- BIOETHICS FORUM ESSAY
Does Practice Make Perfect? The Use of Newly Dead Patients in Medical Training
During my graduate training in public health, I took umpteen bioethics courses. In each class, much attention was given to ethical issues surrounding end-of-life care and decision-making. There were voluminous articles and seemingly never-ending debates about what happens to people before they die, and whether and how clinicians, clergy, and policymakers should be involved in the process. Though I found the information useful then, and now in my career as a policy analyst, I always wondered what happened to bioethical precepts once life actually ended.
Do the infamous four principles apply to a newly dead person? Obviously a dead person can no longer act autonomously, but do clinicians still owe them their respect for person? Can and do clinicians still need to act toward the newly dead in a manner that is nonmalificent — or even beneficent? These questions apply to a number of end-of-life scenarios from autopsy to organ transplants, and although I could wax philosophical on each, it is informative to consider the use of newly dead patients for training purposes.
Although many medical procedures can be taught using animals, mannequins, training videos, or computer simulators, there may be a distinct educational benefit to allowing students to perform certain procedures on real bodies. Medical students often train using cadavers that have been donated for educational purposes. However, donated cadavers undergo a chemical preservation process that may affect their realism and quality. Some medical educators believe that rather than using suboptimal cadavers, certain procedures can be better learned using the bodies of newly dead patients. Thus, teaching hospitals commonly permit their use for training and practice purposes. Procedures performed are generally limited to endotracheal intubation, central line placement, skin incisions, thoracotomies, pericardiocentesis and biopsies.
In theory, I do not disagree with the use of newly dead bodies for training purposes. However, the actual practice raises ethical red flags. In practice, because of time constraints and inability to locate family members, physicians and students often do not obtain consent for training purposes. But if the dead neither derive benefit nor ascribe any risk from postmortem procedures, is informed consent really necessary?
Despite the inability of some patients to chose where their care is received, some physicians believe that obtaining consent is unnecessary because patients entering teaching hospitals implicitly agree to participate in the educational process. This presumed consent is troublesome to me and to many physicians and students. Additionally, I believe that the patient’s right to privacy does not expire upon death, and therefore consent for use in training, either the patient’s premortem or via family postmortem, is required.
Having the consent of patients prior to their death is ideal. While some patients make their preferences for postmortem handling known in a living will or in the narrative portion of a health care proxy form, most have not specified their wishes. Additionally, the opportunity for physicians to discuss the possibility of postmortem training with patients does not often present itself. In the event that it does, physicians risk refusal by forcing patients to acknowledge their own mortality in order to consent.
In many facilities, in the absence of explicit patient wishes regarding postmortem handling, physicians assume decision-making authority. The physician can choose to proceed with training or may decide to obtain consent from the deceased’s family. When proceeding without consent or under presumed consent, physicians often do not disclose information to the deceased’s family, and training is conducted secretly.
Proceeding without the family’s consent has substantial risks, the greatest being the cultural or religious disservice that might be done to the deceased. Specifically, some religions teach that what happens to a corpse has an impact on the afterlife. Another risk is the potential for increased public distrust of the medical profession, of health care facilities and providers. Further, physicians and students may be apprehensive about concealing information from families. These providers may be violating their personal and professional ethics by bypassing the moral obligation of truth-telling.
To be sure, when seeking consent from the family physicians run the risk of refusal by angering and upsetting those that are already distressed. However, qualitative research indicates that most families will consent. I believe the probability of consent is likely to increase if physicians discuss the educational needs that will be served by the deceased while reassuring the family that their loved one will not be disrespected.
Teaching hospitals have a responsibility to their employees, patients, and the community to provide respectful, appropriate care while producing well qualified, competent physicians. It is critical to balance the rights of patients and their families with the needs of the institution and the potential benefits to society. Because I view medical training as a cumulative process, I do not believe it is necessary to perform procedures on newly dead patients to properly educate trainees. However, opportunities of significant educational merit that require the use of a newly dead body do arise. In these cases, it is imperative that physicians and students respect the known premortem wishes of the deceased. Nothing that is incompatible with those wishes, including training, should be done. In the absence of expressed preferences, physicians, students, or both must make a reasonable effort to obtain consent from the family of the deceased in a manner that is sensitive to their grief. If efforts to obtain consent prove futile, training procedures should not be performed.
This commentary appears by arrangement with the American Society for Law, Medicine, and Ethics.
Published on: August 3, 2006
Published in: Bioethics