Social Reverse Triage in Washington State

assisted suicide, Our News & Commentary Blog, Washington state

You’ve taken over 300 million breaths in your life. You can’t imagine your next breath being your last.

Most of us don’t like thinking about dying. Those who do think about it usually do so in a clinical or academic way. Confronting death for real is hard.

Washington Compassion and Choices plans to wage another statewide initiative to legalize assisted suicide. They have decided the quality of life of people with terminal illnesses is so bad that it’s not worth living.

The right to die movement is more about politics than “end of life” decisions. A person with a terminal illness using assisted suicide to end their life is an insurance company’s dream.

Opposition to assisted suicide by Not Dead Yet and people with disabilities has tempered the right to die movement’s political efforts to include disability as a reason for using assisted suicide. Many of the people Dr. Jack Kevorkian helped to end their life were people with disabilities. The most vocal champion of Washington’s assisted suicide initiative is former Governor Booth Gardner. Governor Gardner has a disability and believes assisted suicide should be a choice available to him in ending his life.

We are not sure if the initiative will include people with disabilities as eligible candidates or stick to technically limiting the target population to people with terminal illnesses. In February, 2006 Booth Gardner told the Seattle Times-Intelligencer he wanted a law that would allow “doctors to give lethal injections to patients. Whether it’s “limited” or not, if the initiative passes it won’t take long for the right to die movement to push for something broader. The right to die “movement” considers itself a “movement” because their efforts today are just the beginning of where they plan to go in promoting assisted suicide and euthanasia. (see editor note at the end)

People with disabilities in Washington state know it’s too easy for doctors to decide that a disability is a terminal illness. We know assisted suicide will be recommended for people with disabilities if it becomes legal.

When I read materials from Washington Compassion and Choices it reminds me of Dr. Anna Pou, the New Orleans Doctor who inexplicably escaped criminal charges of giving a lethal doses (Pou denies her intention was to kill, but witness accounts are at odds with her claim) of morphine and versed to four patients. Dr. Pou describes “reverse triage.” “Reverse triage” is the approach she used in deciding what patients would leave the hospital and what patients would receive heavy doses of morphine and versed.

“We divided patients into groups one, two and three. Patients in category one are able to sit up and walk and are not very sick. Patients in three are critically ill, “Do Not Resuscitate.” The ones in category two were sick, but doing much [better than those in category three]. The triage system was very crude—we’d write the number 1, 2 or 3 on a sheet of paper and tape it across the patient’s chest with their hospital records.”

I believe the people of Washington state will again decide that we do not want to adopt a sick method of social reverse triage and defeat the assisted suicide initiative. —Duane French

(Note – for a recent example that gives a rare look at the broader agenda within the pro-assisted suicide movement, please check out “Death Wish,” which will get more discussion here at a later date. — editor)

NY Times Story on NHBD – Selling instead of Reporting

bioethics, Jane E. Brody, media issues, Our News & Commentary Blog, Ruben Navarro

Given the national publicity surrounding the death of Ruben Navarro, I thought the time could be ripe for a renewed discussion of the ethics surrounding the increasing implementation of the “non heart-beating donor” protocol. According to Maurice Bernstein, on his bioethics discussion blog, there’s a bunch of ethicists discussing whether or not the public is ready to accept this protocol on some email list. That’s the wrong discussion to be having.

The real question, which the Ruben Navarro case reveals, is whether or not medical professionals have the ability to competently and ethically implement the protocol.

(For a review of the details of the Navarro case, please check “Ruben Navarro and Our Need to Speak Out.” A transplant surgeon is facing serious charges for an alleged attempt to “hasten” Navarro’s death during this protocol when his heart refused to stop beating after a ventilator removal. No other professionals in the room – who stood by and did nothing – have faced consequences in terms of criminal charges or disciplinary actions by their respective review boards.)

I had reason to think that we all might revisit the complications and the high standard of performance that has to exist if this protocol can be defended. It was clear from a number of news stories that transplant advocates were worried about the impact of the publicity surrounding the Navarro case.

Well, it looks like they’ve gotten over being worried about it – or at least a reporter at the NY Times and her interviewees failed to show any need to discuss concerns.

The August 28th story by Jane E. Brody titled “The Solvable Problem of Organ Shortages,” falls short of real reporting and can best be described as a public relations piece for the NHBD protocol and the medical institutions implementing the protocol.

