Days after hurricane Katrina hit, Memorial Medical Center in New Orleans looked more like a battle zone than a hospital: flooded, without power or running water, temperatures topping 100 degrees F. inside, and sounds of gunshots outside.
In those desperate conditions, state officials say, a doctor and two nurses administered lethal doses of drugs to four elderly patients they claimed might not survive an evacuation. The three were arrested Monday, then released, pending formal charges.
Now, ethicists are debating whether those wild conditions carved out for caregivers a new moral landscape beyond the ethics of the American Medical Association, which condemns mercy killing, even with the patient's permission. The issue: Is it justified when disaster strikes and a person seems destined to endure a torturous death?
The case has far-reaching implications for the way norms of ethical behavior shift – or don't shift – when circumstances governing public health are extreme, observers say.
"This case has much bigger significance than just becoming a battle about euthanasia," says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. "It's about what we're going to expect doctors to do in [a pandemic of] avian flu. It's about what we're going to expect nurses to do in the face of bioterror .... It has to do with professional duty, professional responsibility, and what we expect healthcare workers to do in the toughest of circumstances."
After months of speculation about some of the 34 fatalities at Memorial Medical Center in the aftermath of Katrina last year, authorities arrested Dr. Anna Pou and nurses Cheri Landry and Lori Budo. The warrant charged that they were responsible in the deaths of four elderly patients whose autopsies showed unusually high levels of morphine and the sedative Versed. Lawyers for all three have said their clients are innocent.
While many ethicists condemn mercy killing without permission, some say disaster conditions create an environment in which physicians may deliver a lethal dose with patient consent. Military ethicist David Perry, for instance, says the conditions at Memorial Medical may have resembled those in which a field medic "recognizes there's no way this person is going to survive, and so it's just a matter of how soon and with what sort of suffering or lack of suffering."
Although the military prohibits mercy killing under all circumstances, Mr. Perry notes that in cases where death seems imminent, "it might be worse to let this person die of starvation or suffocation or drowning if the person didn't want that ... than to do something more actively."
An extreme situation "makes actions that would not be condoned under normal circumstances more permissible," says James Walters, of Loma Linda University's Center for Christian Bioethics. "It's not an ethical lapse. It's service to the most fundamental ethical norms [to] help a person die a less horrible death."
Others counter that no one really knows when death is just around the corner.
Roman Catholics go a step further, arguing that life is God's alone to give and take, and no amount of anticipated suffering can justify a life-taking act. It's "always morally wrong," says the Rev. Thomas Weinandy, director of the office of doctrine and pastoral practices at the United States Conference of Catholic Bishops.
"If you could do it [when death seems imminent], well, other circumstances could arise" to justify it in routine circumstances, he says. A family caring for infirm elders might say, for instance, " 'They're going to die anyway, and they're just going to cost us a heck of a lot of money for the next month. So, we're better off to do it now.' But you can never take an innocent life by directly intending to kill someone."
Islamic bioethicist Abdulaziz Sachedina agrees that because life belongs to God, humans are merely its "stewards" and may not opt to cut it short. Forced to choose between leaving a sick patient behind in an evacuation and taking that person's life, a caregiver would do better by leaving, says the University of Virginia professor.
Hindus similarly balk at the notion of mercy killing. "Hastening the death will only postpone [the suffering that] needs to happen," says Dr. Aseem Shukla, a board member with the Hindu American Foundation. "In a sense, it's a momentary relief, but it's not a real relief, knowing that you'll have to pay for it in the next life."