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Medicine Monday
30Jul
Dr. Anna Pou: A Final Word
Monday, July 30, 2007 at 12:15AM As most of my readers are already aware, this past week a grand jury in New Orleans refused to indict Dr. Anna Pou for murder. The response to the news in the medical blogging world has been characteristically divided: While most medical people are saying justice was served, a few are saying a murderer has slipped the noose. I have posted about this topic several times before, but would like to make a final comment before this topic passes out of our collective memory.
First a quick refresher: Anna Pou, MD, is an otolaryngologist (ears, nose, and throat specialist) who was working at Memorial Hospital in New Orleans when Hurricane Katrina struck. An affidavit issued by the Louisiana State Attorney General just over a year ago accused Dr. Pou and two nurses, Cheri Landry and Lisa Budo, of murdering four patients five days after the storm hit with lethal doses of morphine and benzodiazapines. Since that time, the New Orleans District Attorney's office has been preparing the case for prosecution. A grand jury was impaneled in March and had been hearing witness testimony for the past 4 months. A few months ago, the two nurses were granted immunity in the case, presumably in exchange for testimony. This was widely assumed to be a move on the part of prosecutors to isolate Dr. Pou. Now that the grand jury has chosen not to indict, all charges are dropped and the case is essentially dead.
In my view, the grand jury did the right thing -- the only thing it could do given the weakness of the case. No one saw the fatal doses given other than the accused individuals, and there was no clear evidence in the medical record that any medication was given with the intent to kill. The original affidavit quotes several witnesses who said Dr. Pou indicated that she intended to deliver fatal doses of pain medication to patients, but Dr. Pou has vehemently denied she has said any such thing. Although the witnesses had some credibility, their testimony amounts to hearsay. Dr. Pou could have said any number of things in advance, but saying something in advance only suggests intention, not proof that the action was carried out.
But the real weakness of the case was the lack of physical evidence. The substance of the charges were based on autopsy reports, but the bodies of the patients were not removed from the hospital for three weeks after the storm. In those three weeks the bodies decomposed significantly, and there is no way under these conditions that toxicology reports could prove that the medication dose was high enough to have been intentionally fatal. Toxicology reports can be difficult to interpret mere hours after an overdose. A lapse of weeks made this impossible. Frank Minyard, the Orleans Parish Coroner, underscored this problem when he issued a report in February 2007 stating that the cause of death of all four patients, based on autopsy evidence, was "indeterminate."
The outcome of this case has not satisfied everyone. After all, four patients died under heavy sedation shortly after their doctor suggested to several witnesses that she intended to euthanize them. This temporal association is hard to ignore. On the other hand, it is undisputed that all four patients were very near death, and could easily have died from natural processes.
It is very possible that the morphine in the patients' blood was administered for therapeutic reasons. Pain relief is a necessary and very important part of medical care. Commonly accepted medical guidelines clearly permit doctors to use large amounts of pain medication for dying patients when necessary, even in quantities that could hasten the dying process. Intent is the key. If the doctor is giving the medication to relieve pain, then giving painkilllers is ethical; if the intent is to kill, then it is not.
If this assertion sounds foreign, consider a more familiar example. It is permissible for a doctor to give highly toxic chemotherapy to a cancer patient even though the treatment could kill. As with pain medication, the act is ethical as long as the intent is to help the patient. If the treatment, which is intended to help, inadvertently kills the patient, this does not mean the doctor has done anything wrong.
All that being said, I have some sympathy with the people who feel that dropping the case for lack of evidence is not as satisfying as proving it one way or another. I don't want to know that wrongdoing cannot be proven; I want to know that wrongdoing did not happen. I also wholeheartedly agree that even given the extremity of the situation (100 degree heat, no running water, no electricity, no antibiotics, no IV fluids, 10 feet of standing water in the street, and no help coming) it remains illegal to kill patients, even if the intent is to relieve suffering. A law does not become less of a law because conditions make it harder to obey. I don't get to kill someone just because I am seriously aggrieved and I don't get to steal simply because I am broke. It is true that in extreme situations physical and emotional pressures distort judgment, and courts of law must account for this. In the event of a guilty verdict, a judge should weigh the matters of distorted judgment and extreme situations before sentencing. But before that time, only the facts should rule. It is regrettable that there are not enough facts available to allow the facts to rule.
