Classic cases revisited: Of hurricanes,cyanide and moral courage

Abstract

All decisions made by doctors have a moral dimension. When a moral judgement demands a different course of action to one that represents the usual practice, many doctors do struggle. The inability to embrace such decisions can represent moral negligence, as often the consequence is greater suffering for the individual in question or loss of utility for the population. On the other hand, it takes courage to make such decisions as the society fails to accept them, even though decisions made are rational and morally valid. Clinical practice that does not conform to moral judgements can result in moral distress, burn out and job-leave. Reflective practice evaluating moral dimensions of clinical decision making is an important aspect of nurturing humanity, empathy and professionalism in the therapeutic endeavour.

It is curious that physical courage should be so common in the world and moral courage so rare. (Mark Twain)

Courage is being scared to death and saddling up anyway. (John Wayne)

Introduction

In this paper, I would argue that the extreme examples presented here, merely serve to highlight the everyday need for moral judgements in medicine. The heart-wrenching nature of those decisions is exemplified by those extreme cases, but in truth, those judgements, along with clinical decisions, are part of everyday practice. The inability to embrace the need for such decisions should be viewed as moral negligence, as often the consequence is greater suffering for the individual or in the case of populations, loss of utility. The burden of those decisions takes its toll on the practitioners of the art of medicine, and can lead to disillusionment, stress, burn-out and possibly moral distress or apathy. Failing to recognise the above, and to build in understanding and resilience along with important safeguards, can potentially harm individual patients, doctors and in the long run lead to the collapse of the modern health care system as we know it.

Case history 1: Warsaw Ghetto

Marek Edelman was the sole surviving commander of the Jewish Upraising in the Warsaw Ghetto during the Second World War. In his moving account, The Ghetto Fights, detailing the fate of the Jewish population of the Warsaw Ghetto during Nazi occupation, he describes an act of mercy and compassion, which may seem hard to believe –

No words of any human language are strong enough to describe the Umschlag now, when no help from anywhere or anybody can be expected. The sick, adults as well as children, previously brought here from the hospital, lie deserted in the cold halls. They relieve themselves right where they lie, and remain in the stinking slime of excrement and urine. Nurses search the crowd for their fathers and mothers and, having found them, inject longed-for deathly morphine into their veins, their own eyes gleaming wildly. One doctor compassionately pours a cyanide solution into the feverish mouths of strange sick children. To offer one’s cyanide to somebody else is now the most precious, the most irreplaceable thing. It brings a quiet, peaceful death, it saves from the horror of the cars. ¹

Those words echo in another account – I remember nothing more – this time of then a young paediatrician, Adina Blady Szwajger, who again describes those very events. She was asked by a nursing sister –

‘Doctor, please give my mother an injection. I can’t do it. I beg you, please. I don’t want them to shoot her in bed, and she can’t walk’. So I asked her what was in the syringe and she told me it was morphine. I knew it then what I could do for the children […]

Having helped the elderly lady, Adina continued –

I took morphine upstairs. Dr Margolis was there and I told her what I wanted to do. So we took a spoon and went to the infants room. And just as, during those two years of real work in the hospital, I had bent down over the little beds, so now I poured this last medicine into those tiny mouths. Only Dr Margolis was with me. And downstairs, there was screaming because Szaulis ^a and the Germans were already there, taking the sick from wards to the cattle trucks. ²

Case history 2: Hurricane Katrina

Hurricane Katrina was born as a tropical storm off the coast of Florida on 23 August 2005. It washed over Florida and grew in size and strength over the Gulf of Mexico. It acquired the fearsome status of a category five hurricane, the highest category within the Saffir-Simpson wind scale. Winds of over 157 mph tore over the sea towards the states of Louisiana, Mississippi and Alabama. On 27 August, President G W Bush declared a state of emergency and on 29 August, the Hurricane hit the cost of Louisiana near Buras-Triumph. By then, the strength of the storm relented and it was reclassified as category three, but winds with speeds of 125 mph still brought destruction to anything within their path. Importantly, a number of flood defenses were destroyed, and massive flooding resulted. The city of New Orleans found itself in the eye of the storm. Within it, in a flooded hospital, without electricity, without fresh water or sanitation, with temperatures in excess of 37C and with limited staff, a dramatic series of events occurred. Memorial Medical Centre located three feet below sea level, ceased to be able to function as a hospital, and became an island, with its occupants, medical staff and patients alike marooned and awaiting rescue. Evacuation from this concrete island was not easy.

