State v. Naramore
1998 Kan. App. LEXIS 79, 965 P.2d 211, 25 Kan. App. 2d 302 (1998)
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Rule of Law:
A physician cannot be found guilty of murder or attempted murder beyond a reasonable doubt when a substantial body of competent medical expert testimony establishes a reasonable, noncriminal, and medically appropriate explanation for the physician's actions in treating terminally or critically ill patients.
Facts:
- Ruth Leach, a 78-year-old woman with terminal cancer, was a patient of Dr. Lloyd Stanley Naramore and was experiencing significant pain.
- On August 2, 1992, Leach's family consulted with Dr. Naramore and requested more pain medication for her, understanding the risk that increased doses could hasten her death.
- Dr. Naramore administered Versed and Fentanyl, causing Leach's respiration to slow dramatically. He then prepared a syringe of morphine.
- Leach's son, Jim, believing the morphine would be fatal, intervened and told Dr. Naramore not to administer it, and Dr. Naramore complied. Leach died several days later.
- On August 5, 1992, Chris Willt, an 81-year-old diabetic with severe heart disease, was found collapsed and brought to the hospital where Dr. Naramore treated him for a suspected massive stroke.
- Dr. Naramore administered Norcuron, a paralyzing agent, to intubate Willt and maintain an airway. Willt's family agreed to a do-not-resuscitate order.
- When Willt began showing involuntary movements, which Dr. Naramore believed were seizure activity, he administered a second dose of Norcuron to maintain the breathing tube while awaiting a second opinion.
- After another physician, Dr. Cram, examined Willt and found no pulse or respiration, mechanical ventilation was stopped with family consent, and Willt was pronounced dead.
Procedural Posture:
- The State of Kansas filed a two-count complaint against Dr. Lloyd Stanley Naramore in the trial court.
- Count I charged him with the attempted murder of Ruth Leach, and Count II charged him with the first-degree murder of Chris Willt.
- Following a jury trial, the jury returned a verdict of guilty of attempted murder on Count I.
- On Count II, the jury found Dr. Naramore guilty of the lesser included offense of intentional and malicious second-degree murder.
- Dr. Naramore was sentenced and subsequently appealed his convictions to the Kansas Court of Appeals, arguing insufficient evidence among other errors.
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Issue:
Is the evidence sufficient to support a physician's criminal conviction for murder and attempted murder when the physician's actions during the treatment of terminally or critically ill patients are supported by a strong, authoritative consensus of medical expert opinion as being medically appropriate?
Opinions:
Majority - Pierron, J.
No. The evidence is insufficient to support a conviction for murder and attempted murder beyond a reasonable doubt. When there is a strong, reasonable, and noncriminal explanation for a defendant's actions, supported by substantial competent evidence, a jury is not free to ignore it and find guilt beyond a reasonable doubt. Here, six highly qualified medical experts testified that Dr. Naramore's actions were not only noncriminal but medically appropriate and within the standard of care for palliative treatment and end-of-life resuscitation efforts. The state's contrary expert testimony creates a mere conflict in medical opinion, which is insufficient to overcome the high burden of proof required for a criminal conviction. To uphold a conviction based on highly controverted expert evidence would effectively criminalize medical malpractice or even legitimate differences in clinical judgment.
Dissenting - Brazil, C.J.
The conviction should be reversed and remanded for a new trial, not reversed outright for insufficient evidence. The fundamental error was the trial court's failure to properly instruct the jury on the complex medical standards of care applicable to palliative treatment and termination of resuscitation. The jury was left to decide issues of homicidal intent without any legal guidance on a physician's duties and responsibilities in these unique end-of-life scenarios. The defendant's entire theory of the case—that he acted within his professional duties—was supported by evidence but was not explained to the jury through proper instructions, creating a real possibility that the jury would have returned a different verdict if properly guided.
Analysis:
This case establishes a significant precedent protecting physicians from criminal homicide charges arising from difficult end-of-life treatment decisions. The court sets a high evidentiary bar, holding that a mere disagreement among medical experts about the appropriateness of a treatment does not suffice to prove criminal intent beyond a reasonable doubt. The decision distinguishes between medical malpractice, which involves a deviation from the standard of care, and murder, which requires proof of malicious intent. This ruling provides a degree of legal protection for doctors exercising clinical judgment in palliative care, ensuring they are not chilled from providing aggressive pain management for fear of criminal prosecution.
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