>> you start. >> okay. i'll start then by agreement. first, it's wonderful to be here with so many friends and new friends and new acquaintances, and also just definitely new america. it's a wonderful program that they have supporting authors, people who are working public policy, research for books are welcome to apply every year to the program and it just gives us a huge amount of freedom to pursue and support and wonderful colleague so i'm very grateful for having had that support and being a part of that program. and so i think we're going to try to have just a really good discussion today, and that means all of you, hopefully, we'll get involved as well. we will talk for a little while and then open it up for discussion, and then have some wine and cheese after.

and really, a big reason why i wrote "five days at memorial" is i really feel that these questions, difficult, conundrums that arose during katrina are things that we all have as a public, should have a say if they're not the purview of just small group of doctors on the front line and emergency, but something we should all think about before disaster ever happens. so we'll get into some of that, and i'll just start with kind of summarizing the book is setting up some of those dilemmas all of it and read just a tiny bit of where dr. baden comes in and then we will discuss. the question, do exceptional times allow us to make exceptions to moral rules? or does a time of crisis called for an even eager commitment to our deepest moral values? that is kind of essentially one of the questions that is at the heart of hurricane katrina --

"five days at memorial" as post by one of the eminent medical ethicists. memorial medical center was surrounded by floodwaters after hurricane katrina in 25 -- 2005 when the levees failed. the packet generator system was not protected against flooding, which as you will know here in new york city from hurricanes and last year, it turns out it is a major vulnerability of american hospitals, that these systems are circuits and they're only as strong as the weakest part. if your fuel pump is below flood level, like at bellevue, and it's not protected adequately against flooding, you will face the possibility that you will lose your backup power even if your generators are above flood level. we saw major hospitals in the city almost exactly a year ago this terrific singer that was all too similar to katrina.

so by this point when the flood water started to rise they knew that all power would soon fill. rescue helicopters began arriving at memorial medical center but they could take one occupations at a time and there were roughly 242 patients. there were about 2000 people in all, 600 staff, a lot of family members, even pets because family members to bring their pets to the hospital rather than having to leave them at home in a hurricane. who would you rescue first? would it be perhaps the sickest because of course their lives depend so much on electricity pretty much everything these days in an american hospital runs on electricity. and perhaps the healthiest, because they could be moved more quickly and you might have a better chance of helping people who could survive the longest overall. could it be that babies in the neonatal i see you, these very vulnerable babies who might have risk of death but if they did

survive they could have a whole life ahead of them. or when it may be be the oldest in the population because of all the years that they lived in the wisdom that they had gathered and each one of them is so valuable, too. and, of course, they had served their communities for so many years. something that was medical professionals themselves of course, some of them had health issues and were tired and worn and, of course, as we saw after katrina there was a huge need for their services. so should some of them get privatization when the helicopters start to come? katrina was not unique and, in fact, these situations of triage do arise every time that there's a case where medical needs outmatch resources, whether it was after the haiti earthquake in 2010 or even some cases that arose here in new york city after sandy, particularly in the book, in the epilogue of the book is a discussion of bellevue hospital where they feared they

would lose all power except for six outlets in their icu of typing 55 patients their over all, and head of the icu was literally passed, in a one hour to decide to tell us which patients would get those outlets. this is not just katrina, fortunately. we will talk about what happens there but some creative thinking prevented that from taking place. that's another lesson of the book, is that sometimes when you think that there's no hope and that these really bad decisions have to be made, sometimes they can be averted with creative thinking. >> well, doctors at this hospital did get some of the sickest patients out first before the floodwaters rose to high, and all power was lost. and they wrote numbers on pieces of paper to prioritize patients, and then they change the order. so the ones where the healthiest. the queues were a little bit

sicker and the threes with a very sickest. the patients with the do not resuscitate order to the threes would go last. as rescue efforts lagged, a desperately sick got even sector. what was to be done about and tm when it was time for everyone else to leave? what is the line between comfort care and mercy killing? who decides? well, at least 20 patients, according to the work of forensic pathologists like dr. baden and some of his colleagues found were injected with morphine and/or a powerful sedative, and died. so from these five days of memorial in this age of rising these an ever quickening pace of natural disasters and accidents or threats, what is it that we must learn? five days at memorial is really about what happens when disaster strikes in the places in the system that lives depend on the

most are not there to serve us in the way that we hoped. and we think of our nations competing priorities, it's reasonable to ask what are the stakes of preparedness for these really for siebel and also rare circumstances. i think hopefully in reading the book, what the results are of failing to be better, we can get better sense of how much we may want to invest as a society or as businesses or as individuals in preparedness. and the book itself is also about not type in literature almost, a desert island were suddenly you're cut off and surrounded literally by water, and what happens to society and human behavior and organizational behavior and thinking. so i am -- a bit of a background, i'm a physician by training and that worked in a number of disasters and conflicts zones for some years. my first book was about a war hospital in bosnia, and three

years it was under siege. sort of what the experiences with the doctors and nurses and patients were there, but in all of my work i had never heard of a case outside of really the realm of fiction and movies where the medical staff had gotten so desperate that they literally started thinking about perhaps actually affecting hastening the death of their patients. so that's what really attracted me to the story when these rumors start to come out, and news reports. and i thought it is very urgent that we understand what is it that really happened here before the next disaster. and so the first half of champion is really looking moment by moment at kind of a disaster as it unfolds and then the second half is the part where dr. baden daemon and the question of trying, on the side of the justice system to reconstruct it and figure out what happened, and also how does our society adjudicate acts that

