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 HEALTH COMMUNICATION, 22(1), 1–10
Copyright © 2007, Lawrence Erlbaum Associates, Inc.

An Effect of Communication on Medical Decision

Making: Answerability, and the Medically Induced
Death of Paul Mills
R. Wade Kenny
5 Mount Saint Vincent University 1

In this essay, the occasion of a medically induced death is examined to illustrate how social
agents can, on occasion, respond inappropriately to social and communicative demands. The
essay illustrates and assesses an occasion when a health professional, faced with a medical
crisis that was laden with professional, ethical, and even legal considerations, responded in
10 a manner that overlooked all those standards when she injected potassium chloride into her
patient, Paul Mills. In the essay, the case is chronicled and the character of the social and
communicative mechanism that led to the disaster is given and used to interpret the events.

This essay directs health professionals toward a social
competence that, when it is performed unsuccessfully, leads
15 to significant ethical, professional, and even legal conse-
quences: It is a competence to satisfy the legitimate expec-
tations of the actors present within a situation, as well as the
potential actors who might later assess the appropriateness
of the chosen response. The name for this competence is
20 answerability, for it simply describes our capacity to act
in a manner that satisfactorily manages a situation, given
that we will, at one time or another, be held answerable, by
various others, for the action we take. Society expects us to
be answerable in our personal and professional lives, and
25 we consciously and unconsciously take this into considera-
tion in our decision making and our actions, not only when
the matter is a general matter, but even when it is an ethical
one. Although answerability is a social ability, as stated
previously, it expresses itself within communicative action,
30 so it can be regarded as a communicative competence as
well.
Clearly, medical professionals are answerable for their
actions: Performatively, this means they are expected to
act in a manner that satisfies immediate demands as well
35 as expectations that might subsequently arise. Communica-
tively, it means that they are also expected to competently
justify their medical acts on any occasion that they are
legitimately interrogated regarding them. Each process is
complex, the latter dependent on the former, and failures
40 easily occur. When that happens, health professionals may
Correspondence should be addressed to R. Wade Kenny, Mount Saint
2
Vincent University. E-mail:
find themselves in problematic situations that threaten their
professional, ethical, and even legal status.
To illustrate the impact of answerability in medical
action, this essay focuses on an occasion when a doctor
injected what would usually be regarded as a lethal dose 45
of potassium chloride into her patient. The action, which
occurred during what was already an institutionally sanc-
tioned, dying ritual, exceeded both the legal limit for
medical action and the code of professional conduct for care
of terminal patients—it may also have caused the sudden 50
death of the patient. Nevertheless, some part of the public
and some part of the medical community (Galloway, 1999)
argued for the ethical soundness of what the doctor had
done. A heated debate over the rightness or wrongness of the
doctor’s act resulted, and, as is often the case in life-ethics 55
arguments, both sides were intractable, so the combatant
publics came to no clear resolution.
The fact of a public debate over the ethics of the doctor’s
action is not, in itself, however, evidence that the doctor
was ethically motivated, in any direction, at the time of the 60
incident, for it may be that social agents (including health
professionals) regularly forget their ethical compass when
confronting situations that are ethically laden. Indeed, a
recent essay (Kenny, in press) argues that this is a patent 3
aspect of our daily lives. We sit on seats that are made of 65
animal skins, drive automobiles that pollute the atmosphere,
toss donation requests from charitable organizations into the
garbage, purchase diamonds that are the profit of unspeak-
able horrors—the point is not that we always do wrong
when we do such things, rather that we often do them with 70
no reflection on the rightness of wrongness of our acts. It
 2 KENNY
is a tendency quite far-reaching and highly functional—one
that is as relevant to health professionals as it is to other
social actors, particularly in circumstances such as the one
75 faced by the medical practitioner discussed in this essay.
Action remains motivated, however, even when it is not
driven by ethical concern. In particular, it is motivated by
social concern, by the individual’s ongoing ambition to
manage his or her social resources and social status, amidst
80 others. Largely, this is done by showing some concern
for answerability to institutions and to others by attending
to that standard of expectation and consequence, socially
manufactured, which is an organizing feature of the situa-
tional competencies required for the occasion.
85 For the case under consideration, there is reason to
believe that Doctor Nancy Morrison was not motivated by
her ethical sensibilities. The ethical censor is, by definition,
a rational mechanism that arises when evaluating action-
options—by extension, to exercise one’s ethical sensibili-
90 ties, one has to be aware of them in situ; and this would
mean, correlatively, that one would be able to articulate
them on a later date. Morrison, apparently, lacked this
ability. Of her actions, she has only said “I – oh my God! I
don’t know why” (Poirier, 1998, p. 354), when asked about
95 her reasons. She might have said “I did it because I refused
to preside over an unrelenting agony that could end no other
way.” She might have said “I did it to give Paul Mills the
peace no one in this hospital had offered him.” And, had
she given such a reason, we would be able to assess the
100 ethical character of her choice. Her claim, however, that she
does not know her reasons, places her act in an ethically
liminal zone, to the extent an actor’s reason is a condition
for assessing the ethics of an action.
The fact that Morrison could articulate no reason for
105 the action that she took did not mean, however, that there
would be no consequences. Indeed, in terms of codes of
professional conduct and law, there is no argument, legal
or ethical, that would release Nancy Morrison from the
cascading mortifying rituals that were about to arise, given
110 that she had no justification for her action. As the story
that follows reveals, she was clearly held answerable, for
her actions; and, when that occurred, she realized she had
initially acted in a manner that would not allow her to be
answerable. Consequently, she was unable to avoid the sorts
115 of mortifying rituals that she subsequently underwent. Irre-
spective of ethical consideration governing her acts, then
the case illustrates that a health care practitioner can engage
in complex technical routines with less than satisfactory
reflection on the answerabilities of the situation—it, there-
120 fore, makes the Morrison story a cautionary tale, reminding
us of the significance of answerable behavior in professional
settings.
