Executive Summary
Using the newly dead to practice invasive medical procedures results in ethical tension between the provider’s obligations to the decedent and family and societal interests. Living patients undergoing resuscitation or surgery are at risk for harm if used for physician instruction. Some ethical concerns include the following:
- Public trust can be undermined if the practice occurs without the family’s knowledge.
- There is an ethical imperative to ensure practitioners’ proficiency in life-saving procedures.
- Without transparency, the bodies of patients from socioeconomically disadvantaged populations might be used more often than others.
Is it ethical to use the bodies of newly dead patients to practice invasive procedures such as thoracotomies, cricothyrotomies, lateral canthotomies, or venous cutdowns?
“Ethical tension stems from the potentially competing imperatives: To respect the body of the deceased and the family’s interests in and obligations to the decedent, and societal interests,” says Jeffrey T. Berger, MD, FACP, professor of medicine at Stony Brook (NY) University School of Medicine. Berger is also chief of the Division of Palliative Medicine and Bioethics at Winthrop-University Hospital in Mineola, NY.
Clearly, there is a need for technically competent physicians who can provide invasive medical interventions with relatively low risk to patients. If newly dead patients are to be used for learning, however, a degree of transparency about the activity is needed, says Berger. “The profession must maintain public trust,” he says. “This could be undermined if word leaked out that physicians were using dead patients without the family’s knowledge.”
Providers shouldn’t underestimate the downside risk of undermining public trust, says Berger. “If the profession were to advocate for routinely using newly dead patients, a mechanism that would allow patients to opt in or opt out could be considered, although either would be somewhat cumbersome,” he suggests.
Without transparency, there is a risk that the bodies of patients from socioeconomically disadvantaged populations could be used more often than others, says Berger. “This mirrors the historical phenomenon of these patient populations bearing a disproportionate share of medical care rendered by resident physicians,” he adds.
Patients believe consent is necessary
At one time, practicing on the newly dead was very commonly done, says Barry Brenner, MD, PhD, program director of the emergency medicine residency program at University Hospitals Case Medical Center in Cleveland. “People then started questioning whether this was reasonable, and the ethics of this,” he says.
Years ago at an international conference, Brenner was surprised when some attendees suggested simply asking for consent to practice on the newly dead. “I said that saying, ‘Your family member is unfortunately expired, but we have medical students here who need to practice intubation’ would infuriate people,” says Brenner. A Norwegian researcher responded that in his country, most people would readily agree to this practice.
“Things that were considered absolutely fine in Norway, and I suspect throughout Europe, were considered abhorrent here in the U.S.,” says Brenner. The two physicians set out to study the matter by administering identical surveys to adult emergency department patients and family members in Brooklyn and Oslo, to determine their willingness to consent for teaching of specific invasive techniques in the event of their own death or that of a family member. “What we found was an enormous cultural divide,” says Brenner.
Respondents in Brooklyn were much less willing to grant permission than Norwegians: 48.5% indicated they’d be angry if approached for permission, compared with only 8.4% in Oslo.1
Other research suggests that patients and families will often grant permission for such training.2,3,4 In a 2014 study, 150 patients were asked whether they would give consent to have endotracheal intubation training on their own bodies after death; more than half (55%) agreed.4
Obtaining consent entails more than just signing a form, however, says Berger. The informed consent process must include an opportunity for clarifications, questions, and exploration of potential harms, likely benefits, and alternatives.
“Often, there is an over-emphasis on the instrumental component of consent — ‘getting the form signed’ — and under-emphasis on the content and process leading to an informed decision,” says Berger.
Simulation doesn’t accurately mimic doing procedures on real people, according to Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, FIFEM, professor emeritus in the Department of Emergency Medicine at The University of Arizona in Phoenix.
“Even unembalmed cadavers that have been refrigerated and donated for medical purposes often lack the veracity of a live patient or newly deceased corpse,” he says.
Iserson expects that in the future, virtual reality simulators will accurately mimic the human body’s feel and response to procedures. “At that point, no one will permit trainees to do any procedure on live patients without first demonstrating their expertise on these simulators,” he says.
Until that day comes, however, Iserson says there is an ethical imperative to have practitioners learn and be proficient in life-saving procedures. This is especially true of those who will need to act in emergencies.
