Angel is found dead sitting in a parked car; no evidence of foul play. During the course of the investigation, the homicide cops get lots of information that Angel is a VERY bad actor; he beats up his girlfriend, he robs, steals, breaks and enters, assaults, and he dials information for numbers he could easily look up in the directory. They take great care to paint a picture of an individual that should be separated from society; a career criminal with no hope or rehabilitation. They also see sutures in a groin wound that appear fresh and it appears that Angel has visited an Emergency Department recently. They soon find the place and witness an impromptu display of fine trauma doctoring from the Emergency Physician. They are suitably impressed and a discussion of doctoring ensues that puts the physician in a good frame of reference. It turns out that this physician was the one that treated Angel for a bullet wound to the groin, suturing a large vessel in his groin (presumably the artery). OK, it's unlikely that an Emergency Physician would be suturing a femoral artery in the ED, but be that as it may, she explains that he was treated appropriately and should not have died from anything done at the hospital.
The autopsy shows that Angel died of massive internal hemorrhage. The cops start to get suspicious and return to talk again to the ED personnel. They come in peripheral contact with a VERY angry and hostile nurse who, as it turns out, had a scuffle with Angel. It comes out that Angel was not the most popular customer the ED had seen, and also that he was a regular customer, having had lots of trauma related to social misbehavior. They take in the nurse for questioning and during the course he makes the statement that (relating to the Emergency Physician) :"it was not the best work I have seen her do".
They make a trek to the Emergency Physician's home to ask a few questions and it turns out that her husband had been assaulted at a Bank Machine recently and suffered broken bones and an eye injury from facial trauma that threatened his eyesight. They go to some length to describe the family as the American Ideal. The ED Doc is a wife, mother and the family are hardworking taxpayers. It also comes out that there is a real possibility that Angel is the person who assaulted the husband.
During the conversation the physician, not knowing she is at this point under suspicion, and surely not knowing how to talk to cops, casually drifts into a conversation where she states she has grown to hate the dirt balls she has to treat every day. She simply gives them the wherewithal to go back and commit more crimes. Her husband was viciously attacked by the type of person she makes well and regularly throws back into the cesspool again. The cops can do nothing about it.
ED Doc: "Al right, so sometimes I maybe doesn't give them my 100% effort. I think of it as sort of leaving it up to God. If they survive, or if they don't, it's more up to God than me."
Det.. Bayliss: "Doctor....do you realize that you have just confessed to murder?"
Det.. Pembleton flashes cuffs. ED Doc clutches frightened small child......look of horror as realization sets in. Det.. Bayliss prevents Pembleton from cuffing the suspect. He tells her that they will think about this and for her not to leave town. The detectives return to their car visible shaken. Pembleton, normally tough as nails, is close to tears and can barely speak. Bayliss tries to make sense of it.
What does society gain by putting this woman in prison? What has society lost by Angel's death? They are the only ones that know and it is highly unlikely that anyone will ever put it together. They sit in the car and look at the house in stunned silence.
What would you do?
Ken Mattox:
Security and law enforcement is in the venue of government and the police. Health care is the domain of physicians. To each his own. Osler expressed an excellent approach to these issues in his book, "Aequanimitas" , MUST reading for all physicians, especially those working in trauma centers, emergency centers, and ICUs.
I see and treat both VIPs and persons who are identical to the ones described by Dr. Crippen almost on a daily basis. I often recognize the patients in both groups. To myself, the residents, the hospital, and the nurses, we MUST treat each one who comes through the door identically. WE, cannot be the ones to decide to reject the illegal alien, the drug pusher, the child abuser, the bank president who does not take her/his insulin, etc. just because they have a medical complication of a life-style decision. As at least 50% of the acute historical information is suspect, we cannot react to hearsay information. As in all areas of medicine, we should treat those who ask us for help, the same way we will want to be treated when our roles will be reversed.
There is no dilemma here. For me this is a reflex issue, I will give my best medical therapy to all, even if they attempt to spit in my face while suturing their wound.
David Crippen:
This doesn't answer my question. Your personal ideology is moot here. The deed is done. The dilemma is not the quality of care, the dilemma is what do do about this situation after the fact. Even the hard nosed Baltimore homicide cops have figured out that this is not a cut and dried situation where you cuff the offender, drag her to the station and book her. This VERY complex situation has reduced tough cops who have seen it all to stunned silence. They don't know what is best for all concerned and what long term justice may be served by their choices.
Help them out.
Deanna Mau:
I would let her go. Sometimes you have to do what is RIGHT, not what is CORRECT. Of course what the doctor has done is probably wrong and certainly illegal, But it serves no purpose to lock her up. She has to live with what she did and sometimes justice is served outside the law. I am not advocating killing criminals in the ER, just responding to the situation after the fact. Angel got just what he deserved in this case.
Gordon Doig:
The screenplay I would write would go something like this Dets re-enter house, ask small child to go upstairs. Place cuffs on Woman. Read her her rights, take out to care and drive towards downtown. During the trip towards downtown, Dets tell woman about all the 'perps' they have cuffed, booked and/or shot. Three blocks from downtown one Detective tells the story of being called to a break and enter. He goes into the house, with his gun drawn and hears noises in the basement. [Flashback to younger detective, stalking down basement stairs, as he gets to the bottom, flash of movement and clear picture of gun in someone's hands, flashes of shots] In return to present the detective tells how he was in the wrong house, and he shot the owner's son, who was hiding in the basement with a replica gun. Moral of the story is no person is an island, and everyone makes mistakes.
They return the Doc to her house, letting her know that this time, she did not make a mistake, but from now on, we'll be watching. The justice system has checks and balances, her justice does not.
Tim Buchman:
The discussion regarding the episode of NBC's drama, "Homicide" in which an emergency medicine physician suggests that less-than-the-best care was given to a shooting victim is interesting and enlightening. My initial response is similar to that of Dr. Mattox--namely, that to do less-than-our-best because we don't like a patient's morals is a violation of our professional oath. Dr. Crippen raises a different question, however. Having heard such a confession, how do we respond? Put yourself in the position of a review committee member--perhaps a member of the state licensure board hearing such a confession. How to react?
