NAJM Press Release 5:

The Wall Street Journal - Tuesday, November 12, 2002

Doctors Question Use of Dead Or Dying Patients for Training
By Paul Glader
Staff Reporter of The Wall Street Journal

Unbeknownst 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.

The medical 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.

In 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.

Doctors 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 says.

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.
Although training 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 way."

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 the door."

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.

"There 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."