The blur that is ethics

This was a rather interesting article from CNN.com today. Although more likely to run across poems, anecdotes, and grammatical philosophizing as one strolls down Mulberry Street, sometimes the reader might encounter something a bit more complicated. In these cases, one should tread carefully, remembering that there are two sides of the street.

Take that to mean whatever you want. I found this article interesting since I remember hearing a different spin on the story a year or two ago after the hurricane. "Euthanasia" and "homicide" were terms more apt than "abandoned by his government." I don't mean to imply that all ethical issues are gray, but reading the doctor's perspective provided me with another occasion to imagine the sights and sounds of Memorial Medical Center in the aftermath of the post-Katrina flooding. (It was the fact that the city is built below sea level and that the levees could not hold the surge, more so than the actual hurricane, that did so much damage, if I recall correctly.)

In this sweltering hospital with no electricity and no operational pharmacy, patients languish and the staff is stretched thin in terms of both numbers and emotions. At the time, no one knows if help will come in a day, a week, or weeks. (Pre-Katrina, a week would have been inconceivable. However, now's not the time to discuss the politics of it.) Doctors and nurses are doing their best to take care of patients, night and day, that they may know little about. If the staff's suffering is difficult to imagine, how much more so that of the ailing patients.

The facts are that morphine and midazolam hydrochloride were given to some patients. This sounds like a very reasonable regimen for ICU sedation. The doses given, curiously, are absent from the article. In any case, I suppose the question comes down to one of intent: did the physician intend to kill the patients, or to relieve their suffering? The ethical dilemma stems from the paradox that actions based on divergent intentions may appear very similar.

In other words, a dose of morphine and midazolam that is necessary to treat a patient who is hyperventilating, anxious, in pain, or otherwise decompensating may lead to a fatal respiratory depression. Goodness knows that if the congestive heart failure exacerbation patients weren't getting their diurectics and ACE inhibitors (because, as I understand, the pharmacies were shut down), or if the septic patients were not getting their antibiotics, then there is no fine line between easing suffering and hastening death in these patients already on the brink. Rather, they overlap to the degree that there may be no difference, other than that of intent.

As I recall, the Hippocratic Oath does state that the physician shall not "prescribe a deadly drug..." To take this literally would mean that nearly no drug could be prescribed. After all, Tylenol is deadly in large doses. So is water. Coumadin (a common blood thinner) was developed first as rat poison. So what the oath is getting at, I believe, is the intention behind the prescription. Medicines don't treat patients; physicians do.

In this case I cannot make a clear judgement, other than simply to say that from the facts presented, I cannot disprove that the doctor intended only to relieve suffering. And I can also say that I noticed the author used the everyday term "morphine" but included the very technical "midazolam hydrochloride", the latter word being thoroughly unnecessary to all but the pharmacosynthetic chemists out there.