My Moral Compass and The Plaintiff vs Dr Conrad Murray

I’m not an MJ fan. While I appreciate he’s an idol to music (much like The Beatles), his songs don’t do it for me. I don’t own any of his songs, but I appreciate that he’s had a big effect on the music industry. I therefore don’t say what I say as a person who loves or hates MJ: he was just a strange famous dude to me, who could dance, sing and write internationally catchy songs.

I haven’t obsessed over this trial (no watching it on Sky everyday like some folk) but I have read articles a couple of times a week about the witnesses called and the changes that have occurred. I’ve found it intriguing as it lies between the medical and criminal boundaries, with a charge of involuntary manslaughter. This is the least ‘serious’ of the four homicide charges in California: first degree (fully premeditated murder), second degree (partially premeditated essentially), voluntary manslaughter (crime passionelle – heat of the moment, non-premeditated murder) and involuntary manslaughter (unintentional homicide). From what I can remember however, their federal law actually has another charge of accidental killing (can’t remember its exact term), which is less serious again and isn’t counted as homicide. I can only guess it means e.g. tackling someone in a sports match and accidentally causing brain stem death.

Apparently there’s two ways Murray could have been guilty though, and I wish I could remember or find them. I presume it’s giving too much of a dangerous drug, or not sustaining his life by poor action once MJ was found unconscious. They found him criminally negligent, but could not officially comment whether it was on one or both grounds. If I can find the same piece of journalism that describes these two options more fully, I’ll correct this paragraph. The jury are now allowed to speak if they choose to however, so it may be that this information is released in coming days and weeks.

What I’ve found funny is my instinctive moral stance actually sided with Conrad Murray: I suppose I thought to myself he was doing what his patient wanted, and it seems harsh to be criminally punished for that. I also, for some reason, had this feeling he was going to get off. However, with this blog post rather than arguing my point of view, I’m trying to work out why this was my instinctual feeling, and review it. I rather think I’ll end up showing my ‘feeling’ to be wrong, or at least morally inarguable.

So for this case, as the jurors were told, forget that it was Michael Jackson. This is about the right or wrongs of a doctor, and whether it constitutes a crime (as opposed to a non-criminal, medical error). So, let’s consider some of the facts first.

MJ’s autopsy said he died of a propofol overdose, and had other sleep-related drugs in his stomach. My burning question here is whether the dose of propofol would have been fatal on its own without the oral meds. I’m going to assume yes however, as the defence of the case was not based on Jackson overdosing as he'd swallowed tablets while Murray was out of the room, rather that Michael had administered his own extra propofol (a claim later dropped by the defence following the testimony of a propofol specialist).

So, MJ died of an overdose. Not only that, but Murray was found to be making a personal call, not monitoring his patient while MJ stopped breathing. When found, a member of staff testified that Murray was trying to revive Michael, and told the bodyguard to hide drugs before he called 911. Apparently it took 20mins before he told the bodyguards to ring for paramedics, the BG trusting in Dr Murray’s medical knowledge and that Conrad had Michael's welfare as his priority. This bodyguard also reported seeing a saline bag with drug bottle, and the ‘milky’ propofol liquid visible in the bottom of the bag. This bag and a syringe were used as evidence.

At the hospital, when trying to revive a man who doctors have since admitted was a hopeless case, Murray did not admit that propofol was likely to be the cause of his unconsciousness. While this was wrong, it was irrelevant as it turned out. Jackson was long dead at that point. Combined with the fact that Murray hid drugs before calling 911 certainly leans towards the explanation that Murray was in the wrong and knew as much, at least medically if not criminally.

Propofol, while not a controlled drug in the way many other prescription medicines are (don’t ask me what they meant by that: I thought prescription = controlled drug, but I guess some compounds are subject to more rules than others) it had never been used in a home setting before, only in hospital as an anaesthetic. A anaesthesiologist who specialises in the study of propofol said it should not be used without the correct monitoring equipment (MJ didn’t have that apparatus at home), that if Michael had drank the propofol it would not have led to overdose, and that MJ could not have administered himself a second dose as he wouldn’t have been physically incapable after the original 25mg.

So, when I put this down in black and white, why did I think Murray might be found innocent? Well, I suppose part of it was related to not understanding fully the charge against him: I didn’t think Murray murdered MJ. I thought he gave him the treatment that he wanted nut made an error in dose, so while medically negligent he was not criminally negligent. I think it came from me thinking Murray definitely did not want or mean to kill Jackson. 

Hang on, it’s just clicked: it’s the Kantian in me. I thought as he was giving someone his wishes, propofol use at home wasn’t actually illegal, and he didn’t mean to kill Michael, that Conrad may well not be found to be guilty. There’s my moral compass being based on intent rather than outcome again! I think I also found it so objectionable that everyone had him pegged as guilty before reviewing the trial evidence: I’m very much a proponent of innocent until proven guilty.