were taken and it really kind of in the context of utter failure of governments and hospital corporations and organizations, and so can we bring somebody to justice for these attacks, even if they did occur? so the deaths of some of the patients in particular dupont meeting, and i think a lot of people who worked o on the case. one of them honestly about briefly, his name was m. it ever. he was 61, a merry gentlemen, a doting grandfather, but he weighed nearly 400 pounds. he was partially paralyzed and he is on the seventh floor of the hospital but no longer had working elevators. and he asked his caregivers that morning, are we ready to rock 'n roll? he was awake. he ate breakfast. effect himself breakfast that way, was very conscious and very motivated to get out of this situation. he was one of the patients who

died with all the other patients with these drugs in their bodies. so after a year of investigation, one of the doctors at the hospital and two nurses were arrested and accused of second degree murder. and a young lawyer was assigned to prosecute them. and he struggled before a grand jury, attempting, as decide, to try to apply justice to a war zone. what i've learned in every disaster where i've worked is that what matters most in the immediate crisis situation, where often the larger systems fail as we saw in sandy, it's really the action of you and me and the people around us, and our own personal preparedness in decisions that can help make the difference between life and death. and so that's why trend can really focus is on individual decision-making. so with that i thought i would read a little section that dr. baden is in and then maybe you can take it away from their and

bring up some of those important issues that we discussed earlier today. >> so, about a month after the arrest happened, a group of friends and pathologists and toxicologists and the local corner it was an obstetrician gynecology i couldn't, so he called in these experts to help them with classifying the deaths, they all convened at the corners office, his actual office has been flooded so they met at a former come at the vacant good roads funeral home, a single story concrete building with bordered up houses and which upsets neighbors. that's what he was using as an office. the importance of the meeting was clear. the attorney general's staff at arrested these health professionals, but it was the

district attorneys and staff who had to decide whether and how to prosecute them. they were also invited, those members of the staff are also invited. as of that moment the local corner that kept most of the patient's death certificates. he called them pending investigations. with a kick in the check box under sometimes accident or hurricane katrina related deaths, among them he said. the experts at around a large table and begin considering evidence. the lead investigator and two nurses who worked the case in the fraud unit had prepared charts and tables depicting the drugs found in each body. robert middleburg, the director of the pennsylvania toxicology laboratory where the autopsy -- autopsy samples were tested joined them to resent has resulted the three al-kibar fisa been arrested on the basis for death by 23 of the 41 bodies from memorial, and the local hospital called lifecare that

was leasing a part of the building, tested positive for morphine and other drugs. the toxicologtoxicolog ists handled thousands of cases in his career in the drug concentrations found in many of these patients seemed high to him made him think these numbers are speaking out sort of like a sore thumb. so interpreting toxicology results from tests on postmortem tissues was not as straightforward as interpreting blood tests including patients. the fact that the bodies had sat out in the heat for a long time before sampled could have changed the concentrations of the drug. middleburg advice his colleagues to consider each patient's clinical history in conjunction with the lab numbers and the group began pouring through the available medical records case by case but were many questions to consider. typify me suggest the patients received a single massive dose of the drug shortly before death come or repeated doses that

allowed the drugs to cumulate? with the morphine, nation have been contraindicated in patients with certain medical problems? with large courses -- goes of these drugs known to suppress breathing the dangers to any patients not on a respirator? how long would it take for the drugs to decrease the breathing rate and blood pressure? if this match up with the times of the death to the extent these were known? the experts went over evidence related to lifecare patient, a 90 year-old nursing home resident who was being treated for pneumonia. the drugs are found in her liver, brain and muscle tissue but not the drug had been prescribed according to our chart. which was kept going until a few hours before her death was recorded on thursday september 1 pitch she had been quote resting comfortably on wednesday afternoon and that night and nurses didn't document any complaints of pain or distress the indicated a need for the

drug. so then they go on and each of the forensic pathologist takes note and makes the decision about what they think about those deaths. and so they looked at all the patients that were on that one for and they thought -- dr. baden thought all nine were homicides. and let's see here. i think that i will -- oh, i'll just read a bit about what happened when the staff showed up. so the first day of the meeting passed with no participation from the district attorney's office. hearing firsthand from the experts was apparently not a priority for those who might be presenting the case to a grand jury. on the second victim to assistant district attorney finally showed up. the lead prosecutor on the memorial case was a young dark admin was slightly crossed eyes,

give prosecutors homicides were only about two years and arrived at the corners office with his boss. what do you have, one of them asked? their manner, particularly the short test the one struck the to forensic pathologist as unusually hostile to the experts were accustomed to ass kissing from huskies but i think that was your quote. but these attorneys acted suspicious, skeptical and uninterested. the lawyers left after about a half an hour. obviously these guys don't want to do anything, dr. baden commented. what was striking was the pattern. almost every patient who died after the helicopters and boats arrived on thursday morning and whose bodies were tested were positive for the drugs.

