Transcripts For CSPAN2 Five Days 20131117

Great debt to Jagdish Bhagwati for sustained writing and thinking, some who informed the policy debates in this country and around the world. So, thank you, sir, and congratulations. Thank you, too. Youre watching booktv. Next, sheri fink discusses what happened at memorial until center in new orleans in the n the days following Hurricane Katrina. She says that due to a total loss of power caused by the flooding tore had to come up with an evacuation plan and pick the order in which patients were rescued in total, 45 people died in the hospital. Including some 20 patients who were euthanized by doctors. This is an hour and 15 minutes. [applause] you start. Okay. Ill start by agreement. First, its wonderful to be here with so many friends and new friends and new acquaintances, and also just definitely new america its a Wonderful Program that they have supporting authors, people working on public policy, research for becomes, are welcome to apply to the program, and it gives us a huge amount of freedom to pursue and support wonderful colleagues so im grateful for having had that support and being part of that program. And so i think were going to try to have just a really good discussion today, and that means all of you hopefully will get involved as well. Well talk for a little while and then open it up for discussion, and then have the wine and cheese after, and really a big reason why i wrote five days at memorial i feel that these questions, difficult, ethical conundrums that arose during katrina are things we all have, as a public, should have a say in. Theyre not the purview of just a small group of doctors on the front nine front line in an emergency and something we should think about before disaster happens. So well get into that. And ill just start with summarizing the book and settling out the dilemmas and read a tiny bit where the doctor comes in. So, the question, do exceptional times allow us to make exceptions to moral rules . Or does a time of crisis call for an even deep commitment to our deepest moral values . Chat is one of the questions that of the heart of five days at memorial as posed by one of the imminent medical ethicists. Memorial Medical Center was surrounded by flood waters after Hurricane Katrina in 2005. When the levees failed. The heat rose very quickly there, and the backup generator system was not protected against flooding, which, as we well know here in new york city, from Hurricane Sandy last year, it turns out it is a major vulnerability of American Hospitalsthat these systems are circuits and only as strong as their weakest part, and if your fuel pump is below flood level, like at bellevue, and its not protected adequately against flooding, you will face the possibility that you willy your backup power, even if your generators are above flood level. We sauce major hospitals in new york city face the horrific scenario that was all too similar to katrina. So, at this point, when the flood waters started to rise, they knew that all power would soon fail. Rescue helicopters began arriving at memorial Medical Center, but they could take one or two patients at a time, and there were roughly 242 patients. About 2,000 people in all, 600 staff, a lot of family members, even pets, because family members could bring their pets to the hospital rather than having to leave them at home in a hurricane. Who would you rescue first . It would be perhaps the sickest . Because of course their lives depend so much on electricity, pretty much everything these days in an American Hospital runs on electricity. And perhaps the healthiest, because they could be moved more quickly and you might have a better chance of helping people whoa could survive the longest overall. It could be the babies in the neonatal icu, very vulnerable babies who might have a risk of death, but if they did survive they could have a whole life ahead of system or would it maybe be the oldest in the population because of all the years they lived and the wisdom they had gathered and each one of them is valuable, too. And of course they had served their communities for so many years. So then there was the medical professionals themselves, some of them had Health Issues and were tired and worn and as we saw after katrina, a huge need for their services. So some of them get priority when the helicopter comes . Well, katrina was not unique, and in fact these situations of triage do arise everytime theres a case where medical need outmatch resources, whether it was after the haiti quake in 2010 or some cases that arose here in new york city after sandy, particularly in the book in the epilogue of the book theres a discussion of Bellevue Hospital where they feared they would lose all power except for six outlets in the icu of 55 patients there overall, and the head of the icu was literally asked you have one hour to decide. Tell us which patients would get those outlets. So, this is not just katrina. Fortunately. Well talk about what happened there but some creative thinking prevented that from taking place, and thats another lesson of the book. That sometimes when you think theres no hope and these really dire decisions have to be made, sometimes they can be averted with creative thinking. Well, doctors at this hospital did get some of their sickest patients out first before the flood waters rose too high, and all power was lost. And they wrote numbers on pieces of paper and to prioritize patients and then they changed the order. So the ones were the healthiests, the 2s were sicker, and the 3s were the very sickest, and the patients with do not resuscitate orders, and the 3s would go last. As rescue efforts lag, the desperately sick got even sicker, and what was to be done about them when it was time for everyone else to leave . Where is the line between comfort care and mercy killing . Who decides . Well, at least 20 patients, according to the work of Forensic Pathologists, found were inducted with morphine and or a powerful sedative and died. So, from these five days at memorial, and this age of rising seas and ever quickening pass pace of natural disaster, what is that we must learn . So, five days at memorial is about what happens when disaster strikes and the places in the system that are lives depend on the most are not there to serve us in the way that we hoped. And when we think another our nations competing priorities its reasonable to ask what are the stakes of preparedness for these really foreseeable and also rare circumstances. And i think hopefully in reading the book and marching through what the results are of failing to prepare, we can get a better sense