Sheri Fink, an investigative reporter, writing for The New York Times, described the conditions faced by the healthcare teams left at the hospital –

A crew of doctors, nurses and family members carried Memorial patients down flights of stairs and wheeled them to the hospital wing where the last working elevator brought them to the second floor. Each patient was then maneuvered onto a stretcher and passed through a roughly three-by-three foot opening in the machine-room wall that offered a shortcut to the parking garage. Many patients were placed in the back of pickup truck, which drove them to the top of the garage. Two flight of metal steps led to the helipad. ³

Still, patients remained. In particular within the Memorial Hospital, there operated a separate private facility (with its own staff and administration) called LifeCare. LifeCare provided 24-h critical care support to long-term patients with gross chronic disabilities, but also with some survival potential. Sheri Fink describes them thus – “Many of the 52 patients at LifeCare were bed-bound or required electric ventilators to breathe, and clearly, they would be at significant risk if the hospital lost power in its elevators.” ³

On 31 August, emergency generators stopped working, plunging the hospital into hot, dark, quiet stillness. While some of the patients from Memorial and in particular children, mothers and the critically ill were evacuated, the patients within LifeCare facility remained. An attempt was made to evacuate them with volunteers carrying patients down five flights of stairs. The following paragraph reflects the harrowing nature of this attempt at evacuation:

A LifeCare nurse navigated the staircase alongside an 80-year old man on a stretcher, manually squeezing air into his lungs with an Ambu bag. As he waited for evacuation on the second floor, she bagged him for nearly an hour. Finally a physician stopped by the stretcher and told her that there was no oxygen for the patient and that he was already too far gone. She hugged the man and stroked his hair as he died. ³

One of a number of dedicated doctors that remained on duty and had not fled from the hospital during those eventful days was a 49-year-old, highly respected, ENT surgeon Dr Anna Pou. Active throughout the evacuation, she and her colleagues hit a snag. Nine patients described as “chronically deathbound,” ³ some of whom were also morbidly obese, were stuck in the LifeCare Facility on the seventh floor. No outside help arrived, to help and for the exhausted staff to carry them down seemed a physical impossibility. Many physicians and senior nursing staff deliberated amidst the chaos the most compassionate course of action. Eventually, morphine and midazolam in sufficient dose to ensure comfort and perhaps death were prepared and given to those who were too unwell to survive evacuation or who the team were unable to move. Dr Pou bearing syringes of the drugs climbed to the seventh floor to attend to the comfort of those too unwell to survive.