I want to make a final point. This case is a very poor example of a euthanasia, and has no place in ethical discussions about euthanasia. Right-to-die activists who think the Anna Pou case is a milestone for their cause need to rethink their positions. Personally, I am strongly opposed to euthanasia in any form, but, for or against, if we are going to argue about it we need to avoid sloppiness. The term euthanasia, as it is used in medical ethics, refers to the voluntary killing of a patient for the purposes of alleviating pain. The operative word here is voluntary. Even right-to-die advocates (at least the sensible ones) would agree that a patient should never be euthanized against his will. In countries like the Netherlands where euthanasia is practiced, a patient who requests euthanasia goes through a careful multi-step process to determine if he is sound of mind, has a terminal condition, and truly wishes to die. Only if all three of these criteria are strictly met is the final act carried out.
Even in the case of Dr. Jack Kevorkian, there was never any question that the patients who died were willing to die, asked to die, and assisted in carrying out the administration of the fatal dose.
In the Pou case, there is no documentation that the patients wished to die. No proof that they were of sound mind. In fact, given the circumstances, at an abandoned hospital without fresh food or running water, without medication, in 100 degree heat, it is unlikely that any of the patients were fit to consent to euthanasia.
The State Attorney General maintained that Dr. Pou murdered the patients, not that she euthanized them. Dr. Pou has always maintained that she did not kill the patients, not that she did and should be excused from doing so. Such a defense would not work under Louisiana law anyway, which prohibits physician-assisted suicide just as well as murder. As far as I know, Dr. Pou is not nor ever has been an advocate of euthanasia.
It would be lunacy for right-to-die advocates to use Dr. Pou's case as an object lesson in their cause, any more than it would make sense for death penalty advocates to use a lynching case as an example of a justified death sentence. If right-to-die advocates consider Dr. Pou's case meaningful than they are a dangerous lot indeed. Extreme circumstances don't justify relaxing the rules, and there is no reasonable person who believes that people should be euthanized without asking them first. If there is anything that supersedes the duty of the doctor to relieve pain, it is the right of the patient to self-determination.
One final question the reader may ask: Do I think Dr. Pou did it?
I don't know Dr. Pou personally, but I do find it difficult to believe that a doctor educated in the United States, knowing the law as all doctors do, would have tried to do something like this. It would have been much easier for her to simply sedate the patients with the aim to relieve pain. She had no obligation to kill them, and, in fact, with sufficient morphine on hand to keep pain at bay, no need to kill them either. She could have managed them to to the point of natural death without having to make such a terrible decision. So on balance, I would have to say probably not.
Of course, only Dr. Pou knows the truth. The rest of us are left, like the grand jury, with nothing more than insufficient evidence.
Update on Monday, July 30, 2007 at 09:34AM by
Michael Hebert
Michael Hebert
This morning when I came into my office, I found a letter on my desk soliciting a political contribution for Charles Foti's opponent in the upcoming State Attorney General election. (Charles Foti is responsible for bringing charges against Anna Pou.) The letter is signed by three medical doctors, and opens this way:
To say that Charles Foti is over his head is kind. To say that he has blundered and stumbled from one disaster to another and failed to take the initiative in protecting our citizens is much more accurate.
The doctors then go on to tell what is really on their minds:
Most illustrative of his ego-centered abuse of the power of his office for personal political gain was his handling of the issues at Memorial Hospital after Hurricane Katrina . . . .
Remember, this time, this election is truly about protecting Louisiana -- from Charles Foti.
It is an understatement to say the doctors in Louisiana are furious about this case.