>> positive for the drugs that they shouldn't have gotten from our review of the records. let's see, lessons i've learned. i've been down to new orleans a number of times where they had problems. the corner had been there for 40 years, very nice fellow. has to get elected every four years. so the corners system is probably the oldest municipal system that we still have that was inherited from mother country england in the 17th century. most other things have changed. this is a no reamer shoe same as was in the 17th century in england. he made great strides in improving the system.

we happen. any citizen of voting age can run for corner. everybody -- the medical examiner system came in the end of the 1900s, the end of the 19th century, put a doctor in charge. the doctor in charge became a pathologist. new york city 1950 was the first system to say that -- >> that coroner did not have to be a doctor. >> he was one of the few who is also a physician. a physician runs for office against the directors. they are the ones are interested in dead bodies. and what's important here is,

thinking about what happened, is that in louisiana, this goes different state-by-state. in louisiana, the attorney general can investigate a case like this and bring charges against doctor poe and some nurses, but it's the local district attorney in this place, jordan who might gather, i never met him, not a very good district attorney to i think that something like 15% conviction rate in murders in new orleans, which even by american general stands is very low. and the local people are the ones who prosecute. so the state brings an action as here, it's up to the local district attorneys to decide,

the local district during the get elected who decides it wants to pursue the matter speeders and the local coroner had this hugo and he was also elected. and you were saying about we told you about how conflicted this was between the evidence and the will of the community. >> the coroner in new orleans is a trumpet player. i came down after sheri fink's first section about which, i think she brilliantly describes what was happening in the memorial hospital, not only with excellent writing, pulitzer prize level writing, but with the ph.d's knowledge of what goes on with the hospital. and the very little things that doctors reactor, what the beds look like, what the ventilators

look like and all was just, i mean, made me feel i was right there, those five days, which i wasn't. i can a few days later to do the autopsies. what was a, 1200 s. altogether? >> that dry. ufology. because of a larger number of patients, not patience, what a lot of patients. many have died in hospitals but the vast majority have died out in the city so they needed volunteers to come down and work at this big collection point that turned into a large mortgage. >> saint george's? >> saint gabriel spent in saint gabriel, they created a center, a place to do autopsies. and at the same time fema aid $20 million to build a proper one. it was an old building we did the autopsies in. ride across the way.

fema gave like $22 million to build a proper facility for autopsies. by the time it was built, we finished, and that $22 million facility just stands there with nobody using it and doing anything in paying rent to the owner of the land, which is some of the frustrations of dealing with government. >> so let's go back to the case. >> no, no. what i was saying is that, so i came down and of course going over lots of autopsies and these nine cases, all of them came in that were in with all the other deaths were lots to talk about those which is not pertinent tonight. what was concern to me was that after, and with some great pathologist of canada, chief

bioethicists from the united states. a few forensic pathologists who hahave been through lots of deaths. we all had determined that these were homicides. >> we should say that a medical homicide, this is different than whole question of what, where the send us a tweet to jail. this is purely whether the action -- to me if i'm right, the action of one human being leads to the death of another. that's what you guys are charged with. notwithstanding whether somebody should be held responsible for that. your job is simply to say whether this is technically a homicide, is that right? >> not quite. >> please. >> if i might, if a doctor is something wrong, if the doctor takes off the wrong leg or puts the anesthesia than in the stomach instead of the lungs and the patient dies, you know, the kind of things that are medical malpractice, we don't, that's a

death called by doctor. doctor. we don't call it on the site unless it has something to do with -- therapeutic misadventures. [laughter] one of these lovely words that was made up. >> you guys don't look at -- >> we only treat our patients if it results in death. so all our patients are dead. we have to speak for the patience, you see. no. i think what it is is we have categories. easier on some see as i think, national accident, suicide or undetermined are the mode, the manner of death. when we say homicide in general, it's death of dance of another which may or may not be a crime. >> that's the point i was trying to make spent if it were self-defense or if a person dies by lethal injection, legally.

>> in this case you weren't being asked who to hold responsibly or you were just asked whether these drugs were injected may have caused their death. >> that's right. one factor. that is, so that when we say homicide, then it's up to the district attorney or someone else to decide if it's a crime or not because not all homicides are crimes. would we decide is this is a homicide, we say homicide because this wasn't just one death. this was just one death with morphine and%, but nine deaths occur at the same time from all the other factors involved to our judgments was intentional. it was intentional but we don't say whodunit. that's again up to the police. sheri fink can figure that out.

that it was intentional and, therefore, we call them homicides. the problem and part was from the corner was a lovely fellow, i've known for years, explained to me, look, he's here to help in new orleans growing out of this terrible disaster. and they've been hit hard by the storm and he didn't field, he says to me, that he could just go into the grand jury and say that there are nine murders because that wouldn't be good for new orleans. he did tell me that he did testify -- i haven't seen the grand jury, that one of them, effort, this fellow who was totally alive and well and had no reason -- >> kind of sick but not on the

verge of death. >> he shouldn't have died when he died. >> i want to push back on one thing though which is nine deaths at one time with these drugs in the bargain you could still mount a defense that this is just giving them the wrong doses. that intentionality is wouldn't necessarily follow. it was highly suspicious, but -- >> it would be suspicious enough for us to call them homicides, and then it's up to the district attorney to decide whether to proceed. now, the problem i have, so let's see, so i think that whenever the reason the local people didn't want to call it what it was, even though they knew what our opinions were, and the district attorney didn't call any of us into the grand jury. normally we give our opinions to the grand jury when we issue a

cause of death and it could be criminal charges. >> so none of the experts. >> by the state and the county, what isn't? >> orleans parish. >> thank you. spent everything is different in louisiana spent this is what you call the napoleonic code stuff. >> all right. you want to leave them with that and we go into discussion board you want to make another -- >> i want to make another point. so what it reminds me of that at the center talking, deaths are too important to lea leave justo doctors to make their own decisions. i think with all that's gone through, there is no justification for euthanizing somebody without their permission to there's a big