Moral courage

When Germans established the Jewish Ghetto in occupied Warsaw, its population was estimated at 400,000. By the time they retreated, only 11,500 Jews were left alive. ⁴ Hurricane Katrina was responsible for 1833 deaths and 125 billion USD worth of material damage. ⁵ The above cases may seem extreme, in that they raise the taboo topic of mercy killing, alien to most clinicians. The situations faced by those involved were abhorrent or cataclysmic in nature, and their acts can be viewed as lesser evil, with kindness at the heart of intention. The acts were a consequence of moral judgements, where in absence of any other avenue to pursue, the abolition of suffering and prevention of a degrading and cruel death was the morally correct course of action. It felt right to do it. So, what? Many may ask. Chances of it happening in “real life” are small. I would argue that moral judgements are inherent to our job as clinicians. They co-exist with every clinical judgement we make and also, perhaps surprisingly, they are different to value judgements (or at least they are a specific type of value judgements). Moral judgements are a prerogative of the human species. Morality is what makes us different from other animals which are driven by predominantly biological imperatives, but are unable otherwise to differentiate between good or bad, or right and wrong in the moral sense. Those are the judgements that make us deviate from protocols, or choose which guidelines we decide to follow. So, when faced with a patient presenting with opacification of the left lung field on a radiograph, with signs of infection and impending respiratory collapse, as clinicians, we know the correct course of action. Our clinical judgement may suggest the presence of pneumonia, which demands urgent and specific treatment and possible organ support with the intention of saving this patient’s life. The clinical judgement and the moral judgement are aligned, so the latter becomes invisible. We are on a noble quest to save a life. On the other hand, if the patient described above had a history of progressive deterioration in physical and cognitive function, with significant frailty, sarcopenia and prolonged prior hospital stay during which he failed to respond to offered treatments, we may arrive at same diagnosis, but make a judgement that aggressive intervention such as intubation may be a wrong course of action. The likelihood of this patient deriving meaningful benefit from invasive organ support is scant, and the potential for concomitant harm is great. To claim otherwise could also be deceitful. It may be the same disease process; however, the clinical interventions offered would lean towards a palliative approach. Here, a moral judgement is somewhat more visible. Clinical judgements are perhaps more disease-centred, whereas moral judgements are patient-centred taking into account the wider context. The context may be simply the presence of an advance directive or, on the other hand, it may relate to the capacity of ICU, enactment of triage in the context of a major incident, epidemic or war. One would be well advised to review influenza pandemic triage tool at this point.^6,7 A tool that directs doctors away from actively treating the very sick is there to provide a moral decision “crutch” for those that are struggling. As such, the correct course of action for the clinician may change as the circumstances change. Acknowledging uncertainty and the limits of medical knowledge, the clinician is forced to decide if his actions are going to result in good for the patient (or society) or not. If, as the consequence of treatment, there is significant suffering without significant prospect for the patient to regain any enjoyment from their existence, then clearly to give such treatment is morally wrong. If treatment will not result in net benefit for the patient and yet will consume significant and limited resources depriving the rest of the society from these, then such treatment should be viewed as morally wrong. Pursuing treatments which most would see as morally wrong may arise from a misguided sense of power (God-like psychopathic attitude), religious or cultural imperatives, institutional constraints, lack of knowledge, defensive practice where any intervention is seen as doing “something” for the “benefit” of the patient, burnout or from moral cowardice. It takes sometimes a brave clinician, or a group of clinicians to say – “This is wrong.” It takes courage to stand by your “moral judgement” rather than walk away, as many could perhaps see themselves do when faced with cases presented above (“not my problem” attitude). Moral courage can be defined as the courage to take action for moral reasons despite the risk of adverse consequences. Our modern society surprisingly does not always value moral courage. Examples abound of the treatment awaiting whistleblowers such as Stephen Bolsin – ostracised and betrayed, or those involved in the care of dying children like Alfie Evans or Charlie Gard – vilified by the media and the public. In the aftermath of Hurricane Katarina, in July 2006, Attorney General of Louisiana arrested Dr Pou and two nurses, accusing them of administering morphine and midazolam with the intention to kill four elderly patients on 1 September 2005. Eventually on hearing all the evidence, the Grand Jury refused to indict Dr Pou, although a number of civil law suits followed. ⁸ Since then, Dr Pou worked tirelessly to facilitate the introduction and change of laws that protect doctors making difficult decisions during disasters when resources are insufficient to deal with the number of victims and when doctors are forced to prioritise not the sickest, but those most likely to survive.