We all know of failed answerability from our own expe-
rience, and it is simple enough to find an example that all
125 can recognize: a boy is challenged by his friends to climb
a tree—he answers that demand, but in doing so fails to
answer his mother’s preexisting demand that he never do
so. Even here we see how easy it is for answerabilities
to fail under incommensurable manners pressure, making
answerability, under many circumstances quite difficult, 130
even impossible to achieve. In small matters, this may
mean little; but, in a complex and critical medical setting,
failed answerability can have disastrous results. Thus, the
issue is of significant concern for health professionals, who
regularly find themselves answerable to the most desperate 135
of human situations—situations such as the one faced by
Dr. Morrison. That said, this essay uses the Nancy Morrison
case as an illustrative vehicle for suggesting the effect of
answerability in the medical setting.
Nancy Morrison is a Canadian physician who introduced 140
an injection of nitroglycerine into the drip of her dying
patient. She shortly thereafter administered a second injec-
tion of potassium chloride. The patient died minutes later,
and the physician eventually found herself facing murder
charges. In the essay that follows, I will initially present 145
a summation of the circumstances leading up to the death.
Thereafter, I will briefly discuss the character of answer-
ability. Then I will attempt to examine the case by reading
the events that transpired against the theory of answerability
as it will be elaborated in this essay. 150
THE BASIC FACTS OF THE NANCY
MORRISON CASE
Paul Mills was a 65 year old patient at the Queen
Elizabeth II Health Sciences Center in Halifax, Nova Scotia,
in November of 1996, and he was dying of complications 155
associated with the surgical removal of his cancer-ridden
esophagus. Months earlier the cancer had been excised, and
the surgeon had attempted to reconnect the stomach directly
to the throat, in lieu of the now removed esophagus that
ran between them. However, the stomach, now stretched a 160
foot to reach the back of the mouth, was no longer able to
satisfy its blood supply needs; gangrene consequently set
in, and half the stomach died, leading to gastrointestinal
leakages and infection idiosyncratically proliferating within
the chest cavity (because the stomach was now up in the 165
area of the heart and lungs). Of serious note, the leakages
also delivered hydrochloric acid into the lungs, a condition
described by his last treating surgeon (Bethune, 1996) as “a 4
disastrous complication” (p. 449). Nine surgeries followed,
each attempting to resolve treatment complications. The 170
primary strategy involved replacing dead tissue in a diges-
tive tract that ran through his throat, chest, and abdomen
with portions of small intestine and bowel. Each surgery
failed, however, leading to complications such as leakage
of bowel and salivary fluids into the chest cavity. Even- 175
tually physicians were forced to cut directly through the
chest, opening the sternum, to provide an adequate supply
to the grafted tissue. But even that operation failed. Fluids
 EFFECT OF COMMUNICATION ON MEDICAL DECISION MAKING
continued to escape into the abdomen and chest, infec-
180 tions continued to spread, and tissue continued to die. The
sternum itself also became infected, and this made it neces-
sary to load antibiotics, remove affected tissue, and leave
the chest as an open cavity packed with gauze—the sternum,
previously wired shut, was now unclosed to cope with these
185 complications, and vents were inserted through the ribs and
stomach to drain pus, a procedure so extreme that one could
afterward see Mills’ beating heart if the gauze pushed into
his open chest were not in place.
The last surgical attempt to give Paul Mills a functional
190 esophageal tract occurred on October 1. Subsequent surg-
eries were performed only to manage complications that
prevented that final bypass from healing. By October 17 it
was clear that hope was fading—previous surgical attach-
ments were unsealed and more fluids were escaping through
195 them. A Do Not Resuscitate order was therefore put in
place. Nevertheless, Mills’ condition was still not treated
as terminal, and two more surgeries were performed in the
next 11 days—the first an attempt to seal an opening in the
bypass and manage complications discovered in the process,
200 the second to drain pus. Despite these efforts, later scans
revealed that new pools of pus were forming beneath the
now-closed chest opening.
Clearly the medical efforts that were made on Mills’
behalf were creative and heroic attempts to rescue a human
205 being. They well illustrate the aggressive character of
medical practice—how it attacks the body in its benign
effort to eliminate whatever it is that ultimately threatens
the human being as an active, viable person. There comes a
point, however, when it is known that such heroic measures
210 cannot rescue the person, and that point had been reached.
Paul Mills’s artificially created gastrointestinal tract would
not heal, and the infections would not abate. Thus, it was
universally agreed that Mills could not survive, had suffered
greatly and uselessly over the 6 months of surgeries, and
215 would continue to suffer mercilessly if he ever regained
consciousness. Such was the case when the head of infec-
5 tious diseases declared the infection in Mr. Mills to be
incurable, and the chief surgeon also declared that Mills’s
stomach and throat could never be successfully connected.
220 This was their way of announcing that Mr. Mills was on
an irreversible and cascading pathway to system failures
and death, and that additional measures were unthinkable.
Consequently, on the morning of November 10, life support
was removed from Mr. Mills and all treatments other than
225 palliative were stopped by virtue of the family’s request,
after consulting with the physician. With the cessation of
tube feeding and antibiotics, as well as the removal of the
breathing tube that had been surgically inserted into the
throat and connected to a respirator, Paul Mills began the
230 dying process.
It was not an easy death. Despite palliative medi-
cation administered at levels the bedside nurse (Bland-
MacInnes, 1998) had never seen, levels she characterized
3
as “astronomical,” (p. 316) the patient continued to demon-
strate gasping, agonal breathing. Mr. Mills had received an 235
intravenous administration of 800 mg of Dilaudid, 230 mg
of Versed, and 40 mg of morphine, but he continued to
die a horrible and agonizing death, one characterized by his
ICU nurse (Bland-MacInnes, 1998) as “beyond a shadow
of a doubt the worst death I have ever witnessed” (p. 320). 240
Technically unconscious, his agonal breathing and generally
distressed state nevertheless gave at least the appearance
that he was suffering greatly.
The ICU nurse interpreted Mills’ dying state as one of
profound and unnecessary suffering. After his disconnec- 245
tion from the respirator, and despite his low blood pres-
sure, he not only continued to breathe, he gasped for air.