argument whether you should have euthanasia at all, i won't go into that because doctor kevorkian and all that, but in this situation not of these patients signed up relatives or said they wanted to be euthanized and they were. now, if they had requested it but this is nonconsensual euthanasia, which in my book is homicide. >> most of them couldn't -- >> but they had relatives spent the relatives were made to leave before action was taken. >> made to leave by armed guards. before this action, guards appeared hired by the corporation who owned it, or -- >> no, no. they didn't only. yet, it's not clear whether it was the police or whoever, and the made in a separate action. so at that very moment, this is the key about your resources can change. these doctors and nurses felt very, very desperate, and

they've been waiting a couple of days for the hospital to be emptied and it was going very, very slowly. and ironically or horribly just at the moment when find all of these resources were focused in on this hospital and helicopters were literally waiting overhead as wonderland and the next and the next, and boats were coming and thanks to creative thinking of some doctors, they went out and other staff at hotwired the votes in the neighborhood that were on trailers and brought them back so they could take the healthier people out by boat to dry land which is only eight blocks away. as this i was happening there we calling out women and children, women and children. there was this big urgency to can get all the healthy people downstairs to get on the votes. this may been -- may not appear again it looked suspicious. they are whisked away just before the drugs are given but it's not clear that those were actually linked. they were temporarily linked but i did not uncover evidence that they were called then

specifically to tear these loved ones away from their family members pick and they did tear them away. these people did not want to leave the relatives. >> they were there all through the five days. some of them were there with their loved ones that needed assistance and all. and they were forced at gunpoint to leave the seventh floor just before a doctor and nurses come in and make injections, according to some people. >> families were being separated all along. these were some of the horrific scenes that everybody was eating with. >> sheri should be a lower, too. spent know. i think the key is the truth and understand the truth, and the truth is very nuanced. the truth is very clear but it's also, we need to keep the context spent we teach medical students, we can teach them that it's all right to euthanized patients under any circumstances

if a patient doesn't agree. that if the patient does agree, a kevorkian argument, that's different. but somebody going around and injecting morphine and an anesthetic type is like injecting propofol. we've heard about willful fall. because the death would occur within just a few minutes. the person is dead. because they can't breathe and these are sick people anyway. but the point i want to make is that some of you probably -- some you're probably football fans. the football he has a bit of a problem with traumatic brain injuries. the reason they have the problem is for 20 years, the national football league has said that had concussions, head injuries have no cause for injuries going down the line and that's because

they had their own doctors, their own neurologists who published -- they got paid from national football league ended it with the national football league wanted and they published -- >> conflict of interest. >> but what happened is that until the bus came up recently, they published -- files. they published an article say there's no reason to be concerned about head injuries, even just because they get knocked out doesn't mean anything over time. and now that's all suddenly change because suddenly they are being sued and all that. now, when i was reading the book, sheri's book, what struck me was how similar what went on in sheri's writing with what used to go on in prisons, where prisoners, in new york state,

complained of inadequate medical care and complained of coverups of deaths, and which led to the avatar rising in 1971 where 43 people were killed, 12 guards and the rest are presented as a result, governor rockefeller set up an oversight panel, to oversight the department of corrections which was in charge, and appointed a medical review board, a five member medical review board, a forensic pathologist, i was at -- and some other people. and to look into every death that occurs and since 1971, there hasn't been a single death in a riot in new york state because all the jails and prisons throughout the city and the state, because when there's

oversight come when they know that someone is looking over their shoulder, that care becomes better. and i bring that up to the memorial hospital because the investigation, and this is beautifully described by sheri, of the medicaid fraud unit of louisiana, attorney general, investigated these deaths. >> that did all this research and into the investigation. >> there something wrong. these people were not being treated properly and that's what led to the governor arresting them. spent attorney general. >> attorney general, i'm sorry. and that there has to be some kind of national standard, and i think in raising this, what happened here, of how to protect people in nursing homes

especially. this is like a nursing home, this seventh floor thing. because we are going to have increasing number of people in nursing homes over, as the years progress. and there's no oversight. it's a situation where a lot of it is privatized. we are having fights about the privatization of medical care in jails and prisons. remember, about 40% of the money paid to private companies for medical care just goes into the bottom line. you get a lot less money and not as good of doctors to take care of the prisoners so we have increasing deaths because of privatization. and i think in the nursing home business, there's a lot of privatization just like the seventh floor was privatized spent the whole hospital spent

the whole hospital. and we have to be careful, and i think this is a plea also for increasing for the state authority, you can't rely on the local counties. what happened with the corrections commission was governor rockefeller set up a state investigation unit to bypass the local people who get elected. that's what made, with a subpoena powers and a lot of things that made the ability to take action by the state, even though the local coroner, 50 of the 62 counties in new york, the police, they go shooting and need somebody to oversight that, and that should happen. and i think that's one of the discussion points. >> this is a really interesting point. is to summarize this idea but in this case the arrests were extreme and popular in the local population because people felt,

again, everything felt around these doctors and nurses, and yet they were the ones arrested. so it was very unpopular. the local district attorney was facing a huge lawsuit. he had recently been elected. he was the first african-american district attorney in orleans parish, and he let go a number of employees who were white, and he was sued for racial discrimination. so he did not need another unpopular cause because he was fighting that fight. this became very unpopular. and so i think what dr. baden is interesting is that when that's the case and won a coroner also is elected and feels this pressure from the local community that they may not be able to be objective in terms of presenting the evidence and there was a big pushback from the attorney general of the state saying that the grand jury didn't hear the strongest evidence, and that's why these women didn't see jail time. and that may or may not be true.

