In the wake of the devastating earthquake and tsunami in Japan, rescue workers found 128 elderly people abandoned by medical staff at a hospital six miles from the damaged Fukushima Dai-ichi nuclear power plant. The tsunami also killed nearly half the 113 residents at a retirement home in Kesennuma. Eleven of those who lived died of exposure, and the other 53 are in a shelter with only kerosene heaters to keep them warm in near-freezing condition.
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For the most part, help can’t get to the ailing and injured. Doctors without Borders says it may pull out of the area near the nuclear plant. In Japan, where nearly one in four residents is over 65, the disaster will likely take the largest toll on the elderly.
"We're trying to comfort and help them, but we can't do too much," Keiko Endo, a nurse at the Kesennuma shelter told the Associated Press.
The crisis calls to mind America’s devastating natural disaster of 2005 — Hurricane Katrina. In the aftermath, workers in New Orleans hospitals were left frantically trying to care for ailing patients without electricity, water, supplies — or anyone to rescue them. The ethical questions raised during that national disaster about what should be done for those left helpless and dying are so difficult that Americans never directly answered them.
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In New Orleans, Tenet’s Memorial Medical Center was marooned by the floodwaters. As temperatures climbed to 95 degrees and above, the hospital became a fetid, smelly hell. Most doctors and nurses left. Some patients were too sick, too fragile, or too obese to be moved. Dr. Anna Pou and two nurses heroically stayed on with their patients.
Without power, they knew those kept alive by technology would face terrible deaths. Nine of them did die. Each of those had massive doses of narcotic drugs such as morphine or Versed present in their bodies. There is no doubt in my mind, as I wrote in a report to the Attorney General’s Office for the State of Louisiana, that they died as a result of active euthanasia —mercy killing. Was that the right thing to do? I do not think it was.
When faced with the unimaginable choice of what to do for suffering patients for whom no rescue is likely, I think doctors and nurses still ought not kill. But what they must do is provide as much pain medication as they can, even leaving their patients close to death. The line is fine, but there is a line. Aggressive pain relief must be offered. Massive lethal doses should not be.
In Japan, the few doctors and nurses caring for the stranded, ailing and perhaps dying elderly or injured may be facing similar questions. We hold out hope that help will somehow reach them but if they have no electricity, food, medicines or water, and if those caring for them feel they must leave should radiation become a dire threat, or if rescue becomes impossible, then, well then, what?
Should they be left to die a prolonged death, or do extraordinary circumstances create conditions in which what would normally be morally unthinkable — deliberately accelerating a patient’s death — must not only be thought about but acted upon? My view is no. Pain relief, even risky doses are called for but not killing. Still what if there are no drugs or no one familiar with how to use them?
No society, including Japan, wants to discuss such horrible choices. Many nations, including Japan, find the notion of assisted suicide so morally abhorrent that it is rarely mentioned. Japan has had one court case in which a doctor was tried for helping a suffering patient die. The court ruled in 1995 that assisted suicide was justifiable as an absolute last resort. But that case did not lead to any change in the law, and few Japanese health care workers are even aware of it.
But, when disaster forces the issue of what to do for the frail who cannot escape a dire fate, more is required of each of us.
Shouldn’t Katrina, 9/11, the earthquakes that devastated Haiti and Japan and other calamities lead us to have the courage to face the hardest questions? If euthanasia isn’t an option, then what ought to be, short of abandonment? Every health care worker should know that pain control is an absolute duty when conditions become impossible even if it risks the death of the frail and the weak. And, if mercy killing is to be an option then we should develop clear guidelines about when and how in order to prevent confusion, doubt and abuse.
Most of us can do little but watch the efforts being made in Japan today. But the little we can do is set policies to help those whose lives may be ended or shortened and their caregivers know what we expect of them.
Arthur Caplan is director of the Center for Bioethics at the University of Pennsylvania.
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