College Quarterly
Winter 2006 - Volume 9 Number 1
Reviews No Moral Conscience: The Hospital for Sick Children and the Death of Lisa Shore
Sharon Shore
Victoria: Trafford, 2004

Reviewed by Howard A. Doughty

The Toronto Hospital for Sick Children, known familiarly as “Sick Kids,” is an institution with a deservedly excellent reputation for patient care and for caring. It is one of the premier pediatric institutions in the world. It is also, on occasion, a site of controversy.

Twenty-five years ago, the controversy centred on Nurse Susan Nelles. A suspicious number of infants had died in the cardiac care unit. Nurse Nelles was arrested and charged with four counts of murder, although the prosecution let it be known that as many as two dozen babies may have perished. The alleged victims were said to have died of a massive overdose of the heart medication, digoxin. Nurse Nelles, as I wrote in the Toronto Star at the time, was brought under suspicion because of her demeanor. When accused by police of the alleged murders, she immediately (as they say on “Law and Order”) “lawyered up.” Other nurses, when confronted, tended to react by weeping and protesting their innocence. Nurses Nelles, a pretty, petite blonde, calmly asked to speak to an attorney. That seemed to be all the evidence that was needed. Why would she need a lawyer if she were innocent? In time, a sensible judge dismissed all charges. Not only was there no evidence linking Nurse Nelles to the crime, there was scant evidence that a crime had been committed at all, for the test used to reveal the large quantities of digoxin was “experimental” and had a history of delivering false positives. It is notable that the nursing staff displayed extraordinary solidarity and blamed hospital policies for the entire mess. The hospital denied any responsibility. In the end, the only real victims may have been Nurse Nelles, her father (a physician who died during the ordeal, possibly of stress related to his daughter’s legal troubles), and the reputation of Sick Kids hospital.

Ten years ago, the controversy centred on Dr. Nancy Olivieri. Her case has become a lightning rod for discussions about academic freedom. For those who are unfamiliar with the matter, Dr. Olivieri won a contract with the pharmaceutical firm, Apotex, to conduct clinical trials on a new product. The trials revealed some dangerous “side-effects.” Concerned that harm might be done, Dr. Olivieri published her findings, apparently contrary to a contractual stipulation that Apotex had the right to veto any such publication. Several years of disputation followed in which Dr. Olivieri suffered, among other things, the loss of her position at Sick Kids and at the University of Toronto. Academics and the public rallied to her cause insisting, on the one hand, that researchers should be free to publish their work and, on the other hand, that a doctor should not be punished for alerting the public to a dangerous drug. It was widely believed that Sick Kids had opted to protect its material interests and was prepared to sacrifice Dr. Olivieri’s career rather than run afoul of the powerful drug industry. In time, Dr. Olivieri was reinstated, but the damage done to Sick Kids’ reputation was considerable.

The case discussed in No Moral Conscience is not yet eight years old. It concerns Lisa Shore, who would have been turned nineteen this year. The book was written by her mother. It does not pretend to objectivity, though it does claim to be accurate and fair. It cries out for justice.

I shall not rehearse the agonies—both physical and emotional—that the child and her mother endured. It is enough to say that from her initial treatment for a broken leg to her eventual death, Lisa Shore experienced the worst a health care system can provide. From the outset, Sharon Shore is direct and unrepentant in her claims that over an eight-month period ending in death, the doctors and nurses kept up a record of “stupidity, mistakes, indifference, incompetence and outright negligence” made worse in some instances by “intentional and pointless cruelty”.

Lest this appear (as the staff at Sick Kids tried to make it appear) to be an irrational lashing out by a grief-stricken mother who experienced the worst parental tragedy—the needless death of a child—it is important to add only that Sharon Shore’s allegations were upheld by a coroner’s inquest and jury finding of homicide, and led to charges laid by the Ontario College of Nurses. Throughout, says, Sharon Shore, Sick Kids hospital and its legal counsel “never stopped trying to conceal the truth.”

Sharon Shore was an intelligent, educated woman and a professional accountant at the time of Lisa’s death. Her book is a meticulous narrative that takes the reader through the last months of Lisa’s life and beyond into the domain of hospital administration and the law. Though the outcome is known from the start, the story is told in a compelling and often emotionally wrenching way. As a human drama, it is riveting. As a study in corporate behaviour, it is precisely not a text book case, for no text book in public or private sector management could handle the truth that is so clearly revealed.

Despite its intensity, this is not merely a “muck-raking” volume. It should be read carefully by anyone interested in corporate governance, though especially by managers and workers in the several “helping professions” including health care, social work and education.

Discerning a pattern in the three instances briefly outlined here, the Nelles, Olivieri and Shore cases, is not immediately easy. An inappropriate prosecution of an innocent nurse, a question of the interpretation of research contracts and the ineffective criminal prosecution of two nurses whom Sharon Shore accuses of gross incompetence and negligence in the death of her daughter do not seem to have a great deal in common. There is, however, at least one thread joining them—the tendency of corporate structures to consider institutional legal liability and public reputation to be more important than the truth. Sick Kids hospital had a material interest in all three cases and the truth has been at least the temporary victim. All would have been better handled if the hospital administration had stood firmly on the side of truth, admitted its mistakes, pressed for open disclosure of research results, refrained from concealing errors and refused to attempt to defend itself with malicious smear-campaigns against its accusers as it did with Sharon Shore.

I said at the outset that Sick Kids deserves its reputation for excellence. Generally speaking, it does. But even the finest “world class” institutions can be guilty of reprehensible behaviour when revelations of isolated instances of misbehaviour are seen as greater threats than honesty and accountability.

A footnote to this gripping work: Sharon Shore, energized by her experience in the legal procedures that followed Lisa Shore’s passing, abandoned her former career and attended Osgoode Hall Law School. She explains: "I decided I wanted to be an intimate part of [the legal] system because that was the only way that I could do whatever I could for other people that are not able to deal with the combined resources of large institutions." She has graduated, passed her bar exams and, at last report, is articling with a Toronto law firm.



Howard A. Doughty teaches in the Faculty of Applied Arts and Health Sciences at Seneca College in King City, Ontario. He can be reached at <howard.doughty@senecac.on.ca>.

Reviews

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2006 - The College Quarterly, Seneca College of Applied Arts and Technology