My personal sense is that this scenario tends to blur the distinction between personal and professional integrities. Each has been compromised. Dr. Mattox has highlighted the professional integrity issue nicely. From a personal integrity standpoint, I am reminded that we are "a nation of laws, not a nation of men". Those who bend/break the law must be prepared to suffer the consequences of their actions. At what point is it no longer acceptable to "look the other way" ?
Would you be willing to hire or work with someone who gave less than their best based on a moral judgment about a patient?
Frederic Cole:
It seems I recall the doctor making a comment something like "so what if I didn't tie that last suture" during her stream of consciousness revelations to the detectives concerning the futility and frustration she experiences treating some of her crime prone patients. It was at that point that they asked her whether she realized she had just confessed to murder. In my mind she has knowingly committed an error of omission which has certainly resulted in harm to her patient. This is at least malpractice if not murder. Somehow I can not equate this action with the wrongful shooting that Gordon Doig describes. Will the greater good for society and justice be served by allowing this physician to continue to practice? I agree with Dr. Mattox that our duty as physicians is to provide the best care we can to all of our patients when they need it. It is up to society as a whole to deal with the problems which result in Angel's recidivism. We as physicians and members of society can and should participate in working to solve those problems. However, when faced with an individual "dirt ball"/"victim" whose life blood is escaping from a torn femoral artery, our sole responsibility is to effectively, safely, and permanently stop that hemorrhage. Value judgments as to the individual's "fitness to live" are for another venue.
Dick Burrows:
Sorry FL there is neither moral, ethical or legal dilemma here. Some years ago a nutter went wild outside the hospital, broke into a kung fu shop, stole the vicious wares therein and promptly set about the local populace. He was a kind of Manson nutter. Any way he couldn't take on the whole crowd some of whom had a bigger stick than he had - he ended up in my unit with a couple of nine mil bullets in his gut alongside one of his innocent victims on whom he had committed a laparotomy. The issues were clear - he was saved for the hangman. There was plenty of dissent in the unit and plenty of discussion which was as it should be and which may well have meant that I didn't come in one morning to find a stiff in the bed.
Its not easy and sometimes one would really like to slip in "the Kevorkian mixture" but then one becomes judge, jury, executioner and vigilante - A medical Judge Dread all in one neat little package. It might also lead to the "slippery slope" criminals today, people with squints tomorrow I don't know. That said, the law must also be tempered with mercy. It doesn't mean that your ER Doc needs to walk to the electric chair but she certainly need to be taken out of her present situation.
After all He said love thy neighbor, He didn't say you had to like the bastards we find ourselves treating.
David Crippen:
I think this is an authentic moral dilemma not because of the need for corrective action but in the direction it's best taken. Remember that these cops are thoroughly PROFESSIONALS. They normally have a clear vision of their duty. I have seen these guys reduce enormous, street smart bullys to jelly in an interrogation room. They don't have any bullshit and they don't give any. If they think you're lying to them they'll eat you alive. If THESE guys have cause to take a minute and consider this situation; that is pretty remarkable and a good reason for us to do the same.
In my opinion, these guys are holding back because they know what's coming next and it bothers them. They know how the game is played, and the game involves throwing this woman into the criminal justice system; a system with a narrow sensitivity for unusual cases. In the criminal justice system, the attorneys are no longer function as officers of the court. The "truth" is no longer an issue. Defense attorneys are out to "win at any cost" because they are rewarded for doing so. Prosecutors will do anything they can to get a conviction, including move the trial to a locale where any jury is guaranteed to provide a predicted response. Either side will vigorously suppress the truth if it isn't in their best interest. The public is too easy to bumfoozle.
If you want to see how our system of justice works, you don''t trot out the OJ case. Almost everyone agrees that the whole OJ Circus from stem to stern demonstrates little about how the system works. If you want to see the criminal justice system in action, look at the Menendez Brothers and the Rodney King cases.
So what that means as a practical matter is that the criminal justice system works best for guilty career offenders. If they are found guilty, they have a reasonable probability of some kind of punishment. If they are found innocent, they get tossed back into the pool to get caught again another day. Where the criminal justice seems to break down quickest is in dealing with innocent people wrongly accused, or offenders with significant extenuating or mitigating circumstances. Courtroom manipulations and technical game-playing are far too insensitive to trust if you are innocent or offenders who are incapacitated or impaired.
This woman has clearly done something that is morally wrong that requires redress but she is at severe jeopardy in a criminal justice system exceptionally insensitive to her unique extenuating and circumstances. Dets. Bayliss and Pembleton are HEARTBROKEN because they know the system they understand well is not equipped to deal effectively with her. She might as well be tossed buck naked onto a Greek freighter. So, therefore, I ask.....what more effective alternatives are available?
What does the group think about the following rewrite of the script:
Bayliss and Pembleton sit in the car for a while and talk this over. They the return to the house and speak to the physician and her husband. "Doctor (and spouse), we have a big problem here and we have decided on a solution that will redress your debt to society without destroying both of your lives. First thing tomorrow, you will walk into the Chief of Staff's office in your hospital facility and announce that you have come to the conclusion you are an impaired physician. Because of circumstances you understand poorly, you have put patients in jeopardy and you must throw yourself upon the mercy of a system more sensitive to your situation than the alternative". She'll do it, and they'll check on it periodically.
Committees for Impaired Physicians are becoming more common. She will quickly be directed to the right place, and (presumably) dealt with in a system more responsive to the circumstances. It is inevitable that she will undergo extensive psychiatric evaluation and counseling that will lead to a career that doesn't involve dealing with live patients...or maybe she'll lose her license. Some kind of justice will come of it. Clearly, she will never be able to practice acute care medicine again, but there may be found some niche where she can function productively. I might add that no one would seriously consider prison rehabilitative in any way.