Foti's behavior in the Pou case was inexcusably bad. He called a press conference to announce the charges -- something the Attorney General almost never does -- and continued to call press conferences each time he made a move in the case. He arrested Pou in the middle of the night instead of allowing her to voluntarily surrender -- and notified the media so they could film it. He repeatedly called the case a murder case, even though the decision to charge Pou with murder was not his, but that of the New Orleans DA's office. And he failed to disclose to the press a serious conflict of interest in this case. Since Anna Pou is a state university employee, her legal defense comes from the state -- the AG office. In other words, Foti was both Pou's accuser and, in theory, her defense attorney.
Needless to say, Foti is not a popular figure in Louisiana these days. I think Foti's hijinks made it easier for the public to sympathize with Dr. Pou. Foti came off as the bad guy, and Dr. Pou as the innocent. I don't know that it would have made a difference in the final outcome, but if Foti had simply filed his report and kept his mouth shut more people would have examined the case on its merits. Instead, once the labels were applied, Dr. Pou was tried and exonerated in the public mind.
Sometimes, rather than speaking for the facts, it is better to let the facts speak for themselves.
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Reader Comments (9)
What is clear is that the Grand Jury verdict was not "innocent" but "insufficient evidence." That verdict was the correct one. My guess is that Dr. Pou did nothing wrong, but I do not pretend to know.
The only reason I am writing this to you and your readers is because I still daily struggle with the ramifications of my conversations with Anna and Jullie and Michael, all of which began back in late June of 2006 after having read a single article about the case and the events that occured on both the second and seventh floors of Memorial Hospital. I wanted to know how such a thing, if indeed it happened, could possible have occured. So, in search of an answer to the question, I contacted Anna and thus begun a one year and one month conversation that included both email and phone discussions. Initially, I did not think that she would directly deal witht the case at hand, since it was indeed an on going investigation. However, I hoped that perhaps over time I could get to know her and that in getting to know the person, perhaps find an answer to the original question. At the time, I had absolutely no idea what I was getting myself into. But you know what they say about hindsight!
The first email I sent Anna was basically a letter of introduction. At the time I wrote it, I really did not think that she would respond since I neither knew her and she did not know me. A day later howerver, I received a very warm and friendly response. I was actually suprised but happy at the same time. I sent Anna a second email, thanking her for her response. Sometime after that, I received an email from Anna. While I cannot tell you what she said,there was one particular statement or remark that was upsetting to say the least. Without telling you what Anna said, it had to do with an observation about how the media would never understand the motivation behind her actions at Memorial and how I should not listen to anything the media reported.(the nature of the observation I cannot say for as I have already indicated I made I promise to Anna, just as she also made a promise to me).I remember the hair on my neck standing up and the goose bumps all up and down my arms. Still, at the time I don't think the reality of what she said completely sunk in. I was just happy that we where talking and perhaps I would eventually get an answer to my original question.
Our first phone conversation occured about a month or so later. It did not last particularly long and I remember walking home from the pay phone, since at the time I did not have a phone, thinking how nice it was to have talked with her. At the time, what was said, simply did not register. Looking back on the conversation was like almost resurrecting a foggy dream. It took me approximately a week before I fully understood the words of that conversation. I remember feeling angry and at the same time a deep sense of sorrow not just for Anna but the patients as well. The next time I wrote to Anna was kind of an angry correspondence in which I explained to her that I simply could not do this any more, that I did not know what I had gotten myself into. Needless to say, Anna did not respond to that particular correspondence. I did not talk to Anna again for six weeks.
After six weeks of thought and reflection, I realized that I still did not have an answer to my original question and that if I wanted an answer, I would have to try and pick up the conversation with her. So, I wrote to her again and about a day later got a friendly response. From that point on we continued to talk, usually once a month, sometimes twice. While we did not talk again about the case until the following April, 2007, the conversations where very pleasent and covered a wide range of topics.
As a result of these conversations, I came to a number of conclusions about Anna. First, she is a very private person with a very strong and vibrant religious conviction. Second, she is a very kind and gentle person. The more I got to know her, the more my heart broke for her and the ordeal she was going through. The anger I had originally felt had given way to a feeling of emptiness and sorrow, that remains with me to this very day. Then something happened and the nature and tone of the conversations took on an almost desperate sense. I still don't know what happened in April but whatever it was greatly upset Anna.
