Wall Street Journal - Tuesday, November 12, 2002
Question Use of Dead Or Dying Patients for Training
Staff Reporter of The Wall Street Journal
to the vast majority of family members, after a patient dies in the emergency
room of many hospitals, a senior physician draws a curtain and supervises young
doctors practicing several rounds of emergency medical techniques on the deceased.
In addition, several hospitals permit young doctors to practice on patients who
are nearly dead, that is, who are technically still alive, but beyond the help
of even extraordinary measures.
The procedures include inserting needles
into major veins, drawing body fluids and performing endotracheal intubation,
a technique for opening a person's airway. Though rarely discussed, the practices
have been standard at many teaching hospitals, and some other hospitals, since
the 1970s. Furthermore, hospitals sometimes bill the nearly dead patients' insurance
company for the procedures performed for medical training.
community is increasingly divided on the ethics of such practices. Two years ago,
medical-student members of the American Medical Association asked the AMA's Council
on Ethical and Judicial Affairs to study the issue and develop ethical guidelines
for using newly dead patients for training purposes. As a result, the AMA adopted
a nonbinding policy that no training be performed on newly dead patients unless
the patient or family members had given consent. Since then, several of the nation's
1,100 teaching hospitals have stopped using newly dead patients for training or
have implemented new rules regarding consent. The AMA didn't address the practice
of doing medical training on nearly dead patients.
There are no hard numbers
on how many hospitals engage in these practices and the ethical policies governing
such training vary widely between hospitals, at times even among departments within
a single hospital. "There is no consistency on this," says Jessica Berg,
an assistant professor of law and biomedical ethics at Case Western Reserve University,
Cleveland, who supports the AMA's calls for consent.
A paper published
in the Journal of General Internal Medicine this month shows that controversy
has surrounded the practice at least since the 1970s. "Physicians have a
sense that this is not completely appropriate, and much of the practice flies
under the radar," says Dr. Jeffrey Berger, one of the paper's authors, who
practices at Winthrop University Hospital, Mineola, N.Y., and is Assistant Professor
of Clinical Medicine at State University of New York at Stony Brook.
a survey of 96 emergency-room directors, published in Academic Emergency Medicine
in June, about half the directors said they were training residents on newly dead
patients in their hospitals. Only four of the respondents said they had written
policies requiring family members' consent for performing intubations on patients,
while 76% said they "almost never" ask for such consent.
who support the practice say it is the best way to learn life-saving emergency
procedures. "We don't get a magic wand," says Kenneth Iserson, a professor
of emergency medicine and director of the bioethics program at the University
of Arizona who uses newly dead ER patients to train his students. He defends teaching
students on fresh corpses without consent. "We have to actually learn these
procedures," he says.
"[The AMA's nonbinding ban is] a bad position.
It's a bad policy," says Dr. Iserson, who also is head of the ethics committee
at the University of Arizona Medical Center, "If the doctors in the emergency
room units don't know how to do these procedures, these patients die," he
Catherine A. Marco, chairwoman of the ethics committee of both the
Society for Academic Emergency Medicine and the American College of Emergency
Physicians, said the college's committee had discussed the issue at length some
years ago but didn't reach a decision "because there are so many divergent
opinions" about the practice.
An emergency room physician at St.
Vincent Mercy Medical Center in Toledo, Ohio, Dr. Marco says the 14 emergency
doctors there decided on an unwritten policy in the past five years that they
wouldn't perform medical training on the newly deceased without consent. Instead,
she says they often use nearly dead patients to train the hospital's 36 residents,
but don't specifically tell family members or ask for consent.
procedures on nearly dead are in the medical record, families of deceased patients
are sometimes unaware of medical teaching, she says. "I'm not sure it is
beneficial to explain that to grieving families," Dr. Marco says. "It
would be kind of cruel to tell a grieving family we could have pronounced him
dead five minutes earlier."
The patients' insurance companies can
get billed for procedures used for training purposes in clinical settings, which
can amount to hundreds of dollars, Dr. Marco says. These procedures fall into
a gray area, she says: "Suppose in a resuscitation scenario we realize that
the outcome is unlikely to be successful. We may perform a few more procedures
that have a limited chance of benefiting the patient, but also serve a teaching
function. The issue is not entirely clear since it is impossible in many cases
to clearly separate the two objectives."
The idea of using dying
patients for medical training shocks other experts. "I can't see how you
would justify that ethically or legally, no matter what," says Case Western's
Ms. Berg about the practice in general.
Representatives for insurance
companies Aetna Inc., Hartford, Conn., and Philadelphia's Cigna Corp. said the
companies weren't aware of such practices or that insurers were being billed for
them. Susan Pisano, vice president of communications for the American Association
of Health Plans in Washington D.C. said, "If this is a process largely hidden
below the surface, it does need to be discussed in a very explicit and aboveboard
Then there are religious questions about these kinds of medical
training. Some cultures and religions, such as Orthodox Judaism, believe the spirit
of a newly dead person could be disturbed by postmortem medical practice. "This
is something they should not be doing," says Rochelle Silberman, an administrator
of the National Association of Judaism and Medicine, in New York. "It's not
right. It is unethical."
Dr. Paul Wolpe, a fellow at the Center of
Bioethics and the University of Pennsylvania in Philadelphia, believes the AMA
policy, though not binding, will serve as a "gold standard" for hospital
ethics boards. He says the recommendation "is going to shut down an enormous
number of procedures that are now being done without anyone's consent."
Doug Smith, a third-year medical resident at the University of Arizona's Medical
Center in Tucson, says he agrees with Dr. Iserson that young residents learn best
from newly dead patients. Board certification through the American Board of Emergency
Medicine involves written and oral exams, but no physical demonstrations. "I
think it is just like many ethical issues. There are definitely two sides to it,"
Dr. Smith says. "We are doing this to help the next patient who comes through
Dr. Wolpe and other critics of the practice say it is
damaging for young physicians to develop habits of performing procedures without
consent. Dr. Leonard Morse of the AMA council and the University of Massachusetts,
thinks the answer could be a simple consent form on admission to a teaching hospital
to perform. "So many questions are asked when you enter the hospital, this
would be another good one," he says.
Dr. Iserson says if residents
can't train on newly dead patients, more emergency departments would resort to
prolonging life support for nearly dead patients. In a study, published in 1999
in the New England Journal of Medicine, of 234 internal medicine residents in
three training programs at hospitals affiliated with Yale University, a third
of the residents said prolonging the life of patients for practice is appropriate
and 16% had done so.
As an alternative, some hospitals such as Yale-New
Haven Hospital in Connecticut, Stanford University Medical Center and the University
of Pittsburgh Medical Center are using a combination of hands-on training on real
patients and practice on the corpses of people who donated their bodies to science,
on mannequins and, in a few cases, on animals. Some believe virtual reality, fiber-optic
and mannequin technology will continue to improve as an alternative.
has been absolutely no motivation in the medical community, up till now, to find
alternative training methods or to gain consent, because there has been tolerance
of doing these procedures on newly deceased patients," says Dr. Wolpe. "I
think the patience with that method has ended."
Note: The conference and pre-conference seminars are fully accredited through
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more information please contact Dr. Akerman at SUNY or the NAJM office at 917-760-2770.
Tentatively to be held
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CME accreditation provided by:
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more information, contact us:
Michael Akerman, MD, Chairman, Conference on Judaism and Medicine
c/o SUNY-Downstate Medical Center
450 Clarkson Avenue, Box 19
Brooklyn, New York 11203