Ken Mattox:
I recall while working in a hospital in another part of the world where public executions were common, but where religious fiber is strong. A condemned man was sentenced to death, but had both injuries and degenerative conditions which required "fixing". Expensive operations on the extremities and even open heart surgery was performed. After the patient was whole and was no longer a patient, but a prisoner, he was released from the hospital, brought to swift justice and within one week of his dismissal from the hospital was put to death in a public square. He met his god a "whole" human being. At the time I thought of how much time and energy went into the diagnostic workup, the operation, the critical care time and the recovery. Both the patient and the state wanted and received the best that could be offered at the time and place as far as health care.
Was justice and medicine both served-I guess so. In today's time of corporate raiding, cost shifting, white collar crime, governmental laws aimed at medical McCarthyism, Quality management, and even practice guidelines, is the "legal" raping and killing of a health care system any less of a crime than the breaking into a home and stealing a television and raping the home owner. Only the laws are different, the hurt is the same and the impact on society may be worse with the first. Politicians tend to always get unquestioned access to health care. Thomas Holian:
The scenario is an interesting one. The answer, as I see it, is rather straightforward. If the police have enough evidence to seek an arrest warrant, they must do so. It is not for police to play the part of judge, jury and executioner or pardoner. The court system is in place to determine guilt or innocence. I do not want police deciding guilt or innocence.
Kresten Holk:
If she is guilty according to internationally, civilized juridical principles:
If she's innocent - and so far I have seen nothing that resembles trace of proof - nothing.....What has society lost by Angel's death? Probably not much. On the other hand, what does society lose by MY death?
They are the only ones that know and it is highly unlikely that anyone will ever put it together. They sit in the car and look at the house in stunned silence.
What would I do?
If I suspected a colleague had killed a patient because said patient was criminal, had offended/assaulted the colleagues' relatives, or belonged to a group the colleague dislikes for some reason ... I would report via proper channels. I'm no judge&jury, no less a god. Decisions like that should not be made in the backseat of a shabby police car. That's precisely the reason we made courts in the first hand.
John Salyer:
My response would be ........have you ever heard of the ethical concept of "the slippery slope"? Beware what you may find at the bottom of such an inclined plane. Further, I would answer your question with a question (apologies to all you trained debaters out there). Are there any absolutes? Is there anything that would be absolutely wrong, no matter the circumstance, e.g. deliberately taking (or through inaction allowing the end of) another life for anything other than self-defense?
We have of course, as a society, begun to embrace the concept of total relativism. Nothing is absolute, there is no higher authority (except for some "the state"). Thus, every aspect of ethical and moral behavior finally becomes completely subjective. Under such a premise it is easy to generate an argument of justification for the good doctor. The icons of our culture now allow that rugged individualism is of course the highest and purist form of behavior. Thus, Stallone, Arnold, Bruce, Jean-Claude; can dispatch hords of bad guys summarily....because of course they judges them to be, after all, bad. Add to this list now.....the good doctor.
Jeffrey M. Rosenberg:
It is not their decision to make, they are not judge and jury. Their sworn duty is to uphold the law, not just as they see it. It is up to the judicial system to determine what is just. It is the prosecutor who decides whether to proceed, and if so, then it is up to the jury to decide her fate. I would bet that most jurors are sick of crime and would sympathize with the Doc.
Louis Brusco:
Yes, I agree that she was right in doing what she did. I also think she should be brought up on malpractice charges if she did do what is intimated. Maybe even criminal charges. Sound confusing; that is \ because it is. These people are dirt, and don't deserve medical care. I personally feel that we should deny all emergent care to all alcoholics and drug abusers, and to all criminals like this guy. However, society has not come to the same realization, and we live in a civilized society, so we must live by its rules.
Jennifer Woissard:
This particular case has made me very sad for a number of reasons. The responses really don't show much of empathy or compassion for Angel. Sure he did some terrible things, but, again, I must ask this group: How do you know he was not impaired in some strictly biological way? and How would you react if Angel was your brother or other relative? I personally do not care if the doctor in question's life is destroyed. She destroyed a life, and deserves consequences. Real life consequences, not some overly sensitive committee. The dead Angel will never have an opportunity to reform or atone for what he has done and this is a direct result of the doctor's actions. I am very sad for those who have responded to this issue in a harsh and unempathetic manner. You will never truly understand human life and it terrifies me that you are medical professionals.
I don't mean to offend, but I work in a homeless shelter and see people like Angel every day. These people can get help and live "normal" productive lives. We will never know what might have become of the character, Angel and that is because of that doctor. He could have become almost anything. There are many famous and successful people who have (one way or another) pulled themselves out of a terrible situation (like Angel's) where they have impaired judgement to lead a full and productive life filled with great and wonderful contributions to society. Many of the comments I have read in response to this story have made me sick. I recommend that each of us spend time with people we despise - because we often do not understand why they are that way or if they can change. Many on this list have just reaffirmed that for me. If you truly want to claim that you are a "good" medical professional, you need to have an understanding of the human condition and how it becomes that way. I could offer specific suggestions on how to get in touch with people who are different and understand them, but I doubt that many on this list would care or change at all.
I don't pretend to be all-empathetic, but at least I am working on that. As for the law student, I am terrified that such a closed-minded, apathetic individual may someday be working with people such as Angel. But you will probably only want to work for people with money anyhow, so it may not matter. Thanks for adding to my discouragement.
David Crippen:
Jennifer, with all due respect, I could have predicted you were a social worker without looking at your signature block ;-)). It is possible that Angel has some biological condition that makes him a career criminal. It is also possible that Godzilla might stick his head out of the Fort Pitt tunnel at the peak of rush hour and start eating cars. For purposes of this argument, suggesting that Angel has mitigating and extenuating circumstances in his life that might make you and most nuns in the world like him serves only to complicate the issue to the point where it cannot be assimilated. For purposes of this particular argument, it is necessary to postulate that Angel is a career criminal who would cheerfully beat you to a pulp for pocket change, then do an impromptu body cavity search looking for more.
