.D., on January 8 of this year in the New England Journal of Medicine.
Nine critically ill patients, four women and five men between sixty-one and ninety years of age, who were being cared for on the seventh floor by Life Care Hospitals of Plano, Texas, died under controversial circumstances. Life Care Hospitals had leased the spaced from Memorial Medical Center, a for-profit hospital owned by the Tenet Health Care Corporation in Dallas.
Just what happened is not exactly clear. The nine bodies were not recovered from the “sweltering hospital” until ten days had passed, and at least another week transpired before the autopsies were performed, making the causes of their deaths impossible to determine with certainty. Significant amounts of morphine were found in the liver and purge fluids of all nine patients and midazolam in seven of them. Examinations of brain tissue identified one or both drugs in eight of the nine.
In July 2006, almost a year after the day the nine patients died, Louisiana’s attorney general, Charles Foti, arrested Doctor Anna Maria Pou and two nurses. He charged them with intentionally killing four of the nine patients. Although the nurses co-operated with him in exchange for immunity from prosecution, in August of 2007, after considering what happened to all nine patients, the grand jury refused to indict Doctor Pou. Relatives of the dead patients have filed three civil law suits against her that are still pending.
In April 2006, Doctor Pou had become Director of Resident Education and in October of that year she had become Director of Medical Education at Louisiana State University Health Sciences Center, where she had been an associate professor of otolaryngology since 2004. Before then, she served for several years in similar positions at the University of Texas Medical Branch in Galveston.
Doctor Pou, who had a reputation for being a “dedicated, hard-working physician who, though physically small, had a ‘huge presence,’” probably impressed the grand jurors. Doctor Timothy Quill, long an advocate of relaxing some of our taboos regarding active and direct euthanasia, publicly stated that the kinds and amounts of medications used were consistent with the aim of relieving pain, not intentionally killing. Such comments probably helped Doctor Pou, as did the historic reluctance of all grand juries to indict cases like this.
Yet perhaps the most important consideration was that the grand jurors were sensitive to the desparateness of the situation and Doctor Pou’s few options, particularly because she and others had been told correctly that the government was not going to rescue the remaining patients and that they did not know that others were preparing to do so.
Most of the evidence against Doctor Pou consisted of statements made by people who were on hand on September 1, the day of the incident. At some point, the staff decided that the nine patients would not be evacuated. Susan Mulderick, Memorial’s “incident commander” was quoted as saying in a committee meeting that the nine patients probably would not be rescued and then somewhat later that no living patient would be left behind. Therese Mendez, a nurse and administrator with LifeCare, reported that Doctor Poe told her a decision had been made to give the nine patients lethal injections. Stephen Harris, LifeCare’s pharmacy director, stated that Doctor Pou had told him the same thing. She showed him twenty-seven vials of morphine and he gave her more, plus some midazolam.
Kristy Johnson, director of physical medicine for LifeCare, stated that she had guided Pou and two nurses, who had drawn liquids into syringes, to the room of Emmett Everett, aged sixty-one, who was alert and interactive. Pou appeared nervous. According to Johnson, Pou said that she planned to tell Everett that she was giving him something to help him with his dizziness. “I had to give her three doses, she’s fighting,” Doctor Pou said regarding another patient, Johnson alleged.
John Skinner, M.D., director of pathology at Memorial, stated that in the afternoon of September 1 he saw Doctor Pou with an apparently alive patient; however, when he returned to the same area later that afternoon “he found that all the patients were dead.” That several patients died within a relatively short time has caused some to wonder what Doctor Pou did.
Her position is that she gave the patients enough medication to prevent pain and panic, but no more. If so, she acted within standard ethical expectations for physicians. Under the principle of double effect, these norms allow a doctor to provide pain relieving medications even though they might hasten death as an unintended outcome. The important distinction is between merely foreseeing a swifter death and intending it as well. Most medical ethicists condone the first and condemn the second. Pou insists that she foresaw but did not intend the nine patient’s swifter deaths. The Grand Jury took her at her word.
There are those who privately think that Doctor Pou actually intended these deaths. Some of these condemn what she did, and others condone it. Those who condone what happened hold that under the circumstances a swift and painless death was in each patient’s interests. Besides, they often contend, the distinction between foreseeing and intending outcomes is itself of doubtful merit.
This is likely to become a “classic case” in medical ethics!
David Larson teaches in the School of Religion at Loma Linda University.
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Comments
Dave
I'm not sure if the double effect principle truly applies here. I, for one, doubt the wisdom of giving combination drugs, such as morphine and midazolam together, for pain relief alone. I could be wrong. More than anything else, this case requires better education on the part of health providers and caregivers.
"The doctrine of double effect is considered in relation to the use of opiates, and it is argued that appropriate use of opiates does not foreshorten life; indeed, it may even extend life."
- EUTHANASIA AND ASSISTED SUICIDE: THERE IS AN ALTERNATIVE
Ethics & Medicine, Summer 2007 by Ledger, Sylvia Dianne
http://findarticles.com/p/articles/mi_qa4004/is_200707/ai_n19433624
Joselito
Thanks! I'll read the article. Does the combination of drugs give you a hint as to her probable intent? This is a factual question.
But the bigger question is the ethical one. Under such circumstances would actually intending the deaths of the patients be ethically acceptable?
It's fascinating for me to read about the exchange between Dr. Pou and the alert and communicative Emmett Everett. There is a lot of complexity here for sure but Emmett provides us, I think, with the clearest instance of possible misconduct.
