Update
Volume 13, Number 2 (July 1997)
Much of this article was originally published as: Iserson KV: "Life versus death: exposing a misapplication of ethical reasoning,". Journal of Clinical Ethics (1994); 5:3:261-4. Those sections are reprinted with permission of the publisher.
In the Brothers Grimm version of the classic fairy tale, Little Red Riding Hood ventures into the forest where she meets the Big Bad Wolf. The Wolf, in disguise, seems kindly, initially lulling Little Red Riding Hood into a false sense of security. Not having had to deal with wolves before, Little Red Riding Hood scarcely understands her situation, let alone the danger she is in.
Little Red Riding Hood ventured into trouble when she mistook the Big Bad Wolf for her kindly grandmother. We dare not make an analogous mistake in medicine or in bioethics--confusing good appearances with real and practical benefits for all of society. Unlike Little Red Riding Hood, mistaking what we see for what we want to see can prove fatal--not for us, but for our patients. Like Little Red Riding Hood, though, we need to look through the disguise of misapplied "ethical principles" to see where the truth lies.
The Knowledge Base
Good ethics begins with good information--in policy development as well as in clinical consultations. In regard to discussing postmortem practice and teaching, the information comes in two parts: the setting in which clinicians use lifesaving skills, such as intubation; and what happens to corpses, both in the hospital and elsewhere. If sought, clinical ethicists can easily obtain the former information from their colleagues in emergency and intensive care medicine, and from paramedics in their emergency medical system. While they might not themselves experience the dread of not passing a tube into the trachea of a dying child, or having to reach for the scalpel to cut a surgical airway when their skills at intubation failed, they can certainly vicariously feel these experiences. They can view the patient's neck with a fresh cricothyrotomy scar, or visit the morgue and see those in whom the clinicians could not obtain an airway (or maybe watch the television show "ER").
The second important piece of information necessary for rational policy development is what can and does happen to corpses. Clinical ethicists can easily determine what happens to corpses in and just after they leave the emergency department, intensive care units, or wards. As some bioethicists belatedly discovered after promoting an intrusive policy requiring informed consent before practicing and teaching on cadavers could occur, cadavers do not idly lie around in busy hospital beds. Rather, nurses or in-house morticians quickly whisk them to the morgue, so valuable bed space can be opened. Perhaps they should have asked; it's the same in every hospital in the nation.
No public outcry has demanded that clinicians stop using the newly dead in this manner; it is only misguided ethicists. One recent situation may be instructive in this matter. The U.S. media publicized an exposé in Germany that cadavers were being used as crash dummies, and then tried to create public outrage that the same practice was occurring in the U.S. The public, informed that cadaver studies were saving lives through innovations in automobile safety, showed no concern, even though the source of many of the cadavers used is uncertain.
The Corpse As A Symbol
Despite all this, societies should respect their dead; it remains the mark of a civilized society. Respect is due because the newly dead corpse symbolizes the recently deceased person, as well as all of humanity. Yet 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."
Another way of viewing this situation is to see postmortem practice as the ultimate respect for the corpse. The clinicians who worked to save a person's life (and failed) now will use that person's shell to hone skills with which they will try to save their next critical patient. 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 main question is whether the living, in the person of the next patient needing the health professional's critical life-saving skills to survive, should be sacrificed to the memory of the dead. As I understand it, human sacrifice was banned in Western religious practice in Biblical times [Genesis 22]. It would be a travesty to reverse this noble advance for civilization under the guise of "bioethics."
Skills and Societal Expectations
Imagine for a minute that you are traveling in a commercial airliner when the captain comes on and informs the passengers that, unfortunately, both he and the copilot have neither flown nor been in a trainer for the past six months, having just returned from a wonderful prolonged vacation in Tahiti. "Don't worry," he says. "It's just like riding a bike." Think about how reassured you would be. Flying a commercial jet is not like "riding a bike," and neither is placing an endotracheal tube or a central venous catheter in a dying patient. In both circumstances new and unexpected problems occur, variations from the norm exist, and equipment changes over time. Unfortunately, unlike most commercial pilots, not all clinicians needing to perform these procedures had exhaustive training to make them even initially proficient. Yet their skill level will be what saves (or loses) lives. Those who excel at these procedures need to teach others and remain proficient themselves.