You state that you personally do not care if the doctor in question's life is destroyed. She destroyed a life, and deserves consequences.
The entire point of this dilemma rests on the supposition that this is not technically true. She did not intentionally leave a suture open with the foreknowledge that Angel would bleed to death. She simply didn't do her "best" job. There is a big difference in these concepts. She readily states that her methodology "takes the pressure off me and puts the pressure on God, where it belongs". Her modus operandi is to simply give "chance" a bigger hand in the future outcomes. This makes "proximate cause" a much fuzzier deal. Angel presumably had at least equal odds for surviving to maim again. That he didn't may very well have been a shake of the dice from above rather than in the ED. In this respect, I do believe that she meets the conditions for an impaired person and not a criminal person. I am asking you to consider the supposition that these groups be treated differently before the fact.
You state that the the dead Angel will never have an opportunity to reform or atone for what he has done and this is a direct result of the doctor's actions.
I must add that destroying the physician and her nuclear family denies them the possibility of repentance as well. Are you interested in punishment here or rehabilitation of the remaining players. Prison is non rehabilitative by its nature. In prison she would quickly become the personal pet of whichever powermonger claimed her, and she would more than likely be a high risk for suicide. Would this make you feel better about the fate of poor angel? If so, then splitting a child involved in a marital custody battle right down the middle with a cleaver, one half to each side would presumably not be too big a problem for you.
You further state: You will never truly understand human life and it terrifies me that you are medical professionals. I don't mean to offend, but I work in a homeless shelter and see people like Angel every day.
I work in an emergency department and I see the same people. They frequently drop by their local ED on the way to the shelter. There are many ways of looking at this problem, and I don't think you are very amenable to looking at much other than those colored by your own personal biases. So therefore, I will spare you an argument intended to proselytize you.
I do, however, hope that you find a niche in life away from hospitals. There is a very big need for advocates of the poor and the homeless and society's unwashed but you clearly don't like physicians very much and you certainly have little or no understanding of how the medical game is played in real life. It will be very difficult, if not impossible for you to be effective in a system you have no faith in and that you greet with open hostility and animosity. The people that you must work with will develop incentives to minimize you.
Michael Rhodes:
Regarding the "Life on the Streets Dilemma" it should be noted that matters of justice have proven troublesome since ancient times. Suppose it was the physician's (P's) husband (H) who had been assaulted by Angel (A). If H had managed to respond to A's aggression by delivering a fatal blow to A, then we would most likely have regarded H as acting appropriately, since A surrendered his "right to life" the moment he began a life-threatening assault upon H. But if A attacks H and manages immediately thereafter to flee to a local ER, then H will have, by virtue of his successful escape, reclaimed his right-to- life and all at the ER are expected to embrace him and to do everything within their means to restore A to good health. If P had been at the scene, and if in response to A's aggression against H she inflicted a fatal blow to H, P would be celebrated for having saved her husband's life--in the course of rendering justice H was killed by P. But, in the ER case, P is a nefarious murderer.
Before we take intellectual refuge behind cliche≠s about justice, due process, etc. we should be prepared to explicate precisely how someone can surrender a right-to-life as a violent aggressor, yet "reclaim" this right once having inflicted his damage upon an innocent victim and fled the scene. As a caveat from someone who has spent a great deal of scholarly time engaged in philosophy of law, I submit that reference to the fact that "at the time of the aggression a life was being defended while at the ER no life was being defended" is, however prima facie tempting an avenue, a dead end. One must find a coherent counter to the claim that since at the time of his aggression H deserved to die, P's ER omission was a means of rendering justice in so far as H got what he deserved (due process notwithstanding).
What typically happens is that we overlook the fact that justice was served because we do not accept the means by which it was served. We accuse persons like P as having unjustly rendered justice. Our legal procedures purportedly are the ideal means to justice and serve as safeguards against injustice. If we adhere to the notion that "the end cannot justify the means," then we end up with such cases in which "justice was rendered unjustly" and we are troubled. We are torn between our praise for the end and our disdain for the means by which it was achieved. I think this tension is particularly pronounced for physicians who often operate under "the end justifies the means" as a guiding principle. After all, how else could one justify a procedure such as an exploratory lap?
Our legal procedures in the U.S. (the stipulated "just means" of rendering "justice") can legitimately be criticized on the grounds that the ends are too frequently unjust. If a set of procedures consistently spews guilty criminals back into the streets, it seems wholly appropriate to question such procedures. After all, what are the criteria by reference to which we assess procedures, if they do not include an evaluation of their applied results? Gate-keeping adages such as "it's better to let a hundred guilty persons go free than to wrongly imprison one innocent person" can be seriously drawn into question once we realize that freeing the guilty in such cases often results in the suffering and deaths of many innocent victims. If such a principle is based on respecting the lives of the innocent, then we can explore the cost to innocent lives resulting from procedures based on such a principle.
Greg Heibel:
As neither a clinician nor a researcher, but one of the most feared and (probably rightfully) loathed animals in American society: a law student, I am a confirmed lurker on this list. On this topic, though, if I may add a couple of comments. The American Law Institute's Model Penal Code, which most states follow roughly defines negligent homicide as the negligent causing of the death of another human being. It specifically defines a person's negligent acts as:
"When he should be aware of a substantial and unjustifiable risk that the material element exists or will result from his conduct. The risk must be of such a nature and degree that the actor's failure to perceive it, considering the nature and purpose of his conduct and the circumstances known to him, involves a gross deviation from the standard of care that a reasonable person would observe in the actor's situation."
