Mar 27, 2015 By David Singer 6 min read

When Hurricane Katrina leveled New Orleans in 2005, it left hospitals in disarray, with flood waters swallowing power generators and thousands of people pouring into the buildings seeking life-saving care. As resources waned and evacuation of patients had to be prioritized, Memorial Hospital chief physician Ana Pou told doctors to administer lethal doses of drugs to patients in palliative care and faced criminal homicide charges.

A grand jury that investigated Pou dismissed the charges, but in the wake of the controversy, Pou drew attention to ethical considerations doctors use in disaster situations. The topic was discussed at the Upper St. Clair Library March 26 as part of the Allegheny County Library Association’s annual “One Community One Book” selection of “Five Days at Memorial,” which two local bio-medical ethicists commented on and used as a springboard for understanding doctors’ roles in end-of-life healthcare decisions.

“So what happens in a situation like Katrina is triage care, or assigning importance of care to patients: those who need it immediately, those who need evacuated immediately, and those who should be evacuated last,” said Jason Byron, manager of medical ethics at UPMC Presbyterian Shadyside.

Babies were first for treatment and evacuation, leaving those in palliative care or that had elected “do not resuscitate” (DNR) status in their medical directions to be left last. According to Byron, because palliative care is treating symptoms of illness, like pain, those patients’ elective status was similar to DNR patients in that sustaining life was not a priority, only maintaining comfort was.

Pou has said informed consent is impossible during disasters, and used as protocol those who were in the best health should be evacuated first. Yet this, bioethicists agree, is unique to disaster or triage scenarios and not in ideal care situations. The parallel problem, according to Sarah Stockey, a clinical ethics supervisor at Duquesne University, is a breakdown in communication.

“We put as much authority in the hands of the patient as possible … but if those (directions for care) aren’t communicated to family or to a medical attorney whom you assign power of attorney for that purpose, your autonomy near end of life and through healthcare during it are diminished,” she said, “and the best starting point is to have candid conversation with family about fears and anxieties about illness and death, and your expectations for quality of life in certain circumstances.”

A living will is a way to provide instruction to doctors when a person’s ability to make rational decisions is taken away by loss of consciousness or severe mental degradation, such as late-stage dementia. But even with these tools, ethicists still take both the wishes of the patient and the patient’s family into consideration.

“Ethicists and doctors in hospitals will weigh those concerns of the family and make sure they’re heard … we try to reach an agreement where everyone is comfortable while honoring the patient’s wishes,” Stockey said.

Despite these approaches, resident Matt McClaughlin was skeptical, and told the two bioethicists they and others shouldn’t use utilitarian ethics – like the practice of triage care – in general care situations.

“You people need to stop reading Peter Singer and using that as your basis. You have to start from somewhere, you have to have values underlying all these decisions,” he said. Peter Singer is a controversial philosopher who advocates for the welfare of animals and sometimes presents vexing arguments involving children’s’ ages as to their “utility” or worthiness of being saved when weighed against other individuals.

The two panelists ignored McClaughin’s comments for the most part. McClaughlin, who eventually identified himself as a Catholic, said the presumption of any medical decision should be preservation of life.

“Utilitarianism as a practice leads to evil. I don’t think the philosophy is inherently evil when it’s approached with care, but it can’t be your underlying philosophy as a medical practitioner,” he said.

Stockey and Byron never said they were utilitarians, nor that they use that lens as a starting point, but they did say ethical decisions should be filtered through three principles: beneficence, or, to provide care that provides actual benefits; mitigation, or, preventing further harm; and justice, or, to treat patients fairly, particularly in regards to patients in similar situations.

The principle of “do no harm” is what prevents euthanasia as a legal practice in the United States. Stockey said the idea of doctor-assisted suicide may gain traction over euthanasia in the coming decades because it places responsibility and autonomy solely in the hands of the patient.

“With euthanasia, the doctor is administering lethal drugs to end suffering or prevent further suffering, whereas doctor-assisted suicide would have a doctor providing the materials to a patient and instructing them how to administer the drugs,” she said. Canada’s Supreme Court ruled in February to overturn a 1993 ban on doctor-assisted suicide. The country’s government now has until next February to re-write its laws on the procedure. The practice is currently legal in Oregon, Vermont and Washington, and is being debated in New Jersey.

For McClaughlin, it comes down to sanctity of life he doesn’t believe bioethicists are accounting for in practice.

“What is it, of the concept of life itself, and why do we value it so much? I don’t know, but even atheists know they don’t want to die and that life is important. I don’t know what that is, but you have to account for it,” he said.

“I, too, come from a Catholic background and understand where (Mr. McClaughlin) is coming from, in that I believe there is dignity to life in and of itself,” Stockey said, “but we live in a pluralistic society, so that might be the starting point for me or other ethicists, but not for a patient. So we always have to consider that.”

Stockey and Byron continue their conversation on medical ethics through May, with the next local talk to be held at the Bethel Park Public Library on May 12 starting at 6 p.m.