Should medical personnel be allowed to practice procedures on patients who are newly deceased?
This question has been posed for many years, but remains controversial, with persuasive arguments favoring either side. Of the many papers on the subject, 2 fairly recent ones summarize the debating points.
In a 2011 paper, Jones and McCullough present a hypothetical case of a homeless pedestrian who dies in the emergency room after being struck by a car. They discuss multiple options regarding the decision to practice or not practice on this patient.
Although the dead have no legal rights and cannot be harmed, “the obligation to respect a moral agent’s wishes passes to the next of kin,” and no training or research should be performed on a decedent without the informed consent of the nearest relative. They also feel that the moral integrity of medical education could be undermined by allowing trainees to practice on corpses without consent. In their eyes, there is no distinction between practicing endotracheal intubation, which leaves no visible signs, and invasive procedures such as central venous catheterization.
In the case of the homeless pedestrian, they believe that in the absence of consent, no practice of any kind should occur. This viewpoint is supported by the Committee on Medical Ethics of the American Medical Association, which stated the following in 2002:
”In the absence of previously expressed preferences, physicians should obtain permission from the family before performing such procedures. When reasonable efforts to discover previously expressed preferences of the deceased or to find someone with authority to grant permission for the procedure have failed, physicians must not perform procedures for training purposes on the newly deceased patient. In the event post-mortem procedures are undertaken on the newly deceased, they must be recorded in the medical record.” I have never heard of this and would be amazed if anyone actually does it.
The counterpoint is espoused by Iserson, who lists a number of reasons why practicing on the newly dead should be permitted. Only a live or freshly deceased patient will do for many procedures requiring repetitive practice because of the shortcomings of embalmed cadavers, animals such as dogs or pigs (also the subjects of ethical debates), and simulators.
Intubation of the airway is routinely taught on patients undergoing general anesthesia for elective surgery. In most instances, these patients are unaware that this critical procedure will be undertaken by an inexperienced person, and informed consent may not have been obtained.
Another way of avoiding practicing on the newly dead is to prolong a resuscitation that is clearly futile so that trainees can practice performing procedures. This too is an ethical dilemma that may lead to unnecessary expenses if charges have to be generated for procedures done on patients who are technically still alive.
Citing the accepted principle that the dead have no rights, Iserson argues that obtaining informed consent from relatives is not only difficult, it is not legally necessary. Most importantly, Iserson counters the ethical argument about postmortem practicing by stating that physicians have an ethical responsibility to prepare for the next patient who needs resuscitation and that the greater good is served by honing one’s skills on patients who have recently died.
Here’s a thought I have not read before. Except for cases involving a medical examiner, an autopsy cannot be done without first obtaining consent from the closest living relative. Obviously, performing an autopsy differs from practicing an endotracheal intubation. Or does it?
As I said, it’s a controversial issue.
What do you think?