Looking coldly at the facts though, Murray was treating Michael in a way that contravened best and typical medical practice. While perhaps not criminally wrong, this is likely to be a big factor in whether the Board of Medical Examiners will strike him off or not. Without Dr Murray giving MJ that propofol (with all the evidence pointing that Murray was the only person capable of administering the drug), MJ would have been alive that afternoon. If , after an accidental overdose, 911 was called immediately and medical treatment was given immediately with all the facts made available (i.e. that the cause of unconsciousness was a propofol overdose), Michael certainly would have had a much better chance of being resuscitated.  Also, imagine if Conrad wasn’t a doctor and MJ wasn’t a celeb: so if Joe Public hadn’t called 911 to help an unconscious but not yet dead friend, then he’d at least be culpable of letting him die (if not killing him). So perhaps Involuntary Manslaughter is the closest thing to criminally letting die.

What it all boils down to is that the question the jury has to answer was “Did Conrad Murray cause the death of Michael Jackson?” Well, if he wasn’t there, that drug hadn’t been given, then Michael would have lived. So I guess ‘guilty’ was obvious.

On subjectively reviewing the evidence, it seems clear that Murray is indeed guilty of involuntary manslaughter. I'm just glad that I now understand why my moral compass wasn't instinctively lying in the 'guilty' camp. 

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ADDENDUM

So, I’ve done a bit more digging and finally been able to find more of Dr Murray’s point of view, rather than outside documentation and speculation from very biased press. It’s made me think even more about things, so I just thought I’d try and get it down while it’s fresh in my head.

One thing that I have found confusing in this whole thing is the idea of drug interaction: was the dose of propofol itself lethal, or did it combine with the drugs in Michael’s stomach to create a cocktail that arrested his breathing and heart rate? As I hadn’t heard more about this, I assumed it wasn’t an issue. Now however, I’m not so sure.

So, it turns out that the 25ml dose of propofol Murray said he gave would last 20mins. A female doctor that regularly uses it stood testimony that she starts dosing at 60ml, as less than that would have no real effect on most patients.  So, surely the toxicology reports are able to work back and calculate the amount in his system at the time of autopsy, extrapolating to estimate the original dose?  This would make clear if MJ had been given an OD. However, I have neither heard nor found any information that suggest MJ had a dose big enough to count as overdose e.g. 120ml – twice the amount used to induce unconsciousness in a medical setting. How then was the CoD listed as “acute propofol intake”?

The voice over of the documentary however, said MJ died of a lorazepam and propofol overdose. That wasn’t in that CoD box, but without seeing the whole report in detail, it’s hard to find out if the coroner listed it as a contributing factor in some way.  Given that MJ had been given 3 medications and was not asleep hours later suggests that a minor propofol dose, enough to tip Michael over the precipice of sleep as Murray describes, would be fine and not cause any problems.

What did become clear was the pressure Murray was under. He was invited to become Michael and his family’s physician to help them eat more healthily, avoid catching bugs and viruses, and treating any colds etc if they did occur. Once in, he said he was ‘entrapped’, caged in by a sweet man who was addicted to several medications, and had learned to treat the side-effect of insomnia with propofol. The fact he MJ a dose so small as to only cause light dozing for no more than 20mins does fit with a man not happy just to accept that propofol was best for putting MJ to sleep at night. After all, there are no legal or regulatory contraindications over using propofol in a home-setting.

He did however say that he told MJ he’d already had enough drugs to “tranquilise an elephant” and didn’t know how he wasn’t asleep already (pre-propofol). This gives the suggestion somehow that perhaps Murray wasn’t fully clued up on the pharmacological interactions between the drugs. That’s just connotations from his wording however, and isn’t necessarily fact. I know however, that a lot of my questions are arising over the lack of information about the interaction of these drugs, and I wonder if that was an element of the trial also.

In the original blog post I also had concerns about Murray taking so long to call 911. Well, in fairness to him, as a cardiologist by speciality and presented with a highly private patient in cardiac arrest, he was in fact the best person to have treated him. In fact, leaving MJ to go and call 911 could have been considered a bigger breach of his ethical code as a doctor. However, there is a discrepancy in the bodyguard saying how quickly Murray told him to call 911 and what Murray claims to have told him. This point is therefore difficult to settle as it’s tit for tat, and Murray did not stand in court to testify this.

So all in all, I still feel sympathy for Murray – a man the world considered guilty before even let him have a fair trial. I don’t envy the position he was in – a difficult, addicted, troubled and high profile patient, who was said to often enter his private chamber in a temper. Seeing photographs of that private chamber that even maids weren’t allowed in was shocking – it was a mess of books, bottles and what appeared to be some medicines. On top of that, Murray was hired to keep Jackson and family healthy through his come back tour in London – the first since the child molestation case. Jackson told Murray that without sleep the whole thing would fail and he’d remain poor – he couldn’t compose, choreograph or be creative unless he was drugged asleep every night. To be the man that wouldn’t give anaesthetic drugs which, while unconventional could still legally and medically used at home, would allow the King of Pop to restore his name and his fortune, both of which had faltered.

So, all in all, I still sympathise with Murray and, in all honesty, if he approached me as my physician on a cardiac ward, I would not turn him away and refuse to be treated. Just because he got into a difficult situation (perhaps through greed as it’s been argued - $150K per month, not that he received his payment mind you), doesn’t mean he’s a bad doctor or would knowingly or wittingly kill someone. I’d happily let him treat me.