Not long ago the emergency room staff at Miami’s Jackson Memorial Hospital encountered one of the most ethical predicaments they had ever witnessed. So from a Medical Ethics perspective what would you do?
A 70-year-old man was brought into the facility unconscious and rapidly failing. Even in a perfect world, and as a “healthy individual” he would have had a slim chance. However, this man was an alcoholic who had abused his body “on the street” for many years. He was a diabetic and had heart disease. Without intervention it was certain this patient would die.
Physicians and nurses, doing what they were trained to do, rushed to save him. However, when they removed his shirt, there was a tattoo across his chest with the words “Do Not Resuscitate.” There was nothing fancy about the art, it was printed in simple straightforward text, and in fact, the text “Not” was underlined. Enter the issue of Medical Ethics.
He had no friends or relatives. The physicians gathered, uncertain as to what to do. The “body art” was not art, but was it an end-of-life directive?
Medical Ethics – When is a Joke Real Life?
True story: I recall that many years ago a good acquaintance at college, tired of receiving junk mail for various donations, wrote a letter in the alumni office (in the third person!) saying that he had passed away. The announcement of the death appeared in the college newspaper.
This disturbed many of us, of course, as a class reunion was being arranged and frankly we fondly recalled our friendships with him and were sorry to hear of his passing. It was not until many years later that he surfaced on Facebook! I wrote to him and told him we all thought he had died. He laughed it off. He said he was “tired of getting crap” from the college. I thought at the time how hurtful and self-centered his actions had been, how he did not care what effect his selfishness would have on others. However, his behavior paled in comparison to the unconscious patient with the tattooed do not resuscitate, (DNR).
The tattoo made the dilemma of the physicians more confused than clear. Did the man get the tattoo as a joke? Was it a stupid tattoo made on a bet or dare? Or was it a sincere wish made by an alcoholic who no longer wished to live, and who had made peace with himself? The staff was able to learn that the patient had a long history of heart and lung problems in addition to everything else. He apparently lived in a nursing home for a while, but preferred the streets.
As the man’s body began to fail him, a medical ethicist was called in who was asked to resolve the case. Unfortunately, the man never regained consciousness. They tried to buy the man time. The gave him life-sustaining support including oxygen, but they did not put him on a respirator that would breath for him. They were making a Medical Ethics decision.
No one had ever seen such a tattoo but in the end the medical ethicist and the emergency room doctors presumed the tattoo reflected the patient’s wishes. According to the case study that appeared in the New England Journal of Medicine (December 1, 2017):
“After reviewing the patient’s case, the ethics consultants advised us to honor the patient’s do not resuscitate (DNR) tattoo. They suggested that it was most reasonable to infer that the tattoo expressed an authentic preference, that what might be seen as caution could also be seen as standing on ceremony, and that the law is sometimes not nimble enough to support patient-centered care and respect for patients’ best interests.”
Medical Ethics: The Quandary
The patient lasted only the night. They let the patient die even though there were no legal documents permitting non-intervention. While medical ethicists tell us it is always better to do something, suppose the man realizing he was alone and in his mind realizing he was, “beyond help,” wanted to go on his own terms?
Modern medical science is not set up to these kinds of end-of- life decisions. In most situations, physicians will do what they can to save someone’s life. It is safer for the patient and certainly less risky for the hospital.
Suppose it wasn’t a 70-year-old man, but a 17-year-old-college freshman who had gotten a tattoo on a night when she felt depressed? What then?
These types of ethical medical issues will only increase in the future as issues of Medical Ethics become front and center for many.
I often think of my college acquaintance who rejected so many friends because he did not want to get junk mail. He had lost out on so much because he did something on a whim.
Whatever body art represents to the individual in getting the tattoo, it may well be time to revisit the ethics of such personal statements and the effects it has on others. Once a pendulum is set in motion, it may be impossible to stop.
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