The nurse went to the attending respirologist, and stressed
her concern that the sedatives were ineffective in relieving
Mills’ suffering. Her behavior was recalled (Poirier, 1998) 250
as “hysterical,” and she begged Morrison to do some-
thing about the patient. (p. 356). One can understand his
nurse’s state. Given the patient’s nonresponsiveness to the
remarkable levels of narcotics that had been given for
pain reduction, it must have seemed that an inhuman force 255
was sadistically torturing Paul Mills beyond the limits that
the dying ritual itself was supposed to curtail. It must
also have appeared, one imagines, that medicine had been
made, not only an accomplice, but even the active agent of
this torturous process. Morrison listened to the nurse and 260
committed herself to a resolution of the crisis. She injected
Mills with 10 cc of nitroglycerine through an IV push, which
she said would decrease the blood pressure and thereby
end the patient’s suffering. However, Mills’s blood pressure
rallied shortly after the injection. So Morrison administered 265
a second 10 cc injection, this one potassium chloride. Within
a minute Mr. Mills’s heart stopped.
On the day of his death, Mills had received Ativan,
Versed, Dilaudid, and morphine as palliative medication—
their combined effect would be equal to a total injection of 270
between 4,400 and 6,800 mg of morphine. (Sneiderman &
Deutscher, 2002, p. 2). The journal Palliative Medicine
reports far lower dosages for patients with intractable
suffering in 28 of 30 cases. (Chater et al., 1998, p. 260) 6
Only two of the cases examined in the Palliative Medicine 275
study involved dosages similar to those received by Mills,
and those dosages were given over 24 hr, whereas Mills
received his in less than 7. Moreover, no traces of these
drugs were found in Mills’s liver. Consequently, Morrison’s
attorneys were able to argue during the preliminary hearing 280
that IV injections were not entering Mill’s bloodstream
(probably because the IV line had drifted free of its vein). It
could not, therefore, be clearly demonstrated that the potas-
sium chloride injection, also injected through this line, was
the cause of death. Consequently, the case was dismissed 285
before going to trial. The Crown appealed, but the appeal
was denied. Despite the case’s dismissal, Morrison paid a
heavy price for her action. She was the subject of national
 4 KENNY
attention between the time 60 police officers, including a
290 SWAT team, arrested her at the hospital, and the dismissal
of charges. She underwent internal review and had hospital
privileges suspended for 3 months. She was permanently
removed from the ICU. In addition, the College of Physi-
cians and Surgeons reprimanded her. Perhaps most painful,
295 she has been left to recognize that the most significant
professional act for which she will be remembered will be
this event.
We can reasonably assume that Morrison gave the injec-
tions because she intended to hasten the patient’s death. For
300 a great number of people, that is all they need to know
to opine on the ethical character of the action. They will
say, “This doctor is morally justified, acting to hasten the
end of the patient’s life,” or they will say “This physician’s
death-hastening actions cannot be morally justified.” Thus,
305 as is so often the case in life-ethics disputation, people of
good will and sincere concern, who have some capacity for
ethical reason, come to opposite conclusions. However, it is
possible that Dr. Morrison’s actions were not governed by a
moral sensibility, rather that they were directed by another
310 part of what it means to be an agent acting in situation:
answerability. That possibility is examined below.
ETHICS AND ANSWERABILITY: TOWARD AN
UNDERSTANDING OF THE NANCY
MORRISON CASE
7 315 Kenny (in press) characterizes answerability as a social
mechanism that governs conduct. He organizes this mech-
anism around two fundamental talents: a talent to hold
answerable and a talent to be answerable. The capacity
to hold answerable is expressed on those occasions when
320 social agents exercise legitimate judicial rights over the
actions of another. These rights include the right to demand
an action, the right to interrogate why the demand was
not satisfied, and the right to effect consequences. Holding
answerable occurs, for example, when an office supervisor
325 deals with a receptionist who has, for the third time, arrived
at work 1 hour late. Because such rights for holding answer-
8 able exist, Kenny (in press) argues that a competency for
being answerable must also exist—that is to say, social
agents must be able to anticipate the answerabilities that
330 others will hold over them, and they must be able to act in
such a way that they will be able to resolve these answer-
abilities, or possibly justify their decision not to do so.
In terms of being answerable, there are two fundamental
9 competencies, mentioned by Kenny (in press), that are
335 particularly relevant to this case. These are the competencies
for discernment and discrimination. The competency for
discernment is the competency to recognize those holding
answerable expectations that are specific to the situation.
It involves the ability to recognize how one’s role carries
340 specific duties to others, some of which remain consistent
and some of which vary as one moves through role space
and time. A patient may complain that a nurse did not check
his blood pressure at the appropriate time (an attempt to
hold answerable), yet the nurse may report that there was
a medical emergency that took precedence. If, indeed, the 345
nurse did manage a medical emergency, then she would
have discerned the degree to which she could be answer-
able for the various action expectations specific to her role,
and she would consequently be able to justify those actions,
when she was interrogated. 350
Answerability also requires a talent for discrimination,
for the world exerts so many calls on us that our capacity to
answer any one of them is largely dependent on our ability to
prioritize and even disregard many others. The classic illus-
tration of this talent for discrimination is triage medicine, but 355
it is common to a variety of other medical circumstances as
well. Whenever and wherever medical resources are limited,
the health professional’s capacity for discrimination plays
a determining role in the manner that medical actions are
answerable, in terms of resource and treatment allocation, 360
discriminating what is absolutely necessary as an answer in
a manner that will necessarily privilege some and disregard
other expectations. Discrimination is also required when a
health professional considers what constitutes a reasonable
answer to the medical situation. There are many ways, for 365
example, to get rid of a wart, ranging up to the amputa-
tion of the affected limb. An effective physician answers
the demand to treat the wart by discriminating among the
options for handling it and answering with a “best” option.
Of course, this sort of discrimination is regularly performed, 370
when answering an illness with a prescription, or even when
answering a cancer with a treatment plan.
