Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a physician should illegally assist suicide in a dire circumstance.
Yes: 60%
No: 40%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Should competent adults be allowed to end their own lives with physician assistance, and, if so, under what circumstances? Jurisdictions permitting "aid in dying" in the United States generally confine the practice to the terminally ill and require consistent, repeated requests over a period of time. However, doctors are allowed to prescribe medications that shorten life if their primary purpose is to relieve pain or suffering.
This exception is known as the "double effect doctrine." In the state where Abigail Bartlet, MD, lives, physician-assisted suicide is illegal; she may well face criminal charges. A key question for the courts would be whether she intended to kill Sylvia -- or, rather, to sedate her with the morphine to alleviate her discomfort until help could arrive.
From the standpoint of ethical analysis, one might also ask whether Sylvia could really have made an autonomous, fully informed decision in the context of an isolated, storm-ravaged hospital.
The second question raised by this scenario is to what degree emergency circumstances, such as mass-casualty events, allow for exceptions to the general rules of medical conduct. Historically, some ethical codes have embraced the "doctrine of necessity" -- the argument that an otherwise unacceptable action was justified to prevent a greater crime or moral offense. Survivors of shipwrecks who resorted to murder and cannibalism -- like those from the whaleship Essex (1820), which inspired Moby-Dick, and the French yacht Mignonette (1884) -- often justified their actions on these grounds.
However, no consensus exists among ethicists as to whether necessity can be used to justify assisted suicide to prevent suffering during a catastrophic event. During the aftermath of Hurricane Katrina, the staff at Memorial Medical Center in New Orleans, under the direction of Anna Pou, MD, allegedly injected lethal cocktails into patients who could not be evacuated. Colleagues defended Pou, a highly regarded clinician, who insisted the medication was aimed at relieving pain and suffering. She was later charged with murder, but a grand jury declined to indict her, and she has since played a role in rewriting Louisiana law to provide medical personal with civil immunity for such conduct during emergencies.
Journalist Sheri Fink, who has been critical of the choices made at Memorial, won the Pulitzer Prize for her coverage of the episode, and later expanded into the 2013 book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital.
Medical writer Amanda Schaffer observed in the The New Yorker that "medical workers under siege can easily lose perspective. They can start to make decisions based on their own dark fears rather than the changing facts on the ground."
One way to avoid this seemingly inevitable problem might be to establish clear rules in advance for medical conduct during large-scale disasters. However, physicians might still violate such rules when confronting extreme circumstances if they believe doing so reflects the ethical course of action.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
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