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Ethics In Emergency Medicine

CASE: PRACTICING PROCEDURES ON THE NEWLY DEAD

Kenneth V. Iserson, M.D., MBA

From: Ethics In Emergency Medicine, Second Edition

Iserson KV, Sanders AB, Mathieu D (Editors)

ISBN 1-883620-14-7
$39.95 Soft Cover
589 pages, Bibliography, index
©Galen Press, Ltd., Tucson, AZ, 1995

Case 7-4
An elderly man collapses on the street and is brought into the ED in cardiac arrest. A prolonged resuscitation is unsuccessful, and he is pronounced dead by the attending physician. Several interns and residents who assisted in the resuscitation procedure are present. All say that they need more experience in intubation and would like to practice on this individual. Considering the fact that there is no adequate substitute (including plastic models, preserved cadavers, and animals) for a live or recently dead human body for practicing intubation skills, and knowing that there will be no mark on or damage to the individual by doing this procedure, should the attending physician allow them to go ahead? The family is in the waiting room, and the medical examiner has released the body. (In many regions, the bodies of all patients who die under suspicious circumstances, by violent means, or who have not been seen by a physician within twenty-four hours are the property of the medical examiner until he releases them. This precludes the removal of any device-such as intravenous lines, endotracheal tubes, or chest tubes-from the body.) The residents also request that they be allowed to practice punctures of central veins. This procedure, which involves placing a catheter into one of the major veins of the body, is a necessary procedure for most physicians to know. Practicing it will require several needle punctures around the lower neck and clavicles. Neither technique will incur an additional expense to anyone. Should someone ask the family for permission to practice on the body'? What if the patient has no known family? What if the family is not present?

Commentary
Emergency clinicians do not spring fully trained into the medical world, whether they are physicians, nurse practitioners, paramedics, or physician assistants. All must be patiently taught those lifesaving skills society expects them to have. While it may be distasteful to many to think about learning or practicing these procedures on corpses (since death and the dead are two of the greatest fears in Western civilization, especially in the United States), arguments against this practice lack any substance-ethically or legally. They merely appeal to the fear and dread of death and a misunderstanding of ethics and law. In this case, the residents have asked to practice placing a tube in the windpipe (endotracheal intubation). To practice it on this now-dead patient means opening the mouth, inserting a laryngoscope (essentially a large, lighted tongue blade), and passing the plastic tube into the windpipe. The most adverse effect would be chipped teeth. This procedure cannot be practiced once rigor mortis sets in, since the mouth cannot be opened. (Rigor mortis begins at varying times, often less than two hours after the patient arrives in the ED, depending upon how long the patient has been without effective circulation, his pre-existing medical condition, and the ambient temperature. It always starts in the face.') All emergency medicine practitioners, be they in the hospital or in an ambulance, must be proficient at doing this procedure which is one of the key lifesaving techniques in medicine. This tube must be inserted before patients can be placed on ventilators, have most surgery, or, usually, be resuscitated from cardiac or respiratory arrest. If it is done wrong, the tube either does not go in or goes into the esophagus-I and the patient dies.
Residents have also specifically requested to practice placing a "central" venous line through a needle puncture in the neck. If they do this, it will mean, at most, an additional needle puncture in the neck. This procedure cannot be adequately practiced on anatomical (embalmed) cadavers that have been donated for scientific study, since the sign of successful needle placement is the blood return through the catheter. Blood in embalmed bodies is the consistency of clay. It is necessary to practice this common medical procedure, because if not done correctly, it may collapse a lung, puncture an artery, introduce air into the circulation, cut the vein, or cause other damage. If not done at all, it may deny the patient needed fluids, medication, or monitoring of vital medical indices (e.g., placement of a Swan-Ganz catheter to monitor the heart's output and pressures).
While other procedures have been practiced on newly dead ED patients, placing central venous lines (through the neck, upper chest, or groin) and endotracheal intubation are two that cannot easily be practiced on animals, models, or anatomical cadavers.
A useful way to examine the issue of practicing procedures on the newly dead is to analyze the most common arguments against it. Opponents of this practice suggest that it shows disrespect for the dead, which it can be as easily done on animal or other models, that some religions explicitly ban the practice, that it violates patient autonomy, or that it violates survivors' rights if done without consent. Each of these objections will be examined more closely.