Imagining the worst possible outcome, that Emmett would be left in a flooding room with absolutely zero help for days facing a likely death due to starvation or complications,
I cannot imagine any scenario which would justify Dr. Pou taking any action which could possibly (and likely) lead to Emmett's death without his express consent.
NEJM's expanded section of what you cited says-
So did Emmett consent to medicine to relieve him of life or nauseousness? Hardly the same thing! How much did Dr. Pou tell Emmett Everett and what exactly did Emmett Everett consent to?
I am with those in the penultimate paragraph who think that a doctor's intending death can be permissible and who also disdain the foresight/intention distinction (especially where options existed that didn't include the foreseen consequence). The easy cases in this example would have been DNR, a poor prognosis, and not alert oriented and interactive. Emmett Everett, I think, needed to be consulted on his wishes.
Taking an absolute stand on the preservation of life makes decision making easier for doctors, but the different ways in which we treat plants vs worms vs dogs vs people shows that it is not life per se that we value but something else. The something else, consciousness perhaps?, is a greater good than the good of easy decisions by whomever.
If midazolam wasn't on the regular medication list of the patient concerned, then it gives us a hint as to why it was added. I understand that in states where capital punishment is constitutional and legal, the drug is routinely offered prisoners on death row, prior to lethal injection.
An important variable submitted in defense of this case was
"... the desparateness of the situation and Doctor Pou’s few options, particularly because she and others had been told correctly that the government was not going to rescue the remaining patients...."
Be that as it may, I disagree with the contention that
"under the circumstances a swift and painless death was in each patient’s interests."
Briefly and finally, the classic distinction between foreseeing and intending, also cited by the defence, to my mind, is a form of prevarication: a lie!
All I can say is that if I had been one of those patients, particularly one who was aware of my situation and panicking, I would have been grateful for medication to reduce my misery, even if hastened death were a possible outcome. The same goes for my fragile, 92-year-old mother. I wouldn't want her to suffer and be frightened if I thought there was no likelihood of her being rescued.
As one who is/has dealt with a lifetime of surgeries, medical complications, illnesses, a car accident and cancer, I get particularly frustrated at the lack of input on a subject like this from those who have "been there." Dealing singularly from an intellectual angle I believe that one can easily find themselves advocating a viewpoint that would be 180 degrees from what they would do if faced with the reality of overwhelming pain vs. death.
I have lived through having to beg God to help me keep breathing when my body so wanted to just shut down, but I wanted to keep living. I've also been in so much pain that it would have been horribly cruel to leave me in that condition if death was my ultimate fate. I'd like to hear from anyone who has lived through, or been with someone who's experienced, situations where death would have been welcomed sooner rather than later. I understand how it could be very complicated if you were to have to make the decision for someone else. It's not nearly as complicated if you are the patient.
To many Dr. Jack Kvorkian came across as a monster. I’m inclined to believe that he had a very soft and kind heart towards those who suffered greatly. This does not mean I am unaware of the slippery slope of mercy killings. It does, however, mean that we still need to address what I believe to be a very important question: “How much right should I, the patient, have over my own body?”
It might be helpful to find out if there are cases on record (or even from a hypothetical standpoint) when physicians as well as allied health professionals who, themselves being terminally ill and placed in a roughly similar crisis situation described here, have agreed to take the exact same combination medications (or alternative prescription) for the so-called double effect: allaying their anxiety and ending their life as as a byproduct. I've asked myself this question and I may be guilty of presuming to know more than anyone else when advising patients regarding what I believe was in their best interest.
As one of the few here who is closer to death by the fact of age, and also having undergone both moderate and severe pain, if I were in a similar situation and knowing there was no hope of rescue, I would gladly opt for a quiet and blissful eternal sleep. Death is not to be feared, but can be a welcome relief, much like going to sleep under anesthetic, oblivious of all the cutting, dicing and slicing on one's body. They shoot horses, don't they? We euthanize our pets rather than watching them suffer needlessly. When there is excessive suffering with no hope of other than more suffering in the future and no exit, death will be a blissful relief. My children know my desires and will follow the durable power of attorney if there are such circumstances. The prolongation of life with no hope for resuming consciousness and a vegetative existence is not the life any of us would choose for ourselves, nor should we advocate it for others.
Elaine
All nine terminally ill cancer patients died following the administration of combination drugs. One was 61 years old, alert and interactive. Not 82. Was the outcome only foreseen but unintentional? If you/I were the attending physician and rescue was at best uncertain for all nine living....
Joselito
I agree that in the overwhelming majority of cases intentionally causing the death of a terminally ill patient is ethically wrong. But are there any justifiable exceptions?
Has someone polled the members of the Grand Jury on this issue? Perhaps they accepted Doctor Pou's claim that she foresaw but did not intend the deaths of these patients. But perhaps they thought she actually did intend their deaths but that she should not be prosecuted because of the dreadful circumstances in which she found herself.
I am bothered about the Emmett Everett case. That reportedly he was alert, oriented and interactive haunts me.
Thanks!
Dave
Let's assume among the nine terminally-ill cancer patients was an 82-year old male, with an associated medical condition. Days prior to his present confinement and shortly before Katrina struck, he was actively blogging for Spectrum. Alert, interactive, anxious. You be the jury.
I personally won't indict the physician in charge of this case either. However, I also believe the matter is better taken up in a medical ground rounds instead of by a grand jury.
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