it may also be true that the citizens decide as they often do in case of mercy killing, it's very red if somebody is accused of that actually goes to jail because there some discretion that a jury has. so i want us to stop talking now so that we can have a few minutes. is fascinating. you have so much history that you bring to this but let's -- >> current events. >> i want us to learn from history. >> euthanasia is never done without the consent of the person being euthanized. >> so even dr. kevorkian who really wanted this to be an issue was acting -- >> total consent. >> he is one of the few who's gone to jail or tried. >> one other thing. >> is that okay with the audience? >> in 1947, in england, an

english girl, 16 or 17, was raped by an american soldier, got pregnant. england have very strong antiabortion laws. when this girl was brought to the attention of the chief obstetrician, the president in england, he thought that she should have an abortion because this would destroy her, this pregnancy. he does the abortion against the law, calls up the police here to please come and arrest them afterwards. he stands trial, and the court ruled in his favor. that changed a lot of things in england at that time. now, dr. poe, any doctor wants to make a point about euthanasia, or -- they should tell the truth. yes, we did. there were witnesses.

witnesses saw them getting injections. on the seventh floor. yes, yes, we did it. we thought it was the best thing. if you want to arrest us, arrest us. but in july about because they lied about and they teach other people to lie. is medical students learn you can lie about it, the nurses or want, that's one of the things that concerns me a great deal. that's beautiful he brought up by sheri in such a way that she can't get sued. [laughter] my wife is an attorney. she doesn't say this is what happened to sh jason this is wht somebody said happened. my opinion is -- >> that's journalism them especially when people had to use. but fortunately there were a couple of doctors who were willing to speak with me and to say on the record, and i think very bravely after dr. poe had

been arrested, yes, i injected patients and i intended to hasten death, and here's why i did it. and i do really respect him for doing that. figured there was very much a code of silence around these events and many health professionals to this day do not want this discussed it and i think that is dishonoring incredible hard work of the medical professionals who worked so hard in the memories of these patients cannot do this to the world for us to learn so we don't have to go, put our health professionals in this situation. put our patients and family members in this situation. so that's my take on tha on thee controversy. but anyways, thank you so much. i mean, the history that you bring to this is very important. [applause] >> we are not done. >> let's get some wider discussion.

yeah, there's a microphone. >> i wonder, sheri, argue seeing today, present, and never to bring attention to him medical ethics in the states across america? and if so, are you seeing sort of increased efforts to bring that attention to that issue? and if so, what parts of the country are you seeing it the most? >> yeah, i think medical ethics are always a topic of discussion in medical school, and we have like a current american view. [inaudible] >> okay, okay. so what there is now, and this is a big part of the epilogue of the book is that after katrina it was a realization that these decisions might have to be made about to do you prioritize when you have in this case helicopters coming slowly, what we also the scenario like in

1918 style flu pandemic which, god forbid, could happen. we have some very scary avian flu cases that made people think that this might be on the verge of happening. to our efforts around the country of small groups of medical professionals getting together and coming out with a prioritization guidelines to help people so they don't come it's not just a small group of doctors in a room as the flood waters rise, but whereas these guidelines would exist in events that would help you decide, for example, in that case it would get access to an icu. because the ic would be overrun. it would not have enough bandwidth for everybody who needed that to get through the flu. so they've come up with some interesting guidelines for doing this. it's also a bit problematic because, for two reasons, one is what i have a lot of research on when you decide what your goal is and is it maximizing your supply, is it factoring in age?

everyone wants -- we all want the same innings of life. should it be random, tried to make it more fair, first come, first serve? that would bias against people who live far from hospitals. all these different factors you to bring to it. is not a purely medical decision. .. >> what they found was that they didn't predict that well, and

there was dissension. even the people who had come up with the protocols couldn't agree on how certain patients should be categorized. so that was problematic. also some of these protocols call for people to be taken off of ventilators if they haven't improving fast enough without consent, and that would require a change in law, most likely. and just thing of the trauma to the medical rollsals and the fam -- professionals and the families, that's a little troubling. and the other way this is troubling is that all over the country this is happening, but how many of you guys knew about this who haven't read the book? that's a pretty good -- okay. so like about six people this in this crowd. a lot of people don't know about this. interestingly, in new york we do have one of these protocols, and even a lot of doctors who i speak with don't -- aren't aware of it and haven't been aware of it. and certainly the wider public hasn't been aware of it.

so if you were to institute these in the midst of a disaster, there would be little awareness or transparency. and so i write about this very interesting project going on in maryland now, it's a two-year project. they're going all over the state, and doctors are engage anything this deliberative democracy with just regular folks. you and me, everyone comes in for a few hours and quickly grasps these ethical principles that could be applied to this problem and hashes it out and comes out with some thoughts on that. and the goal is to get all this input before the state makes a plan which is the opposite of how it's been done everywhere else. and i think that's really encouraging. so that is one example of how this is being grappled with. there was a question back there. >> i have a question and a comment. i don't think you can take what happened out of the situation of this crisis that you have to look at it within that crisis,

that some patients were going to die, right? i mean, some patients were going to die because the electricity was going to go off. so the question then is how were they going to die? so if the ventilator just goes off, that is an excruciatingly painful death versus giving a person more fine and -- morphine and them dying, essentially, pain free. >> i should have said, actually, they were giving morphine all along. this was different, what happened at the end. so they were giving morphine, small, normal doses were being given throughout when a patient looked uncomfortable. so they were not withholding that through the disaster. >> okay. >> if i might just comment -- >> well, can i just, can i finish? >> yeah. >> my other question is why not have a discussion with the patients who could talk to you and their families? why not have a discussion, say