Respect for the Dead
Some writers claim that using the newly dead for practice and teaching is disrespectful. Civilized societies should respect their dead, they argue, because that shell symbolizes the recently deceased person, as well as all humanity. To what extent must we pay homage to the symbol? Respecting the symbol by denying physicians the skills to keep the living from joining the dead is, as Feinberg says, "a poor sort of 'respect' to show a sacred symbol." It is important to remember that the corpse is not the person and using the body to help others is not disrespectful of the person's memory.
Another way of viewing this situation is to scc postmortem practice as the ultimate respect for the corpse. Anyone who has seen this practice knows that it is done with respect, some would say awe. If respect means paying homage, showing deference, and bestowing honor, this procedure is more respectful than many of the after-death rites in our society, such as embalming. The clinicians who worked to save her life (and failed) now will use this patient's shell to hone skills which they will use to try to save their next critical patient. Participation in training emergency clinicians to save lives may be the penultimate gift the deceased can give to her fellow man. (The ultimate gift may be organ, tissue, or whole-body donation.)

Animals and Models
The claim has been made that lifesaving procedures such as intubation and central venous catheter placement can easily be taught or practiced on animal or other models. While animal models poorly represent most human endotracheal intubation (kitten models work as infant substitutes), there is no good animal model for central line placement. Some people also have ethical problems with using animals for this type of practice and teaching. Non-animal models are either very poor representations, or at present, too expensive. (In future decades, affordable virtual reality models may make this entire discussion moot.)
When medical personnel do not use cadavers for teaching and practicing lifesaving procedures, they commonly use two alternative "models"-nearly dead and live patients. Clinicians use nearly dead patients every day for practice and teaching. Most commonly, this takes the form of not pronouncing patients "dead" until trainees have completed the procedures that they are practicing. These include not only intubation (or re-intubation once it is clear that the person is beyond recovery) and central line placement, but also performing venous cutdowns (surgically opening veins to place catheters), thoracotomies (opening the chest), and placing various other catheters in the chest or abdomen. While this does no harm to the patient (except in the very rare case that these "practice" procedures last long enough to restore life temporarily), it can often be very expensive for survivors and third-party payers, who must pay for all medical and surgical procedures done before the patient is officially pronounced dead.
The other, more dangerous custom is to use live patients for training. This often occurs in the operating room on unsuspecting (and anesthetized) patients, but may also occur in other parts of the hospital. The living can be harmed when they are used as teaching models for invasive procedures. Nonmaleficence is a keystone of medical ethics for good reason. While there is often no need to use the living in this manner, they should never be used without having given explicit informed consent.