of how much we may want to invest as a society or as businesses or individuals, in preparedness. And the book itself is really also about that archetype in literature, the Desert Island where suddenly youre cut off and surrounded literally by water and what happens to society and Human Behavior and organizational behavior and thinking. So i am a physician by training and i worked in a number of disasters in conflict zones as an aid worker for some years. My first book was about a war hospital in bosnia, and three years it was under siege, and sort of what the experiences of the doctors and the nurses and the patients were there. But in all of my work, i had never heard of a case outside of really the realm of fiction and movies, where the medical staff had gotten so desperate they literally started thinking about perhaps affecting hastening the death of their patients. That is what attracted me to the story when these rumors started to come out and news reports, and i thought, it is very urgent that we understand what is it that really happened here before the next disaster. So the first half of five days at memorial is looking moment by moment at the disaster as it unfolds, and then the second half is the part where the doctor came in and the whole question of trying on the side of the Justice System to reconstruct it, and figure out what happened, and also how does our society adjudicate acts taken in a really kind of context of utter failure of government and hospital corporations and organizations and so can we bring somebody to justice for these acts, even if they did occur . So, the deaths of some of the patients in particular do haunt me and i think haunt a lot of people who worked on the cases. One of them ill just tell you about briefly. Emmett everett. 61 years old, married, a together grandfather, but he weighed nearly 400pounds and was partially paralyzed and was on the seventh floor of the hospital that no longer had working elevators, and he asked his caregivers that more than, are we ready to rock and roll . So he ate breakfast, was conscious and very motivated to get out of this situation. And he was one of the patients who died with all the other patients with these drugs in their bodies. So, after a year of investigation, one of the doctors at the hospital and two nurses were arrested, and accused over Second Degree murder, and a young lawyer was assigned to prosecutor them, and he struggled before a grand jury, attempting to, as he saw it, try to apply justice to a war zone. And so what ive learned in every disaster where ive work, is that what matters most in the immediate crisis situation, where often the larger systems fail, as we saw in sandy, its really the action of you and me and the people around us and our own personal preparedness in decisions that can help make the difference between life and death. Thats why five days at memorial focuses on decisionmaking, so i thought i would read a section and then maybe you can take it away from there and bring up some of those really important issues that we discussed a little earlier today. About a month after the arrest happened, a group of friends, pathologists and toxicologists and the local coroner, who was an obstetrician gynecologist by training so he called in the experts to help him with classifying the deaths at memorial. They all convened at the core mores office his Actual Office was flooded so they met at a former at the vacant good roads funeral home, single story concrete building, and thats what he was using as the Coroners Office, and the importance of the meeting was clear. The attorney attorney generalsd arrested these Health Professionals bet it was the District Attorneys staff who had to decide whether and how to prosecute them. So they were invited, the members of that staff were also invited. And as of that moment the local coroner had kept most of the patients death certificates. He called them pending investigations. With a tick in a check box under sometimes accident or Hurricane Katrina related deaths, some of them said. The experts sat around a large table and began considering evidence. Virginia rider, the lead investigator, and two nurses who worked the case in the fraud unit with her, had prepared charts and tables depicting the drugs found in each body. Robert middleberg, the director of the pennsylvania Toxicology Laboratory where the autopsy samples were tested for drugs, joined them to present his results. The three Healthcare Providers had been arrested on the basis of four deaths but 23 of the 41 bodies from memorial and a local hospital called life care that was leasing a part of the building tested positive for morphine another drug or both. Middleberg, the toxicologist, had handled thousands of cases in his career and the drug concentrations seemed high to him and made him think these numbers are sticking out. Do the findings suggest that patients received a single massive dose of the drug surely before death for repeated doses that allow the drugs to accumulate . With a morphine midazolam drug combination had been contraindicated in patients with certain medical problems . With large death doses of these best known to suppress breathing be dangerous to any patient not on a respirator and how long would it take for the drugs to decrease the breathing rate and Blood Pressure . To this matchup with the times of the deaths to the extent these were known . The experts won over evidence to lifecare patient ms. Alice hustler the nursing home resident treated for pneumonia. Morphine and midazolam are found in her liver brain and muscle tissue but neither drug had been prescribed according to her charge which was kept current until a few hours before her death was recorded on thursday september 1 by the pathologist. She had been quote resting comfortably wednesday afternoon and that night her nurses didnt document any complaints of pain or distress that indicated the need for drugs. Then they go one and pathologist take notes and makes the decision about what they think about those deaths. They looked at all of the patients deaths on that one floor and they thought that all nine were homicides. Lets see here. I think that i will oh i will just read a bit about what happened when the ada staff showed up. The first day of the meeting passed with no participation from the District Attorneys office. Hearing firsthand from the experts was apparently not a priority for those who might be presenting the case to a grand jury. On the second day two assistant District Attorneys finally showed up. The lead prosecutor on the memorial case was a young darkhaired man was slightly crossed eyes District