We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place. Please send any cases that you would like considered for inclusion to: info@plainviews.org

We hope that this new addition will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

CaseConference #11 (please scroll down for responses)

With the recent decision by the Louisiana Attorney General to ask a grand jury to indict a doctor and two nurses for "administering lethal doses" to patients who were under their care during the aftermath of hurricane Katrina, we thought we would invite chaplains to comment on the situation. For those of you not familiar with the situation, we will give you the "details" as they were presented in The New York Times (July 20 & 21). Since there has not been an indictment nor a trial, no "facts" are yet established. The "details" below are those that have been released to the public.

It is 4 days after Katrina. The temperature is over 100 degrees and 5 feet of water surrounds the hospital. Only one wing remains usable for patient care. Most patients have been evacuated but the most acute have been moved to the available wing and left with the staff that agreed to stay on duty. Over-heated patients are dying. Medicines are running low and there is no electricity. Machines that are being used to keep patients alive are running on batteries and the batteries are beginning to run out. There is no way to know if or when the remaining staff and patients will be evacuated. The doctor who has stayed pulls you aside and asks you to consider the alternatives she and the medical staff have for caring for these acutely ill patients in this crisis situation.

What is your role as chaplain to this doctor?”

As the chaplain, how would you approach a discussion about making the patients "comfortable," even though it might hasten their death?

What is your role with the patients? The rest of the staff? Does this particular crisis make your role different than it is under "normal" hospital conditions?

What are the ethical issues that you need to consider?

How would you balance these ethical considerations?

Responses to Case #11

My first priority would be to assess the doctor. Is the physician in seeking an ethical consult asking indirectly for emotional spiritual and physical relief? The fatigue and stress in such a setting could well take a bitter human toll on the caregivers. The doctor may need more support for personal suffering than advice on the management of the patients' suffering. The first ethical question for me then is "Does the doctor need to be rescued?"

While as a culture we can easily understand the failure of machines and the final consumption of supplies, we are less likely to accept failure in our caregivers. Yet it is not impossible for me to imagine that the doctor can be in very real danger of failure and at some point the welfare, perhaps even the survival of the physician and staff, has to be triaged into the scenerio. Lacking clear guidelines, the immediate leadership may need to rethink the situation. Did their willingness to stay and care for these most fragile patients imply an expectation that the staff or any of its members would give the best possible care or to give it all?

To my thinking, the best possible care does not include self-destruction and the physician should not be asked to choose between the barest minimums of self care and patient welfare. The life of a patient does not take priority over the life of a doctor. Heroic measures should not include physical, emotional or spiritual martyrdom for the caregiver. And if, at the moment when the staff reaches the conclusion that euthanasia is the only remaining option for best possible care, then I believe they would have fulfilled their oaths and their obligations to their patients.

Keith Goheen, MDiv
Chaplain
Beebe Medical Center
Lewes, DE USA

I can imagine that my response in this situation would depend in large part according to the degree to which staff are open to being companioned and the level of acuity in the remaining patient population.

I would see my role to the healthcare team as both a member of the team as it affected patient care discussions and distinct among the team, being present to help the remaining doctor and the rest of the staff name their own experience in the moment. Naturally this sort of debriefing would have to be bracketed, but enabling the team to speak to their experience could also be huge, in terms of caring for the team. Likewise, I would see my role with the patients as helping them speak to the present moment and enabling them to claim their spiritual needs and attending to these needs as best I could.

Ideally my input to the team would be in the context of some sort of consult in which a range of ethical considerations would need to be brought forward, beneficence/non-malfeasance, common good and autonomy playing a large role, but common good would seem, in some ways to be the driving ethical consideration. There are limited resources, people are dying, people are going to die but all deserve to be treated with respect and dignity. And, all deserve the best care that can be given to them as best as the situation and resources allow. There would be a natural role here for Palliative Care, including comfort care that might hasten death.

Does this particular crisis make my role different? Yes and no. None of the principles/practices are different from every day practice; however, given the situation tension and anxiety must be higher with more immediately at stake.

Andrew Schoenfield, M.Div.
Priest-Chaplain, Archdiocese of Seattle
Department of Spiritual Care
Harborview Medical Center
University of Washington Medicine

Although it is important to consider the ethical and legal questions that arise from this case, we must also consider the luxury we have of looking at this situation from a distance. In the days after Katrina
our healthcare colleagues on the Louisiana, Mississippi, and Alabama Gulf Coast faced emotional, spiritual, and physcial distress that is unimaginable to those of us who were not there. We who look at the situation from a distance can only speculate how we might react in such a situation. One would hope that our ethical judgement would remain intact or even be enhanced under such stress. But how can any of us who were not there know for sure? This uncertainty does not excuse illegal or unethical actions, but does remind each us of how easy it is to judge from a distance. We also cannot escape the questions of social justice that arise from this case. Why were people not evacuated sooner, thus leaving the healthcare community in such a situation? Were the poor and disadvantaged left to bear the brunt of the hardship? If wrongful acts were committed, do we as a society share the responsibility? What is our societal responsibility to the victims of this crisis? What is our societal responsibility to protect others from ever having to face such a situation again? Hurricanes Katrina and Rita have called us to an examination of our ethical barometer as a society.

Jeffery Murphy, MDiv, BCC
University of Mississippi Medical Center
Jackson, MS

We all are servant of the living God but was it ethical to respect the life and dignity of a person or are we acting like gods? We know when the conditions are dificult we have to make dificult decisions but the best is ask our self is it correct to kill? We all know the answer so was it an bad decision. Yes we can't play the paper of God even in bad situation we need to depend in his grace an do our best and wait for him to act and then he will show us an better way.

Pastor Samuel Santos, Gods servernt and yours.
Iglesia Evangelica Bautista de Bayamon Inc.
Bayamon PR

Please check the archives below for comments made about the last CaseConference.

Send your comments about CaseConference to info@PlainViews.org.