Religious Bans
Some religions explicitly ban any manipulation of the dead except as necessary for burial. Orthodox Judaism and Islam are frequently cited in this regard. These religious sects are relatively small in the United States, yet they may constitute a large part of some ED's patients. Should these individuals have the right to refuse to participate in a procedure from which they might have benefited? If the patient dies in the ED, it is likely that he or she was intubated and had al least one central line placed in an attempted resuscitation. The resuscitation may not have succeeded (physicians, after all, are not God), but the clinicians used techniques on the patient that they learned and practiced on other (hopefully dead) patients. While the whole question of whether segments of any population should reap benefits of medical practice but not contribute up to their ability is beyond the scope of this discussion, it is something to seriously consider. The same issues have been raised with the U.S. Social Security program and around the world with organ and tissue transplantation. Few answers have emerged.
When considering special groups of any kind, one should note that universal practice and teaching on new ED corpses is highly equitable. The patients who die in any ED represent a cross-section of the patients on whom the practiced lifesaving techniques will be used in the future. No group would be over-represented.
No one suggests that refusing to allow a sect's corpses to be used for minimally invasive practice and teaching should ban them from the use of these techniques while they are alive. Where the individual can be identified as a member of such a group, and the sect represents a small part of an ED's patients, clinicians might eschew such practice. Consider, though, what happens if such groups make up a large percentage of an ED's patient population. In that case, the entire population (not just this group) may be in danger of being treated by ED personnel inexperienced in some lifesaving procedures.
Patient Autonomy
A common complaint is that practicing and teaching on newly dead ED patients violates patient autonomy, a key ethical and legal principle. This claim, however, fails to recognize the elements necessary for autonomy-the main, although usually unstated, element being that the person must still be alive. Patient autonomy, as described by Justice Cardozo, meant that "Every human being of adult years and sound mind has a right to determine what shall be done with his own body. . . ." The dead are, by definition, neither "human beings" (living people) nor "of sound mind." Therefore, there can be no question that they lack autonomy. Similarly, patient autonomy is invoked (as is informed consent), in part because medical intervention may cause some harm to the individual. As Callahan said, however, maintaining that any harm or wrong can come to the dead are "legal fictions." Since this is clear, perhaps we should look at arguments surrounding those who do have decision-making capacity, the survivors.
Consent
Some claim that practicing or teaching on newly dead ED patients violates survivors' rights if done without their consent. This presumes that ED personnel know who the patient is, that decision-making survivors are available in the ED at the time of death or soon after, that survivors have a moral or legal right to refuse clinicians' practice on the corpse (otherwise they could not give consent), and that any moral, legal, or professional obligation that ED personnel may have to ask survivors for permission outweighs their duty to become and remain proficient in lifesaving skills.
As a matter of practicality, many patients who die in the ED have not yet been positively identified at the time they die. In some cases, identification may not occur for several hours or longer. Likewise, relatives may not be in attendance, especially those who have surrogate decision-making authority for the patient. If either the patient cannot be identified or no surrogate is present at the time of death, or soon after before the body goes to the morgue, the question of consent becomes moot. Well-meaning ethics policymakers effectively shut down resident practice on the newly dead in one large Texas institution when they made a policy requiring prior family consent, not realizing how fast bodies were sent to the morgue,
Whether survivors have a "right" to refuse clinicians' opportunity to teach or practice on a new corpse has not been well defined, Relatives do have a "quasi-property" right in the corpse, but that is limited to corpse disposition. Even a survivor's "right" to permit or refuse organ and tissue donation is questionable, although it has become a common practice to recognize such a power. Neither statute nor common law has explicitly given relatives the right to refuse use of the new corpse in this manner. The ethics of the situation are similarly murky, with some arguing for the necessity of survivor consent to make this procedure public and to improve the image of the medical profession. Others have taken an opposite position.
Even if ED personnel have a moral, legal, or professional obligation to ask survivors for permission, does this outweigh their duty to become and remain proficient in lifesaving skills? Society places a heavy obligation on the emergency clinician-to act quickly, professionally, and expertly to save lives, when possible. This demand, and the ED personnel's corresponding responsibility to be prepared to act in this manner, allows for no leeway. This societal demand is neither irrational nor arbitrary, representing as it does both the group's and the individual's need for a place (the ED) for potential rescue from any health disaster one encounters. If the only way to initially teach lifesaving skills and to remain proficient in them is to use new cadavers, then that outweighs other considerations. The Utilitarian argument, to give the greatest happiness (benefit) to the greatest number, may not always be comfortable, but in this case, it appears obvious.
Protecting and treating the living remain medicine's goals. Society expects no less. We should not confuse what some believe to be social amenities with our striving to help, and not to harm, our patients.