Attorney michael morales. He prosecuted homicides for only two years in a two years in a right that the Coroners Office with his boss ada craig samuel arrow. What do you have . Their manner particularly the short testy one struck the two forensic pathologist is unusually hostile. The experts were accused were accustomed to ask his sing from prosecutors and i think that was your quote. These attorneys acted suspicious skeptical and uninterested. The lawyers left after half an hour. Obviously these guys dont want to do anything but pathologist commented to the coroner. Maynard and contrasting to agree that many deaths at memorial for homicides. What was striking was the pattern. Almost every patient who died after the helicopters and boats arrived on thursday morning and whose bodies were tested were positive for the drugs. Positive for the drugs that they should not have gotten from our review of the records. The lessons that ive learned. Im a Forensic Pathologists and i have been down to new orleans a number of times where the doctor heads many problems and he was the coroner there for 40 years. A very nice fellow and has to get elected every four years, so the Congress System coroner system is probably the oldest, the oldest municipal system that we still have that was inherited from mother country england in the 17 century. Most other things have changed. Coroners now is the same as it was in 17th 17th century england. England has made Great Strides in improving the system and we havent. Any citizen of voting age can run for coroner. Half of the United States counties have coroner systems. The medical Examiner System came at the end of the 19th century to put a doctor in charge. The doctor in charge became a pathologist in new york city. 1950 was the first system to say lots of scandals with the coroner to say that this coroner did not have to be a doctor. It pathologist who does autopsies. One of the few coroners was also a physician who runs the office together with Funeral Directors in most corners in the United States or the Funeral Directors because they are the ones who are interested in the dead hotties are you whats important here, thinking about what happened is that in louisiana, this goes differently statebystate. In louisiana the attorney general can investigate the case like this and bring charges against dr. Proand some nurses but its the local District Attorney in this place, jordan who from what i gathered and i had never met him was not a good District Attorney who i think i had Something Like teen conviction rate in new orleans which even by American General standards is very low and the local people are the ones who prosecute, so if the state brings an action as here, its up to the local District Attorney to decide if the local District Attorney gets elected who decides whether he wants to or sue the matter. The local coroner had this huge role and he was also elect did. And you are saying what he told you about how conflicted he was between the evidence and the will of the community. The coroner in new orleans is a lovely fellow who is a trumpet player. He called me down and i came down after sheri finks first session in which she brilliantly i think describes all this happening and they Memorial Hospital not only with excellent writing, Pulitzer Prize level writing but with the m. D. Ph. D. s knowledge of what goes on in the hospital. The very Little Things that doctors react to, with the beds look like, what the ventilators look like i mean made me feel i was right there for those five days which i wasnt. I came a few days later to do the autopsy. Was it 1200 deaths altogether . Thats right. There were larger number of patients, a significant have died in the hospitals but the vast majority have died in the city so they needed volunteers to come down and work at this big collection point for this large morgue. Saint georges . Saint gabriel. In saint gabriel, they created a center, a place to do autopsies and at the same time fema gave 20 million to build it hopper one. It was an old building we did do autopsies and. Right across the way they fumigated 22 million for autopsies. By the time it was told we had finished. We had 22 milliondollar facility that just stands there with nobody using it in doing anything in paying rent to the owner of the land which is some of the frustration of dealing with government. Lets go back to the case oh okay. No, what i was saying is that i came down in the course of going over lots of autopsies these nine cases also came in that were in with all the other deaths. Theres a lot to talk about with those which is not pertinent for tonight. What was concerning to me was and we have some great forensic pathologist from canada. Cheap the bioethicists from the United States. A few forensic pathologist who had been through lots of deaths. We all had determined that these were homicides. We should say that a medical homicide, this is different from the whole question whether you send somebody to jail. This is purely and tell me if im right, the action of one human being leads to the death of another. This is what you guys are charged with, notwithstanding whether somebody should be held responsible for that. Your job is to say whether this is technically a homicide. Is that right . Right. The doctor does something wrong. The doctor takes off the wrong leg or puts the anesthesia into the stomach instead of the lungs and the patient dies. These are the things that are medical malpractice. We dont call it a homicide unless there were some intent to do it. Its a therapeutic misadventure. [laughter] one of these lovely words i made up. It results in death. We only treat our patients in the results of death. We have to speak for the patient you see. I think what it is is we have categories. Csi, suicide natural or undetermined and the manner of death. When we say homicide in general its death at the hands of another which may or may not be a crime. If it were selfdefense or if a person dies by lethal injection legally. In this case you werent being asked who to hold responsible. You were simply being asked whether these drugs injected not by the patients who were not able to inject themselves may have caused their deaths. Thats right with one factor there. That is, when we say homicide the District Attorney or someone decides whether its a crime or not. Not all homicides are crimes. When we decided that this was a homicide we say homicide because this wasnt just one death. If this was just one death with morphine, but nine deaths that occurred at the same time with all the other factors involved to our judgment was intentional. We dont say whodunit. We