When I checked, it looks like the NY Times was one of the few major papers that published only one short AP story on the Navarro case. I can wonder why the Times didn’t find the story worth publishing, but the absence of that coverage certainly helped to provide cover in parts of the story that begged for some reference to the case. For example, there is this paragraph with a blanket and unchallenged statement about “strict regulations”:

Although willingness to donate has risen in recent years, major hurdles remain. Some people, for example, believe incorrectly that patients who might otherwise be saved are sometimes “killed” for their organs. Strict regulations are in place to prevent this.

Anyone familiar with the details of Ruben Navarro’s death would know that, at least in his case, “strict regulations” meant absolutely nothing when a transplant surgeon took over his “care” while Navarro was still alive. The surgeon then allegedly directed massive amounts of morphine and ativan be given to Navarro, which the authorities have said were intended to “hasten” Navarro’s death so his organs would be usable. Anyone who fears being “killed for their organs” now has evidence that this can happen.

Navarro’s unfortunate demise was connected to the practice of planning a death ahead of time, at a convenient time, which has obvious advantages for transplant teams:

Dr. Steinbrook said potential donors included patients on ventilators after devastating and irreversible brain injuries, as might follow a hemorrhagic stroke, as well as patients with high spinal cord injuries and terminal musculoskeletal diseases like ALS, for whom further medical treatment is deemed futile

This is the minefield that Ruben Navarro was placed in. In a wrongful death suit, Navarro’s mother has claimed that she was told the hospital had a policy that limited ventilator connection for coma patients to five days. If the allegation is true, it means that her “consent” to disconnect the ventilator could be viewed as coerced.

The paragraph that follows the discussion of the potential candidates contains some very troubling language:

These patients are technically not dead.

Odd. I would think that someone with high spinal cord injuries or a person with ALS would be considered both legally and “technically” very alive. What’s being implied here?

What it sounds like, is “these patients aren’t technically dead but we can treat them as though they really are dead.”

Patients like Ruben Navarro. –Stephen Drake

Did Katrina Prosecutor Mean to Lose All Along?

AMA, Art Caplan, Katrina, medical killings, Our News & Commentary Blog

(Note – I’ve made slight edits from yesterday’s original version of this entry to eliminate some ambiguity in places. Hopefully, these minor edits fix that ambiguity.)

During the last week of July, the news broke that a grand jury refused to indict Dr. Anna Pou on charges related to the deaths of four patients in the aftermath of Hurricane Katrina. A couple critical voices buried in the coverage were easily missed. For example, Arthur Caplan, who frequently disagrees with disability activists (which is fair enough, but he’s also been known to misrepresent what we say to his larger audience at MSNBC) and doesn’t welcome our input into bioethics discussions, expressed his disappointment over the failure to indict:

“There is evidence that merits a trial and consideration of the claims and counter claims of all parties involved,” Caplan said in an e-mail response to written questions. He was out of the country.

“I don’t know and would not predict what the outcome of a trial would be, but I think there is more than enough evidence to justify a trial,” he wrote. Caplan said in his report for the state that he reviewed nine deaths at the hospital.

“Each person died with massive doses of narcotic drugs in their bodies,” he wrote. “There is no evidence of consent. There is no documentation or record of any request on the part of any patient for assistance in dying.”

Had Caplan known at the time that even more important evidence and testimony allegedly never reached the Grand Jury, he might not have been surprised at the outcome.

Over the weekend, there were disturbing allegations that the grand jury never got to hear important testimony – testimony supporting the allegations that patients were indeed intentionally killed by Pou and possibly others:

A New Orleans grand jury that declined to indict a doctor on charges that she murdered patients in the chaotic days after Hurricane Katrina never heard testimony from five medical experts brought in by the state to analyze the deaths.

All five concluded that as many as nine patients were victims of homicide.

In detailed, written statements, the five specialists — whose expertise includes forensic medicine, medical ethics and palliative care — determined that patients at Memorial Medical Center had been deliberately killed with overdoses of drugs after Katrina struck New Orleans in 2005.

(Report with expert witnesses – pdf)

The experts weren’t the only ones whose accounts weren’t heard by the grand jury:

Family members of another one of the patients, Elaine Nelson, hired their own forensic expert to explore why the 90-year-old woman died. The report alarmed her son, Craig, a New Orleans lawyer.

“It showed that Mom had received on September 1 eight milligrams of morphine, which was four times the amount that she was prescribed by her doctor, and which was a lethal amount that was certainly enough to kill her,” Nelson said.

