Ethics of practicing medical procedures on newly dead and nearly dead patients

Abstract

OBJECTIVE:To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients. DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices. RESULTS:Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians' clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consentdependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement.CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

Patients' diverse beliefs about what happens at the time of death

“…When differences may exist over the signs or duration of death, the best way to avoid agonizing arguments or decisional paralysis when death occurs is to articulate any differences beforehand and to resolve them with a mutually acceptable management plan. 27 Health professionals should also honor survivor beliefs about sentience of the dead. Unlike differences over signs and duration of death, differences over sentience of the dead may often be accommodated without definitive resolution.…”

Practicing on Newly Dead

“…Lack of preparedness or competency in performing various lifesaving skills, when caring for a critically ill patient or trying to apply a new or untrained skill, may itself be considered as an act of maleficence. Berger et al (2002) point out the unethical practices of extended resuscitative activities expressly to create practice opportunities for learners. Rationalization for extended resuscitative activities is based on the following ground: (a) As a deceased body has no interest and is non-autonomous, corpses cannot be harmed, but only can be physically damaged, and (b) novice practitioners are more likely to result in harm and hence pose risk to patients.…”

“…The key factor in the popularity of newly dead cadaver simulation is related to the "affect" of simulation (dealing with a human body in practicing skills). Berger, Rosner, and Cassell (2002) make the argument that, besides "affect," newly dead cadavers also provide learners with accurate anatomical and physiological responses (e.g., fluid return), which can facilitate technical success in practice. On the contrary, Warnick (2004) suggests no difference between a computer-based simulation and a cadaver-based simulation.…”

“…Personal beliefs such as moral absolutes, cultural values, ethnicity, or religious values may prohibit the participation of some learners. Extended codes as described by Berger et al (2002) have a greater potential of conflict than newly dead cadaver simulation with participant's moral and ethical absolutes. Unlike in a newly dead cadaver simulation, in an extended code, the patient is actually not pronounced dead.…”

Análise bioética do uso de recém-cadáveres na aprendizagem prática em medicina

“…32 Based on the clear pertinence of learning the procedures, we can then argue that learning them in cadavers does not cause any additional harm to the deceased, 33,34 thus justifying the use of the body and grounding it in medical tradition. 35,36 However, the body can suffer new damage, and the family may suffer from the perception that unnecessary procedures are disrespectful to the deceased. 37,38 Therefore, some harm would be caused, but to relatives.…”