leave that to sheri fink to figure out. It was intentional and therefore we call them homicides. The problem in part was from the lovely fellow i have known for years to who explained to me, look, he is here to help in new orleans growing out of this terrible disaster and they get hit hard with the storm and he didnt feel he says to me, that he could go into the grand jury and say that there were nine murders because that wouldnt be good for new orleans. He did tell me that he said he did testify that i hadnt seen the grand jury that this fellow was totally alive and well and had no reason to die. Its kind of sick but not on the verge of death. In the morgue. Compared to usual patience. He should not have died when he died. Can i push back on one thing though . Nine deaths all at one time with these drugs in their body you could mount the defense that they were given the wrong doses. That intentionality piece wouldnt necessary follow. It was highly suspicious. You was suspicious enough for us to call a homicide and its up to the District Attorney to decide whether to proceed. The problem i have, so i think for whatever reason the local people didnt want to call it what it was even though he knew what her opinions were in the District Attorney didnt call any of us into the grand jury. Normally we give our opinions to a grand jury when we issue a cost of death for criminal charges. Not one of the experts and there were five of them hired by the state to look into it. By the state in the county. Orleans parish. Thank you. Everything is different. This is the napoleonic code stuff. Do you want to leave them with that and go into discussion i want to make another point. What it reminds me of as we sit here talking, deaths are too important for doctors to make their own decisions. I think all that is going through, there is no justification for euthanizing somebody without their permission. Theres a big argument whether you should have euthanasia and i wont go into that because dr. Kevorkian and all that but in this situation none of these patients signed up relatives who said they wanted to be euthanized and they were. If they had requested it but this is nonconsensual euthanasia which in my book is homicide. Of course most of them couldnt. Some of them at relatives in the relatives were made to leave. Made to leave by armed guards. The guards appeared hired by the corporation who owned it. They did own it. Yeah its not clear. Whether was the police or whoever and there may have been a separate action so at that very moment and this is the key about how resources can change. These doctors felt very desperate and they had waiting a couple of days for the hospital to be emptied. It was moving very slowly. Ironically our hoa blade horribly when the resources were focused in on this hospital and helicopters were literally wading overhead as is one with land and the next and boats were coming and thanks to the creative thinking of some doctors who went out and other staff that hot wired the boats on trailers and brought them back so they could take the healthier people out by boats on dry land which was only eight walks away. As this was happening calling out women and children there was this big urgency to kind of get all the Healthy People downstairs and get on the boat. Again it looked suspicious. They are whisked away just before the drugs are given but its not clear that those two were actually linked. They were temporary linked but i did not see evidence that they were called and specifically to tear the loved ones away from their family members. They did tear them away. These people did not want to leave their relatives. All through the five days, some of them were with loved ones and needed assistance and all and they were forced at gunpoint to leave the seventh floor just before doctor and nurses came in and gave the injections according to some. Families are being separated all a long and some of the horrific scenes that everyone is dealing with. Sheri should be a lawyer too. The key is the truth and understanding the truth and the truth is very nuanced here. The truth is very clear but we need to keep the context. We teach medical students. You can teach them that its all right to euthanized patients under any circumstances if a patient doesnt agree. If the patient doesnt agree its a kevorkian argument that one has to happen thats different. Somebody going around in injecting morphine and first said which is an anesthetic type of antiseptic is like injecting propofol. The death would occur within just a few minutes and within a few minutes the person is dead because they cant breed. These are sick evil anyway but the point i want to make is that some of you are probably football fans. The National Football league has a bit of a problem with traumatic brain injuries. The reason they have the problem is for years the National Football league has said had concussions and head injuries have no cause for injury going down the line and that is because they had the old neurologist who published they didnt have a conflict. They got paid by the National Football league ended with the National Football league wanted. What happened is that until this fuss came up recently, they published lots of articles saying theres absolutely no reason to be concerned about had concussions or head injuries even with kids leaks. Just because they get knocked out doesnt mean anything over time. Now that has all changed because suddenly they are being sued and all that. When i was reading the book, sheris book what stumped me was how similar with what went on with sheris writing when im in prisons where prisoners complained of inadequate medical care and complained of coverups of deaths and which led to the writing in 1971 where people were killed, 12 guards and the rest prisoners. As a result governor rockefeller set up an oversight panel, the department of corrections which was in charge and appointed a medical review board, fivemember medic heal medical review board were the leading cause of death was hanging in suicide and some other people. To look at every death that occurs and look at the health care and since 1971 there hasnt been a single death in new york state because all the jails and prisons throughout the city and state because when there is oversight when they know someone is looking over their shoulder, the care becomes better. I bring that up to the Memorial Hospital because the investigation and this is beautifully described by sheri, the medicaid fraud unit of Louisiana Attorney general investigated these deaths. They did all this research and the investigation. These people were not being treated