Death in a Halifax hospital: a murder case highlights a profession's divisions
Nancy Robb
CMAJ 1997;157:757-62
[ en bref ]
Nancy Robb is a freelance writer living in Halifax.
© Nancy Robb
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In brief
In this exhaustive report, Nancy Robb discusses the murder charge laid against respirologist Nancy Morrison following the death of a patient in a Halifax hospital. There appear to be no blacks and whites in the sea of grey surrounding this case, she reports.
En bref
Dans ce rapport détaillé, Nancy Robb discute de l'accusation de meurtre pesant sur la respirologue Nancy Morrison suite au décès d'un patient dans un hôpital de Halifax. Elle explique que rien ne semble clairement tranché dans ce cas.
By all accounts, Halifax respirologist Nancy Morrison is a well-respected physician and teacher. Last December she won the prize Dalhousie University medical students present for excellence in clinical teaching. Her colleagues and patients call her dedicated, competent, compassionate. Some say she's a physician who goes by the book.
When Morrison, 41, was arrested and charged with first-degree murder in May, her peers were stunned. The charges involved the death of a terminally ill cancer patient in the intensive care unit at the Queen Elizabeth II Health Sciences Centre (QE II).
This is the sequence of events. Cancer patient Paul Mills died in November. In a peer review following his death, Morrison was suspended from the hospital's Critical Care Unit (CCU) for 3 months; she later resigned from it. In March another physician went to police because of his concerns about Mills' death. On May 6 she was arrested at the hospital and charged by Halifax police.
"I was shocked and astonished," says Dalhousie Dean John Ruedy, who has known Morrison since she was a respirology fellow in Vancouver. "If you were to identify someone in faculty who would have been in this situation, I suspect Nancy Morrison would have been almost last on my list."
The case has resonated far beyond Halifax. "This is the highest-profile case of a physician being accused of murdering a patient in the context of an intensive-care setting," says Dr. Philip Hebert, director of the ethics centre at the Sunnybrook Health Science Centre in Toronto. "Physicians are involved in various ways in the death of their patients on an extremely routine basis. If the only thing it's going to do is put a chill through what intensivists do every day in terms of stopping or withdrawing treatment for patients . . . it will be felt throughout the profession."
A patient dies
Mills, 65, of Moncton, NB, died while under Morrison's care in the CCU at the Victoria General Hospital Division of the QE II. (A publication ban prevents CMAJ from reporting the details of his death.) After her May arrest Morrison pleaded not guilty. "I have done nothing wrong," she told the Toronto Star.
When lawyer Joel Pink arrived at Morrison's office the morning of her arrest, police were milling around her floor. "She was in a state of shock," he recalls. Pink, who turned down a request for an interview with Morrison, says the case reveals "great confusion" about care of the terminally ill. "Doctors have to stop thinking that because there is a therapeutic component to [a] drug, that [is] justification for allowing the person to die with dignity," he says. "It may be very difficult to find a prosecutor who will prosecute a doctor who is giving a morphine drip, but the bottom line is exactly the same. I don't believe doctors should be charged, but if you believe in dying with dignity and dying in comfort, there has to be a set of rules for doctors to follow."
Pink stressed that Mills' death is not a case of euthanasia or assisted suicide: "What this was is nothing more than a doctor making a judgement call that this person should be dying in comfort."
Morrison isn't the first Canadian physician to face this type of criminal charge. In 1993 Timmins, Ont., general surgeon Alberto De La Rocha was charged with second-degree murder after a cancer patient received a potassium-chloride injection. He pleaded guilty to administering a noxious substance, received a suspended sentence and lost his medical licence for 90 days. In Toronto, Dr. Maurice Genereux is awaiting a preliminary hearing on a charge of assisting in the suicide of an HIV-positive patient. In 1992 a Toronto nurse pleaded guilty to administering a noxious substance after first being charged with first-degree murder. He gave potassium chloride to a dying patient.
"The fact that these types of cases keep occurring means we must have a public discussion," says Dr. Hugh Devitt, president of the Canadian Critical Care Society (CCCS) and assistant director of the Intensive Care Unit at Sunnybrook.
Devitt, who heads Sunnybrook's Department of Anesthesia, says there are moral, ethical and legal issues surrounding Morrison's case. "In many instances there are no absolute answers and the approach to the dying patient is going to be different in each circumstance."
In June the CCCS endorsed an education and consensus paper that helps intensivists negotiate this slippery terrain. Devitt says the paper, "Withholding or withdrawal of life support", concludes that "the duty of the health care team and the physician is to the patient. Essentially the patient's and patient's family's wishes must be respected."
The secrecy issue
According to media reports, Mills' family did not find out how he died until Morrison was arrested. Nor did the QE II notify the province's chief medical examiner, the police or the provincial medical board (see sidebar). "The secretiveness bothers me," says Sunnybrook's Hebert. "If you're doing something that is ethically right, you should be prepared to pass the publicity test. If you have an internal inquiry into a patient's death, it's only proper respect to let the family know you're looking at this. . . . Often these things have bigger legal and professional consequences because people don't share information."
Hebert says most doctors know the boundaries concerning terminally ill patients. "It's quite acceptable ethically and legally to stop someone's life-sustaining treatment but to do something in a more active way to hasten the dying process, unless it's in the context of palliative care, is unacceptable legally. . . .