we're all in this together? because, actually, you are. these are the options we think we have, these are the choices. if your ventilator dose off, this is -- goes off, this is what could happen to you. this is the way you would exit this world. why not have that discussion? i think part of it might be -- i'm a medical social worker. doctors have a really hard time talking to patients about death. it's really, it makes them uncomfortable. my other question is what were you thinking, sheri? here you are, you're a physician, you're a journal. you must have freaking out -- can have been freaking out. you're a human being, you're seeing all this suffering. i'm wondering what you were thinking. and just my comment is to put it in the bigger context. we ration health care in this country every single day by race and class. if you're poor and black, you get less access to health care resources, you die younger. every disease out there, people

of color die sooner, you're poor, you die sooner. 45,000 people tie -- die in this country every year because they lack access to health care. our system actually kills people every single year, 45,000 people according to a study done out of harvard. and there is a way to end all of these deaths and not put those health care professionals at that a hospital in that position, and that is to spend lots of money to make sure that hospitals have all the equipment they need in a situation like that. a national health care system, health care is a human right that is not a commodity, and then people would never find themselves in these situations where they have to play god. we have a way right now to make sure every single hospital has the amount of power and is designed so that people are never put in that position. i really believe that. >> thanks. thank you for your comments and

your questions, and, you know, we can't address all of those points, but they're well taken, and i think i like what you said about having the discussion, and there's some -- you know, you could imagine a scenario where maybe some people in that hospital would say just getting back to the triage question of who gets the helicopter slot, maybe if you came to some families and they felt their loved one was closer to death, they may surprise you and say, yeah, let the others go first. in fact, there's a case where before hurricane sandy there's a hospice in connecticut that had to evacuate on very short notice, and the administrators there assumed that they wanted to move the patients who were closest to death first because they thought they were the most fragile and it would be most urgent to move them, but, in fact, they did exactly what you said. they went to these family members of these patients -- all of them hospice, so not

necessarily long to live -- and they said what do you think? and these families surprised them, and they said, actually, yeah, we want to stay at hospice as long as possible before you move us, just in case our loved one would have the chance to die here. so when you ask the question, you may find out things that surprise you, and i think that is a very well taken point. and in terms of preparedness and spending the money, yes. and, again, a question of what's going to, what's going to make us spend that money? is it going to be some more firm regulations about how hospitals should be prepared? interestingly, here in new york city after sandy part of the mayor's proposal includes some of these stricter building codes and also codes for not only new buildings, but old buildings to be up to a certain standard. unfortunately, the proposed deadlines are 2030, so we have a lot of years between now and then until we in new york can even feel a little more

protected. and then you go to the question of, well, if you know you're going to be vulnerable, then maybe you evacuate people because with the hurricane, you actually have a warning. and you can't predict perfectly, but we're getting even better. there's new now systems for predicting storm surge that we didn't even have a year ago with sandy. so i'll just stop there. there's plenty more to say. oh, well, sorry. one last thing. which is you made an interesting point about the inherent discrimination. so there are certain groups that have poor health status, and that is a legacy of discrimination and the way that patients have been treated and sewer acted with for many years. so some of the people, actually an interesting public engagement exercise outside of maryland, there's been very few places that have brought the discussions of triage into these emergencies. and they actually said, they

said something like if we try to maximize survival and so we try to make sure that the ventilators go to people who have a better health status and are likely to benefit from them, we are actually inadvertently discriminating against groups of people who have poor per health status. and i thought that was status. like. doctors, we wouldn't have come up with that. i wonder if heir yept washington -- harriet washington wants to jump in here? sorry to put you on the spot, but is this anything you'd like to add? >> [inaudible] >> i have worked in hospitals, including emergency departments for a long time. and i think one of the really important, insufficiently examined factors here is that physicians are trained intensely in science and in clinical scenarios, but they're also very intensely trained in social

behavior, in social norms. one of the really important social norms is that physicians are throughout their training encouraged to lie in certain ethical situations, including one that parallels this. i'm considering the use of morphine, for example. it becomes very tempting and physicians routinely succumb to the temptation of increasing doses of morphine in the name of alleviating pain but with the actual ulterior mote pif of dispatching the patient. it's very neat, it's very convenient because the patient will die, and the physician more than likely -- i don't try to look into people's hearts and tell you what they're thinking, but with there is a strong argument that the physician thinks it's the best thing for the patient, the patient's going to die anyway, and this way they die relatively peacefully and smoothly. it's a clean end. except that the physician is lying to himself and very likely to the patient, because he's not

giving the morphine, you know, because of pain. he's giving the morphine for, you know, to help the patient along without admitting that. >> and this is actually one of the main people had the book said that he sort of, there's a quote in the book that really makes that point. specialists argue, no, there's this really thin line, and it all does hinge on intentionality. and then this doctor says in the book, and a lot of people would disagree with this, he says any doctor who thinks giving a lot of morphine to a patient isn't prematurely ending his life is a naive doctor. >> you can look it up for yourself. >> but one of the debates that that's discussed this the book. and also the element of the

physician's own pain which you just mentioned, that social worker brought up this idea of the experience of the health worker in that situation. and so one of the -- it's not in the book, but it's a quote i almost wish i had put in there. a very eminent pailtive care physician, he passed away about a year ago, two years ago, but he -- when we were discussing this situation, and he's from louisiana and knows a lot of the people involved, he said that there's this element of the physician, a nurse wanting to relieve their own pain and perhaps even a confusion over where that, where your pain ends and their pain starts. it may not even be a patient, in some cases the doctors describe these patients as not being conscious at all. but yet it looked awful, you know? lying there in sweat and, you know, just looking terrible.

