The Girl Who Died Twice: The Libby Zion Case and the Hidden Hazards of Hospitals
Except for Karen Ann Quinlan’s, no other patient’s death has transformed American medical practice so much as that of Libby Zion. Karen Ann Quinlan made history in the mid-1970s when the medical staff at St. Clare’s Hospital in New Jersey would not remove her from a respirator, as her parents wished them to do, even though she was in a “persistent vegetative state.” The Quinlans took the hospital to court and eventually won their lawsuit on appeal; in doing so they helped to define the ethical standards by which the question of when to take someone off life-support systems is now decided. Libby Zion made history in 1984, when she died eight hours after entering New York Hospital’s emergency room with seemingly minor complaints of fever and earache. Her parents, too, took the hospital to court. Even though they did not win their case, they brought into the open the need to reform one of the least well understood aspects of American medicine, its residency training programs.
After years of inquiry into Libby Zion’s death no one can be sure why she died, and who, if anyone, was to blame. A grand jury considered bringing criminal charges against her doctors; the state’s Professional Medical Conduct board held extensive hearings, and a civil court gathered testimony in a trial that lasted several months. To this day no one is certain why an apparently healthy eighteen-year-old suddenly developed a fever that soared to a fatal 108 degrees.
One popularly held theory appeared as Question 49 of the November 1995 pharmacology examination given to second-year students at the Columbia College of Physicians and Surgeons.
Which of the following drugs was administered in the Zion case at New York Hospital and had an interaction with an antidepressant MAO inhibitor that was fatal?
The correct answer, according to the examiners, was B, meperidine, more commonly known as Demerol. That answer, however, was wrong. It is true that Libby Zion was taking an anti-depressant, and that the New York Hospital staff should have known better than to give her a sedative like Demerol. But the dose they gave her was very low (in fact, too low to be effective), and there is no case on record of anyone’s dying from the two drugs as administered.
Libby’s parents also got it wrong. Their major claim (among many others) was that the staff physicians were so exhausted from lack of sleep that they could not treat their daughter properly. Not only did they prescribe Demerol incorrectly, but when the nurse on duty reported that Libby was thrashing about, the intern, instead of going to see her, ordered her tied to her bed. In fact, whatever errors were committed were not the result of fatigue. One of the interns was coming off a weekend break and the other had just begun his shift in the emergency room.
New York Hospital also got it wrong. Its lawyers and spokesmen blamed the patient. Had Libby Zion candidly informed the hospital staff about all the drugs she was taking—more precisely, had she told them that she was using cocaine—the outcome, they said, would have been different. But while there was evidence that Libby had taken cocaine shortly before being admitted to the hospital, it was not conclusive. One postmortem analysis revealed a trace of the drug in her nostrils; a second did not. Indeed, the bungling that surrounded the testing of blood and tissue in the Zion case calls to mind the O.J. Simpson case. In both, medical examiners showed a knack for raising more questions than they could resolve.
Even more important, New York Hospital’s effort to shift the blame makes one ask why its doctors had not diagnosed the drug problem themselves. Libby had several textbook symptoms of cocaine use—fever, spastic movements, disorientation—which should have prompted doctors in the emergency room to admit her to intensive care for close observation. But the failure to send Libby to that unit never received the attention it deserved, in or out of court—not the least of the reasons being that the Zions were unwilling to concede that their daughter was likely to have used cocaine. Had they been more open about it, they might have won their case on grounds that even if their daughter had used cocaine, she still should have had the more careful treatment that would have saved her life.
The various legal and medical groups that reviewed the incident did nothing to clarify the cause of death or to ascertain where the ultimate responsibility for it lay. Not only did a grand jury refuse to indict the doctors on criminal charges, but the state Professional Medical Conduct board refused to revoke their licenses. The jury in the civil suit brought by the Zions found fault with both sides. It said that the physicians were negligent in prescribing Demerol and that the intern in charge of Libby Zion was negligent in not following her changing condition more closely and not consulting with senior doctors. But it also found that Libby Zion had taken cocaine soon before her death and had herself been negligent in not providing her doctors with a full and accurate medical history. By blaming everyone, the jury left open the question of whether Demerol, cocaine, incompetence, or viral disease had precipitated Zion’s death.
In her recent book, The Girl Who Died Twice, Natalie Robins is not able to answer the questions that have eluded so many others. A diligent journalist, Robins provides a thorough, if somewhat disjointed, account of a very complex case. She tracked down Libby’s friends, followed the various court hearings assiduously, and spoke to many doctors about medical training in hospitals (although that did not, as we will see, save her from some serious misconceptions about it). Her account moves back and forth between scenes from Libby’s life as she grew up and interviews with the doctors who treated her at New York Hospital. As the book’s title suggests, to understand the death of Libby Zion one must look into the history of both the Zion family and of New York Hospital.
