The [UK] Mail is reporting that dying patients in some New Orleans hospitals were given terminal sedation prior to evacuating the hospital wards after Hurricane Katrina, because the staff were convinced they could not live through an evacuation.

Unfortunately, the paper buries the apparent reasoning process used by medical staff in favor of somewhat sensational prose:

Doctors working in hurricane-ravaged New Orleans killed critically ill patients rather than leaving them to die in agony as they evacuated hospitals, The Mail on Sunday can reveal.

With gangs of rapists and looters rampaging through wards in the flooded city, senior doctors took the harrowing decision to give massive overdoses of morphine to those they believed could not make it out alive.

In an extraordinary interview with The Mail on Sunday, one New Orleans doctor told how she ‘prayed for God to have mercy on her soul’ after she ignored every tenet of medical ethics and ended the lives of patients she had earlier fought to save.

It’s clear that this was an extraordinary act under extraordinary circumstances; it may also be possible that some of these patients would have lived if the hurricane hadn’t happened or if there had been effective relief and evacuation. But it seems clear that most of these patients were dying or even in extremis to begin with.

“I injected morphine into those patients who were dying and in agony. If the first dose was not enough, I gave a double dose. And at night I prayed to God to have mercy on my soul.”

The doctor, who finally fled her hospital late last week in fear of being murdered by the armed looters, said: “This was not murder, this was compassion. They would have been dead within hours, if not days. We did not put people down. What we did was give comfort to the end.

“I had cancer patients who were in agony. In some cases the drugs may have speeded up the death process.

This description – that the patients were actively dying and could not have survived even with optimal care, and that the doctor is not sure that the morphine actually was the proximate cause of death in any given case – makes the Mail‘s opening sentence, about “killing critically ill patients” somewhat overblown. The actions described above seem more closely akin to “terminal sedation” – a practice of providing any level of sedation needed to kill pain when death is imminent, irrespective of the effect on patient consciousness or respiration – than to deliberate euthanasia. To be sure, “terminal sedation” is itself, in many cases, a kind of bad-faith double-effect end run around the controversy of voluntary euthanasia. (That is, in many cases of terminal sedation, it is understood that the drug is likely to hasten death, and the sedation is justified only because death is regarded as an acceptable outcome under the circumstances; the rubric of giving it “for pain”, with death an “unintended side effect”, may satisfy the traditional requirements of “double effect” doctrine, but that all sounds to me to be merely a way of obfuscating the full impact of the caregiver’s decisions and actions.) Nonetheless, it is a concept, and a practice, that has a controversial but recognized place in healthcare today, unlike outright euthanasia when called by that name.

Rhetoric aside, however, this is a remarkable event and one that deserves acknowledgment. There is no way of knowing exactly what factors, in general and in particular patient cases, contributed to these decisions, or of gauging easily whether the decisions were right in each case. They were probably (but, again, in light of “terminal sedation” practice, not necessarily) illegal, and the Mail is withholding the doctors’ and patients’ names, so a full investigation may never be conducted. But that these doctors were willing to act, in one of the most controversial but also time-honored traditions of medical practice, to prevent suffering when no other option existed, resurrects an obvious controversy over providers’ roles and the goals of healthcare, especially when a cure or significantly-extended life is not an option.

Undoubtedly we will hear the usual gasps and shriekings from the right-wing blogosphere over this act of compassion in crisis. What I hope is that it will be recognized at the same time that euthanasia in the face of otherwise-unrelievable suffering is both and old practice and one that springs from the same motivation that the cure and relief of suffering does in other medical contexts.

This event also illustrates the argument for non-voluntary euthanasia, since it appears that these patients were non-responsive and, presumably, had no proxy decisionmakers available. (At least, the story seems to suggest the doctors acted unilaterally, and I will go out on a limb and assume they would not have done so in any case in which a competent patient or representative was available.) One justification for euthanasia in the absence of an explicit patient request is, of course, the situation in which a patient cannot express a preference, no responsible proxy is available, and the patient faces significant suffering unless action is taken. In the modern setting, that situation rarely arises, and even when it does legal authorities have been unwilling in most countries to authorize non-voluntary euthanasia, so this argument has come to seem somewhat academic. The horrid circumstances in the hurricane zone, in which patients would not only die without access to definitive pain treatment, but would actually have to be abandoned untreated in the last days of their lives, give the issue a macabre realism that most people would never have expected it to take on, but which underscores the significance of this aspect of the euthanasia debate.

In the end, I hope the public will see and respect the humanitarianism that clearly prompted these acts, and understand the position of the doctors in question. From there, I hope that this incident will put a more realistic face on the euthanasia/assisted suicide debate – making it clear that there are real people in true desperation, and not only in disaster zones – for whom the only available relief should not be withheld out of some prissy right-wing moral obstructionism. Whether the facts as reported above are accurate, and whether these doctors acted rightly in whatever it is they did, I don’t know. But I am sure there are circumstances in which the most compassionate act is to end a life that no longer serves the patient’s values and goals, and offers only suffering in excess of any remaining benefit to the patient. We have been slow and squeamish in recognizing and acting in these cases, and the result has been to leave some of our most desperate fellows to die in unrelieved misery. That end is hardly more desirable in a hospital that is not in a hurricane zone. If the plight of the patients in a hospital that is in a hurricane zone brings that point more forcefully to mind, it will have done some good.

Pet Peeve: People who do something for moral reasons and then claim they knew they were doing wrong. Then why did they do it?! Presumably, they did it because it was the right thing to do!

The author of the story above says the doctor “ignored every tenet of medical ethics” and then “prayed for God to have mercy on her soul” after performing euthanasia on her patients. (The story implies these are her words in both cases.) But it is clear that she acted because she felt she had an obligation to help the patients and this was the best (only) way to do so. So . . . she acted out of moral compulsion. But, strangely, she herself then says she feels this violates medical ethics! (It seems obvious to me that that is wrong, as a general proposition at least, but that’s not the point here.) If she felt medical ethics really precluded euthanasia, then she shouldn’t have done it, and, more to the point, then presumably she wouldn’t have felt it was something she had to do. If she felt that the obligation to relieve suffering really outweighed the prohibition on euthanasia, then she should have realized and accepted that it was the right thing to do. In either of these cases, there is a failure to conform her personal reactions to what she knows is right for good reason, which implies a weak commitment to doing what she knows is right.

However, what I suspect she is saying is either that she thought it was right but she knew it violated a certain conservative reading of traditional medical ethics (in which case she should have been able to see the problems with that reading, and reject it), or that she was acting out of her own personal, emotionally-driven inability to ignore these patients’ suffering even though she felt medical ethics required her to do so (which would really scare me, since it implies she acted – even if rightly – “just because she felt that way” and not out of some considered conviction regarding the right thing to do). This is even worse, for it implies that either she knows the right but still somehow regards the conservative tradition as “real medical ethics” and her own beliefs as something other, or, worse, that she regards the conservative tradition as actually correct and her own beliefs as wrong, but does not have the will to act morally. These require both a wrong understanding of ethics and, in the second case, also a kind of weakness of moral will.

If you know something is right you should be willing to act on it. If you know your beliefs violate some purported ethical precept, you should examine them both and reconcile the disagreement by rejecting one or the other. You should never do what you actually believe is wrong and claim that you can simply set ethics in a secondary place out of personal preference.