I recall that the show is set in Baltimore, Maryland, and a quick review of the case law in Maryland finds that the courts in that state differ a bit from many states, as there can be a verdict of murder as opposed to manslaughter, even if the defendant did not intend to kill the victim, if there is a finding of "implied malice." The courts held that in the absence of justification or excuse of a mitigating circumstance (the fact that her husband had been beaten up by Angel does not constitute such an excuse) and "even conceding that there was no actual intent to injure, an act was done or duty omitted willfully, the natural tendency of which was to cause death or great bodily harm."
The long and short of this is that Bayliss and Pembleton don't have much of a choice. She committed a crime. The question of whether she should be indicted and brought to trial is not one for the police. It is for the prosecutor. The detectives have violated their duty, as well as administered their own brand of justice by squelching the information.
I'm blessed that no one close to me has been the victim of a violent crime. I don't work in an ED or an ICU, so I don't have to treat trash like Angel on a daily basis. and personally, I don't think she should go to trial. I don't think a prosecutor would take this case to trial. First, her "confession" really isn't, because it wasn't specific to Angel, and she had not been advised of her Miranda rights ("you have the right to remain silent. . .") so the statement would never be admissible, and even a law student would know when she got to the station with the Doctor not to let her open her mouth again.
More importantly, no jury would ever convict a doctor with children who treats the sick and wounded every day and whose husband had just been beaten. It's an ugly story to try to sell a jury, that she should be locked away for maybe not trying as hard on the trash as she does on everyone else in the world. BUT, this diatribe aside, it's not Bayliss' and Pembleton's role to make this decision. This should be purely in the realm of the prosecutor. If the doctor were to go away, society would lose. The absence of Angel's scowling mug on the streets is no loss. What would be a loss in a society built on equality and law, is the unequal administration of justice. Let the prosecutors sort it out. That's their responsibility.
Mike Darwin:
I am impressed and fascinated by the wide range of positions taken on this case, and the articulateness with which they have been argued. I find my self agreeing in principle with much of what has been said:
Here are my thoughts, for what they are worth. It may make them a little more meaningful to note that I have been in a situation where I was unjustly accused of a very serious crime (homicide) but not prosecuted (not yet anyway: there is no statute of limitations on homicide).
The emotional turmoil, depression, terror and guilt (yes, even when you have done nothing wrong) are overwhelming. Your life will never be the same. Young Mr. Rosenberg should reflect on this. This comment is not made with malice, but with warmth and sympathy towards Rosenberg. The real world is sometimes a hard and terrible place. Neither law school, medical school, or any other kind of school can begin to prepare you for the reality of it.
The caveat here is that law, due process, and respect for law, must produce *justice.* In the absence of justice, law, due process, and so on become not only a mockery, but a vicious evil. In tort law in the US suits are brought for reasons of extortion, more often than for reasons for addressing an injustice. Junk science is used freely, and the defendant, even if found not guilty, must still pay the ruinous costs of the litigation. One of our neighbors doesn't like animal research. He precipitated nonspecific action (23 regulators showing up on one day) by the city. We retained an attorney -- a VERY good one. Everything was resolved amicably with the city and we got outstanding support from all our other neighbors. However, there is the small matter that we are $5000 poorer not to mention lost time, worry and planning. Total hit was about $10K. Just because someone doesn't like what we do, even though it is legal and done well.
In the criminal justice system the stakes are higher. Homicidal maniacs are let loose to rape, pillage and kill. Further, "we," the society, and we as individuals must care for these people and pay for it; with our money, our lives and our peace of mind and sense of wellbeing. The former *may* arguably be justified (money) the latter are inexcusable. Law and due process without justice result in a disintegration of the civility and order that law and due process are created to serve just as surely as their flagrant disregard will result in the same undesirable outcome. This is the message I get from Rhodes, and I agree with it.
So what would I have done were I the treating physician? I would have treated Angel competently if I had entered into an agreement with him directly or indirectly to do so. By working for a hospital that accepts the likes of Angel, this physician *consented* to provide such quality care. I would then have tried to get the DA to prosecute Angel. If such prosecution failed due to the kind of problems in the CJS that have repeatedly put Angel out on the street, I would have given careful consideration to using other courses of action to dealing with him which did not involve violation of my contract and professional ethic in treating him. The intelligent reader can no doubt come up with many scenarios within and outside of the law to accomplish this end.
Bill Griggs:
Think about this doctor.
Bottom line - I have enormous faith in the law. If OJ can get off............
Louis Brusco:
I'm blessed that no one close to me has been the victim of a violent crime. I don't work in an ED or an ICU, so I don't have to treat trash like Angel on a daily basis. and personally, I don't think she should go to trial. I don't think a prosecutor would take this case to trial. First, her "confession" really isn't, because it wasn't specific to Angel, and she had not been advised of her Miranda rights ("you have the right to remain silent. . .") so the statement would never be admissible, and even a law student would know when she got to the station with the Doctor not to let her open her mouth again. More importantly, no jury would ever convict a doctor with children who treats the sick and wounded every day and whose husband had just been beaten. It's an ugly story to try to sell a jury, that she should be locked away for maybe not trying as hard on the trash as she does on everyone else in the world. BUT, this diatribe aside, it's not Bayliss' and Pembleton's role to make this decision. This should be purely in the realm of the prosecutor.
I am reminded of an incident in our ER about 7 years ago. A crack head with pneumonia He had signed out of the hospital on Friday to do crack. Came back 12 hours later to be readmitted His bed had been given away. He was told he would be readmitted to the hosp. but would have to wait for a bed in the ER for 12-24 hours. He got mad and stormed off. He came back 6 hours later. He again requested to be readmitted to his old room. When he was told it had been given away, he pulled out a gun and took a security guard and an aide hostage. To make a long story short, after waving the gun around and threatening to kill everyone, he took them upstairs. Once out of sight, the hostages got away and the guy ran into a stairwell where, met by police, he shot himself. Now he was brought down to the ER where we had to take care of him!! He died, and we made our best efforts, but it was not easy, and I would hate to have a tape recording of the conversations going on during the resuscitation!