Besides these factors, answerable agents also must
possess general social competence, and this is because
answerability is socially determined. For example, when 375
a man falls over at a restaurant, a waiter will immedi-
ately realize that only certain social agents can manage
such a situation, and will therefore not answer this crisis
by performing a tracheotomy, but by calling out “Is there
a doctor in the house?” As the doctor moves toward the 380
collapsed man, bystanders will also behave in a socially
competent manner—they will realize their comparative
insignificance in the midst of a crisis situation and they
will step aside to let through the physician, who repre-
sents a significant social figure in these circumstances. The 385
example is comparatively nonproblematic, but it need not
be, for the subtleties of the social order can make it very hard
to detect what the appropriate response in a given situation
might be. Consequently both the situational competence of
agents and the rules that govern a social exchange may 390
play a determining role in any agent’s ability to interpolate
a complex event and answer it effectively. Of course, the
medical setting provides a context in which health profes-
sionals must regularly answer critical demands as they are
imposed on them. They can do this only if they understand 395
 EFFECT OF COMMUNICATION ON MEDICAL DECISION MAKING
that complex and ever-shifting social order that appears in
the midst of the medical situation and the hierarchy of rela-
tions that is associated with it, making doctors answerable
to nurses in ways that nurses are not answerable to doctors,
400 and the reverse, and so on.
On the basis of what has been said previously we can
describe answerability as a demand that expresses itself
on us, calling for our answer in the form of actions and
statements. The demands of answerability exist at a variety
405 of levels, many of them social, and they are constituted
within a field of social relations, often under the heading
of professional conduct. Answerability is also subject to
interpretability: We answer based on what we interpret to be
the request. Further, we might even do so unconscious that
410 answerability is taking place. Such features do not exhaust
the character of answerability; however they do provide
sufficient foundation for us to examine the Nancy Morrison
story with a view to the role answerability played in her
action. That part of the assignment will follow.
415 Answerability in the Death of Paul Mills: The Occasion
of the Act
In this essay we treat the Nancy Morrison case as an occa-
sion of failed answerable performance, in particular as an
occasion when a medical practitioner failed to effectively
420 discern her answerabilities and discriminate, among action-
options, those that would manage all contingencies associ-
ated with the event. With that in mind, we will examine
how her action, as it is characterized by testimony, resulted
from and resolved her apparent discernment of answerabili-
425 ties demanded within the emergency event, but we will also
examine how this discernment did not include a compe-
tency for anticipating those answerabilities that might occur
after the fact, through parties not immediately present at the
events. Given her failure to effectively manage the subtleties
430 of discernment required of the situation, we will further
indicate how she failed to discriminate appropriate choices,
among the options that were available to her.
While Morrison did not discern the holding-answerable
rights of nonpresent others in the midst of the situation, she
435 did, nevertheless, act in ways that demonstrated a compe-
tency for discerning and discriminating those relational
duties that are immediately apparent in the midst of an
answerability crisis—specifically, she showed, through a
number of her actions, that she was capable of discerning
440 answerability demands specific to the apparent situation. To
show how this is so, some context is offered.
Doctors had already determined that nothing could
restore Paul Mills to health, and they had decided that it
was medically inappropriate to prolong his dying crisis.
445 They therefore ended the treatment measures they had intro-
duced to prolong his life, disconnecting his respirator that
morning and introducing very high levels of pain-relieving
narcotics. As time passed, however, the attending nurse saw
5
no peace in Mills’ death, although the patient had graduated
to remarkable levels of morphine and Dilaudid—levels of 450
narcotic that would, under normal circumstances, result in
death. Indeed, the nurse thought (Bland-MacInnes, 1998)
his death to be “a horrible and hideous scene” (p. 309),
one that no level of narcotic seemed to relieve. The patient
gasped for air and moved so restlessly that Bland-MacInnes 455
(1998) later testified “It was beyond a shadow of a doubt
the worst death that I have ever witnessed” (p. 320). In
this state of witnessing, believing that Mills was suffering
horribly, Bland-MacInnes turned to Morrison, the doctor on
duty. She informed Morrison that the drugs were still not 460
working and she begged the doctor to do something about
this suffering.
The story we tell can be read in a few minutes, but we
should keep in mind that it actually describes a prolonged
death ritual—one that, in some senses had been unfolding 465
for months. With that in mind, the official withdrawing of
treatment was really no more than the last stage in a drama
of medical suffering played out against an irreversible and
demoralizing deterioration of quality of life and health—one
that a well-known, regional ethicist has characterized as “a 470
dramatic example of ‘cascade iatrogenesis’   ,” with “inap-
propriate interventions long before the death.”1 Thus, when
Morrison went to the bedside, she observed a patient she
had been treating through the months of his hopeless dete-
rioration, depression, and (one assumes) agony. Morrison 475
knew that Mills would die, the hospital expected him to die.
All that remained was useless suffering—indeed, suffering
that was not consistent with the narcotics he had received,
and suffering that was not consistent with the hospital’s
intention when it originally directed that he be removed 480
from the respirator. She then left to obtain a syringe with
10 cc of nitroglycerine and she returned and injected it into
Mills’s arm. MacInnes asked what she had injected, and
Morrison (Bland-MacInnes, 1998) told her it was “10 cc
of nitroglycerine. It will lower his blood pressure and end 485
his suffering” (p. 294). Mills’ blood pressure was already
around 55 and lowering, so this could only imply that the 10
suffering would end by dipping the blood pressure further—
in other words “end his suffering” was a code that meant
Mills would die, hence his suffering would be over. The 490
blood pressure dropped only for a moment, however, and
Bland-MacInnes, who later said that she would never inject
either drug because she needed to keep her job, then said,
(1998) “The only thing that will end this suffering is KCl.”
Let us situate the above conversational remnants within 495
the contextual framework from which they emerged, and
with some consideration to the ways that language takes
on meaning that is specific to the interaction itself. Judy
Segal (2000) has already characterized a code that emerges
in end-of-life hospital dramas. The code is consequent to 500
1
Personal communication from Nuala Kenny, O.C., M.D., FRCPC,
Professor, Departments of Bioethics and Pediatrics, Dalhousie University,
Halifax, Nova Scotia, Canada, May 23, 2005.