properly and that is what the governor the attorney general, im sorry. And there has to be some kind of national standard. I think in raising this, how to protect people in Nursing Homes especially. This is the seventh floor thing. We are going have increasing numbers of evil in Nursing Homes as the years progress and there is no oversight. Its a situation where a lot of them are privatized. We are having fights about the privatization of medical care in jails and prisons and remember 40 of the money paid to private companies for medical care goes into the bottom line and their art is good at doctors and increasing deaths because of privatization. In the nursing Home Business there is a lot of privatization just like the seventh floor was privatized. The whole hospital. The whole hospital and we have to be careful and i think this is a plea also for increasing the state authority. You cant rely on the local counties. What happened with the Corrections Commission is governor rockefeller set up a state Investigation Unit to bypass the local people who get elected. That is made with subpoena powers and a lot of things that gave the ability to take action by the state even though the local coroner, 50 of the 62 counties of course the police. You need somebody with oversight and that should happen. I think thats one of the discussion points the this is an interesting points to summarize this idea that in this case the arrests were extremely unpopular in the local population because people felt again everything failed around these doctors and nurses and yet they were the ones arrested. It was very unpopular. The local District Attorney was facing a huge loss. He had recently been elected, the first africanamerican District Attorney in Orleans Parish and he let go a number of employees who were white and he was sued for racial discrimination. He did not need another unpopular cause because he was fighting that fight. This became very unpopular. So i think what he is saying is that when that is the case the coroner is elected and feels this pressure from the local community that they may not able to be objective in terms of presenting the evidence. There was a big pushback from the attorney general of the state saying that the grand jury didnt hear the strongest evidence and that is why these people didnt see jail time. That may or may not be true and the citizens decided in the often do in cases of mercy killing is the rare someone accused of actually goes to jail. There is some discretion that a jury has so i want us to stop talking now so that we can have a few minutes. Its fascinating. You know so much history that you bring to this. I want us to learn from history. Remember euthanasia euthanasia is never done without the consent of the person being euthanized. Even dr. Kevorkian was he was one of the view that went to jail because he tried. Just one of the thing to discuss. Is that okay with the audience . In 1947, in england, an english girl, 16 or 17 was raped by an american soldier and got pregnant. Even with a strong antiabortion laws, when this girl was brought to the attention of the chief obstetrician and the president in england he thought that she should have an abortion because this would destroy her, this pregnancy. He does the abortion against the law, calls up the police and the police, and arrest him afterwards. He stands trial and the court ruled in his favor. That changed a lot of things in england at that time. Any doctor who wanted to make a point about euthanasia, they should tell the truth. Yes there were witnesses, eyewitnesses who saw them giving the injections. Yes, we did it. We thought it was the best thing if you want to arrest us, our rest is but to lie about it because they lied about it and theyd got other people to lie end of medical students learned that you can lie and the nurses, that is one of the things that others made great deal and its beautifully brought up by sheri in such away that she cant get sued. [laughter] my wife is an attorney. She doesnt say this is what happens. This is what somebody said happened. In journalism people have different views. Fortunately there were a couple of doctors who were willing to speak with me and to say on that record and i think very bravely after dr. Cho had been arrested yes i injected patients than i intended to hasten death and heres why did it. I do respect them for doing that there was very much a code of silence around these events and many Health Professionals to this day do not want this discussed. I think that is dishonoring incredibly hard work of the medical professionals who work so hard. And that members of these patients, to not give this to the world for us to learn so that we dont have to put our Health Care Professionals in this situation in patients and family members in the situation. That is my take on that whole controversy but anyways thank you so much. The history that you bring to this is very important. [applause] we are not done. Lets get some wider discussion. There is a microphone. I wonder sheri are you seeing today present an effort to bring attention to medical ethics in the states across america and if so are there increased efforts to bring that attention to that issue and if so what parts of the country are you seeing it the most . Be so yeah i think medical ethics are always a topic of discussion in medical school and the current american view. [inaudible] yeah. What there is now and this is the big part of the book is after katrina there was a realization that these decisions might have to be made about who do you prioritize when you have in this case helicopters coming in slowly but we also have scenarios like the 1918 style flu pandemic which god forbid could happen. We have had some very scary avian flu cases that made people think that this might be on the verge of happening. There are efforts around the country of small groups and medical professionals getting together and coming out with the prioritization guidelines to help people. Its not just a small group of doctors in the room as the floodwaters rise that exists in advance and would help you decide for example in that flu case who would get access to an icu because the icu would be overrun and there would not be enough ventilators for everyone to get through the flu. So they have come up with interesting guidelines for doing this. Its also a bit problematic because for two reasons. One is we dont have a lot of research on when you decide what your goal is and isnt maximizing years of life . Is that factoring in age . We all want the same innings in life. Should it be random to try to make it more fair, first come first