Libby and her father, Sidney Zion, dominate Robins’s account of the family. (She says little about relations between mother and daughter and it is hard to imagine what they were.) Drawing on interviews with Libby’s friends and on their court depositions, Robins depicts Libby as a likable but confused and lonely teenager. She missed many classes in high school and at Bennington College. Her relationships with young men were tangled and unhappy. Like many others of her generation, she used drugs, including cocaine and marijuana. (Her letters, which were introduced as evidence, include passages in which she says that her brain is in a state of “confusion… due to increased amounts of a certain powder entering it.”) And, more than most of her friends, Libby went to doctors. She consulted at least seven, including an internist, a gynecologist, a pediatrician, a psychiatrist, a dentist, and two school physicians; she collected prescriptions to combat stomach trouble, sleeplessness, and depression. Her internist’s chart, which was incomplete, noted that she was taking or had taken Tagamet (for ulcers), Motrin (for pain relief), Actifed (for allergies), Valium and Dalmane (for anxiety), an antibiotic, two anti-inflammatories, an antihistamine, and an antispasmatic; she was also on Nardil, an antidepressant.
Yet her physicians were either unconcerned about or ignorant of the variety of medicines she was taking. Each of them appears to have treated the specific symptoms Libby reported (in person or on the telephone), but paid considerably less attention to the young woman herself. Like many others, Libby knew how to play the medical system, which is so fragmented into mutually exclusive specialties that she had an easy time getting whatever prescription she wanted.
Sidney Zion, a former columnist for The New York Times and later co-owner of a midtown Manhattan steak house, was the main complainant against Libby’s doctors. Robins’s portrait of him is not sympathetic, although she notes that she has known him for over twenty-five years and that he helped with her research. She describes him as aggressive, self-centered, and self-promoting. (Many people have never forgiven him for divulging on a late-night radio talk show that it was Daniel Ellsberg who had leaked the Pentagon Papers to The New York Times.) And, according to Robins, his eulogy at his daughter’s funeral had less to say about her life than about his feelings of indignation at what her doctors had done or failed to do.
Sidney Zion pursued New York Hospital and its doctors with an uncontrolled fury. In his view, they had not committed a regrettable but unavoidable medical error, but outright homicide. “It is my definition of a murder,” he told the state Professional Medical Conduct board. This judgment was malicious and preposterous, but he used it to turn the incident into one of the most effective means for bringing change to American medicine: a scandal.
Although physicians are reluctant to concede it, during the past twenty years the most significant reforms in medicine have been brought about by outsiders. It was mainly lawyers and journalists who helped to stop medical experimentation on human subjects in the US by exposing, among other abuses, the use of unwitting black men for research on syphilis in Alabama and the use of retarded children for research on hepatitis at the Willowbrook State School in New York. It was the relatives of people close to death who forced hospitals and doctors to ask patients whether or not they wished to be kept alive; they supported their case with surreptitiously taken photographs of chalk boards that, unknown to the patients or their families, coded patients on a scale that went from “do everything” to “do nothing.” Patients and their advocates have forced doctors to start giving more accurate accounts of their diagnoses. And women patients helped to change the dominant practice of performing mastectomies in breast cancer cases, allowing women to choose from among far less drastic alternatives. While some doctors were important in introducing these changes, the medical profession left to itself would not have initiated or accomplished any of them.
The training of hospital residents has now also been subject to reform. If not for Sidney Zion’s relentless pursuit of New York Hospital, the unreasonable demands to which hospital residents have been submitted, and their consequences for patients, would have remained unmodified. Several prominent doctors have expressed regret that it took Sidney Zion to reveal the defects of medical training in hospitals. “My wish would be,” conceded Robert Petersdorf, president of the Association of American Medical Colleges, “that the profession had been more perceptive in recognizing the issue and making appropriate changes in training prior to its becoming a cause célèbre.” It was, he said, “unfortunate that long-overdue changes in structuring residency training were not initiated within our own community prior to the serendipitous stimulus of the Zion case.”1 But the profession’s inertia persisted for decades.
Robert G. Petersdorf, M.D., "Regulation of Residency Training," Bulletin of the New York Academy of Medicine, July-August 1991, p. 330.↩
Robert G. Petersdorf, M.D., “Regulation of Residency Training,” Bulletin of the New York Academy of Medicine, July-August 1991, p. 330.↩