Requiring clinicians formally to request permission before practicing these life-saving skills guarantees that many of them will simply either not ask and not practice (putting many lives in jeopardy) or practice without asking (placing other bioethics policies and any respect for bioethicists in harm's way). Putting any barriers in the way of maintaining these skills does a disservice to all patients relying on these clinicians to save or maintain their lives.
Autonomy--An Artificial Barrier
The basis for requesting consent to practice or teach on the newly dead stems from the mistaken assumption that autonomy survives death, or that the "quasi-property" rights over the corpse given to next-of-kin allow them to disallow non-disfiguring practice and teaching. Neither is true.
Patient autonomy and the associated process of informed consent derives from the respect individuals are shown by others. Simple as the concept is, corpses no longer are individuals and cannot be the basis for either autonomy or informed consent. They are merely symbols. As Callahan said, maintaining that any harm or wrong can come to the dead is "legal fiction." In a similar way, it appears to be "ethical fiction," a preposterous extension of an ethical principle far beyond its meaning or usefulness. One might wonder whether it might not be useful to first extend the practice of respecting individual patients and their autonomy to the clinical setting, where experience shows it has yet to be accepted by the vast majority of clinicians.
The question however, arises: what about cultural sensitivity, especially in groups who disallow manipulation of the dead? One group often cited is Orthodox Jews (although Native Americans and other groups also have similar beliefs). In fact, Israel's Chief Rabbinate recently ruled that practicing endotracheal intubation on the newly deceased is allowable, specifically because other identifiable persons will be saved. Which others? The "others" are the next patients in respiratory arrest or distress coming through the doors of the emergency department.
A Communitarian Ethic and Emergency Care
Although Americans only reluctantly admit it, we exist in a community of others not too dissimilar to ourselves. We access the services this community provides and owe a duty to our cocommunitarians to perpetuate and improve the best of these services. Dialing 911 to get emergency help is just such an outstanding community-provided service. Most of the time, those accessing the system go to the emergency department, are treated, and eventually go home. Some, however, die despite the best efforts of the emergency medical team. When this happens, those who have used their skills attempting to save the patient's life have a responsibility to the community to pass on these skills to other members of the team, to ensure that their skills remain proficient, and to upgrade their skill levels. The patient implicitly agreed to this practice and teaching not only by using the services of emergency medical personnel, but also by merely living in our society, which provides everyone a right to this care.
Unlike other methods of entering into research or teaching protocols, temporarily becoming an emergency department teaching cadaver describes one of our society's most egalitarian systems. No one knows who will be the next to exit life in the emergency department's resuscitation room. The person will be, however, someone who at least temporarily existed within the ED's catchment area, and is very likely to be similar to both the last dead patient (from whom some providers learned how to do life-saving procedures) and the next dying patient (for whom some providers will use skills they learn from this cadaver). With a generalized policy of practice and teaching, neither rich nor poor, young nor old, black nor white will be over-represented among the educational cadavers--they will simply parallel the population seen in an ED by a particular group of providers.
The communitarian ethic now successfully thrives and demonstrably serves society in other Western medical cultures. Yet, some will not agree that Americans should be bound by a communitarian ethic, preferring to champion individuality, especially differences in religious and cultural beliefs that may not condone manipulation of the cadaver. Respect for religious beliefs remains a basic tenet that ties our nation together. In many cases, however, these religious traditions are malleable, based on the realistic needs of co-religionists. In other instances, cadaveric integrity is often (sometimes unknowingly) violated during the mutilating processes of "restoration" and embalming. A question we must answer as a society, then, is whether individuals can benefit from societal goods (such as resuscitation) and simultaneously not contribute to this good (by lending one's corpse to education in life-saving skills if the resuscitation is unsuccessful). Answering this complex societal question, though, goes well beyond the scope of this paper or of medical practitioners alone.
Common Alternatives
When not using the newly dead to practice and teach these procedures, clinicians commonly use animals--often dogs or pigs. These undoubtedly represent poor models since they only minimally represent human anatomy and pose little difficulty for many procedures, including intubation. Even more common is the use of mannequins. While some sophisticated mannequins seem to be successful at giving trainees at least a rudimentary intubation experience, and virtual-reality models may make the whole question of practicing or teaching any medical procedure using either living or dead bodies moot in twenty years, adequate models do not now exist in most locations. Those that do exist, when available to clinicians, again poorly represent the human form. So how do many clinicians learn their skills? Many learn and practice on unsuspecting patients undergoing general anesthesia. Unlike cadavers, these are live patients who can, and not infrequently are, harmed by a neophyts' practice. This common scenario can only be considered abhorrent, given the availability of bodies who can no longer be harmed.