 6 KENNY
those protocols governing pain management and life ending
that have been established for such situations (i.e., pain
management should occur even if its application results in
death). Segal notes that (within such dying rituals) this has
505 resulted in a discourse of pain management that regularly
carries within it the suggestion of life ending. Thus, one can
never say, “Let us bring an end to this person’s hopeless
state,” but one can say, “I believe this patient is in pain
and needs more pain treatment.” To some extent, even on
510 occasions that practitioners may not be aware that it is
happening, the latter has become the coded method by which
to express the former. Thus, one may regularly speak of
pain reduction to advocate death hastening.
Once a patient has entered an irreversible death ritual,
515 there are a variety of reasons hospital professionals and
others (including families) might prefer an expeditious
end—consequently, a code that speaks to that objective
may unintentionally emerge if members of the death ritual
community refuse to acknowledge the ambition directly,
520 and such a code will adhere to conventions that make it
appear that it is not actually being used. Thus when Bland-
MacInnes appeals to Nancy Morrison to end this horrible
suffering, she makes what may be, in such circumstances, a
functionally nebulous request which, in such circumstances,
11 525 could mean “lower pain” or “hasten death”. It appears that
Morrison responded to the statement by leaning toward a
more radical interpretation of it. Clearly, she expresses her
12 intention to the nurse in this code when she (1998) says
“It will lower his blood pressure and end his suffering”
530 (p. 294), for both nurse and doctor understand the unlikely
therapeutic value and probable outcome of a nitroglyc-
erine injection in such a case. Thus, when Bland-MacInnes
(1998) consequently says “The only thing that will end this
suffering is KCl,” there is no reason to believe that she
535 is making a random comment dissociated from the context
of the events and the code that appears to govern it, for
the words fit ideally into this coded interaction chain—
particularly in that Bland-MacInnes, as a medical practi-
tioner, would know that KCL would stop the heart. We thus
540 locate Bland-MacInnes’s statement within a chain of inter-
actions that include a nurse’s functionally nebulous request
to “end a patient’s suffering”; a doctor’s, contraindicated,
injection of nitroglycerine; and a nurse’s subsequent, func-
tionally nebulous suggestion that more radical action would
545 be necessary to achieve the ambiguous goal.
Of course, this all matters because Bland-MacInnes’
statement was immediately followed by Morrison’s injec-
tion of potassium chloride, and because that injection
brought an end to the discourse of distress that Bland-
550 MacInnes was producing. Recognize that Bland-MacInnes
could have continued a postinjection discussion with state-
ments such as “What have you done!” or simply “I hope
you didn’t think that I was serious.” She could have, but
there is no record of anything said after Morrison performed
555 the injection. Thus, as a communicative event, associated
with answerable expectations, the discourse-action pattern
that began when Bland-MacInnes first turned to Morrison 13
for help ended when the potassium chloride was injected
and Mills died—in other words, Bland-MacInnes’s demand
had been answered regardless that she never explicitly made 560
it, and even if she never intended it seriously. The event
concluded as if Morrison had been successfully answerable
to Bland-MacInnes’s communication of a vague answer-
ability demand. In that regard Laing’s (1967) words are
instructive, for he says that a conversation can include state- 565
ments that might be “disclaimed, unavowed, contradictory,
and paradoxical” (p. 140), yet this would not necessarily
mean that the interaction was ineffective or inefficient, for
as Bateson (1980) reminds us, and this is particularly rele-
vant to the occasion of this analysis, “the metarelations 570
between particular signals may be confused but under-
standing may emerge again as true at the next more abstract
level” (p. 131), in this case, at the level of the action
itself.
Both Bateson (1980) and Laing (1967) would attune us 575
to the context of message making to understand what has
happened. When we do so, and consider the issue of social
relations in this case, the first thing that we notice is that,
in terms of the discursive and practical action involved,
it is a medical event that occurs between a nurse and a 580
doctor. Having recognized that, we should be on the lookout
for interactions that correspond with a pattern of answer-
ability, typical of medical practice, a pattern that might
even occur under the most radical medical circumstances.
We find, looking at the case from that perspective, that 585
there does indeed emerge a pattern of answerability—a
pattern that Morrison and Bland-MacInnes evidence they
employ even as they engage with each other. Anxiety,
frustration, empathy—these must all have been present in
the event. However, it was an ICU ward, where such 590
emotions would often be present and where patterned action
between medical practitioners would be expected, even
when practitioners were under stress—indeed habituated
medical routines are critical in an environment in which
radical decisions must be made, not only treatment routines, 595
but even social routines (orderlies knowing where to stand,
nurses knowing when to step aside). These are not the disin-
terested and humdrum routines of the ticket salesman or
the bank teller, to be sure—they are the invaluable social
patterns that are specific to emergency and critical circum- 600
stances. The pattern of this routine is, however, implicit in
the action, specifically when this nurse in distress over the
condition of her patient, turns to the physician to resolve
the crisis. Although this is a structure of answerability in
the noncritical medical setting, it grows even more signif- 605
icant in the critical context. One will not find doctors
turning to nurses with an expectation that they will solve
medical crisis, but it is a prerogative for nurses within insti-
tutional medicine that they can require a doctor to provide
answers at levels that exceed any expected of them. In other 610
 EFFECT OF COMMUNICATION ON MEDICAL DECISION MAKING
words, a significant dimension of our understanding of what
happened can be explained through the socially constructed,
implicit code of answerability that exists between a doctor
and a nurse, not only in their everyday relations, but
615 even in those most pressing and emotional of medical
circumstances.