serve . All these different factors we could bring to it so its not a purely medical decision. We dont have enough research to know necessarily how if we did select this group or that group that it would maximize survival. A lot of people would agree on it that interestingly they tested some of these protocols with h1n1 and some Research Groups looked and said what if we had put these guidelines we came up with into place . The people who would have likely survive the flu because that was their goal, lets triage based on whos likely to survive with a few days of support on a ventilator so we could quickly get these ventilators turned around. What they found was they didnt didnt and there was dissension. Even the people had protocols doing these exercises couldnt agree on how certain patients should be categorized. That was problematic and also people taken off of ventilators if they are improving fast enough without their consent and that of course would require a change in laws most likely. If he did that today thinking of the trauma to the medical professionals and families to do that if you dont even know youre going to improve survival is a little troubling. The other thing that is troubling is how many of you guys knew about this who have not read the book . That is pretty good. Like about six people in this crowd. A lot of people dont know about this. Interestingly in new york we do have one of these protocols and even a lot of dock theres who i speak with arent aware of it and havent been aware of it. Certainly the wider public isnt aware of it. There would be little awareness let alone having be part of the conversation could i write about this interesting project going on in maryland a twoyear project. Doctors are engaging in this delivered a democracy with regular folks where everyone comes in for a few hours and quickly grasps these Ethical Principles that can be applied to this problem and caches it out and comes out with some thoughts on that. The goal is to get all this input before the state makes a plan which is the opposite of how its been done everywhere else. That is one example. Its there was a question back there. I have a question or comment. I dont think you can take what happened out of the situation of this crisis that you have to look at it within that crisis that some patients were going to die, right some patients were going to die because the electricity was going to go off so the question is how were they going to die . Its a ventilator just goes off thats an excruciatingly painful death. Versus a patient dying painfree. This is a little different what happened. They were actually given morphine in small normal doses being given throughout when the patient looked uncomfortable. They were not withholding that through the disaster. If i might just comment. Can i finish . My other question is why not have a discussion with patients who can talk to you and their families . Why not have the discussion saying we are all in this together. These are the options we think we have and these are the choices. If youre ventilator goes off this is what could happen to you. We have these medicines and we could give them to you. Why not have that discussion . Part of it might be and im a social worker. Doctors have a hard time telling patients about death. It makes them a comfortable. My other question is what were you thinking, sheri . Here you are, youre a physician and a journalist. You are freaking out because you are a human being and seeing all this suffering. Im wondering what you were thinking and just my comment is to put it in a bigger context the fact is we have ration health care in country every single day. The poor and black get less access to Health Care Resources and you die younger. Every disease that there people of color die sooner. 45,000 people die in this country every year because of lack of health care. Our system actually kills people. 45,000 people according to a study. There is a way to end all of these deaths and not put those Health Care Professionals at that hospital in that position. That is to spend lots of money to make sure hospitals have all the equipment they need in a situation like that. Our National Health care system, health care is a human right. Its not a commodity and people would never find themselves in these situations where they have to play god. To make sure every single hospital has the power and is designed so people are never put in that position. I really believe that. Thank you for your comments and questions. We cant address all of those points but they are well taken and i like what you said about having a discussion and you could imagine a scenario where some people in that hospital would say getting back to the triage question, maybe if he came to some families and they felt their loved one was closer to death they may surprise you and say yeah at the other scope urged. In the apple appears a case a case where before Hurricane Sandy theres a hospice in connecticut that had to evacuate on short notice. The administrators there assumed they wanted to move the patience who were closest to death first because they thought they were the most fragile and the most urgent to move them. In fact they did exactly what they said. They went to the family members of the patience who necessarily didnt have long to live and they said what do you hang . They surprise them and said actually yeah we want to stay at hospice as long as possible before you move us just in case or loved one would have the chance to die here. When you asked the question you may find out things that surprise you. I think thats a very well taken point. In terms of preparedness, again its a question of what is going to make us spend that money. If there are going to be firm regulations about how hospital ship repair and interestingly in new york city after sandy sandy part of the mayors proposal includes some of the stricter building codes for not only New Buildings but old openings to be up to certain standards. Unfortunately the proposed deadlines or 2030 so we have a lot of years before then before we in new york feel more protected. Then you go to the question of if you know youre going to be vulnerable then maybe you evacuate people. A hurricane is one of the disasters that you have a warning and you can predict perfect way but we are getting better. There are systems for predict a storm surge that we didnt have a year ago with sandy. I will just stop there. There is plenty more to say. One last thing, you made an eerie interesting point about the inherent discrimination. There are certain groups that have Poor Health Status and that is the legacy of discrimination