Five Days at Memorial by Sheri Fink: A Storm of Ethical Questions

Through the power of 24-hour international news coverage, the world saw the devastation and human tragedy caused when Hurricane Katrina moved ashore over southeast Louisiana and southern Mississippi early on August 29, 2005. It was one of the deadliest hurricanes ever to hit the United States, causing an estimated 1,833 deaths and leaving hundreds of thousands of people homeless.

What the world didn’t know was that at New Orleans’ Memorial Hospital, right in the centre of the maelstrom, life and death decisions were taken that would become the focus of a legal battle. At the heart of the battle lay challenging questions on whether medical practitioners have a duty to protect lives at all costs or whether – in exceptional circumstances – it is acceptable to ease the path of patients to death.

I would have been ignorant of that battle but for an article in The Sunday Times magazine in 2012 (based on Sheri Fink’s award-winning book Five Days at Memorial) which revealed the horrendous conditions at the Medical Centre where thousands of people were trapped for five days without power. Doctors and nurses worked tirelessly in humid, fetid conditions to care for their patients and to get them out as soon as rescue looked possible. But then those very medical staff were arrested and charged with murder when suspicious amounts of morphine were found in the bloodstream of 20 of the 45 patients who died.

Five Days at Memorial grew from a Pulitzer Prize-winning article written by Fink and published in The New York Times Magazine in 2009. She was drawn to the subject because of her experience as a doctor working in areas of conflict and as a journalist reporting on hospitals in war zones. It’s a deeply impressive piece of journalism which draws on more than 2 years of research and interviews with some 500 plus people, from patients to their family members and from hospital staff to legal representatives.

The story she pieces together from emails, phone logs, witness testimonies and floor plans, traces the events from shortly before the hurricane hit land. All her research points to how hopelessly inadequate were the plans of both the hospital, its owners, federal agencies and the city government. Lack of investment in flood water protection and drainage coupled with bad design decisions taken decades earlier meant the hospital quickly lost power for lighting, air conditioning, sewer systems and essential medical equipment. Day after day those trapped in the building waited for rescue by helicopter or boat. Controversially, staff adopted a triage system which saw those with “do not resuscitate” orders placed last in the list for evacuation. What happened on the fifth and final day is clouded with ambiguity. According to prosecutors some medical staff decided to hasten the death of the most critical patients with lethal injections of morphine. Those arrested protested their innocence but for more than two years multiple murder charges were pursued against one doctor and two nurses.

In part 2 of the book, Fink focuses on the investigation against those staff members (a Special Grand Jury refused to indict the three so the charges were dropped) and then examines the ethical issues surrounding euthanasia and health care in disaster scenarios.

Fink doesn’t pull any punches in her assessment of what went wrong at Memorial, seeing it as a microcosm of the larger failures that assailed New Orleans during Katrina, “with compromised physical structure, compromised operating systems, compromised individuals. And also instances of heroism.” She also points to a broader issue in America at that time with emergency preparations skewed, in the light of post-9/11 fears, towards acts of terrorism, not natural disasters.

By 2005, more than a billion dollars had been made available to the nation’s roughly 5,000 hospitals to promote bioterrorism preparedness. Memorial’s most detailed and by far its longest emergency planning scenario was written shortly after the 2001 attacks. This bioterrorism plan ran to 101 pages, as opposed to the 11 pages devoted to hurricanes.

Nor does she let the owners of Memorial off the hook, showing from email traffic how responded with indifference until the acute nature of the problem was staring them in the face. Staff felt their employer had abandoned them despite the extraordinary dedication they had shown in those five days. They received no thank you letter for their efforts and only partial pay when the hospital was closed for a six month clean up.

What lessons can be learned from the events at Memorial, Fink asks in the final sections of her book. She is in no doubt that some kind of crime took place at the hospital though she tempers this with respect and sympathy for the exhausted medical team and the conditions they endured.  They took action for the best of intentions but in the absence of any agreed protocols to decide how to ration medical aid, how could they be sure those were the right decisions?  “Moral clarity,” she writes, describing the moment the patients were injected with a powerful cocktail of drugs, “was easier to maintain in concept than in execution.”  And therein lies Fink’s key point, ethical questions of this magnitude cannot be resolved in the heat of the moment, under what are effectively war time conditions when judgements can be clouded.

To the extent that protections and plans have been put in place since Katrina, recent events have shown them to be inadequate or misguided. Life and death in the immediate aftermath of a crisis most often depends on the preparedness, performance and decision making of the individuals on the scene.

It is hard for any of us to know how we would act under such terrible pressure.

But we have the luxury to prepare and resolve how we would want to make the decision

Five Days at Memorial is a masterful and compelling piece of journalism though not a comfortable reading experience given its subject matter. It was tough going at times because of the sheer weight of information – I became quickly lost in a fog of names of doctors and patients and the finer points of the responsibilities of each federal agency – but the desire to want to know what happened and why kept me reading.  The reviewer for the Star Tribune in Minnesota exactly captured my reaction when he described it as “an important book that will make your blood boil no matter which side of the issue you support”

End Notes

Five Days at Memorial by Sheri Fink was published in the UK by Atlantic Books in 2013