Robert W. Donnell, MD: A Bright Line
Soon after Hurricane Katrina hit in 2005, news media reported instances of "mercy killing" of stranded victims, severely ill, or injured beyond hope of recovery. Many observers, doubting the veracity of the reports, dismissed the story as urban legend. But months later, Louisiana authorities leveled second-degree murder accusations against a doctor and 2 nurses for allegedly euthanizing patients confined to a New Orleans hospital in the wake of the disaster. Few details are available, and it would be premature to render judgment on these allegations. The episode does, however, raise a broader question: Can euthanasia be justified in extreme conditions such as disaster or combat?
Although relatively little seems to have been written about this particular aspect of euthanasia, we have much to guide us about general issues involved in physician-assisted death. Increasing acceptance of euthanasia and assisted suicide is relatively recent in the history of medical ethics, representing a significant departure from historic traditions that hold life as a nonnegotiable value.
The Hippocratic Oath states, "I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan..." The Christian Medical and Dental Associations (CMDA) proscribe physician-assisted death with this statement: "We oppose active intervention with the intent to produce death for the relief of suffering, economic considerations or convenience of patient, family or society." CMDA recognizes the responsibility of physicians to relieve suffering, but not at any cost.
Dr. Mark Siegler, Director of the MacLean Bioethics Center at the University of Chicago, summed it up best when interviewed by The New York Times: "We begin with the general rule that doctors don't kill patients." He went on to say that even in extreme conditions, doctors have a responsibility to relieve pain and suffering, "but not to the point of putting patients to death."
Two examples from the combat setting are worth considering, one from ancient history and one from recent headlines. In the Old Testament, II Samuel 1, we read that a soldier, hoping to win favor with David, claimed the mercy killing of King Saul. According to the soldier's account, the mortally wounded King Saul said, "Come, stand over me and kill me; for convulsions have seized me, and yet my life still lingers." The soldier continued: "So I stood over him, and killed him, for I knew that he could not live after he had fallen." David, however, considered the act to be murder and ordered the soldier punished.
On May 21, 2005, an Iraqi insurgent severely wounded in a clash with the First Armored Division tank company was shot by Capt. Rogelio Maynulet, to "put him out of his misery." Reports indicate that the Iraqi was wounded so severely that doctors viewing footage of the event disagreed on whether the victim was still alive at the time of the mercy killing. Maynulet was convicted of assault with intent to commit voluntary manslaughter. What is unusual is that this episode was caught on tape. We can only speculate how many mercy killings on the battle field go undocumented. Nevertheless, the US military justice system condemns euthanasia, even in such extreme circumstances.
The story of Captain Maynulet affords a vivid example with which to test our question, "Can euthanasia ever be justified in unusual situations?" What could have been more extreme? A portion of the victim's skull was blown away, and the medic advised Captain Maynulet that nothing could be done. If a case for euthanasia ever existed, can we imagine a more compelling one? Yet, over time, doubts began to surface. The medic gave conflicting testimony and later expressed second thoughts. A seemingly open-and-shut case began to crumble as conflicting testimony unfolded.
If we allow exceptions to the prohibition of euthanasia, how should the exceptions be defined and applied? Endless questions would naturally arise, setting the stage for unintended consequences and a dangerous slippery slope. R. Alta Charo, professor of law and bioethics at the University of Wisconsin, speaking of the alleged New Orleans mercy killings, told The New York Times: "But if the killing was intentional, even if it was meant to be merciful, it is something that society draws a 'bright line' against for fear that it will get out of hand."
I make no claim to the high ground in this debate. But I believe that our profession must apply moral absolutes in matters of life and death. Absolutes are needed to guide future actions, not to point fingers or to condemn individuals. None of us can be certain of how we would act in extreme conditions. We are morally frail creatures. Good intentions do not always lead to correct actions. That's why we need a bright line.
Medscape Med Students. 2006;8(2) © 2006 Medscape
Cite this: Could Disaster Conditions Ever Justify Euthanasia? - Medscape - Oct 03, 2006.