and the way that patients have been treated and interacted with the Health Care System for many years. A very interesting public engagements exercise outside of maryland there have been few places that have gotten into discussions of triage and emergencies. There are many ways and many proposals and they actually said Something Like if we try to maximize survival so we try to make sure they go to people who have a better Health Status and are going to benefit from them, we are inadvertently discriminating against groups of peoe who have poorer Health Status. I thought that was fascinating. I wonder if harriet washington to jump in on those who is also a writer on bioethics. Sorry to put you on the spot but is there anything you would like to add . [inaudible] i think one of the really important examined factors here is physicians are trained intensely and science and clinical scenarios but they are also intensely trained in social a friend social norms. One of the really important social norms is that physicians are encouraged to lie in certain ethical situations including one that parallels this. Considering the use of morphine for example. It becomes very tempting and physicians succumb to temptation in morphine in the name of alleviating pain but the ulterior motive of dispatching the patient. Its very neat and very convenient because the patient will die and that position more than likely i dont look into peoples hearts and tell you what theyre thinking that theres a strong argument. This way they die relatively peacefully and relatively smoothly. To very clean and accept that the physician is lying to himself. He is not giving them more thing because it pained. Hes giving the morphine to help the patient into death without admitting that. The this is absolutely people who did engage in hastening deaths said there is a cole in the book that makes that point. Specialists argue theres a firm line between and euthanasia. It all does hinge on intentionality. This doctor says in the book and a lot of people would disagree with this but he says any doctor who thinks giving a lot of morphine to a patient who isnt prematurely ending his life is a very naive doctor. Harvard medical school has published this in the new england journal of medicine. You can look it up yourself. The this is one of the debates that is discussed in the book and the elements of the positions on pain which you just mentioned the social worker brought up the idea of the experience. The Health Worker in that situation. Its not in the book is a quote i wish i had put in their, a very eminent physician who was a bioethicist whose name is escaping me. He passed away a year ago or two years ago. When we were discussing the situation and he is from louisiana and knows a lot of people involved. He said theres this almond of the physician and nurse wanting to relieve their own pain and perhaps confusion of where your pain and send their pain starts. It may not even be a patient in some cases the doctors describe these patience is not in conscious but looked awful. Lying there in sweat and looking terrible. Theres the pain of the Health Professional used to being able to help people unable to do that anymore. The question of whether that could have motivated these acts and the question of whether we need better standards and ethics and laws at the moment of compassion because they stop us from crossing a line, that compassion leads us to. The there are multiple factors influencing it however the arch other large issue that is overlooked is medical ethics has a tendency to look narrowly at questions in terms of time and in terms of scope. Its a lot easier to look at a situation like this as a snapshot. Here is what is happening now. Heres what happened a few years ago when the guidelines were revised but its important to take a more longrange view because this tells you the social factors that have to be adequately examined. One of the problems with medical ethics is it as an insufficient and of history. If you look at the history is this woman had alluded to, if you look at the history of this area theres a very strong history of certain groups of people receiving substandard care but more to the point of physicians being trained again that shadow we tacit training that they dont get from textbooks but they get from mentors and seeing the social situation there put into and seeing which patients are used in what manner and who is used as a teaching example. Who is valued and who is not valued. If you look at the history there is no surprise. If you look at that history its not just the fact that a lot of discrimination is not static and is going on now. Its got this long history of physicians being trained to view black patients differently affecting the way they treat them once they are in practice. Its a good example of this that you have again this very myopic view of social and historical realities and you look at a snapshot but you dont see everything you need to see in that snapshot to make your decision. One of the things that needs to be seen as when you patients who are viewed differently and physicians who dont resent typical patients they are seeing. Youre going to have a problem and youre going to have a conflict and issue it patients not being treated equitably which i think a lot of what we have been seeing here. Thank you. Some of the racial dynamics are discussed quite a bit in the look in the history in these hospitals. There is discussion of these very issues and in fact like i said there were differences of opinion amongst the help professionals at the very moment that these actions were being taken. Some doctors and nurses were saying no this is not right we shouldnt be injecting patients and i will be no part of it. The way history and race played in two things, there are some element of that in the book as well. Do we have time for more . Okay. Thank you. I think what was just shared is another example of power rank and privilege and how it plays itself out. Roughly a little less than two weeks ago peter singer, a Major Medical bioethicist chaired and hosted a conference on at Princeton University about the ethical dilemma of compensating organ donors. What was just shared by your colleague was in his opinion that and excuse me for pair of facing or maybe misquoting but its not possible to euthanize an individual without their consent. Am i correct . Is that a correct assessment of what you said . He is asking you. The there are certain guidelines. Such as you cant euthanize somebody without there can and or family consent and its called murder. The following that track in the very few countries that do