Between April and the begining of May, 2007 the phone conversations began again. The email conversations at that point where a reflection of the phone conversations. It was these phone conversations that so unnerved me. At this point, I was no longer able to sleep well at night and ended up going to my doctor and getting a presciption for ativan I was so anxious. It was also in April in one particualar conversation on the phone when I finally got an answer to my original question. As a result of that conversation, the only thing that I could think of was something from the Bible that went like this: And some of you they will kill and in killing you they will think they are doing a good thing."
At that point I realized I was over my head and needed to contact someone. I ended up contacting Michael. I sent him an email, explaining my ongoing conversations with Anna. Michael never responded to the email and I began to wonder if he ever received it. So I called him. He called back and left a voice message that he wanted to talk to me. So a day later I called him. I explained to him the nature of the conversations and ended up sending him some of the documentation. I also told him about the phone conversations and suggested he could check that too.He told me that he would look at the information but that Eddie had already decided that the case had become so politicized and that Anna's supporters where so vocal, that any additional information would be of little help in the ongoing investigation. I never heard from Michael again.
At this point I was nearly frantic. The conversations with Anna had desintigrated into an almost nightmarish discussion of events at the hospital intermingled with prayer groups and hope of salvation from the Grand Jury. Michael did not seem to want to know about the conversations, so I contacted Jullie who had worked on the original ten month plus investigation. When I finally got through to Jullie, she explained to me that the Grand Jury would refuse to indict Anna and that the case would be dropped because again Eddie had decided that the case was so politically explosive, he was not going to vigoriously present information to the Grand Jury and the end result would be no indictment. That was on July 11, 2007. On July 24, 2007 or there about, the Grand Jury came back with no indicment. On July 12 I wrote to Anna and told her not to worry, the Grand Jury was not going to send this case to trial.
I have not heard from Anna since. I guess she did not like the fact that I spoke with Michael and Jullie but even in my conversations with the two of them, I always explained that Anna was a kind and gentle person.
So there you have it. Make of it what you will. Anna will always be my friend and as I always said to her: I am so sorry the ordeal you went through
Looking back on this past year and the conversations with Anna, there are so many thoughts and feelings, some good, some not so good, but all ultimately leading to an answer to the question I had originally asked: How could something like this have possibly happened? The answer I found is both simple and deeply disturbing and it is this: sometimes very kind and well intentioned people find themselves in very difficult situations and in those horrible situations engage in actions they would never have otherwise engaged in, beleiving in their hearts and in their minds that their actions are in the best interest of those involved. Anna beleives that what happened on the second and seventh floor of Memorial Hospital was done out of the best interest of the patients and in her heart she loved all of those people very, very much. What was done, was an act of love.
The other lesson learned was this: when you go in search of an answer, you had better be sure you want to know the answer because once you find it, the answer becomes a part of you and you, a part of the answer and you cannot give it back again. For my part, in May of 2007 I quit a ten year career in Information Technology and went back to school. I am now a Certified Nursing Assistant and next month start the Nursing Program because I am determined in both my mind and my heart to provide my patients with the care Anna was unable to provide those patients and by my acts of kindness to offsett the pain and suffering Anna's actions have caused. At the time, I talked with Anna about this and she agreed that this was a good thing to do and she also hopes that these acts, however small, might offset the pain and the suffering.
And now I will leave you and your readers with the words and observations I shared with Anna on so many occasions and which I hoped brought her some comfort this past year and the words are these: there is no Judgement and there is no Condemnation, for in my Father's Kingdom there is only Love and always remember, be kind, be gentle, be soft spoken.
