Penultimate Bioethics Post

Haven't put anything up in a relatively long time, so here's something I just wrote for Bioethics. I do not know if it's very good (and in fact I am fairly sure my citations are incorrect), but it is incredibly interesting. We had to read an article and analyze it with bioethical principles. The article itself was amazing. I, too, hope to one day get my writing into NEJM or JAMA. 

In the New England Journal of Medicine's article, "Up in the Air -- Suspending Ethical Medical Practice", a physician recounts his experience on a plane in which a fellow, older passenger goes into cardiac arrest. There are a total of five physicians on the plane, and they all gather around the man to perform CPR. 

The problem arises when, after twenty-five minutes of basic life support (BLS) and attempted resuscitation, the man is still dead. As physicians, they decide to "declare the patient dead" (Shaner 2010); unfortunately, the airline they are flying on has a protocol that requires the flight attendants to continue resuscitation attempts until the plane lands if no one more qualified can do it. So the author and his wife (also a physician), continue to run BLS on a man who is clearly dead. 

The author goes into a beautiful explanation of why he was essentially forced to continue doing something that was futile in order to placate a company's protocol. I think that this situation brings up three good points that we've talked about in this course:

1) Kantianism

Here we must acknowledge that the actions the physician found himself having to go through had no real benefit to the "patient's" health and indeed were done not for a moralistic reason. "… to have moral worth, a person's motive for acting must come from a recognition that he or she intends that which is known to be morally required" (Beauchamp & Childress 344). But the physician, and indeed, all five of the physicians on the plane, did not recognize the continuation of BLS as being morally required. At one point, the author notes that a surgeon had left as soon as they had all been made aware of the company's protocol, saying "This is futile" (Shaner 2010). Thus an argument could be made that the remaining physicians continuing BLS were acting amorally (without morals). "If agents do what is morally right simply because they are scared, because they derive pleasure from doing that kind of thing, or simply because they seek recognition, they lack the requisite goodwill that derives from acting for the sake of obligation" (Beauchamp & Childress 344). The author acknowledges that it was not the best moral option to continue CPR, saying "to prolong [it] under the circumstances in which we found ourselves would be to subvert medicine's goal from the good of the patient to the benefit of the community" (2010). 

2) Contextual Features

What caused the author to continue BLS was not his own moral code (he was very much against it), but rather, the context in which the situation was occurring. Had the event taken place in public, rather than on private property, the physicians involved probably would have little trouble ceasing BLS when deemed inappropriate, or, as the author put it: "CPR should be deemed ineffective when it cannot be expected to meaningfully alter the natural course of the disease…" (2010). Unfortunately, "every medical case is embedded in a larger context of persons, institutions, financial and social arrangements. Patient care is influenced, positively and negatively, by the possibilities and the constraints of the context" (Jonsen, Siegler & Winslade 1998). The most affective context in this story is the institutional one. The author says, "We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline's protocol" (2010).

3) Discernment

In the end, the author firmly believes that medicine and practitioners of medicine should have their own policies that supersede whatever social policies and protocols they may come up against. This is the thesis of the essay, and I believe this whole story is a very practical demonstration of the importance of discernment. In a way, discernment also echoes some of the features of Kantianism. Discernment requires physicians to "… make fitting judgements and reach decisions without being unduly influenced by extraneous considerations, fears, [etc]" (Beauchamp & Childress 40). The fear of litigation is what caused the airline company to create a protocol which in the end proved to be morally damning in this specific case. The airline may have lacked discernment for this and similar health issues, but physicians are more able to understand what is necessary in terms of health outcomes without worrying over "extraneous considerations." This is because all physicians should, over time, develop "practical wisdom," which is essentially a deep understanding of the situation from a purely health perspective. When we get bogged down by social concerns, we become more at risk for biasing our actions. In the end, the author concludes explicating a very thoughtful idea that I also hold quite fervently: "We should ensure that our medical policies and protocols exclude considerations such as mitigation of liability or the exclusive interests of third parties from playing a role in resuscitative decisions. Such policies will help support the efforts of physicians to act always for the good of the patient and within the bounds enunciated in the Hippocratic Corpus" (Shaner 2010). 

1. Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009. 

2. Albert R. Jonsen, Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 4th edition. New York: McGraw-Hill, Inc., 1998. 

3. D. Malcolm Shander, M.D. "Up in the Air -- Suspending Ethical Medical Practice." New England Journal of Medicine vol 363; 2010.