so there's that pain of the health professional used to being able to help people unable to do that anymore, no power, etc. so the question of whether that could have motivated these acts and the question of whether we need our standards and our ethics and our laws at that very moment of compassion because they stop us from maybe crossing a line, that compassion leads us to. >> doubtless there are multiple factors influencing them, and that was one of them. however, the other large issue that is often, i think, overlooked is that in medical ethics there's a tendency to look very narrowly at questions both in terms of time and scope. so it's a lot easier to look at a lifeboat situation like this as a snapshot. here's what's happening now, here's what's happened a new years ago, etc. but it's important to take a longer view of this because this tells you the social factors

which are perhaps being inadequately examined that are feeding the ethics. one of the problems of medical ethics is that it has an insufficient comprehension of the importance of history. so if you look at the history as i think this woman had alluded to, if you look at the history of this area, there is a strong history of certain groups of people receiving substandard care, but more to the point of physicians being trained, again, that shadowy, tacit training that physicians undergo that they don't get from textbooks, but they get from their mentors, they get from seeing the social situations they're put into and seeing which patients are used in which manner, who's used as teaching example, who's valued, who is not valued. and if you look at that history, there was people of color who were disproportionately injured. it's not just the fact that a lot of discrimination is not static and has not ended, it's going on now, it's the fact that

this long history of a physician being trained the to view black patients differently is affecting them once they're in practice. i think there's a very good example of this. so you have this, again, this very my i croppic view, and you look at a snap shot, and you don't see everything you need to see this that snapshot to make your decision. and one of the things that needs to be seen is when you have patients who need to be viewed differently and physicians who don't represent. when you're in a scenario like that, you're going to have a conflict, and you're going to have an issue with patients not being treated equitably, which is i think a lot of what we've been seeing here. >> thank you. and some of the racial dynamics are discussed quite a bit in the book, in the history in these hospitals, there's some discussion of these very issues. and, in fact, you know, like i said, there were differences of opinion amongst the health

professionals at the very moment that these actions were being taken. some doctors and nurses were saying, no, this is not right, we shouldn't be injecting the patients, i will be no part of it. and the way that history and race and all that played into things is, there's some element of that in the book as well. do we have time for more? there's more questions. okay. >> thank you. i think what was just shared is another example of power, rank and privilege and how it plays itself out. roughly a little less that thano weeks ago, peter singer, bioearth sis, chaired and hosted a conference at princeton university about the ethical dilemma of compensating organ

donors. and, you know, what was just shared, you know, by your colleague was, in his opinion, that it is -- and excuse me for paraphrasing or maybe misquoting -- but it actually is not possible to youth nice an individual without their consent. is that a correct assessment of what you said? >> he's asking you. >> yeah. there are certain guidelinessing -- >> okay. >> such as you can't euthanize somebody without their consent or family's concept, and it's called murder. >> okay. [laughter] >> following that track -- >> in the very few countries that do allow it. >> okay. well, following that track, in england where it is the national health service, you know, individuals at the age of 85 or no longer allowed to receive kidney dialysis.

and as we know, you know, without being able to be die rised, it is certain and absolute death. and certainly that is not the consent of the individual. so i think that there, i would like to hear some conversation about that. the other point is that you started off this dialogue about i guess i would call it empowerment. and i think there are four ps here. there's policy, there's planning, there are politics, and they are all, they're versus the small p which is people. and that goes back to power, rank and privilege. you know, absolute power makes no concessions and demands everything, and if you're in a position where you are not in a power position or empowered, then you are yet again, you know, subjected to decisions

that affect your and your family and your loved one's lives, you know, without your consent or control. and so i think that when you introduce these dynamics, please understand that, you know, it wasn't that individuals were in a decision-making position or empowered enough to raise objections to some of those choices and decisions that were made, albeit under, you know, extreme circumstances. i've been in conflict theaters and seen violence firsthand, and i've also seen amazing compassion in spite of. so i would like to hear your comment, your responses to these comments. >> thank you. i have so much i want to say to that, but i'll just limit it to two things. thank you very much. well, first of all, yes. i mean, i think sometimes we think about excusing certain actions because can we excuse it because of the situation being so extreme. we have to remember we have

doctors who work in war zones all the time, and we still have the ethics and the rules that apply in those situations, and that is important to remember. and it's hard, of course, if it's your first disaster and you're a doctor, and you're thrust into that situation. this is part of why i think, you know, this story needs to be told, because keeping your eye on the fact that there will be a tomorrow and that, you know, that is very hard to remember. uh-huh. >> [inaudible] doctor by doctor, it wasn't the administration, it wasn't the hospital saying this is what we've done as a result of -- >> i see what you're asking. i mean, yeah. when you read the book, you'll see. there is dissension amongst those individuals, and it is interesting because one of the people who felt most strongly that this was an inappropriate act was a physician who was the only physician of color and who had been shut down the previous day when he was arguing with the

ceo about the decision not to allow the neighbors of the hospital who werely people of color to -- who were mostly people of color to come in for shelter. they were coming by on their skiffs, an elderly person being pushed on a mattress, and there was a big debate about whether to allow people in. and he'd sort of been shut down, and he just felt like, you know, my voice didn't mean much. and so, therefore, when this situation arose with, you know, people talking about should we think about hastening the death of the patients, and he felt that this was wrong, but he also said after, well, you know, in explaining why he just refused to participate and left -- and some people criticized him for leaving -- b and he said, well, i felt like my voice did not have a role here. and be i guess that gets to your larger point about do the individuals have a role. but i firmly believe that they do, and i believe in every disaster where i've worked

