I am fascinated by Medical Ethics, and the appalling yet wonderfully complex conversations that take place within the discipline. The following story seems dramatic and far-fetched. It may sound like a new episode of a high stakes medical drama. However, it is not fictitious. In fact, it is riddled with a rare, and seemingly impossible compound; the truth. This tale was recently published in The New England Journal of Medicine. Various news outlets, such as The Washington Post and Gizmodo picked the story, bringing to the world a great (and thoroughly terrifying) story.
Imagine you are a young, anxious doctor ready to repel disease, correct illness and pry the dying from the wretched hands of death. A furious adrenaline cloaks your veins every time you hear about an incoming case. Even after a few months as an intern, this hot energy sends a feisty rattling sensation along your bones. You are ready to face the ugliest problems human beings can face. You are a ready to save lives.
Suddenly, you are alerted that a patient is inbound via ambulance. As always, their condition is less than desirable. They were found drunk and seem to have other problems complicating their situation, in short, they are dying. However, you have the perfect skill set and knowledge base to fix their ailments, after all, you are a doctor. You are ready to thrust your skills upon their flesh, carve away the bad, sown up wounds, and nurse injuries until they are foggy memories of the past.
Upon arrival, your patient presents with all the same symptoms as the paramedics announced, however there is a complication: across their chest in bold letters read the words Do Not Resuscitate. Seemingly, the patient does not want any extreme measures to be taken in order to extend their life. No crash cart. No CPR. No medicine, just a quiet and lonely death on an exam table. To further muddy the waters, the patient has no identification, and they were brought in alone. There is no next-of-kin to discuss the patient’s wishes with.
In the tense seconds after tearing the patient’s shirt open a decision must be made: obey the tattoo, effectively killing the patient, or violate the patient’s wishes and revive them. For some doctors, the decision would be simple, the patient doesn’t want to be revived. For others, the question is more complicated, as there are a weird cocktail of ethical concerns circulating within this situation. In those critical seconds you decide to go in, and start to revive the patient. You disregard the patient’s wishes, don’t call an ethics review (until a few hours later) and begin to save their life.
After the patient has been stabilized and transferred to the ICU, the ethics board is finally called in to assess the situation. After deliberation, they come to the seemingly obvious conclusion: the patient’s wishes must be upheld. The patient died a few hours later, finally succumbing to the abuse they forced their body to endure. Only after this was an old, Advanced Directive discovered, and the doctors were able to sigh a little bit.
Were the Doctors Wrong?
In an effort to defend the doctor’s decision to treat the patient, the authors wrote “[t]his patient’s tattooed DNR request produced more confusion than clarity, given concerns about its legality and likely unfounded beliefs that tattoos might represent permanent reminders of regretted decisions made while the person was intoxicated”. While there could be a rich discussion had on the legality of the tattoo and the doctor’s prejudice toward tattoos, I will stick to another issue.
It seems obvious, but doctors are not lawyers. They do not decipher law and they do not interpret the law. They practice medicine, examine bodies, and combat disease. The doctors in this story decided, on their own without legal assistance or advice, their patient’s tattoo was not a sufficient enough expression of his desire. It was not until a few hours after the patient was brought into the hospital the ethics consultants were requested to review his case. In this time period, the patient had presumably been stabilized in the Emergency Department, and then he was transferred to the Intensive Care Unit, where doctors decided to call the ethicists.
On one hand, the doctors were following what they had been trained to do in medical school: save and preserve lives. The energy and time dedicated to such actions ought to be rewarded with gratitude, because these basic goals of medicine are truly grand and noble acts. However, there is an inherent dark side to these wonderful notions. Doctors have the unique ability to extend or even save their patient’s life. This can happen a number of different ways. Sometimes extreme measures, such as intubation, must be taken, while other times something more tame, such as curing an ailment can save a life. As I mentioned, these acts are well received and highly thought of for the most part. However, at times, a patient may wish to die, or it may actually be in the patient’s best interest to die. A quick example of this might a cancer patient that has lost the will and desire to fight what is seemingly inevitable. Another example would be a patient that has a chronic condition, perhaps HIV or AIDS, that will lead to their death. In this case, I believe the doctors were temporarily ensnared in this darkness.
The care the doctors gave the patient was not extreme, however, they still injected with him fluids, pumped air into his lungs and gave him medication to raise his blood pressure. The basic assumption in an Emergency Room is that a patient wants to live. Life is given precedent in all situations, because only if a patient is stabilized can they communicate their wishes. In this situation, the doctors followed this assumption to the letter. I am not arguing they did otherwise, however, I believe the delay in calling for an ethics review is incorrect. I believe the doctors should have made sure their patient was not going to die while an ethics team was assembled and began to review his case.