Nelson said neither he nor his sister Kathy, a registered nurse who was with their mother after Katrina until guards ordered her to leave the hospital, were called before the grand jury. Their forensic expert wasn’t called either.

Nelson has filed a lawsuit against the hospital owner and others. He said he refused a settlement offer because he wants the truth to come out, especially now that Jordan has closed the case. Nelson said he is disappointed in the way the grand jury was conducted.

“I think they’d want to hear as much evidence as possible to make a well-informed decision,” he said.

In spite of the gleeful applause coming out from organizations like the American Medical Association, the suspicion that maybe this DA presented a case in a way that was guaranteed to lose serves no one. It doesn’t serve the families who want answers. It doesn’t serve the reputation of Anna Pou, who will never be really free of the allegations if her “exoneration” depended on a tainted process.

I find myself in the odd position of agreeing with Art Caplan – although it’s been happening more recently – when he said there is “more than enough evidence to justify a trial.”

In the course of such a trial, the guilt or innocence of Pou could have been argued before a jury. And even if found guilty, a jury of peers that lived through the nightmarish conditions of Katrina would have been ideally suited to decide if the extreme circumstances were mitigating enough to soften its judgement.

Speaking of Caplan, given his stance on the failure to indict in the Katrina deaths, I suspect he and I might be on the same page in regard to the AMA’s move to exploit the publicity surrounding Pou and Katrina. In the same article linked above, it was revealed the AMA plans to “develop model legislation to shield physicians from civil or criminal liability when caring for patients in a declared disaster area.”

Sweet. I am sure the police, who had to deal with the mess out on the streets during and after Katrina would love the same deal. But maybe they don’t have a lot to worry about – maybe no one in positions of authority has anything to worry about.

In the course of researching this, I realized that it’s easy to miss the bigger context of the current events in New Orleans. It’s possible that the less-than-stellar performance is par for the course in this area.

The latest news indicates that prosecutorial blunders may result in effectively ruining the case of police officers facing trial for shooting a man with developmental disabilities in the back during Katrina.

One has to wonder if there are cases in which the District Attorney there is actually playing to win. –Stephen Drake

George Exoo – Suicide Tourist

george exoo, Our News & Commentary Blog, satire, Switzerland

Right now, activists on both sides of the euthanasia debate are awaiting the fate of George Exoo. He currently resides in a jail cell in West Virginia while Judge R. Clarke VanDervort weighs his decision in regard to Ireland’s request to extradite Exoo. Irish authorities want to try Exoo on charges related to his role in the death of Rosemary Toole Gilhooley in 2002.

Gilhooley reportedly paid Exoo and a companion $2500 to pay for his travel and expenses.

Exoo was founder of the Compassionate Chaplaincy, that by its own description, was “a 501(c)(3) nonprofit organization provides end-of-life counseling and compassionate terminal assistance to those whose lives have become insurmountably, unrelentingly, and endlessly painful and wish to end their lives at their own chosen times.”

This got me thinking. People who follow euthanasia-related news are familiar with the bizarre “suicide tourism” that has developed in Switzerland. In “suicide tourism,” disabled and ill people from outside Switzerland have entered the country for the purpose of getting “help” in committing suicide from the group Dignitas.

Exoo, it seems, took the idea of “suicide tourist” in a new direction. He was able to use the opportunity of Gilhooley’s plight, for example, to get two-way tickets for two between the U.S. and Ireland. To be fair, he and his companion took a trip to Amsterdam on their own dimes, but it is obvious the fare between the U.S. and Ireland is a lot more expensive than that part of the trip.

I’m a child of the 1960s. A popular poster during my teenage years (popular among my crowd, anyway) was a poster that took the established military recruitment posters suggesting enlistees would “see the world” and turned it inside out.

The poster was the conventional “Uncle Sam” pointing at you and said “Join the Army – travel to distant lands; meet exciting, unusual people and kill them.”

I have no idea if Exoo ever recruited members for his “Compassionate Chaplaincy,” but I thought maybe he might have a recruiting poster that looked something like this:


The image above is a poster with the title “Join Reverend Exoo and the Compassionate Chaplaincy.” Below that is a drawn caricature of Exoo. Underneath the caricature are the words: “travel to exotic, distant lands; meet exciting, unusual people and help them kill themselves – all travel, lodging and recreational expenses reimbursed – cash up front.”