individual action can make a huge difference. and if somebody b really had spoken out and stayed, maybe a different decision would be made, you know, if you think that that would be the right decision to not go forward with these injections. so i do think, yes. i don't think we have to -- i think there's a huge pressure, perhaps, from an organization and certainly the failure of this particular hospital's leadership structure to really stay in lace and to offer leadership that a lot of people, you know, would feel comfortable with and more secure and stop some of the desperation and the panic and confusion, that would have been really helpful. but in the end, individuals can make a huge difference. and so i think we can't just say, no, that that's not a role here. and i also wanted to just respond quickly to the dialysis scenario because that's very relevant, and that's in the book

too, believe it or not. but it's the case of south south africa and exactly these decisions. in england you said it's people above a certain age, but in south africa they have to ration dialysis of. four out of every five good candidates, and i just was speaking with the held of the dialysis unit in a huge, vast hospital in capetown, he has to turn away four out of every five people. and so the question is, well, hold up do we do it? i offered that example because they actually at some point the doctor said we need, you know, the government to sort of step up here, because they're the ones not funding us for more slots and create some sort of a transparent system so we're not just doing this ad hoc and discriminating against people. you can imagine appar tiled south africa who got those slots. so recently they came up with

about -- maybe in the last five year withs, they sat down and got cysts at the table and the doctors and the nurses and the social workers and hashed out some sort of system. trust me, not great because they're still turning away the same number of people, but at least they can face people and say here's what we're doing and why. >> i just want to make one distinction. there's a distinction between withholding dialysis and injecting something to kill somebody. while i was a resident doctor at bellevue in the 1960s, the catholic church came down and said withholding ivs and withholding things can be acceptable, but you can't intentionally kill a person. so that has to be taken apart. but -- taken into consideration. but as a medical examiner having been involved with a number of mass disasters, used to be airplane crashes, less now. fires, 20 or 30, maybe more

people can die, we can set general guidelines, but every disaster's different. and there'll be lots of decisions. you can't account for everything that's going to happen in a disaster or how people react, how families react. and having certain guidelines like you can't kill patients just because it's inconvenient, if they're going to die, let 'em die naturally. and especially here, as sheri points out. most of these patients were comatose who were given the injections of morphine. today didn't need to have any -- they didn't need to have painkillers. if you're comatose you have no pain. >> there's some debate about that. >> if a person's not conscious, they're not feeling pain, and giving morphine is not needed for pain killing, for comfort purposes. no? >> well, i mean, i think some

pail yative -- >> but failure to -- >> there's a question of whether there may be some awareness or some discomfort on some level. >> the doctor has discomfort, but what does the patient? [laughter] a slippery slope, but if you're going to -- >> [inaudible] point out there are several -- [inaudible] withholding care are seen as equivalent. so that example that you gave, actually, is not so far afield. it's not -- [inaudible] but if you think about it in scenarios, it does -- [inaudible] the other thing is the examples of foreign countries in which care is -- [inaudible] is shockingly unfair way. we don't have to go abroad. if you look at this country, there are hundreds of examples. [inaudible]

you can, the basic -- [inaudible] i think my point here is to point out that a lot -- [inaudible] >> have work to do, right, at this very moment. thank you for that. oh, we need -- okay. i'm getting the -- we need to wrap it up. so the good thing is that there is wine, and i'll be signing books -- [laughter] and there's snacks. yeah, you can purchase books here, i should say, and thank you. this was a tremendous discussion, and i hope we'll continue it amongst ourselves. [applause] thank you. [applause]

[inaudible conversations] >> every weekend booktv offers 48 hours of programming focused on nonfiction authors and book withs. watch it here on c-span2. >> this fall is booktv's 15th anniversary, be and this weekend we look -- and this weekend we look back at 2009. the national book aa ward for nonfiction that year went to t.j. styles for "the first tycoon." and amity shlaes was awarded the hayek prize for "the forgotten man." the pulitzer prize for biography that year went to jon meacham for "american lion," his account of andrew jackson's presidential tenure. the author discussed his book on

booktv in 2008. >> i began this book, as we just heard, five years ago partly because it was the period in which david mccullough's wonderful john adams was doing so well, walter isaacson's captured the popular imagination, and my sense was if we were going to go back and recover these early figures, we should recover someone who represents the best of us and the worst of us, and andrew jackson surely does that. he teaches as much by his vices as he does by his virtues. so this this is not -- you can't really have anything other than a warts and all coverage of jackson because they're mostly warts, but they are on a man who ultimately capped the progress -- kept the possibility of progress alive by preserving the union. >> over the next few weeks, booktv -- now in its 15th year

on c-span2 -- is taking a look back at authors, books and publishing news. you can watch all the programs from the past 15 years online at booktv.org. >> ann arbor on booktv with the help of our comcast cable partners. for the next 90 minutes, we'll explore the history and literary scene of this city of about 115,000 that is home to the university of michigan. coming up, we'll learn about the poet, robert hayden. >> all his poems are written in different styles, different voices, different forms and techniques. >> we'll see a moon you script from galileo when he discovered the moons of jupiter. >> but he decided to keep track of that little piece of the sky. so he watched jupiter every night for a week. >> and meet others who help us understand the roots of the area. we begin our special look with local author don fakeer, and we learn about the youngest governor in michigan's history. ..