Although it was Nancy Morrison’s responsibility to
discriminate among treatment methods, the ability to
discriminate among options is often affected by the rhetor-
620 ical influence of specific communicative practices, and
this is also true in the practice of medicine. Years ago,
medical sociology recognized that the interaction between
a doctor and nurse, governed by norms of social process,
is partially based on a hierarchy model in which, “while
625 nurses frequently exercise important powers of decision,
they must do so subtly, avoiding the appearance of being
in command” (Mechanic, 1978, p. 361). In the present
context, we would say that the nurse is answerable to a code
of conduct governing the communicative practice between
630 nurse and physician. However, codes of communicative
conduct within hierarchical systems control not only the
articulation, but also the reception of the message. If, as
Mechanic (1978) suggests, there is an inexplicit code that
requires a nurse to “express her [sic] opinion unobtrusively,
635 to suggest alternatives rather than contest physicians’ views,
and to show deference to doctors’ expertness and authority”
(p. 361), and if this is the manner that nurses work “quite
successfully within the system in a fashion that makes excel-
lent use of their judgment and knowledge,” (Mechanic,
640 1978, p. 361) then there must also be a normative tendency
for doctors to attune to such subtleties of nurse commu-
nication, reading the nurse’s advice as a subtext that is
buried within the nurse’s actual words. The Bland-MacInnes
comment is, in other words, typical of the type used by
645 nurses to assess patients and to recommend protocols in
the presence of physicians. Because it is a communica-
tive strategy that plays a regular role within such interac-
tions, it can occur with no conscious strategic intent, like
a hand gesture that one uses everyday without thinking.
650 Moreover, because it is not overt, it bypasses some crit-
ical censors when it is received. Persuasion theory would
characterize it as an enthymeme, a statement that allows the
speaker to maintain some distance from the implications
that seem to naturally arise from the statement, while also
655 causing the listening audience to assume that the impli-
cations they derive have arisen from their own reasoning
processes.
Powerful norms must govern the behavior of physi-
cians in crisis situations because crisis situations do not
660 allow time for elaborate consideration. However, given that
many norms are practiced without an agent’s conscious
awareness of them, this can be a recipe for catastrophe. It
appears that, intentionally or not, some norms of answer-
ability were exploited or evoked by Nurse Bland-MacInnes
665 on the occasion of Paul Mills’ death. Among such norms are
7
the following: (a) Physicians are expected to give answer
to the medical crisis, no matter how spectacular—indeed,
the more difficult it is for other health professionals to
answer the crisis, the more a physician will be expected to
answer. (b) Physicians are expected to answer the patient’s 670
call for care and comfort in the medical crisis; and, where
possible, to bring an end to the critical condition. (c) They
are also expected to provide an answer to the stresses and
hysteria that might arise in the midst of medical crisis,
for the sake of others, such as health professionals, who 675
are present. (d) The physician is expected to direct other
health professionals in their assignments, and when they are
incapable of completing such assignments, the physician is
expected to assume them. (e) Physicians are also expected
to answer such medical crises decisively. (f) And physicians 680
are expected to absorb the burden of responsibility for deci-
sions that are made in the medical crises, especially for the
sake of the patient and other health professionals involved.
(g) Moreover, it is normative to assign a heavy weighting
to a physician’s answerability to the immediate when the 685
situation is interpreted as critical, and this tends to mask
the existence of answerabilities that may come at a later
date. The argument herein suggests that normative factors
such as the ones mentioned previously dominated Nancy
Morrison’s discernment of her answerability in a manner 690
that led her to focus exclusively on the immediate situation
with no regard to subsequent situations within which her
answerability might be more general.
A second and relevant consideration must be presented
here before the discussion can move forward, and that 695
consideration is related to issues of frame and frame leakage.
Wherever there is a communicative code such as the one
suggested previously there is a community that is privy
to the code and a community that is not. Communicative
codes thus imply boundaries, frames within which we find 700
received social agents who speak the code and function
through it and outside of which we locate all others. The
tendency for such codes to remain internal to the cultural
entity that produces them is hindered by leakages. And in
that regard there are several points that should be noted. 705
First, we note that communicative codes function within
bounded relations; second that they serve as a resource for
managing needs internal to the bounded agents; third that
they gain functional value from their secretiveness; and
finally that leakages can lead to dissolution of the code as 710
well as a collapse of the managerial strategies that the codes
organize. If Bland-MacInnes and Morrison were speaking
in a functional code, they would also proceed with the
presumption that the code would remain internal to the
communicative context, as would the action for that is a 715
presumed condition of code-speak. Ultimately, this would
leave Morrison no reason to believe that her answerability
at Mills’s bedside would extend further than the curtain that
was behind her. Thus Morrison may have gone forward,
discerning her duties to the situation and immediate agents 720
 8 KENNY
without reflecting on all nonapparent demands of the situa-
tion. Indeed, we do not know if Morrison acted because she
overassessed the degree of answerability she had toward her
nurse, but the murder charge she faced makes clear that she
725 underassessed the answerability she had toward her hospital
and her government. So we can be minimally certain that
failed answerability in some ways led to disastrous profes-
sional circumstances for Nancy Morrison. And we can be
sure that the code leakage that Bland-MacInnes initiated
730 led to the frame breakdown that ultimately resulted in the
murder charge.
Many actions within a medical complex become second
nature even though they operate as a sort of answerability.
Such routines allow complex procedures to occur with a
735 high level of precision and spontaneity. The advantage of
such spontaneous capacity for answerability in the medical
setting is clear: In a context where multiple life and death
decisions must be made on a moment’s notice, the time
it takes to reflect may be more time than is available.
740 In such a context, habituated action regularly saves lives,
and role relations within a medical complex are certainly
among such valued social practices. However, these habit-
driven responses can be costly when they mechanically
arise on occasions better served by some other routine, or
745 even nonroutine, action. On such occasions, agents may not
choose the wiser path, however, because, under time pres-
sures and the emotions of the situation, they are influenced
by the habitual structure of the experience even though they
do not parse its grammar.
750 Dr. Morrison was involved with a variety of patients
and health professionals that day, and many of her actions
involved norms of answerable conduct. In the middle of all
those experiences she found herself answerable to the Paul
Mills situation. This is not to say that her decision to take
755 the action that possibly ended Mills’ life was routine; it is
rather to suggest that Morrison, for the sake of her patient
and her staff, may have followed her routine habit of making
momentous decisions, possibly within the suggested coded
frame, at a moment’s notice, when no one else was capable
760 or willing.
