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...hurricane Katrina approached Louisiana Sunday, August 2005. By Monday afternoon the storm had passed but the levee walls along the city's canals had begun to fail. A foul mixture of waters from the New Orleans sewer system and Lake Pontchartrain was coursing through the streets, eventually reaching the low-lying area where the hospital stood, inundating the lower floors of its buildings and submerging the cars in the hospital's parking lot. From the outside, MMC had become an island. On the inside, the electricity and plumbing were failing. The staff would have no lighting, no elevators, no toilets, no running water, no overhead pagers, no refrigeration, no air conditioning, no telephones, no ventilation, and no powered medical devices. The flood had crippled the hospital's capacity to provide standard medical care for its patients and, with perhaps 2,000 patients and refugees crowded together, Memorial Medical Center may have become a health hazard. Notwithstanding this, the staff continued to care for patients, moving those they could to the roof of a nearby parking garage, where they might be evacuated by helicopters, or to the second floor, where they might board water craft. (2)
As the days passed, many of those in the hospital were able to leave. But many hundreds remained, including the sickest patients who could not be moved, and the staff who were staying on to care for them until help arrived. There had been assurances of a timely rescue. But early Thursday morning--three days after the hurricane--it was announced that those still in the hospital would be on their own (Deichmann, 2006: 110). There would be no rescue by federal, state, or local government agencies. Dr. Richard Deichmann, the hospital's chief of medicine, described the effect:
It was a phenomenal blow to hear that nobody was coming to get us. The worst thing for us was always waiting for someone to come and get us and then never showing up. There was this feeling of betrayal all the time. That freezes your ability to do things. And that is what happened Wednesday and Thursday (Meitrodt, 2006).
Some clinicians may have concluded, perhaps reasonably, that both they and their patients had been abandoned.
After days of enervating heat, darkness, and sickening stench, some clinicians are said to have ended the lives of some patients before leaving the hospital themselves. No living patients were left behind. Alleging that there had been homicides, Louisiana's attorney general subsequently ordered the arrest of a doctor and two nurses.
It is unclear, at this writing, how many indictments there will be. It is too early to make a confident judgment about what the conditions were at MMC between its isolation in Katrina's floodwaters and the final evacuation by Tenet, the corporation that owned the hospital and that sent helicopters for the last survivors. Nor is it now possible to say who did what during the crisis and what they believed and intended at the time. Journalists have given us a preliminary account, the courts may follow with further evidence, and historians will eventually have the last word. But we may never know the full story.
Despite the obscurity of the actions and circumstances, Katrina has posed a new question that complicates our thinking about caring for patients at the end of life. Can the conditions in a collapsing health care delivery system ever excuse euthanasia? The focus here is on the ethical norms that should govern health care professionals working in extremis. There is a need for responsible standards that, in fairness, should be honored by practitioners and respected both by the law and by society. What might those standards be?
In the pages that follow, I will, first, review some of the current thinking about the causation of death in the clinical setting, looking at some familiar standards from law and ethics. I will then consider the permissibility of euthanasia, focusing initially on what I will call the argument from "intractable suffering," perhaps the strongest and most common justification. I will also survey objections to that argument.
With that as background, I will go on to look at disaster medicine and a different reason for withholding and withdrawing life support. When, following mass casualties, medical resources are in short supply, it becomes justifiable to withhold them from seriously injured patients, allowing them to die even though, on an ordinary day, clinicians would act aggressively to save them. In this context, I will consider an issue that has received comparatively little attention in mainstream bioethics: battlefield euthanasia. Circumstances that may be unheard of in civilian medical care are tragically more familiar in military medicine. I will show that conditions arising on the battlefield can mirror conditions that could have arisen during Katrina. Building on that discussion, I will develop and defend a professional standard for assessing the conduct of health care professionals who are, in this way, in extremis. If not a wholly new line of thought, the narrow defense of euthanasia that is offered here is at least one that has largely gone unnoticed in the bioethics literature. The argument from "forced abandonment" (as I shall call it) sidesteps some objections to the argument from intractable suffering.
So there will be no misunderstanding, the pages that follow are not intended as a defense of what health care professionals did in Louisiana. As has been emphasized, we do not know what that was. Current accounts of the events in question are neither comprehensive nor consistent with each other and, indeed, it would not be a surprise to discover that some elements of my narrative are incorrect. But the argument of this paper does not turn on the accuracy of its account of the Katrina catastrophe. This inquiry is a more abstract one. Are there conditions that, had they been present in New Orleans (or anywhere else), would have excused ending the lives of patients, conditions under which both law and professional ethics should withhold condemnation? The answer offered here is yes. Where it is impossible to evacuate patients and dangerous and medically futile to remain with them, clinicians may have to choose between abandonment and euthanasia. There may be no third option. I will argue...
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