New medical students ponder life-and-death questions
During orientation, Stanford’s new class of medical students met with deans to pause and reflect on the meaning of pledging their lives to the compassionate care of patients and the challenges involved in achieving that goal.
Silence fell in Berg Hall when Alvaro Galdos stood amid a crowd of new medical students and their family members and recalled the decision to end life support for his youngest son, Luis, who was 8 year old.
“Eleven years ago we lost a son at a hospital in Texas due to a congenital heart defect,” Galdos said. His oldest son, Francisco, a first-year medical student at Stanford who was 11 at the time, hopes to become a pediatric cardiologist.
“As much as we loved him, we didn’t want him to suffer anymore,” Galdos said. “We knew the end of his life was coming. We made the decision to stop everything. Was this euthanization? We still wonder.”
What is and isn’t euthanasia? Is there a line between euthanasia and murder? How does a physician always uphold the Hippocratic Oath, which includes a pledge to abstain from doing harm?
These were the types of questions raised during an hour-and-a-half discussion among this year’s class of new medical students and their family members; Lloyd Minor, MD, dean of the School of Medicine; and Charles Prober, MD, senior associate dean for medical education.
The discussion, inspired by the book Five Days at Memorial, a grim recounting of the horror at a New Orleans hospital following Hurricane Katrina 10 years ago, was part of a three-day orientation for new students in preparation for the start of classes Aug. 24. The book was assigned summer reading.
Donning the white coats
Each year, new medical students receive their white coats and stethoscopes during a ceremony on the last day of orientation. Then they stand together as a group and read the Stanford Affirmation, which is a pledge written in the spirit of the Hippocratic Oath — an ancient vow to uphold certain ethical standards of caregiving.
The new cohort of 90 students was chosen from an applicant pool of 7,200. Twenty-six were born outside the United States. Nine entered with graduate degrees — eight with master’s degrees, one with a PhD — and 40 have published in peer-reviewed journals.
Most had not yet faced the responsibilities they will encounter routinely as physicians. It was the ethical and emotional challenges ahead that Minor and Prober hoped to explore during the book discussion. “I think one of the key lessons from this book: If we’re going to make progress in medicine, we’re going to have to face realistically when we make errors," Minor said. "Progress only occurs when we are able to frankly address those situations and acknowledge those errors.”
The book describes health-care workers treating patients in a way that could arguably violate tenets of the Stanford Affirmation. “You will be reciting this later today after you receive your white coats and stethoscopes,” Prober said. “Hopefully, the affirmation will have more meaning to you. It will help you to reflect more deeply on the words as you ponder it into the future.”
Written by Pulitzer Prize-winning investigative reporter and Stanford-trained physician Sheri Fink, Five Days at Memorial is filled with ethical conundrums about what constitutes humane health care.
The book describes how medical staff and patients in the flooded hospital had to fend for themselves in the days following Hurricane Katrina. After the waters receded, authorities discovered that 45 patients had died at the hospital. Three health-care professionals, including one physician, were arrested for murder. A New Orleans grand jury ultimately refused to indict them on charges of involuntary euthanasia and murder, but exactly what happened during those five days, when temperatures soared, sleep was rare and proper sanitation was nonexistent, remains unclear.
What is clear, as Prober described it, is that the lack of planning, communication and panic worsened an already unimaginable situation, one that no physician ever wants to face.
As I read the book, I imagined how horrible it would have been to live through this tragedy.
“As I read the book, I imagined how horrible it would have been to live through this tragedy,” Prober said. “It’s amazing they stayed after abandonment by the federal government.”
The book, which Fink herself said she hoped would inspire discussions, captured the imagination of Prober and Minor, who described how they met over dinner to discuss it.
“When we met, it became very clear what we could talk about,” Prober said. “Did the care providers do the right thing? ... The question is whether or not it was kindness or at the other extreme, murder.”
According to the book, it is clear that physicians administered life-ending injections of morphine or the sedative midazolam, or both, in about half of the patients. The Louisiana Attorney General maintained that a number of the dead were victims of homicide.
“It was definitely hard to know what was right or wrong,” Minor said. “They showed a lot of courage staying behind and working. Lack of communication and leadership was a big problem. If there is a villain in this book, it was the parent hospital chain for Memorial. The crew was told, ‘We can’t do anything. You have to wait for the military and the Coast Guard.’”
Can euthanasia be justified?
Prober and Minor posed the question to the audience, “Is involuntary euthanasia ever justifiable?” The general consensus was that involuntary euthanasia is never OK, even in dire circumstances. But questions remained.
“Isn’t it equally morally reprehensible letting someone die without care?” said incoming medical student Mariposa Garth-Pelly.
Another student added, “I feel like in the reality of the world, [health-care professionals] are also human beings that have needs.”
“I don’t know that I would have made a different decision,” said another student.
The conversation lingered over the book’s vivid description of the helicopters landing in a poorly lit, precarious spot on an aging landing space where health-care workers struggled to carry patients up stairs and through a tunnel to evacuate them. One health-care worker was badly injured while transporting a 300-pound patient to a helicopter. The workers feared some patients would be left behind alone without care following a mandatory evacuation. Panic reigned.
“Mistakes were made,” Minor said. “But progress only occurs when we acknowledge those shortcomings and hopefully grow as a person and as a physician.”
At the end of the discussion, the students and their families walked outside to Alumni Green, where they accepted their white coats and stethoscopes during a ceremony. Parents clicked photos and shed tears. Then the entire class stood together and recited the Stanford Affirmation, which begins: “On my admission to the practice of medicine, I pledge to devote my life to the service of humanity.”
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