allow it. The following that track, in england the National Health service, individuals at the age of 85 are no longer allowed to receive kidney dialysis and as we know it without being able to be dialyzed it is certain and absolute death. That is not with the consent of the individuals l. A. Think i would like to hear some conversation about that. The other part is we started off this dialogue about i guess i would call it empowerment and i think there are four ps, policy, planning, politics versus the small p which is people. That goes back to power, rank and privilege. Absolute power makes no concessions and if you are in a position where you are not in a power position or empowered you and you again are subjugated to decisions that affect your family or your loved ones lives without your consent or control. I think when you introduce these dynamics please understand that it wasnt that individuals were in a decisionmaking position or empowered enough to raise objections to some of those choices and decisions that were made albeit under extreme circumstances. I have been in many complex theaters and seen violence firsthand and ive also seen amazing compassion in spite of, so i would like to hear your comment and your responses to these comments. The i have so much i want to say that but i will just say two things. Thank you very much. First of all, yes. I think sometimes we think about excusing certain actions because you now can we excuse it as of the situation being so extreme that of course we have to remember we have doctors who work all the time and we have the ethics and rules that apply in those situations and that is important to remember. Its hard course if its your first disaster and you are doctor and thrust into that situation. This is part of why i think this story needs to be told. Keeping your eye on the fact that there will be a tomorrow and that is very hard to remember. Isnt in individual light individual decision . [inaudible] i see what you are asking. There is dissension amongst those individuals and its interesting because one of the people who felt most strongly that this was an inappropriate act was safe position who was the only physician of color and who had been shut down the previous day when he was arguing with the ceo about the decision not to allow the neighbors of the hospital who were mostly people of color to come in for shelter. They were coming by in their skiffs and elderly person being pushed on a mattress and there was a dude debate between the Administration Whether to allow people in. He had been shut down and he felt like my voice didnt mean much. Therefore when the situation arose with people talking about should we think about hastening the deaths of patients he felt this was wrong but he also said he next reigning why he refused to dissipate and left so people criticized him for leaving, he said well i felt like my voice did not have a role. I guess that gets to the larger point about to the individuals have a role . I firmly believe that they do and in the disaster that ive worked in any action can make a huge difference and if someone had spoken out and stayed maybe a different decision would he made. The right decision to not go forward with these injections. I think there is a huge pressure perhaps from an organization and certainly the failure of this particular hospitals Leadership Structure to stay in place and to offer leadership that a lot of people would feel comfortable with and more secure and stop some of the dust ration in the panic and confusion that would be really helpful but in the end individuals can make a huge difference. So id rank we cant just say no but that is not a role here. Also wanted to respond to the dialysis scenario and that is in the book to match believe it or not. Its a case of south africa and these decisions. In england its people above a certain age but in south africa they have to ration dialysis. Four out of five good candidates and i was just speaking with the head of the Public Hospital dialysis unit in tiger bird hospital which is a huge hospital in cape town. He has to turn away four out of every five people so the question is how do we do with . I offered that example because at some point the doctors said we need the government to step up here because they are the ones not funding us and create some sort of a transparent system so we are not doing this ad hoc in discriminating against people. You can imagine in apartheid africa. Recently they came up with, within the last five years they sat down and got ethicists and patients at the table and the doctors and nurses and social workers and hashed out a system. Trust me its not great because they are still turning away the same number of people but at least they can face people and say here is what we are doing and why. I want to make one distinction. The distinction between dialysis and injecting something to kill somebody. While i was a resident doctor and bellevue in the 1960s the Catholic Church came down and said withholding things can be acceptable but you cant intentionally kill a person. That has to be taken apart, taking into consideration but as a medical examiner a number of disasters and airplane crashes and fires where more people can die, we can set general guidelines. Every disasters different. Therell be lots of decisions and we count cant account for everything thats going to happen. How people react and how families react in having certain guidelines like you cant kill haitians just because its convenient. If they are going to die let them die naturally and especially here as sheri points out. Most of these patients were, to those who were given the injections of morphine in first said. They didnt need to have pain killing. You are comatose and not in pain. If a person is not conscious and not feeling pain and morphine is not needed for comfort purposes. I think some Palliative Care people there is a question of whether there may be some awareness or some discomfort on some level. What about the patient . Its a slippery slope. Failing to provide care are seen as equivalent, the same thing. Its not really into intuitive but if you think about it its not the same action. The other thing i want to say quickly is [inaudible] if you look at this country there are hundreds of examples. [inaudible] my point here is to point out that a lot of it is just historical as opposed to present day. Thank you for that. We need to wrap it up. There is wine and i will be signing books and there are snacks. You can purchase books here i should say. Thank you. This was a tremendous discussion and i hope we will continue it amongst ourselves. [applause]