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The nurse as "mercy killer"

December 16, 2003 -- Over the last few days the New York Times and other media outlets have run stories about the filing of murder charges against Pennsylvania nurse Charles Cullen, who reportedly told investigators that he had ended the lives of 30-40 patients in his career in order to "alleviate pain and suffering." Today's Times article presents a relatively fair account of Cullen's alleged actions and their wider significance, though it could have provided more context.

According to the Times piece by Robert D. McFadden and Robert Hanley, Cullen had worked at many different facilities in Pennsylvania and his native New Jersey during his 16-year career, and had been fired or forced to resign from at least six of them. Even so, it appeared that neither state nursing boards nor Cullen's many successive employers had been made aware of his problems in previous jobs. Cullen has been charged with killing one patient and trying to kill another at a central New Jersey hospital, apparently with toxic doses of digoxin. Arrested on December 12, Cullen reportedly told prosecutors over the weekend that he had caused many deaths, and on December 15 told a New Jersey state judge that he wanted to plead guilty. According to the Times, the case has sparked investigations by 10 facilities and seven prosecutors.

The Times piece does mention some of the larger issues, noting that Cullen's case "raised a host of questions for the hospitals about the safeguarding of lethal drugs, about reporting serious personnel problems to state licensing authorities and future employers, and about hiring practices and the capacity to obtain accurate records on an applicant's work history." The story also notes that "the case appeared to hold the potential to become a gruesome paragon of its genre: serial murders by nurses, some in the name of mercy killing, that have stunned the nation from time to time," and that the worst previous case in the U.S. involved a nurse's aide who admitted killing 37 people at hospitals in Ohio and Kentucky. Of course, nurse's aides are not registered nurses, who must have at least two years of college-level training to practice, but this distinction is often lost on the press.

Without condoning a health care worker unilaterally killing people he or she believes are suffering too much, the article could have done more to provide context. "Mercy killing" is not merely part of a serial killing "genre." It relates to the larger problem of what society should do at a time when science is able to preserve life so much longer than it can preserve quality of life. This complex area encompasses the long-standing disputes over physician-assisted suicide, and the grey area in which health care workers operate when they give suffering, terminal patients pain-relieving medications that have side effects that some believe may hasten death--though some recent research has indicated that this "double effect" rarely occurs. (The Hospice and Palliative Nurses Association has more information on pain relief in end-of-life care.)

As front line care givers, nurses spend more time with the desperately ill than any other health workers, and they witness an extraordinary amount of suffering. As patient advocates, nurses are the professionals who are primarily focused on relieving that suffering, consistent with legal and ethical rules. Thus, they spend a lot of their time pushing to make sure that patients are getting adequate and appropriate pain relief, and that patient and family wishes as to end of life care are respected. (The Times article does note that the New Jersey prosecutor's reply when asked whether any patients had asked Cullen for lethal injections was: "We don't know definitely.")

Moreover, the article might have noted that there are about 2.7 million nurses in the U.S. In such a large group of people--people who of necessity have ready access to the very ill and to dangerous drugs--there will of course be a tiny minority that abuses its position. The nurse as serial killer may be a "genre," but it is by any measure a very small one. The Center hopes that some piece about Cullen has noted or will note that it is nurses who do most of the difficult work of caring for terminal patients in pain, and that the vast majority do so with great skill, compassion, and respect for the relevant legal and ethical rules.

One reason that people may be "stunned" to learn that nurses can become serial killers is that many don't realize professional nursing requires constant access to medications that if used incorrectly can be lethal. Many people are not aware that nurses have that level of responsibility, or that nurses make thousands of life and death decisions every day--many of which involve medications. Some may believe a nurse who gives a patient an excessive dose has somehow gained access to serious drugs that nurses don't normally have, but of course nurses are the ones who give most of these drugs. Any increased "safeguarding of lethal drugs" to reduce the risk of abuse-- a worthy goal--will have to take account of nurses' need for ready access to them.

Without getting into the facts of any particular case, we might also note that a nurse who ends terminal patients' lives because of a belief that the patients are experiencing unnecessary pain may differ in some respects from a "serial killer" who simply stalks and kills healthy individuals. Without condoning illegal or unethical conduct, and recognizing that no health care worker has the right to make life-ending decisions based solely on her own sense of morality, we hope that the press will in such cases bring to light all potentially relevant factors. These include whether the patients involved were terminal; whether they were in great pain; whether they were receiving proper end-of-life care, including adequate pain relief; whether care givers had made other efforts to provide adequate pain relief that were unsuccessful; the views of the patients and their families on the patient's end-of-life care; and whether the case raises questions about how well the health care system provides such care generally. These issues will only grow more urgent as advances in health care allow the critically ill to live longer.

At a Monday press conference, the Times reports, the New Jersey prosecutor was asked whether the deaths could be considered mercy killings, or whether Cullen could be regarded as an "angel of mercy." The prosecutor reportedly replied that "[i]t may very well be characterized as that." While we would not dispute that this exchange is newsworthy, we would note that in our view the "angel of mercy" formulation is extremely unhelpful in any context, positive or negative. It serves to perpetuate outdated and harmful stereotypes of nurses as spiritual but unskilled beings, rather than the highly trained modern professionals they really are.

See Robert McFadden and Robert Hanley's article "Nurse Charged in Death; Says He Killed Others" in the Dec. 16 the New York Times.

April 16, 2004 -- Also see our news item "New federal nurse disciplinary controls proposed in wake of Cullen case."



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