“Ethics is always a balance between better and worse options,” says Iserson. He says providers should ask themselves this question: Would you rather practice and teach emergency procedures on the newly dead, or tell a grieving family that you didn’t know how to do what may have been a lifesaving procedure?
“The bottom line is that when faced with a moral dilemma, the worst possible action is confused inaction,” says Iserson. Providers have an important choice to make, he says: To train medical personnel using practices that can actually hurt living ill and injured people, or to permit an admittedly distasteful, yet physically harmless, method of teaching to continue on the newly dead.
“We dare not make the mistake, in medicine or in bioethics, of confusing a good public image with real and practical benefits for all of society,” says Iserson.
Live patients are harmed
Iserson routinely asks trainees: “Who does practicing and teaching procedures on harm? Is it the now-deceased patient on whom you or your senior residents and attending physicians used the skills they learned on other patients? Or the live patient, with a chance to live, on whom you will learn or practice an invasive procedure?”
“Much less thought or concern seems to go into preparation for novice practitioners’ learning or practice on living patients,” says Iserson. He says that two groups of living patients are most harmed if they are used for physician instruction: Patients undergoing surgery using general anesthesia, and patients being resuscitated.5
“Surgical training commonly occurs in the operating room, and aside from some very basic anatomical instruction, is not amenable to substitution with corpses,” says Iserson.
Resuscitations are often prolonged until everyone who needs to learn or practice has had a chance to perform a critical procedure. “This process takes place after the team has determined that the person cannot be resuscitated, but before death is pronounced,” says Iserson. “Unfortunately, there can be adverse outcomes to practicing on these still-living patients.”
The patient’s family or third-party payer must pay for any equipment used, and possibly even the unnecessary procedures. “Worse, by this time the patient has invariably suffered severe brain, heart, and other devastating systemic damage,” says Iserson. When continued cardiopulmonary resuscitation during these practice sessions occasionally restarts the patient’s heart or restores the blood pressure to a measurable level, the dying process is prolonged for hours or days.
This comes at an enormous expense, says Iserson — both in terms of money and emotional turmoil for the patient’s survivors.
“This common scenario can only be considered abhorrent, given the availability of newly dead bodies that can no longer be harmed and that offer the same practical opportunities,” he says.6
REFERENCES
- Morag RM, DeSouza S, Steen PA, et al. Performing procedures on the newly deceased for teaching purposes: what if we were to ask? Arch Intern Med 2005; 165(1):92-96.
- Hergenroeder GW, Prator BC, Chow AF, et al. Postmortem intubation training: patient and family opinion. Med Educ 2007; 41:1210–1216.
- Oman KS, Armstrong JD, Stoner M. Perspectives on practicing procedures on the newly dead. Acad Emerg Med 2002; 9:786–790.
- Mirzazadeh A, Ostradrahimi N, Ghalandarpoorattar SM, et al. Teaching endotracheal intubation on the recently deceased: opinion of patients and families. J Med Ethics Hist Med 2014; 7: 5.
- Iserson KV. Law versus life: the ethical imperative to practice and teach using the newly dead emergency department patient. Ann Emerg Med 1995; 25:1:91-94.
- Iserson KV. Teaching without harming the living: performing minimally invasive procedures on the newly dead. Journal of Health Care Law & Policy 2005; 8(2):216-231.
SOURCES
- Jeffrey T. Berger, MD, FACP, Professor of Medicine, Stony Brook University School of Medicine, Chief, Division of Palliative Medicine and Bioethics, Winthrop-University Hospital, Mineola, NY. Phone: (516) 663-4640. Fax: (516) 663.4644. Email: [email protected].
- Barry Brenner, MD, PhD, Program Director, Emergency Medicine Residency Program, University Hospitals Case Medical Center, Cleveland, OH. Phone: (216) 844-3610. Fax: (216) 844-7783. Email: [email protected].
- Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Professor Emeritus, The University of Arizona, Tucson. Phone: (520) 241-7744. Email: [email protected].
Is it ethical to use the bodies of newly dead patients to practice invasive procedures such as thoracotomies, cricothyrotomies, lateral canthotomies, or venous cutdowns?
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