Philip Alcabes discusses myths of health, disease and risk.

The “Deadly Choices” Report

Sheri Fink’s thoughtful and masterfully composed “Deadly Choices” report discusses the death of patients at New Orleans’ Memorial Medical Center (MMC) in the days after Hurricane Katrina in 2005 (additional material is at ProPublica).

“Deadly Choices” is heartbreaking.  It recounts a situation that was miserable, terrifying, and in some cases, fatal.  Fink reports that, among 45 Memorial Medical Center patients who died in the days during and immediately following the storm, 17 were deliberately administered lethal doses of morphine, sometimes along with a sedative, by physicians who apparently intended to hasten the patients’ deaths.  (Many of these 17 were patients at a hospital-within-the-hospital, a long-term care hospital under separate ownership that shared some staff with MMC.  At Slate today, Josh Levin discusses some of the troubling truths about the financing of long-term care hospitals, and Fink fills in some more of the blanks with a response at ProPublica.)

As Fink explained to Amy Goodman in an interview with Democracy Now earlier this week, at least one of the patients who were killed was not in extremis; he had not given up.  He was

“Ready to rock and roll, wanted to get out. And apparently, according to several people who later spoke with investigators, a discussion was had in which they talked about how they might get him out, and they decided that because he was so heavy and it was so hot and people had—I mean, just imagine….They had been going on no sleep for days, the medical workers. They were tired. They were terribly disturbed by all the suffering that they felt that they saw around them. And so, in this sort of moment, they apparently decided that [the patient] could not be brought down, could not be evacuated, that there was no way to get him out.”

The story of what happened at MMC is also profoundly disturbing.  It moves us to ask what sort of moral world physicians are expected, and allowed, to operate in.  And to wonder why moral boundaries should be so elusive to exactly the people who, with access to the means to both prolong life and hasten death, walk on morally fraught territory more often than anyone.

The horrifying events at MMC are especially  germane today — because they highlight a vexing question about health care reform that is very hard to answer:   Is our doctors’ job to alleviate suffering, or is it to improve health?

A favored guru on health care ethics, Ezekiel Emanuel, is explicitly in favor of the latter.  In “Justice and Managed Care” (subscription) in Hastings Center Report in 2000, he writes

“The allocation of health care resources should aim at and be justified by the improvement in people’s health…. The special aim or purpose of health care is curing disease, relieving pain and suffering, promoting public health, pursuing research to improve health, and so on.”

The “and so on” means that improving health — the obligation of a health care system, Emanuel asserts — amounts not just to the relief of pain and suffering but also to research and public health, and other tasks as well.  The relief of suffering might not be a priority, that is.  Or it might be a contingent priority, of importance for a limited time, or in certain circumstances — but not the only thing to worry about.

The point is not to vilify Emanuel.  He has opposed euthanasia and physician-assisted suicide, so we should assume that he was as appalled by the actions of the chief physicians at MMC as others were.

But the Emanuelian sensibility is that the system in which physicians work is not meant to be dedicated to the relief of suffering alone.  Rather, it bears other duties as well:  a broad obligation to the public to promote health, and another obligation to contribute (through research) to the future of health care.

In this narrative, the physician is marshal of a campaign — not merely joined in a series of caring relationships with each of a number of patients, but commander of troops who have a long-term goal and territory to win.   By implication, the rights of patients might take second seat to the needs of the public, or to the desire to learn more about how to improve health in the future.  Patients shouldn’t be killed, this thinking goes, but they will have to understand that the prolongation of life is a luxury commodity to which physicians have the keys — and not everyone can have access.

The sense of the physician as a responsible manager, not merely a giver of care, connects with the utilitarian credo, “the greatest good for the greatest number” — a phrase that occurs three times in Fink’s piece as she strives to characterize the sensibility of MMC providers.

But the killings at MMC should, at the very least, make us ask whether it’s a good idea to have doctors making decisions about the greater good — or whether we want them to recognize individual persons above all.

Public Health and Purity

A week ago, we rode by bus nearly the full length of the old land of Galicia, from L’viv in Ukraine to Kraków, Poland.  Our one long stop was at Belzec, where a moving memorial, the creation of historians and artists, speaks to a double disaster:  the murder of nearly half a million people, predominantly Jews, who were gassed there in 1942 and ’43; and the so-called purification of the region by virtually erasing part (the Jewish part) of a historically complex culture.

The visit spoke to a modern concern, too:  the connections between purity and public health.

The commandant at Belzec, Christian Wirth, had been one of the directors of the Nazi euthansia program, nicknamed T4.  Between 1939 and 1941, T4 killed over 70,000 Germans — mostly full-blooded “Aryans” — who had psychiatric or developmental problems, or congenital conditions, and who were therefore lebensunwerten, unworthy of life.

The T4 program, in its turn, grew out of the Nazi doctrine of racial hygiene — an effort to improve the public’s health by control of breeding.  Racial hygiene was based on eugenics, and led to public health endeavors such as screening for congenital conditions, mandatory sterilization of sexual transgressors and disease carriers, and selective breeding.  The Nazi public health program was much applauded by American public health experts, at least in its first few years.

Once the decision was made to eliminate Jews from Nazi-occupied regions, the experience that Wirth and colleagues acquired through killing the lebensunwerten in T4 was invaluable.  Going from exterminating tens of thousands of mentally ill or developmentally disabled people to eradicating a few million Jews, Gypsies, and other polluters of Aryan health was just a matter of making the process more efficient.

It’s striking how thin the line is between laudable public health goals, like limiting congenital disease through screening, and implementing the concept of race purity.