Institute of Medicine

The Institute of Medicine was an independent advisory organization within the National Academy of Sciences whose disaster-care reports addressed a central tension exposed by Hurricane Katrina: emergencies may force limits on treatment, but those limits do not erase duties to patients or make intentional hastening of death ethically acceptable. Its guidance linked the allocation of scarce medical resources to public participation, fairness, and accountable decision-making.

Institutional Role

The book identifies the Institute of Medicine as a highly regarded, independent advisory organization that is part of the National Academy of Sciences. Its role in the events discussed was not to direct hospital evacuations or make bedside decisions, but to convene disaster experts and issue guidance to policymakers and the public about care during crises.

That advisory role became especially relevant after Anna Pou campaigned for legal protections for medical workers serving in disasters. The legislative discussion drew on her first-hand experience, but, the account notes, lawmakers did not ask whether the protections she supported should extend from altered triage to intentionally hastening patients’ deaths. The Institute’s reports addressed that unresolved boundary directly.

Guidance on Hastening Death

A year after Pou’s campaign, and again three years later, disaster experts convened by the Institute considered the ethics of medical care in disasters after consulting emergency responders across the country. Their conclusion was unequivocal: “Neither the law nor ethics,” they wrote, “support the intentional hastening of death, even in a crisis.” The guidance drew a boundary between adapting care under extraordinary conditions and deliberately causing a patient’s death.

This position supplied an institutional counterpoint to arguments made in the public debate over the Memorial Medical Center deaths. The reports did not settle what had happened in any individual case, but they rejected crisis itself as a justification for intentional life-ending action. Their emphasis was not on inventing exceptional moral rules for exceptional circumstances, but on maintaining ethical limits when ordinary systems of care are under strain.

Resource Allocation and DNR Orders

In 2012, the Institute released an extensive report supporting public involvement in developing guidelines for dividing medical resources during disasters. Drawing on Hurricane Katrina and other cases, its authors recognized that crisis conditions may justify limiting access to scarce treatments while insisting that providers retain duties to care for patients, treat them fairly, and steward resources. Where access must be restricted, decisions should be transparent, consistent, proportionate to the shortage, and accountable.

The report also challenged the use of do-not-resuscitate orders as triage criteria. An earlier Institute report had observed that such orders express advance planning and personal preferences about end-of-life care “more than an accurate estimate of survival.” That distinction mattered in the Memorial evacuation, where doctors placed all patients with DNR orders last, although a DNR order meant that a patient should not be revived if breathing or heartbeat stopped. One patient’s daughter later explained that she had not understood the order to mean that her mother would be denied rescue. The Institute’s guidance treated DNR status as a poor proxy for survival prospects, rather than as a reliable measure of who should receive scarce evacuation or treatment resources.

Significance

Taken together, the Institute’s recommendations addressed two different dangers in disaster medicine: using a patient’s prior end-of-life instruction to make assumptions about their chances of survival, and treating emergency conditions as permission to intentionally hasten death. Its proposed safeguards placed public involvement alongside transparent and accountable procedures, rather than leaving resource decisions to opaque or inconsistent judgments made under pressure.

The Institute’s guidance did not remove the hard choices created by shortages, nor did it resolve the legal and factual disputes surrounding the Memorial case. It did, however, state the ethical limits within which such choices should be made: scarcity may require triage, but fairness and the duty to care remain; crisis does not make intentional hastening of death ethically or legally supportable.