Quality of life

Quality of life is a judgment about the value or acceptability of another person’s life, not simply a clinical finding about a diagnosis or a patient’s chances of recovery. In the book, it becomes a fraught measure at the point where scarce resources, emergency decisions, and end-of-life ethics meet. Its central danger is that an assessment of suffering or dependency can slide into a decision about who counts as worth saving—particularly when the person being judged cannot express a preference.

From assessment to classification

In ordinary speech, a judgment about quality of life may describe how a person experiences illness, disability, dependence, or suffering. In a crisis, however, such language can acquire institutional force: it may help determine who receives treatment, who is moved, and whose needs are set aside. The distinction between describing a condition and assigning a value to a life is therefore crucial. A patient’s poor prognosis, inability to communicate, or dependence on intensive support does not by itself establish what that patient wants, or whether their life is worth protecting.

The book places this distinction against the pressure of Memorial’s unfolding emergency. When Susan Mulderick told staff that floodwaters were approaching, the command meeting took on the character of a military operation, with one immediate objective: move quickly before power failed. Nearly two hundred patients needed safety, and staff discussed sending those most dependent on life support or mechanical aids first. That effort involved prioritizing urgent practical needs, not establishing that some patients had less valuable lives. Yet under pressure, logistical categories and judgments about human worth could become difficult to keep apart.

Patients deemed expendable

That danger appears starkly in the testimony of LifeCare respiratory therapist Terence Stahelin. Recalling patients who were not carried downstairs for evacuation, he said he believed that some had been treated as expendable because they were older women with dementia and were thought to have no quality of life. This was his account of how the patients had been regarded, not a demonstrated clinical assessment of their wishes or worth. Its significance lies in the implication that age, cognitive impairment, and presumed dependence could be converted into a reason to leave people behind.

A separate account from Touro Infirmary raises a related concern. Some staff later described a triage practice in which patients who could not say their names were not given intravenous fluids. The allegation haunted relatives of a man with advanced Parkinson’s disease who could not speak and died unexpectedly. Other patients were reportedly marked as too ill to move and left off the helipad. These reports do not establish that every decision followed a quality-of-life judgment, but they show how the inability to communicate or meet a functional test could become consequential in the allocation of care and evacuation.

The book also distinguishes those reported decisions from the formal plans for patient movement at Memorial. Neonatal nurses resisted a proposed helicopter destination when they did not know whether the receiving hospital could support the babies. The director insisted that the pilot find a way to fly them to Baton Rouge or not take them. The conflict turned on the conditions needed to sustain fragile patients, not on a claim that their lives were less worth saving. The babies arrived safely, and one infant’s oxygen level matched the level maintained with improvised life support. The episode underscores how a patient’s vulnerability can call for more careful protection rather than a lower valuation.

The historical danger of the phrase

The book traces quality-of-life reasoning into the history of euthanasia advocacy. In the nineteenth century, some advocates argued that drugs developed to relieve pain might also help bring about death. Over time, some extended the argument beyond a person’s expressed wishes, claiming that the deaths of sick, dying, or dependent people could relieve burdens on families and society. The book emphasizes the shift in that reasoning: an asserted act of mercy could become a collective judgment that certain lives were not worth living.

That history reached its most violent form under the Nazis. In the early 1940s, the regime implemented involuntary euthanasia programs against people with mental illnesses and physical disabilities, using the language of resource savings and survival to justify killing. The book reports that as many as 200,000 people may have been executed in these programs. The historical example gives the concept a political dimension: a society’s claims about the value of lives can serve not only as private opinions, but as rationales for organized violence against people made vulnerable by illness or disability.

Consent, law, and the right to refuse

The book contrasts involuntary killing with a patient’s right to decide what may be done to their body. At the time of Arthur Caplan’s review of the LifeCare deaths, active euthanasia of a person who had not expressed a wish to die was not legal anywhere. The ethical objection was not only the absence of consent. It was also that a doctor or other decision-maker would be judging what quality of life another person should accept, with the possibility of abuse—including decisions influenced by financial interests.

The account of euthanasia in the Netherlands complicates any simple contrast between safeguards and abuse. The stated criteria included repeated requests and unbearable suffering without the possibility of improvement, assessed by doctors; a study found that the rules were not always followed, and that a small number of people were killed without an explicit request. The book also describes the Groningen Protocol, which set out conditions for ending the lives of very ill or brain-damaged newborns with substituted parental consent. Although the protocol was not explicitly legal, doctors following its guidelines were not prosecuted. The cases sharpen the question of whose judgment is being used when the patient cannot speak.

The NVVE, a Dutch organization advocating for euthanasia and choice in dying, supported broader social acceptance, including for some elderly people who felt dependent, people with dementia, and people with difficult-to-treat psychiatric illnesses. The book presents this advocacy alongside the continuing prohibition on intentionally ending a life to relieve suffering in the United States, where the American Medical Association’s code prohibited active euthanasia. The contrast is not simply national: it exposes competing assumptions about autonomy, dependence, suffering, and the authority to assess another person’s life.

Aftermath and the limits of judgment

The Memorial case leaves these questions entangled with the experiences of patients, staff, and investigators. Gina Isbell described nightmares about patients who died and lasting anger that help came too slowly; she also remembered an elderly woman telling her that her survival would be because of Isbell. Isbell continued to believe that she and her colleagues had done the best they could. Her account preserves both the burden of the decisions and the continuing value she placed on the patients she had cared for.

John Thiele’s later critical illness offers a different caution against equating a grim prognosis with a settled judgment about life. During weeks of sedation, a nurse believed he seemed remorseful about his role in the Memorial events, but Thiele later denied that interpretation and said he remained confident in what he had done. He distinguished his own condition from those of some Memorial patients because, although his prospects were poor, his problems were potentially reversible. The account does not resolve the ethical dispute by making prognosis irrelevant; it shows instead how judgments about reversibility, suffering, and acceptable quality of life depend on distinctions that can be uncertain and morally consequential.

Across these episodes, quality of life is not a neutral score. It can describe suffering, inform care, or become a proxy for a decision that belongs to the patient. The book’s recurring warning is that when a person’s dependence or inability to speak is treated as permission for others to assign their life a lesser value, an assessment has crossed into a claim of authority over another person’s continued existence.