Miranda
Miranda
So would it help if I told the truth that has not yet been spoken, to express in words the absolute pain and suffering, to let your readers know the agony of that day. I had no idea what I was getting involved in. But Anna is now my friend and the things we talked about that April and May swirl like a nightmare I wish I could soon forget. But forgetfullness is not something necessarily easy to come by and those who find it are blessed by something most of us cannot now afford. I still remember the words of the conversations, calm and calculated in their delivery. It was a wonderful April morning. The sun had just come up over the mountain tops as I stood in the kitchen drinking a cup of coffee and listening to the latest news on National Public Radio. Everything seemed right with the world, or as right as it could seem given the nature of the previous conversations. And then the phone rang and nothing has seemed the same. The difficult decision that had to be made, the patients Anna determined could not be moved and therefore saved, the chart room, the injections filled with morphine and Versed, the walking up and down the hall and the sound of silence when they left. And in the end, I still remember the words: " bless you for understanding Miranda for the media never will." I remember the hair standing up on the back of my neck. I remember the goose bumps up and down my arms and I remember the kitchen starting to spin and spin and spin and the spinning never stopped. And I remember what I said. After all the words, and tears and prayers, after all the "please don't worry because I know you are a kind and gentle person", after all of that I finally understood why Anna made that difficult and fatal decision regarding the patients on the seventh floor. "Anna I now understand why you made that difficult and fatal decision for those patients on the seventh floor" I said as the room began its spinning and the tears again began to fall. "I understand now Anna that you made that fatal decision because in your heart and in you mind you loved those patients very much." And Anna's response to my admission, calm and deliberate, almost a whisper in its saying:"Yes Miranda you are absolutely right and bless you for understanding." An act of tragic desperation motivated by love. A single moment in September that has reached out across time and space and changed the lives of many.So now you know and as I explained to Michael those many months ago, most of you will now know me by a different name for I have now indeed betrayed my friend and from this day forth you will call me Judas. But please know this:while you might think badly of me, please do not hold these charges against Anna but rather give them to me, for Anna is a kind and gentle person.
Miranda
You will have to pardon me but I don't believe you really know what you say you know. I have considered taking your posts down, but you have not been abusive or broken any rules of decorum. It is just that you stretch credibility, and if wrong, what you say is libelous. I would suggest that, if what you say is true, you back it up with proof.
I am not trying to me mean. I simply want to be fair to Dr. Pou.
I understand that you are not trying to be mean spirited and that you do indeed have an obligation to protect the integrity of the site. But all along I have indeed told the truth. I handed over most of the email correspondence between Anna and myself to both Michael and to Jullie for the period of June 2006 through July of 2007. Their respective offices have most of the documentation though not all of it. While the phone conversations between Anna and myself where not recorded, they should be easily accessable as part of the public record. All one has to do is check the phone records of Anna and myself and you will see the dates and times the phone conversations occurred during the period of April and May of 2007. I suspect that all the information is readily accessible through the Freedom of Information Act or by contacting Michael at the Homicide Division of the District Attorneys Office of Parish County as well as the Criminal Division of the Attorney Generals Office. Also, copies of all the email correspondence between the two of us, should also be stored on the LSU email servers since it was through these servers that the correspondence went.
In your response, you have asked for proof. What kind of proof are you seeking? A copy of all the emails or a list of the phone logs? For that kind of information, you would need to contact either Michael or Jullie. If on the other hand you are asking me to publically post very private emails, that I cannot nor will I do. But please know this: everything I have told you, including the email about my conversations with Michael and Jullie regarding the politization of the case, has been the truth. I have said nothing that was not true and with a little digging on your part you should have access to the documentation as well. And as for Anna, I am still her friend and in my conversations with Michael and with Jullie I tried to explain to them that what was done on the seventh floor of Memorial, was done out of love. Perhaps Anna was right when she told me those months and months ago that the media would never understand the motivation behind the act.
If you no not feel that I have told the truth, then that is fine. The documentation sent to Michael and to Jullie stand on its own merit. Perhaps they will choose to give it to you. But please know this: my involvement in this whole sad affair has been a nightmare. The sleepless nights, the tears, the prayers, the visits to the doctor for anxiety. And in the end what I was left with was not just an answer to the question originally asked back in June of 2006 but also an almost overwhelming sense of sadness not just for Anna but the victims family members too.
Miranda