Monday, August 31, 2009

Hurricane Katrina, Triage, and the Memorial Hospital Story: Ethical Implications for American Health Care

I have a number of reflections after reading Sheri Fink’s account in the New York Times yesterday of what happened at Memorial Hospital in New Orleans during hurricane Katrina. Fink revives questions about whether a medical team there led by Dr. Mary Pou actively euthanized terminally ill patients as the evacuation process was put off interminably, and as the medical staff in the hospital sought desperately to provide care for patients when the electricity shut down and temperatures inside the hospital reached well over 100 degrees.

Readers will remember that there were reports from all over New Orleans during the hurricane period that care facilities were running out of food, water, and medical supplies, and that those providing care in these facilities were trying to work around the clock while dehydrated and pushed beyond the limits of endurance. Fink’s account of what happened at Memorial Hospital suggests that there is increasing evidence that a team of doctors and nurses injected terminally ill patients with morphine and other sedatives, hastening their death during these gruesome days.

Here are some random thoughts that struck me as I read the story:

▪ Fink defines triage as a sorting procedure “used in accidents and disasters when the number of injured exceeds available resources.” She thinks that “there is no consensus on how best to do this.” She suggests that criteria such as trying to effect the greatest good for the greatest number of people often underlie the sorting process, but that there is no consensus about what the “greatest good” means.

I’m struck by the narrowness of Fink’s definition of triage, and her lack of attention to how triage is used on an everyday, ongoing basis in the American health care system. Our entire health care system is based on constant, implicit triage. A minority of citizens have access to the best health care possible in our nation on a continuous basis—for any and all medical (or cosmetic) needs (or wishes) they might have.

A sizable proportion of citizens have access to at least basic health care on a continuous basis for most of their medical needs, though not always for elective procedures. And in the case of most of these citizens, the health insurance industry constantly sorts who will be permitted even necessary treatment and who will be blocked.

A significant group of citizens have access to health care only in cases of dire need or emergency. They are very likely to experience triage in the emergency rooms to which they have to resort, as their level of need is assessed and decisions are made about whom to treat, when to treat, and whether to do follow-up.

The central norm in this system of ongoing, continuous triage is money. We dispense health care in the United States—and we practice continuous triage as we do so—based on people’s ability to pay.

To talk about triage in the narrow sense of sorting patients in an emergency situation without paying attention to the broader sense in which we are always doing triage in our medical system is to lose sight of the conditions that produce the excruciating decisions that have to be made during events like hurricane Katrina. And it’s also to lose sight of why there is difficulty deciding how to sort patients according to the greatest good for the greatest number of people.

Making a moral judgment of that sort is very difficult in our system due to the sheer weight of financial considerations as we dispense medical treatment to our population. In an emergency, just as in everyday life, we do not make those decisions in a vacuum. We always make them against the backdrop of financial factors that weigh far less in any other industrialized nation in the world than they do in the American health care system.

▪ Fink’s article does not make crystal clear another point that readers need to keep in mind as they think about what happened at Memorial Hospital during Katrina. This is that the kind of end-of-life decision making the article describes takes place on a daily basis in all of our hospitals and care facilities. Decisions about withholding treatment, permitting patients to die, and, yes, about using palliatives that hasten death even as they relieve suffering, are made daily throughout this country.

What the team at Memorial Hospital did is not unique. And it’s not extraordinary. It goes on all the time. It has to go on all the time, because difficult end-of-life medical decisions happen all the time, not merely at times of emergency.

For years, I taught medical ethics as a component of introductory courses in ethics. In my classes, I frequently had students who were medical professionals—including Catholic religious. These students almost always told the class that they routinely made decisions in collaboration with medical ethical teams and family members, about withholding treatment and nutrition at the end of life when a patient was actively dying. They also told the class that they routinely made decisions about the use of palliatives such as morphine that, they well knew, would hasten the death of patients in extremis.

These stories did not shock most of the classes I taught, because the students in those classes were familiar with important norms that used to be routine in Catholic ethical thinking about end-of-life issues, but which are now under assault by the political and religious right. Those norms include 1) the distinction between active and passive killing, and 2) the principle of double effect.

The Catholic ethical tradition has always been clear about the fact that taking an innocent human life directly and intentionally is morally wrong. But the tradition has also recognized that there is a difference between allowing someone to die—in the case of the terminally ill, allowing the dying process to occur naturally without use of extraordinary means to prolong it—and actively killing someone.

That distinction has been muddied in recent years, as the religious and political right do everything possible to depict as active killing the withholding of medical treatment (and nutrition) in cases in which there is no hope of recovery. And the deliberate muddying of that distinction is unfortunate, indeed, at a time in which our ability to keep people “alive” even when their brains have died continues to develop.

We now have extraordinary ability to prolong life in situations in which our ancestors would have died naturally. What we now end up doing in many cases is prolonging the dying process (and the suffering) of those who are dying.

The principle of double effect maintains that, in pursuit of a good end, we can sometimes make ethically justifiable decisions that will have effects we do not will as the primary end of our decision, but which we recognize as necessary if unintended effects of our pursuit of our primary goal. Giving palliatives to a dying patient to ease his or her pain has the unintended effect of shutting down the vital organs and hastening death. The principle of double effect enables us to administer such palliatives with the primary end of relieving the pain of a person in extremis, even when we know that the treatment we are using will also speed the dying process.

▪ Finally, as we assess what happened at Memorial Hospital in New Orleans, it strikes me as important to keep in mind that people are forced to make hard, well-nigh impossible ethical decisions in times of emergency, which they might not make in quite the same way when they have the leisure to reflect about those decisions. And perhaps those of us who have not lived through the situation of extreme stress should not be quick to make judgments about the intent of those who make decisions in such circumstances, and about the decisions they make.

A fundamental principle of the moral life is that we should live each day in such a way that, faced with situations of soul-bending challenge, we tend to move naturally” towards the right and away from the wrong. As we think about the parameters of the moral decisions medical personnel made during Katrina, I think we ought to keep that principle in mind.

Which means, we need to construct the kind of society in which it becomes easier in both routine and extraordinary circumstances to make good decisions about end-of-life care and harder to make bad decisions. As our system is now constructed, it is often difficult everyday—and not just in times of emergency—to make the best decisions possible about medical care for indigent and dying patients.

It was even more difficult during the days of Katrina in New Orleans because of the conspicuous failure of religious and political leaders who like to talk louder than anyone else about respect for life to assist people dealing with gruesome decisions about sustaining life and caring for the dying under horrific conditions. Those who want to shift the blame for moral failure in our system of health care delivery to a handful of medical professionals working around the clock while making decisions unimaginable to most of us are missing an important point.

The point is that the blame for the moral failings of our health care system lies at our own feet—at the feet of an American public content to continue permitting medical treatment to depend on one’s ability to pay. And the blame lies at the feet of leaders who do nothing to challenge this immoral way of approaching medical care.

And it lies at the feet of those in the political and religious right who scream slogans about the sanctity of life even as they resist attempts to create a health care system that would, we hope, make it easier for us to recognize the value of every human life. And would help prevent the kind of impossible choices those working to care for terminally ill people in Katrina were forced to make under the direst possible circumstances.

For a close-up view of the graphic at the head of this posting, click the picture.