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.