Right now, we can just sit along and wait, along with George Exoo. And think about what kinds of things we won’t do for a paid trip to Ireland. –Stephen Drake

Ruben Navarro and Our Need to Speak Out

Our News & Commentary Blog, professional accountability, Ruben Navarro, wrongful death

Ruben Navarro’s death is “old news” by internet standards. He was a man with adrenal leukodystrophy whose path to death included an alleged attempt to kill him by a transplant surgeon. Five medical professionals stood by while transplant physician Hootan Roozrokh ordered massive doses of ativan and morphine for Navarro. One of those physicians was Navarro’s attending physician. A sixth medical professional, a nurse, administered the injections that Roozrokh ordered. Roozrokh is now facing felony charges of dependent adult abuse, administering a harmful substance and prescribing controlled substances without a legitimate medical purpose.

For the full story of Navarro’s life and death, please read Diagnosis: Murder by Cilla Sluga for the most comprehensive investigative reporting on the life and death of Ruben Navarro.

Ruben Navarro’s “medical lynching” occurred under the heart beating cadaver donor protocols. Unlike the more common organ harvesting done when someone is declared “brain dead,” the organs are removed shortly after a person undergoes cardiac arrest. This protocol is somewhat controversial, but many thoughtful people support it as ethical if it is done properly. Wesley Smith, for example, laid out his reasoning about the practice in this essay.

Whether it’s ethical or not, the practice has at least two big problems that don’t exist within the more common practice of harvesting after pronouncement of brain death:

  • In the case of brain death, physical functions can be maintained while arrangements are made to harvest organs after removal of artificial ventilation, minimizing time pressure;

  • The new protocol opens up potential “candidates” for organ harvesting who are not dead or dying at all. Ruben Navarro, for example, could have gone on indefinitely on a ventilator and may even have achieved some level of recovery if he had not been disconnected from his ventilator.

Meanwhile, there are several important issues demanding discussion, but no bioethicist or journalist we can find is discussing them (thanks to Cilla Sluga as a source for more than one of these important questions):

  • Was Ruben Navarro really dying? In the wrongful death complaint brought by Navarro’s mother, she claims the hospital told her that the hospital had a limit of five days for coma patients being on a ventilator? Could Ruben Navarro have experienced some level of recovery if he’d been given longer than five days? Is this claim true? How did she come to believe that? What does that mean about her “consent” to having his ventilator removed?

  • Can we trust the coroner’s report? Cilla Sluga reports that a betadine solution administered into Navarro’s intestines is toxic when taken internally. Navarro lived for hours after the alleged overdoses of ativan and morphine. Did the betadine kill him?

  • Why was no one else in the room charged with a crime? The medical professionals in that room all had a duty to prevent harm from being done to a patient. How did the medical review boards come to a decision that neither the attending physician nor the nurse who administered the injections did nothing wrong? Could they tell us what the heck they did right? What does this tell us about the medical profession’s ability to police itself and discipline its members for misconduct?

Right now, the news coverage has died down on Navarro, but it will flare up again, and more than once. Look for it to flare up again around September 12, when transplant surgeon Hootan Roozrokh will be arraigned.

So far, transplant advocacy organizations, bioethicists, and transplant recipients have made themselves heard in the coverage. That’s exactly what they should be doing in terms of advancing their respective interests.

Ruben Navarro, though, was a member of the disability community, and our voices have been absent. We need to claim our place in this story. The nightmarish treatment of Ruben Navarro resonates with some of the worst nightmares that many of our brothers and sisters talk quietly about.

To put it bluntly, Ruben Navarro would probably have been rejected out of hand as eligible for being a recipient if he had needed a transplant. It makes the circus of horrors accompanying the rush to make him a donor all the more appalling.

It’s time to get louder.

It’s especially important in California where legalization of assisted suicide is being pushed. Part of the “push” includes glowing promises about “safeguards” and “oversight” – the same kinds of safeguards and oversight that “protected” Ruben Navarro.

For some ideas on what to get loud about, check out this archived episode of WBAI’s “The Largest Minority.” Cilla Sluga and I discuss the Navarro case. –Stephen Drake

Addendum: I was just alerted that the archived audio of a show I did last week is now available. Thanks to host Geoff Langhorne of “disRespect disability awareness radio.” Disabled Los Angeles Man Put Down for Organs ? can be now be heard online or downloaded.