Answerability After the Death of Paul Mills: Managing
an Interrogation Ritual
When answerability fails, it regularly gives rise to interro-
gation rituals and consequences. Thus, when Mother learns
765 that Tommy did climb that tree, he will be asked to justify
his action, and should he fail to do so, he will be served
consequences. Often such interrogation rituals are a surprise
to the answerable agent, who, for various reasons, had not
imagined the degree of surveillance internal to the situation
770 or who had not anticipated the possibility of an interro-
gation event. Answerability, of this form, after the fact,
can only occur when some representation of the events is
taken from original occasion to a subsequent occasion, and
answerability rituals do regularly occur when this happens.
It was, therefore, inevitable that an answerability interroga- 775
tion would occur after Bland-MacInnes leaked, to various
others, the coded event in which she had participated.
This is particularly the case because those others absorb
answerabilities simply by listening to what is stated (thus
the expression “don’t ask, don’t tell,” as a mechanism for 780
social management). With all this in mind, several days
after the death of Paul Mills, Nancy Morrison was phoned
by ICU supervisor Paula Poirier and asked why Mills
had been given injections of nitroglycerine and potassium
chloride. This interrogation occurs within a context of ques- 785
tioning, which is part of an answerability ritual. Contextu-
ally speaking, the nurse supervisor is able to do this because,
as the acting nurse manager of the Medical/Surgical ICU
and the Neurological ICU, she possesses holding answer-
able rights that are specific to that role—for example, the 790
nurse supervisor may hold Morrison answerable in a manner
that exceeds the holding answerable rights of a janitor or
an orderly; also she may hold Morrison answerable for
acts that took place days before, when the supervisor was
not even present. Such holding answerable rights provide 795
the foundational context on which professional communi-
cation regularly occurs; and, as a competent professional,
Morrison would know this. On the phone, in that moment,
Morrison would also realize that she could only manage her
contextually determined answerability to the nurse super- 800
visor, if she had, in advance anticipated that Paula Poirier
could hold her answerable—she would need, that is to
say, to already have been mindful of Poirier’s holding-
answerable rights, even at that moment when she acted
on the floor, outside the supervisor’s presence. However, 805
when treating Mills, Morrison was not mindful of Poirier’s
rights to hold answerable, and that is why, with such prac-
tical realities operating over Supervisor Poirier’s phone call,
Morrison was compelled (Poirier, 1998) to answer “I – oh
my God! I don’t know why!” (p. 354). As the occasion 810
illustrates, a social agent’s ability to competently respond
to interrogations associated with an answerability ritual
is significantly determined by the agent’s prior discern-
ment that such an interrogation is possible, and a mindful-
ness of that possibility when discriminating among action 815
options.
The context for questioning is not a burden that expresses
only in terms of the person at the center of the ritual.
Nurse Poirier, for example, is also burdened with a context
that creates ways that she is held answerable, for even 820
those who play ancillary roles within a drama carry burdens
of expectation that are the very condition for their roles.
Poirier’s question thus arose because she was answerable
for any failure to report such violations of professional
conduct to her own supervisors, and ultimately she fulfilled 825
her answerability by submitting such a report. When deter-
mining whether a report was necessary, however, she had
to consider both the actions Morrison had taken, and the
 EFFECT OF COMMUNICATION ON MEDICAL DECISION MAKING
intention of those actions, for the status of a medical act
830 is determined from both the action itself and the actor’s
intention when doing it.2 Poirier’s question was therefore
asked to determine whether Morrison could justify the act
in such a way that no report would be necessary, or in such
a way that the report would include mitigating information.
835 As a competent health professional capable of professional
communication, Morrison would be aware of this, for it is
the sort of communicative grammar we all parse daily. She
would understand, on the occasion of that phone call, that an
organizational ritual had arisen in such a way that all social
840 actors internal to it would be propelled by their own role-
situated, answerable duties into a cascading series of actions
and interactions that would draw in other social agents who
would equally be compelled by their own answerabilities,
and that this could only be avoided if she could find, at
845 that moment, an answer that would legitimately satisfy the
role-situated supervisor in a manner that would forestall
the process. The progression, once initiated that is to say,
locked all participating agents into a cascading drama that
limited role performances to precise and inflexible codes of
850 conduct (Poirier could not, for example, say “I know you’re
a good doctor—let’s just forget this happened,” because
her authority was radically managed by her own answer-
ability in the situation). Even the hospital’s attempt to end
the answerability rituals associated with Morrison’s actions
855 internal to its own institutional structure failed—ultimately,
months later, the police stormed the hospital, and Morrison
was arrested.
Certainly there were answers that Morrison could have
given to Poirier’s question. She could have said, for
860 example, “I was sick of watching useless suffering, so I
ended it.” She could also have said “We were very busy,
so I made a snap emergency decision and acted.” Doubtless
the doctor could have traced back some answer to the ques-
tion, yet she has none. And if we understand the true nature
865 of the question, this makes sense, for Poirier is not asking
for any answer—that is not her role. Poirier is asking for
an answer that can allow her to be answerable to her own
role and bring an end to this interrogation. And that is what
Nancy Morrison reveals, in shock, that she cannot do.
870 Thus it seems likely that Morrison’s answer was not a
lie, nor an absurdity. Rather, it seems that Morrison was
parsing the grammar of answerability before replying to
Poirier’s question, performing a level of intelligibility that
can only be understood within the context of the situation.
875 Morrison understood how Poirier’s question was framed
within a context of circumstance, and therefore required an
answer appropriate to that circumstance. She possessed, on
this secondary occasion, the capacity to discern her answer-
ability on forthcoming occasions and in particular ways,
2
The ethical status of a morphine injection is not, for example, deter-
mined by its size but by the doctor’s intent. High doses intended to relieve
pain are ethically acceptable, but even low doses intended to cause death
are not.