Unnamed participant:
I understand that Angel may have been impaired in some biological way. Yes, you are right that he may have atoned for his wrongdoings. If he had been my family member, I would have been devastated, not only for his death but for his actions against others.
In trying to make sense of the ethical dilemma that has been presented on this list, I have looked back on my own career as a nurse who has worked in both the ED and Trauma ICU in a urban trauma center. I have taken care of *many* "Angels" and after being spit at, manipulated, cursed at (For awhile, I thought my middle name was "white B---H"!), kicked, punched and otherwise verbally assaulted, I STILL had to care for those patients in the very best way I knew how. When this happens day after day after day, it starts to wear you down. You start to wonder where the justice is and why do these people keep coming back from devastating injuries when an innocent mother of three dies a horrific death from a chance motor vehicle crash. There were times that I was very tempted to do less than best but knew I had to look at myself in the mirror every day.
I am NOT condoning what that physician did in any way, shape or form but I can understand why that happened, too. I think what I am trying to tell you, IMHO, is that before you make up your mind about the physician's actions, you need to experience the environment that she has. I have and the world has turned from black and white into many shades of gray.
Martin Rowley:
I certainly believe that the doctor was morally wrong in what she did. We cannot judge others, but more importantly we must be able to judge ourselves. When she realized how she felt about angel, and how she suspected him of being the man who injured her partner, she should have found someone else to treat him. that's what I would do, as quickly as possible. We should all be prepared to help a colleague who has a situation where their emotion is clouding their ability to properly treat a patient.
Mike Darwin:
There seems to be a misconception about the position I took vis a vis the physician in the drama in question. I *was not* defending her actions or condoning them. I think it is wrong and unacceptable to either continue to treat (if there is an alternative) or refuse to treat (if there is no alternative) any patient who rolls into the ED. *Unless* of course, you have some stated or understood policy to the contrary. Perhaps posting a sign and running TV adverts saying "The General Hospital ED treats all patients as competently as it knows how, unless one of our staff personally hates you, you are a dirt bag, or a Democrat (the latter case in which you are automatically presumed brain dead and transferred to the organ harvesting guys :))...
Due process is critical. Law and respect for the law are essential to the operation of a decent productive society. And if the law is wrong or bad, then what of the due process of that law? Many not guilty people have been effectively processed to death.
For the record, I trust the government to make sound decisions about as much as I trust the nearest psychotic. I personally oppose capital punishment because it is *irreversible* and the past and present both document far too frequent a false conviction rate. (Even one unjust execution would be too many.) Execution is also just too damn convenient for governments and societies as it allows the rather permanent silencing of people with unpleasant views. *And it is a given\ that any society that executes people will inevitably broaden the class of offenses for which it executes people. Personally, given the choice as a citizen, I would rather bear the cost of lifetime incarceration with its possibility for *some* redressing the event of error (even if "justice" comes only after years of false imprisonment) rather than none. It just means she should not commit or omit actions that compromise a reasonable standard of care. Even if Angel had killed her husband.
She should not have become involved in this case at all, considering Angel's role in her personal life, even if her lack of involvement resulted in Angel's immediate death. Inaction for cause is hardly an offense. I agree she should have withdrawn from the case if possible. But this is not always possible. There are situations in some EDs where there is no one else to turn to. THAT is where the professionals are separated from the amateurs. If no other course existed, she was obligated to treat him. Your statement that "inaction is hardly an offense" indicates that we have sweepingly different understandings or ideas about what it means to give emergent care in the setting of an ED, or a cryonics organization for that matter (which I view as just an ED to tomorrow's specialists and definitive care Docs). There are colleagues of mine who hate my guts and who have no one to turn to (as I have had no one to turn to) in the event I go down. I expect to get a decent standard of care from them if that happens, and I have given the same to others who I disliked.
I once dialyzed a man who killed a 4 year old boy because he couldn't spell a word right. He held him under a scalding hot shower. He once chewed up a glass thermometer and spit it out in my face for no particular reason other than "he didn't like my honky looks." He lived through the treatment without complications. It took some effort... Justice is as vital to life as food or water...or air. People will pursue it at almost any cost.
Yes, people are fools. But they, some of them, continue to reach for something better, to be a little less foolish... It remains to be seen if they will "ultimately" succeed, whatever that means. And no, perfect justice is no more a reality or a possibility than perfect medicine. Perfect medicine exists only in the pages of textbooks and in the "high-minded" and "idealized" critical expert testimony so often given in courtrooms and mouthed by lawyers who are often persecuting (not prosecuting) good physicians who have given good care. But, I see you, Bucky, still practice medicine, although your practice of it must be far from perfect since you are a man. And, I see, that some lawyers and some others in the world still pursue justice even though justice, like "medicine" is an ideal. Sometimes, in some cases, we achieve the ideal perfectly. In others.... It is the former that keeps us going. It is the latter that educates and elevates the practice of justice and the practice of medicine to ever higher planes. IF we learn from our mistakes.
Dick Burrows:
Hmmm. Any criminal justice system can be abused. The system itself may be fundamentally flawed as Apartheid was flawed. It may be flawed in the way it is applied. Apartheid was not only flawed it was applied in an unjust way (if any flawed system can be applied fairly that is). There is evidence in other countries that the system is applied unfairly against different race groups.But that is a different issue The issue here is one of legal vengeance versus rehabilitation is it not.
Capital punishment and life imprisonment represent legal vengeance It is hard to imagine them being anything else! Dealing with innocent people wrongly accused, or offenders with significant extenuating or mitigating circumstances. Courtroom manipulations and technical game-playing are far too insensitive to trust if you are innocent or offenders who are incapacitated or impaired.
This is a tragedy - it does not necessarily mean the law is wrong. Timothy Evans was wrongly hanged for a murder he did not commit. The tragedy was later discovered and he received a Royal pardon (how he could be pardoned for something he did not do is beyond me) It is a terrible tragedy but it does not make the law wrong for that.
