Dr. Conrad Murray was found guilty on Monday of involuntary manslaughter in the death of Michael Jackson. With overdose deaths tripling in the past decade, should Murray’s conviction be a lesson to other doctors?
Not really. Drawing larger conclusions about medicine based on Murray’s practice is like drawing conclusions about human nature from Michael Jackson’s story: you can’t. Both are outliers. However, the case does have some interesting implications.
Jackson’s death — like his life — was unusual. In the hours leading up to it, he was given doses of oral and intravenous sedatives that themselves would have been deadly for many adults or, at the very least, would have left them unconscious.
But he was still awake. He is said to have begged Murray to give him his “milk”—his pet name for the surgical anesthetic propofol, which is colloquially known in the OR as “milk of amnesia.” Not long afterwards, the King of Pop was dead.
Several facts stand out here. The first is Jackson’s tolerance to the sedatives, which can be a sign of addiction. And indeed, Murray’s defense claimed that Jackson had an addiction that caused his insomnia.
However, they argued that he was addicted not to sedatives, but to the opioid Demerol. They said this addiction was caused by another doctor. And the good doctor Murray was just trying to “wean” him from it. It’s true that no opioids were found in Jackson’s body.
What’s strange here is that if the singer’s insomnia had resulted from opioid withdrawal, using an opioid like methadone to either maintain him or taper him towards abstinence might well have allowed him to sleep and therefore kept him alive. Oddly enough, it may have been failure to provide an opioid — the type of drug that doctors are now being warned off because of overdose risk — that led to Jackson’s death.
Extreme insomnia caused the singer to turn to propofol. If opioid withdrawal indeed caused the insomnia, failure to consider opioid maintenance or slower detox may have been fatal because propofol is actually more dangerous than opioids. Opioids can cause the brain to forget to breathe when given in excessive doses. But Michael’s “milk” slows and can stop breathing even at therapeutic doses: that’s why it’s never used in settings without some sort of anesthetist to monitor respiration.
Even when aided by drugs, sleep doesn’t normally interfere with breathing; otherwise we’d risk death and need monitoring every time we took a sleeping pill. But the ordinary practice of anesthesia uses drug doses that interfere with respiration, which is a big part of why that medical specialty even exists. If patients were merely “asleep” on the operating table, they wouldn’t need to be monitored as intensively to ensure that their brains are getting enough oxygen.
Whoever first provided this drug for “sleep” to Jackson misled him about its real effects and negligently allowed him to delude himself about its safety outside an operating room. “Sleep” is just a euphemism; anesthesia is always a potentially life-threatening suspension of consciousness. But Murray was too star-struck — or desperate for money — to say no.
For celebrity doctors, there are lessons here in not getting seduced into making dangerous exceptions to curry favor. And perhaps, more generally, Murray’s case can teach doctors that addiction medicine is indeed a specialty: treating this disorder isn’t just a matter of making it up as you go along. Indeed, failure to prescribe the right drug may be just as bad as overprescribing the wrong one.
In most cases of prescription drug overdose, patients are not victims of doctors but people with prior histories of addiction who got their drugs from friends or relatives. In most cases, they do not die because a doctor fails to monitor them but because they took their drugs in ways that weren’t prescribed or mixed them with alcohol.
Overdose is a real problem, but so is untreated pain. If we want to effectively help patients, we need to look beyond dramatic stories of murderous malpractice and into the real truth about addiction. To stop overdose in less famous cases than Jackson’s, we need to compassionately address the actions of the people with addictions, not their doctors.