"Frankly, I find that reasoning a bit specious. Everybody knows that when you stop somebody's ventilator you intend for the person to die. There's a bit of fudging of the issues these days. We . . . do end people's lives in an active way every day in Canada."
Hebert believes "there is a role for physicians to help patients die in a more active way," but he wouldn't advise doctors to do so. "We all know there are cases that are very hard to palliate. There are conditions of suffering, not only physical but psychological, that can't be palliated." In such cases "is it better to let nature take its course and allow the patient to die with some suffering, or is the more appropriate course to end their lives sooner? Medically, I think [the latter] is more appropriate."
But, argues Dr. Daniel MacCarthy, "compassion is open to interpretation. That's exactly why we have to have laws and rules, because on a good day I might consider one thing to be compassionate and the next day I might not."
MacCarthy, chair of the British Columbia Medical Association's general assembly, is medical director at 3 long-term-care facilities in West Vancouver. In August 1994 he and another BC physician led the move to have the CMA adopt its current policy on physician-assisted death. The resulting policy summary (CMAJ 1995;152:248A-B) flatly rejects a neutral stand and speaks out firmly against physician participation in euthanasia.
"We felt the CMA should take a strong stand . . . because physician-assisted suicide is a horrifying abrogation of our responsibility," MacCarthy says. "If you have good palliative care and people are assured that the pain and, to some extent, the anguish will be treated well and compassionately, then the need for euthanasia goes away."
MacCarthy says there is "a massive difference" between giving dying patients a fatal injection to end suffering and giving them narcotics such as morphine for symptom relief, even if it may shorten life. "If the intent is to relieve symptoms, either pain, anxiety, agitation or anguish, then it is completely acceptable. People in other provinces have got into trouble because of the inappropriate and one-time use of something."
MacCarthy stresses that he is not referring to the Morrison case because its facts have not yet come to light but thinks the case "is a symptom of an ongoing question."
Amend the law?
Although MacCarthy believes that failure to treat euthanasia as a crime amounts to passive acceptance, it is not an easy crime to prosecute. "Trying to charge someone with murder or manslaughter or administration of a noxious substance is like trying to fit square pegs in round holes," says Dr. Jim Young, Ontario's chief coroner.
In 1994 he told a Senate subcommittee that the Criminal Code should be amended to include an offence called euthanasia that has its own set of penalties. "It's very difficult to say to a jury that if someone who is about to die dies hours, days or months before [he is supposed to], this is first-degree murder."
For Young, cases like Morrison's are old hat. Five cases, including the ones in Timmins and Toronto, have proceeded in Ontario since 1992, and his office conducts 2 to 4 euthanasia investigations a year. "Our approach has been fairly aggressive. If we find cases we report them to police."
About 5 years ago, when euthanasia and assisted suicide were emerging as issues, Young and deputy chief coroner James Cairns developed guidelines on acceptable palliative care. They stipulate that palliative care should be offered to appropriate patients but shouldn't be implemented without the informed consent of the patient or family. The guidelines, which recognize that some drugs may hasten death, outline criteria for appropriate therapy and recommend that drug use be documented.
"It's the right drug in the right dose," says Young, who notes that there has to be a demonstrated need for a drug. "If the dose increases dramatically and quickly, then the intent would appear to be to end life and that line must never be crossed. That line of judging intent is not cut and dried, and I wouldn't want to pretend it is. However, I wouldn't think any practitioner would want to take it that close to the line."
Young says the Morrison case will make doctors in Atlantic Canada aware of that line. "Each time there's a case, a new group of people are asking questions about where the line is and how to stay [on the right side of] it."
The question of "what should be done and can be done to relieve suffering in the terminally ill" is a "societal issue of beliefs and values," says John Ruedy, "and in Canada society has not been placed in a position to address it."
Ruedy, who hopes Morrison's trial offers that opportunity, says Canadians "must come to grips" with whether they want to legalize euthanasia, under what circumstances and with what safeguards.
It's a tall order, but John Butt, Nova Scotia's chief medical examiner, says "these are the very things" that comprise new laws. "If one looks down the road 10 years, where does the [Morrison] case stand in the scheme of developing public information and the consideration necessary to change the law?"
Ruedy predicts that the controversies ignited by this case and others "will gain momentum. Eventually the issue will be dealt with, and the name Morrison will be remembered . . . and not necessarily for bad reasons."
But Jim Young isn't looking that far ahead. "There is always a place for debate. I don't think there is a place for unilaterally changing the law or stretching the law until it is changed. We risk having Jack Kevorkians running around -- [doctors] become judge and jury on their own."
Young adds that the public is not "very discriminating" about euthanasia. The Morrison case and others like it "help focus the issues" but he wishes issues would be decided at forums like Senate hearings, not in a courtroom.
Nancy Morrison would likely agree. Morrison, whose preliminary hearing is set for February 1998, returned to work at a QE II outpatient clinic in July. "I think it is an issue that has to be discussed," she told the Toronto Star nearly a week after her bail hearing. "This is not just a medical issue; it's a public issue.
"But I don't like that I'm the person people are talking about. I want to say that I wish it was somebody else, but that's not even fair. Because I wouldn't wish this experience on anybody else."
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