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Is she a heroine or a murderer?

The question lies at the heart of one of the most harrowing ethical dilemmas in recent years. It came to a head last week as Louisiana’s attorney general, Charles Foti, accused Dr. Anna Pou and two nurses in New Orleans of administering lethal injections to four patients during the post-Katrina chaos last September. And it will surely reverberate in medical-ethics discussions for years to come.

On some details there is little dispute. As Katrina bore down on the city late last August, Dr. Pou arrived for work at Memorial Medical Center. A highly respected surgeon with a distinguished research-and-teaching résumé and a reputation for advocating strongly for patients, she was still there three days later. By then the electricity had failed, temperatures were above 100 degrees, and medicines were running low. Outside, the water around the hospital was five feet deep, and there were looters in the neighborhood and gunshots in the air. Many patients already had been taken out in boats and helicopters.

But for the eldest and sickest in Dr. Pou’s acute-care ward — some of whom she didn’t know since they had been transferred in from a nearby hospital closed just before the storm — there was little hope of surviving an evacuation. And when it was all over, at least 34 patients at Memorial lay dead — including four in her care who, witnesses say, were intentionally killed on September 1, 2005. In arresting Dr. Pou and nurses Lori Budo and Cheri Landry on second-degree murder charges, Mr. Foti described their acts as “not euthanasia” but “plain and simple homicide.”

It’s too soon to render judgment here. Too many questions remain. What do we know of these women’s backgrounds, thinking, and motivations? Why, out of scores of medical professionals connected to Memorial, were these three still there that day? What were the avowed best-practice standards of the hospital — and what was the real ethical culture around the place? As conditions deteriorated hour by hour, what was the relative sense of hope or hopelessness as help from outside inexplicably failed to arrive? And if injections were indeed administered, what drugs were used: potent cocktails to end life, as Mr. Foti argues, or strong sedatives to alleviate pain, as many medical observers believe?

All of these need answering before serious ethical analysis can proceed. But it’s not too soon to begin asking a different question: What should an enlightened and compassionate society want from its medical professionals in such circumstances?

• We probably want them to say, “Never kill patients.” But what should the alternative be in such emergencies? Should doctors in the wards behave like medics on the battlefield by engaging in triage, focusing only on the wounded who might survive and leaving the worst cases untreated? Or should doctors act like captains at sea, sticking to wreck to the end and willing, if necessary, to sacrifice everything for their patients?
• Hospitals are being called on to create detailed plans to ensure evacuations in catastrophic emergencies. Would that exercise sharpen our preparedness in an age of terrorism and large-population natural disasters? Or was Katrina such a one-off event that such planning would be a luxury we can ill afford? If so, should hospitals be required to warn severely incapacitated patients, when they check in, that they can’t be certain of being saved in an emergency? Or does that smack of a fatalism directly at odds with our values of care and compassion?
• Should we be far more diligent in equipping hospital staff with conceptual frameworks for ethical insight and moral reasoning? Assuming that Dr. Pou and her colleagues were not pathological killers, what kinds of right-versus-right dilemmas were they facing — and did they have the tools to address them thoughtfully and explicitly? Under the pressures of the moment, were they equipped to work through the tension between fairness for the many and compassion for the few? What was their understanding of the moral courage that might be required in such situations?
• How much should we, as public observers, be prepared to ask of medical professionals? Is it fair to require of them a level of clarity in extremis that we ourselves may not be willing to demonstrate? How many of us know, with real certainty, what we would do in situations where exhaustion and helplessness conspire with compassion and a deep desire to reduce suffering? If, as a culture, we broadly accept abortion while arguing against euthanasia, are we sending uncertain signals to those on the ethical front lines?

Fortunately, there are pathways forward. Trainers in military and athletic programs know the need of so grooving the ethical responses that, however intense the emergency, the habit of right action kicks in and remains firm. A mountaineer once described to me the value of such training when he faced a life-threatening situation in a mountain-top gale. Even with “mental capacity … at half-mast,” he said, you had to “do the best due diligence you can at 19,000 feet and 27 below zero.” He wanted, in other words, to think right through the extremity, rather than let it do the thinking for him.

Hospitals aren’t mountains, and their staffs don’t think of themselves as mountaineers. In an age of ethical intensity and potential emergency, maybe they should.

©2006 Institute for Global Ethics