Intention to cause death versus foreseeable death

Intention to cause death versus foreseeable death concerns a central distinction in evaluating end-of-life treatment: an intervention may be intended to relieve suffering even when its effects could hasten death, while deliberately causing death is a different claim. At Memorial, the distinction became difficult to apply because patients received morphine and sedatives amid an evacuation crisis, accounts of treatment varied, and postmortem evidence could show drug exposure without settling intent or, by itself, the precise cause of death.

Clinical intention and foreseeable effects

The distinction appears in the contrast between a clinician’s purpose in giving medication and the consequences that treatment might foreseeably have. Roy Culotta described morphine as relieving the distress of gasping while also acknowledging that it could hasten death; he characterized the purpose of treatment as relief of suffering. His account makes the ethical question explicit without resolving it: recognizing a potentially fatal effect is not identical to intending that effect, but the stated aim does not alone establish what occurred in a particular patient’s case.

The difficulty was sharpened by uncertainty about what patients were experiencing. Investigators learned that Cheyne-Stokes breathing could precede death but could also occur in other situations, including sleep among some people with heart failure or brain damage. Agonal breathing, by contrast, was described as a gasping reflex that can occur shortly before death when oxygen levels are extremely low; one medical view held that patients in this state probably were not experiencing pain or suffering. Yet the appearance of gasping could distress family members and nurses, and experts differed over whether medication was ethically justified when discomfort could not be known with certainty. The book locates the moral and legal distinction in the difference between wanting, foreseeing, and intending death.

Medication decisions at Memorial

John Thiele gave patients morphine and Midazolam at doses higher than he ordinarily used in the intensive care unit. He reassured them and, in most cases, patients died within minutes after being medicated. One man continued breathing, and Thiele gave additional morphine, estimating afterward that the total may have reached 100 milligrams. Thiele’s subsequent account describes a moment when the treatment crossed beyond medication: he covered the patient’s face with a towel, and the patient died shortly afterward. Thiele later questioned whether what he had done was right, including whether the patient had been aware and whether he would otherwise have died soon. The episode places stated intentions, chosen actions, and their immediate consequences in direct tension; it does not make those elements interchangeable.

Culotta’s account of Merle Lagasse presented a different description of medication near death. When Lagasse experienced a breathing crisis in the parking garage, he sent a nurse into the hospital to obtain medication, recalling morphine, Ativan, and a sedative. He said that he had assessed another struggling patient, administered medicine, returned after fifteen or twenty minutes, and given more when the patient was still struggling. He also contrasted the emergency circumstances with ordinary practice, in which an intravenous line and electric pump would allow medication to be adjusted in controlled amounts over time. His account supplied investigators with both a stated palliative purpose and details about repeated medication under conditions unlike routine care.

What toxicology could establish

The investigation’s evidence raised a related but separate question: whether drugs were present, whether they contributed to a death, and whether anyone intended a death are distinct propositions. After the bodies had remained in heat for more than a week, Frank Minyard initially warned that conventional blood sampling was not possible. A pathologist advised that drug traces might remain in more durable tissues, and investigators sent tissue samples from eighteen Memorial patients to National Medical Services, Inc. In an initial report on those cases, nine tested positive for morphine and roughly five or six for Midazolam. These findings documented drug exposure in tested tissues, but did not by themselves establish why a drug had been given or what a clinician intended.

A later review covered forty-one bodies from Memorial and LifeCare: twenty-three tested positive for morphine, Midazolam, or both. The director of the laboratory, Robert Middleberg, considered many of the concentrations striking, but cautioned that postmortem tissue results were not as straightforward to interpret as blood tests from living patients. Heat and the time before sampling might have altered drug concentrations. He therefore urged the reviewers to consider each patient’s clinical history alongside the laboratory results, rather than treating a number as a complete account of the medication or its effects.

The reviewers considered whether high levels might reflect a single large dose shortly before death or repeated doses accumulating in patients whose kidney or liver disease could affect drug processing. They also examined whether the combination could suppress breathing, especially in patients not on respirators, and whether the timing of medication fit the recorded timing of death. The questions separate exposure from mechanism and mechanism from intention: even a finding consistent with harmful effects would not automatically establish what a clinician meant to bring about.

Expert disagreement and the limits of inference

Frank Minyard consulted Steven B. Karch, who argued that drug levels measured in bodies kept in extreme heat for days could not reliably determine levels before death. Karch advised leaving the medical causes of death undetermined. Michael Baden countered that uncertainty about the precise dose did not erase the finding that morphine and Versed were present shortly before death, and he noted the absence of another competing cause in the cases he discussed. Cyril Wecht disputed Karch’s account of postmortem changes, reporting very high levels in some samples and describing a small comparison study in which samples exposed to hot, humid conditions did not differ significantly from refrigerated samples. The study was limited and unpublished, so it added evidence without ending the dispute.

The disagreement mattered because the conclusions at stake were not identical. A toxicology result could support a claim that a patient had received a drug; interpreting the result alongside medical records could inform a view about dose and possible physiological effects; neither step alone resolved whether treatment caused a death or whether death was intended. Minyard worried that a trial would become a battle among forensic experts and that the prosecution might fail to overcome reasonable doubt. The book thus presents intention versus foreseeable death not as a formula that settles the case, but as a boundary investigators and clinicians had to assess amid uncertain medical histories, contested evidence, and consequential differences between relieving suffering and intending death.