What she has done is not only morally wrong - it is ethically and legally wrong as well - even though her "confession" might not stand up in court. Then as with other celebrated cases she would have gotten off. Is that "justice" as well. Likewise Al Capone was not a murderer according to your legal system but then that's also the issue - presumption of innocence. It is not satisfactory for a couple of cops to make these kind of decisions. They are there to bring people who have committed a crime to book - Book her Dan-o! clearly she is not in the same league as your most unpleasant criminals. Or is she? She is by her own admission a Judge Dread. "When the doctor goes wrong he is the first of criminals. He has the knowledge and the nerve" - Conan Doyle. Does not society have a right to at least find out?
Getting back to legal vengeance and rehabilitation. she may well be contrite and she may well be remorseful and she may well be rehabilitated but justice is still also an issue. It may well be reasonable for her to be reported to a medical board with authority to strip her of her license and insist on rehabilitation etc. But that is the duty of the magistrate/coroner/DA or whomsoever is responsible. He may not feel the necessity to invoke court proceedings for murder 1 etc but that's the way it has to be. Anything else is the vigilante law of the kangaroo court.
Remember too that this is not simply a colleague (and that's not simple) who is in trouble having sucked a bottle of whiskey before coming on duty and where you can pull him off duty and insist he be investigated by the hospital committee for impaired doctors - it's a real crime admitted and witnessed by a nurse That's also why we have an ethical code of conduct which says you are obliged to do a competent job to the best of your ability on all patients. It does not mean that you have to wind up treatment to insane levels just in case you are criticized for "not doing everything" - just do a reasonable, competent job with the tools you have at hand. Neither do you have to like the gobshites you treat. That would have been her best protection against any sort of action now contemplated.
David Crippen:
But the reality is that they do have a fairly broad discretion as to who to bring into the net. Street cops settle disputes with nightsticks daily rather than drag them in. I suspect that they have connections that would allow such a thing to happen. Recall that someone with a pistol remarkably like that of John Munch killed the perpetrator of the earlier shootings of the members of the inner circle after the legal system let him off on a technicality. It was simply dropped at this point. I suspect that they might even have enough connections to go to the State's Attorney and receive absolution for this deed.
And also recall that when cops don't use this discretion, it is usually taken over by other groups with other interests. Remember from The Godfather (Mario Puzo), the Godfather's rise to power began in the neighborhood by offering rough justice for immigrants when where was none to be found at the level of the police. If your daughter was raped, and the system failed, you could go to the Godfather and he would identify the offender and have one of his goons have a few words with him, prior to an extended hospital stay. Justice was pretty much an eye for an eye, with violent redress for violent offenses. The Godfather did not take money for these favors, but instead accepted favors, the sum of which made him politically powerful.
The point is that she did not realize she was functioning as a Judge Dread at the time. She was, by implication, impaired, and we make allowances in our society for impaired persons. They are not treated the same as career\ criminals. So, I ask again, is the cause of justice served better by having her gang raped in prison until she finds a way to hang herself? Exhorting Dan-o to Book Her gives us the feeling that some kind of justice has been done because this behavior is what we have grown up with and acclimatized to. Does is result in the most justice for all concerned?......I'm not so sure. I sit in the back seat with Pembleton and Bayliss....cops tough enough to eat nails....and I see tears in their eyes. Does this not move you to look for alternatives to this person wearing a dog collar in prison?
Rolando Berger:
I have been following this thread with great interest. It is indeed a very complex issue with a myriad of different practical and ethical facets. I don't have much to add, but it occurred to me as I read Burrows' comments from 2/10, that the criminal justice system and its penalties can be viewed in a light that needs not to be either "legal vengeance" or "rehabilitation", as he proposed. Punishment for a crime can also be viewed simply as a measure taken to "protect the species". People like Angel would be permanently removed from society simply to protect it (society) from further harm. This would be a pseudo-Hobesian (people are basically bad and thus, rehabilitation is a pipe-dream) pragmatic decision made without anger (no interest in revenge as such) nor "misguided" (?) compassion: lets try to rehabilitate this guy to make us feel better, even if in the process a few more innocent people end up hurt, maimed, or dead. As a friend of mine (a district attorney) once said (after having a few more drinks than he should have), "The only good thing about the death penalty is that it sure cuts down on repeat offenses".
Under this type of completely pragmatic analysis, "fairness", "mitigating circumstances", etc., would have a relatively small role to play, as in deciding punishment for a criminal the only important considerations would be:
Obviously, these same criteria would apply in deciding whether/how to punish the physician in Angel's case. We can all draw our own conclusions here. To be honest, I have serious and deep-seated reservations about letting "impersonal pragmatism" be the guiding light of our judicial system. On the other hand, I have even more reservations about people who feel sorry for the criminals but have no qualms in jeopardizing the lives of innocent people put at risk while trying to rehabilitate violent offenders for whom, under the most optimistic of estimates, no better than a 50% chance of success can be predicted. If we use the USA as an example, just look up the yearly FBI crime figures. If you exclude domestic and workplace violence, and impromptu fights ("barroom brawls), of all serious violent crimes in which we know the perpetrator(s), What percentage is committed by individuals who had committed a prior violent crime and were caught for it? Go and look up the figure. Believe me, it can make the argument of my drunk district attorney friend start looking better and better.
Shoshana Edwards:
Doctors are given a great deal of power and privilege in this society. We train them to make decisions of life and death. And with few exceptions we honor those decisions. Great power is placed into the hands of the physician. And great knowledge. We also assume that this power and knowledge will be used wisely, honorably, and judiciously.
Interestingly, we put nearly the same amount of power into the hands of our police. Not, however, the same privilege. But the life and death decision making, and exculpation when mistakes are made, are quite similar. We hope with the same hope we extend to physicians that cops also will exercise wisdom, honor, and judiciousness in enforcing the laws.