Moral distress

The concept of moral distress was first defined by Andrew Jameton in 1984 as the inability of a moral agent to act according to his or her core values and perceived obligations due to internal and external constraints. ⁹ It can also be viewed simply as knowing the right thing to do for a patient but finding it impossible to do due to institutional constraints. It is discussed at length in nursing literature, but only recently has been applied to doctors. ¹⁰ It is by no means a new entity, as the problem of “troubled conscience” is well known. However, the concept of moral distress gains power given its consequences. It results in frustration, feelings of guilt, anger, self-blame and ultimately it is associated with burnout and compassion failure. It differs from mere psychological stress, in that the core principles one lives by are threatened or betrayed. It can ultimately lead to individuals abandoning the job or even the profession. Moral distress is symptomatic of poor communication, inadequate collaboration between specialities, inadequate resources and the perception of powerlessness to do anything about it. In critical care, it is often, but not always, linked to the issues surrounding end of life care and, in particular, disproportionate care. This is a common phenomenon as demonstrated by APPROPRICUS study where out of a sample of 1651 healthcare professionals, 27% perceived inappropriateness of care. Examining a data subset, 23% of 883 ICU beds surveyed were potentially utilised inappropriately. In 89%, this was believed to be excessive treatment. The perception of inappropriateness of care was associated with a higher intent to leave a job. ¹¹ Likewise, conflict is also highly prevalent, experienced by 71.7% of respondents in CONFLICUS study. ¹² A recent 2017 NHS survey indicated that 38% of staff felt unwell due to work-related stress with 51% working beyond the call of duty and having less satisfaction with quality of care delivered. ¹³ The GMC admitted that “the level of dissatisfaction among doctors seems to be higher than ever before.” ¹⁴ Moral distress can be viewed as a cumulative phenomenon where moral residue arising from repeated troubling events is gradually accrued. ¹⁵

It comes with the job…

“Man up” – we hear – “This sort of thing comes with the job.” And yet, there are jobs that are more rewarding than others, jobs that are more or less stressful, and ones that one truly enjoys. The GMC is scant with its advice on one’s “moral” fitness to practice, but it can be quick to judge. It does demand one remains fit to practice. Given moral courage is a virtue, it takes a virtuous doctor to demonstrate it. Such doctor needs to recognise that only being healthy and of sound mind is he or she able to serve her patients best. Moral distress and burnout are a threat to good clinical practice. A doctor has a duty to oneself. It is a duty to look after one’s own physical and mental health. This ideally should form part of the appraisal. When faced with a moral problem, a clinician should not be left to face it alone. Ways to avoid moral distress include collegiate working, institutional support, active ethics committees or ethics consultants. Pastoral or spiritual support should be available. Reflection should not be stifled by the fear of persecution. Resilience training should not be viewed as an antidote to resource shortages. ¹⁰ In times of crisis, mediation can help. Ultimately, in some cases, only societal engagement and education can lead to better understanding of dilemmas handled by clinicians.

Conclusions

Medical science is able to furnish clinician with a diagnosis and treatment. However, knowledge and experience are not enough to be a good doctor – a virtuous doctor. To achieve this, reflective practice is required, where the moral nature of clinical decisions is scrutinised by the doctor. Regardless of what the biology of the disease may dictate, a question that needs to be answered is – is the treatment right for this patient? Is it going to benefit them? Is the society going to benefit from this individual’s treatment? It is important, however, to note that benefit must be viewed in the widest possible sense, not merely as medical benefit. It should be viewed akin to best interests, and those very much have a moral dimension. We are all, as human beings, moral agents. As such, we carry the burden of trying to do what’s right. Theodore Roosevelt once said “Knowing what's right doesn't mean much unless you do what's right.” ¹⁶ It takes courage, however, to do what is right. Sadly, fear, social insecurity, institutional indifference and a host of other factors prevent individuals from acting on their moral instincts. This failure to act may lead to moral distress and remains one of the causes of burnout and disillusionment with the art of medicine. Perhaps our humanity will ultimately prevail; however, medical science and technology have outpaced our ability to know the right treatment from wrong, to judge the context and to remain true to ourselves as doctors.