A Prescription For Clinicians Needing Life-saving Skills
All of the above leads me to the conclusion that those clinicians who need to learn or keep current in life-saving medical skills to decrease their patient's morbidity and mortality not only may--but must--use the newly dead to practice and teach. Artificial barriers must not preclude this. Beneficence--doing good for the (next living) patient--must be the clinician's guiding principle. By doing this, I will never again have to hear a colleague say, "If I had just been a little better at intubation, she would still be alive."
Conclusion
Good ethics begins with good information--in policy development as well as clinical consultations. While information about the disposition of corpses has been difficult to obtain in the past, it is now easily available.
While societies should respect their dead, the living should never be sacrificed to their memory. Difficult life-saving skills in medicine, as in other fields, must not only be taught, but also be constantly practiced and refined. Putting any barriers in the way of physicians practicing and upgrading their skills in performing endotracheal intubation threatens the lives of their future patients. The guise of patient (surrogate) autonomy is stretched thin when ethicists use it to cover postmortem practice and teaching, especially that which is rapid, non-disfiguring, and potentially life-saving for others. (Perhaps we should first concern ourselves with ensuring patient autonomy for the living, who can still be affected by decisions). The common alternatives--practicing and teaching on animals (a poor model) or unsuspecting patients under general anesthesia--can only be considered abhorrent, given the availability of bodies who can no longer be harmed.
While pedants, far removed from the tumult of emergency care, worry over unusual permutations of solid ethical issues, I will encourage my colleagues to continue practicing and teaching, ad lib, on the newly dead. I submit that doing this is not only permissible, it is required. For health professionals to lack needed life-saving skills even once violates the most basic ethical principles.
Little Red Riding Hood unmasked the deception, discovered her peril, and avoided harm. Would that our society will do likewise.
REFERENCES:
1 Hallett, M. and B. Karasek. Folk and Fairy Tales. Ontario, Canada: Broadview Press, Ltd., 1991, 13-15.
2 Iserson, K.V., Death to Dust: What Happens to Dead Bodies? Tucson, AZ: Galen Press, Ltd., 1994.
3 Perkins, H.S. and A.M. Gordon, "Should Hospital Policy Require Consent for Practicing Invasive Procedures on Cadavers? The Arguments, Conclusions, and Lessons from One Ethics Committee's Deliberations," Journal of Clinical Ethics (1994): 3: 204-10.
4 Iserson, K.V., "Postmortem Procedures in the Emergency Department: Using the Recently Dead to Practice (sic) and Teach," Journal of Medical Ethics (1993): 19: 92-98.
5 Iserson, Death to Dust: What Happens to Dead Bodies? 99.
6 Feinberg, J., "The Mistreatment of Dead Bodies," The Hastings Center Report (1985): 31-37.
7 Iserson, K.V. Death to Dust, 182-215.
8 Iserson, K.V., "Requiring Consent to Practice and Teach Using the Recently Dead," Journ. Emerg. Med. (1991): 9:509-10.
9 Iserson, K.V., "Using a Cadaver to Practice and Teach," Hastings Center Report (1986):16:28-29.
10 Iserson, "Postmortem Procedures," 92.
11 Callahan, J.C. "On Harming the Dead," Ethics (1987):1:341-52.
12 Iserson, "Postmortem Procedures," 92.
13 Colpart, J.J., Noury, D., Cochat, P., Kormann, P. Moskovtchenko, J., "Organisation de la Transplantation D'Organes en France," Pediatrie (1991):46:4:313-22.
14 Iserson, K.V., Death to Dust, 182-215.
15 Iserson, K.V., "Law v. Life:The Ethical Imperative to Practice and Teach Using the Newly Dead Emergency Department Patient," Annals of Emergency Medicine (1995);25:1:91-94.
16 Iserson, K.V., Death to Dust, 98. *
Kenneth V. Iserson, MD, MBA, FACEP
Professor of Surgery (Emergency Medicine)
Director, Arizona Bioethics Program
University of Arizona Health Sciences Center
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