We cannot and must not allow doctors to come to believe that there is any basis for withholding treatment or doing less than the best and most thorough job other than triage-type decisions. In other words, the only basis for judgment should be "will it work? Is there any chance that this patient can be saved?" Doctors cannot and must not make life and death treatment decisions on the basis of personal valuation of the life of any individual, no matter the circumstances. Yes, we would even argue this in the face of treating a Hitler, a Genghis Khan, a Stalin.
And this same standard must apply to policemen also. It has long been the position in our society that the courts must make decisions like those contemplated by the cops in this scenario. Their duty is clear. Someone has broken the law, and whether they like it or not it is their obligation to arrest and charge that person. Whether the actions should be exonerated by circumstance is a decision which must be made by the larger society -- in the person of its courts, judges, and/or juries.
Decisions of moral turpitude cannot be left in the hands of those who have been granted the power of life or death: physicians and cops. In this case the doctor was wrong. And if those policemen don't arrest her, they are wrong.
Dick Burrows:
OK OK and maybe there is reason to allow them discretion of a sort. Just as I have the discretion to clip my kid on the lug 'ole when he is naughty - but when does that bacome child abuse. That is probably the same thing that can be said of any decision making process. There can be no absolutes in respect of decision making. It depends on what you see to be the greater evil - vigilante law or anarchy. Stuffed if I know the answer.
Unless the Godfather's son did it. But then nepotism also lives does it not. Rough justice is fine when you want to keep pirates on a brigantine in control. Also the kind of favour the godfather was likely to want in return.....?
If she admitted that she could have done better and should have done better then she was not impaired. This does not mean that she must be thrown to the wolves. It does not mean that all punishments have to be the same. It may be that an act of contrition is all that is necessary. Society doesn't have to punish, doesn't have to extract it's pound of flesh.
I'm glad they have compassion but the law is supposed to be blind - stick your finger in 'is eye :-)
Ellen Rosen:
I concur with Malcolm Fisher and his analogy to the Nuremberg principles. The question of Angel's worth to society (or lack thereof) is irrelevent. So is the question of the physician's worth to society as a health care provider, taxpayer, wife, or mother.
Her act would not be any more or less heinous if her husband had not been mugged, or if she had chosen not to tie that last suture because the patient was black, or gay, or Jewish. What matters is simply that she had no right to deliver substandard -- and possibly lethal -- care simply because she held something against the patient.
Not having seen the TV show, I don't know whether the physician intentionally decided not to tie the last suture or whether she was simply too traumatized to deliver adequate care. If the former is the case, she is guilty of murder -- at least in New York State (once, when a juror on a murder trial, I was taught that a verdict of murder -- as opposed to manslaughter -- could be brought if the jury decided that the defendent knew that a reasonable consequence of his action was the possibility of death.) If the latter is the case, the physician may still be guilty of manslaughter.
When someone callously endangers the life of another, it doesn't matter whether the act is done with a switchblade or a scalpel. The policemen should contact the district attorney to determine if there is enough evidence to bring a charge of manslaughter or murder. The DA can then decide whether to bring charges, to arrange a plea bargain (which might include having the physician lose her license), to simply report the physician to the state medical board, or to do nothing for lack of evidence.
If the physician must go to prison, she has no one to blame but herself.
Caveat lector: My experience with the criminal justice system is not based on TV shows, or news reports of sensational trials, or mafia movies, but rather from the quite dubious privilege of several times having been a juror in Manhattan criminal court. That probably skews my perspective as much as anything else.
C. Gordon Heckel:
Having watched this thread, up to Ellen Rosen's comment, I fell like adding my own $0.02 worth, looking back at my training in law.
I think one point we must keep in mind is that what people have been referring to as the "criminal justice system" is _not_ really a system for administering justice at all, but a _legal_ system. In a society with any significant amount of disorder, the approximation becomes quite rough. I think ours, at least in the urban areas, can be reasonably so described.
In the theory which attempts to provide some order to the field of criminal law, three basic functions or goals of punishment are described: retribution, incapacitation and deterrence. I think that actions proposed with respect to the physician in this case need to be examined with respect to whether they would serve any of these. A decision about what to do should be made on that basis. While I don't think most prosecutors would _act_ on this ground, I think it is not because they believe one of these goals of criminal law would be served. The incentives of their positions and daily exposure to truly immoral persons guilty of really disgusting acts incline them to view all accused persons as guilty, and to see their position as one of obtaining convictions and punishment, rather than one of helping to accomplish justice or serve the legitimate goals of criminal law.
Which of the goals of criminal law would be served by prosecuting the physician? Does she need to be imprisoned to prevent her from doing the same thing (incapacitated)? Does she need to be punished to deter her or someone else from similar behavior? Is there a loss to society which demands retribution against her (punishment just for punishment's sake)?
To my mind, neither incapacitation nor deterrence is served by prosecution and punishment of this physician, because: (1) She is extremely unlikely to repeat the offense; and (2) The act is not one which physicians are generally tempted to commit and from which they must be deterred in a general sense.
The only goal or function of punishment which might be served in this case would be that of retribution, and that is one which I must reject. _My_ ground is theological -- I am Christian, and feel my belief requires this of me -- but the same result can probably be derived from other moral groundings.
In a utilitarian sense, I do not see any reason that prosecution and punishment by imprisonment or other sanction would be expected to increase the total of good or decrease the total of evil in the world. Given the nature of her offense -- not specifically intended death, but negligent risk of injury, and the other factors which might have inclined her to it (i.e., Angel's character and acts), I do not see that the benefit to society of retribution here is sufficient to balance the cost in resources of trying her and imprisoning her.
This is, to me, a case where the exercise of police or prosecutorial discretion is wise -- once she is clearly aware of the possibility and the fact that the threat of prosecution for this will always exist, let her live with her guilt. I wouldn't even make an effort to have the board revoke her license -- that would be an egregious waste of the resources used to train her, and probably would not prevent any future harm, because she is very unlikely to cause any.
"Let anyone among you who is without sin be the first to throw a stone at her..."