9
most probably to a standard of professional conduct as it was 880
immediately objectified in the nurse supervisor, and later
as it might be objectified by a medical review board. The
wording and performance of her surprised answer suggests
not only that she would not be able to answer such a board,
but even that she had not taken that sort of committee into 885
consideration when she performed the act. Effectively, she
discloses a significant factor in any analysis of the case;
that, in terms of the discerning and discriminative char-
acter of answerability, Morrison did not effectively antic-
ipate in her reflections, on the day of Paul Mills’s death, 890
the likely manners that she might later be held answerable
for her immediate actions, nor did she navigate a path that
would satisfy such possibilities. This must be true, unless
we conclude that Morrison, at the time of her witnessed
injection of potassium chloride, both sought an occasion 895
when she would be charged with murder and planned to use
event-specific amnesia as her defense.
Because an event can be judged at various times by
various parties, effective answerability involves a struggle
to discern who those parties might be and to perform action 900
in such a way that she would satisfy those tribunals on such
future occasions. As difficult as this may be to accept, it
appears that a medical review board was not a party that
Nancy Morrison foresaw in the context of her circumstance,
thus her actions were never intended to provide an answer 905
for that community. Moreover, it seems that Morrison did
not discern that her actions might later be answerable to
a judge or a prosecutor, nor an ethical standard, nor the
general public. While those might be the first communities
to whom Morrison might now discern an answerability if 910
she were again placed in the same situation, they apparently
did not appear on the horizon of her reflective processes as
she decided what to do in the midst of the Mills crisis. No
one is capable of perfectly discerning all of the expectations
others hold for them, and Morrison’s surprise when Poirier 915
put the question to her suggests that, on November 10, she
did not discern that she might later be answerable to these
groups. This does not mean she regarded these groups with
contempt. Nor does it mean that she lacked the intelligence
to manage such situations effectively. Rather it suggests 920
that she simply did not discern the possibility of these
answerabilities, at all. This is important, because it suggests
the specific quality associated with the failure of a social
competence, rather than a reduction of her behavior to the
vocabulary of good and bad, a vocabulary that is less than 925
instructive to those who would improve the efficiency of
health care practice. If the claim is correct, that is to say,
then we can suggest that a capacity to discern the expec-
tations of present and potential others who hold answer-
able (and a mindfulness of that possibility) is fundamental 930
for the efficient performance of health care practitioners.
Unlike the good and the bad, answerable expectations are
not contestable, and they can be taught.
 10 KENNY
With Mills before her, Morrison may have lost sight of
935 her potential answerability to a medical review board, a
provincial government, a nurse supervisor, a professional
code of conduct, and even a deity as understood within what
has been characterized (Harris, 1998) as her own Anglican
upbringing. She may have only experienced a sense of
940 answerability to her nurse and the apparent suffering of a
patient immediately in front of her. Moreover she may have
been performing, as a medical practitioner, in a context
that regularly bounds conduct answerability to the context
in which the conduct occurs (so that her failure to discern
945 potential others resulted from a tradition of keeping poten-
tial others outside the coded frame). At any event, it seems
that Morrison’s action was intended to answer the practical
problem of an unrelieved, dying patient and the anxiety of
a hysterical nurse. These commitments were made, unfortu-
950 nately, without foresight to the other sorts of answerability
that might arise on later occasions. If this is true, then
Morrison’s failure should not be understood as an ethical
one, but as a social one that arose because of complexities
associated with the communicative and situational pressures
955 specific to the situation.
CONCLUSION
No one will ever know why Nancy Morrison acted as
she did. However, when we apply the idea of answer-
ability to the events in the ICU that November day, we
960 can see how answerability may play a determining role
in such crisis events. At the very least, Morrison failed
to discern how she would be answerable to the law and
to her hospital. She therefore, at the very least, illustrates
an occasion when a health professional failed to perform
965 answerability satisfactory to all the communities able to
hold her to account. Her case suggests the need for instruc-
tion not only in ethical conduct, but also answerable conduct
for health professionals. In addition, the Nancy Morrison
case can help to bring us greater clarity when consid-
970 ering events such as occurred during the terrible Hurri-
cane Katrina disaster. One better understands events such
as the notorious nursing-home, negligent homicides,3 and
stories of euthanized hospital patients4 when considering
them as stories that can be assessed within a framework
975 that takes into consideration both answerable conduct and
the capacity of agents to discern accountability in the midst
of it. Whether we ultimately decide that the health care
practitioners did the best they could in the circumstances
that they experienced, or whether we wish to conclude that
3
“Nursing Home Owners Face Charges: Couple Charged With
34 Counts of Negligent Homicide,” at http://www.cnn.com/2005/US/
09/13/katrina.impact/, posted September 13, 2005.
4
“Louisiana Probes Euthanasia Allegations: Investigation Focuses
on Reports of ‘Mercy Killings’ At New Orleans Hospital,” at
http://www.msnbc.msn.com/id/9699709/, posted 10/14/2005.
they acted inappropriately, we might recognize, in either 980
case, that a capacity for understanding the conditions that
ground answerable conduct is the best tool to give health
care practitioners if they are to manage the expectations that
will ultimately be associated with their actions.
The notion that medical professionals spend years in 985
training and practice to ultimately bring harm to others is
counterintuitive. Thus, when bad things happen in medical
settings, it may be inappropriate to interpret the event in
terms of a, “good doctor/bad doctor” dialectic. Instead we
might examine events such as the Morrison case with the 990
presumption that the health professional is not evil, but
simply in error. Such a presumption frees us from the notion
that right action is the province of the morally elite. It allows
us to foster the more manageable idea that “proper conduct”
within the professional setting is the consequence of situa- 995
tional competence and institutional protocols, qualities that
can be both developed and managed in the medical setting
through ongoing refinement of those protocols as well as
education and training of physicians and other health profes-
sionals in relation to them. It may also be the case that 1000
health professionals who understand the concept of answer-
ability will be bolstered in their capacity to understand their
situational duties as well as the ethical and practical issues
associated with them.
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