An End in and of Themselves
February 05, 2018
By Hannah Krystal, MS Clinical Ethics expected 2020, The Bioethics Program of Clarkson University and Icahn School of Medicine at Mt. Sinai
During anatomy laboratory today, I saw my cadaver’s face for the first time. The experience was intensely personal, and made a host of bioethical concepts real for the first time. In particular, I grasped at the Kantian doctrine that humans are ends-in-and-of-themselves. Kant defined rational life as a monumental goal that could never be sacrificed in order to justify another, possibly beneficial, end. In the moment, as I unsuccessfully held back tears, the truism felt so perfect it was almost physically tangible.
The Kantian ideal and the realities of cadaveric dissection clashed within me. Although I constantly reminded myself over the course of our dissections that this body no longer belonged to a living, breathing person, the ease with which we flipped our cadaver over to access his shoulder or cavalierly slung his arm across the table to work on his hip unnerved me. I knew that the donor had given his body to us of his own free will, and that he was long past any pain. I even thought I glimpsed a slight smile spread across his lips.
I began to wonder about the circumstances surrounding his death. Had he received hospice care? Had his doctors prescribed morphine? Had he been in any pain? And, most importantly, had he been surrounded by loving friends and family?
This last thought struck a personal chord with me. My grandfather, a former member of the Hemlock Society, died two years ago, and his death felt somewhat problematic at the time. My father still talks with great relief about the ease of his passing, and I, too, take comfort in the knowledge that my grandfather was granted a good death.
But that is not the full story. Two years earlier, my grandfather contracted pneumonia, and his heart had stopped beating. My grandmother chose to resuscitate him with CPR.
While CPR has the potential to save lives by restarting a stalled heart, patients and their families typically hold unreasonably high expectations for the procedure. This false hope results from, among other factors, the romanticization of CPR in the media. In one 1996 study, shows such as ER and Chicago Hope had far higher rates of survival after CPR than are found in the medical literature. While other programs such as House and Grey’s Anatomy have worked to lower CPR success rates in their episodes over the last two decades in order to match real-world survival rates, they still portray a success rate nearly twice as high as that found in actual hospitals. In addition, even when the survival rate on medical television is similar to that in real life, shows rarely portray the fact that patients who survive often experience poor middle- to long-term health outcomes. Such discrepancies can affect patient expectations, encouraging them to request CPR without preparing them for the realities of the procedure, including its mixed outcomes.
During college, I had decided that I would take a stance against the performance of CPR on elderly patients who already suffered from a terminal diagnosis. I would, in fact, discourage the overuse of CPR among all of my future patients. I thought that I would be the brave doctor who bucked the trends, helping patients to realize the error of their falsely positive beliefs. I believed that my crusade against CPR would be of great service to my patients and their families. Learning about the Kantian doctrine of respect for persons, however, made me realize that the decision about CPR represented more than the underwhelming statistics. I, a mere first-year medical student only weeks into my medical training, should not have been so quick to dismiss the procedure, especially if requested by the patient and their family. I needed to prepare myself to treat every patient as an end in and of themselves, even if doing so precipitates the use of CPR.
Because I felt that I could not simply refuse to perform CPR without offering any alternatives, I always intended to thoroughly discuss current and past personal beliefs, advance directives, POLST and MOLST forms, legal proxies, and other methods of preparation for end of life care with my patients and their families. I planned to help them make, prepare to make, or feel confident in the ability of others to make, the right decision regarding end-of-life care, including but not limited to CPR. Now that I see the connection between Kantian respect for persons and my patients’ (or their families’) wish to perform CPR, however, I am much more willing to perform the procedure in the future. I still believe in the necessity of planning for the end of life, but I accept that CPR can, and sometimes should, be included in those plans.
Had my grandfather not been resuscitated, my family would not have been granted their heartwarming moment to say goodbye. My grandmother had viewed my grandfather in a way that I had not: as an end in and of himself. In a move that still seems somewhat counterintuitive to me, she did not decide to resuscitate based on the poor outcomes of elderly patients suffering from pneumonia, or contemplate whether a former member of the Hemlock society would have wanted to be revived. I am not sure what my grandfather would have wanted. Due to the prolonged nature of his decline, I also doubt that he expressed his wishes to my grandmother before his death. But, acting without guidance, my grandmother thought only of the man she married at the age of twenty-two, and how she was not yet ready to say goodbye.
Perhaps she dragged out his suffering in a manner that does not perfectly fit the Kantian ideal, but my grandmother devoted years of her life to my grandfather’s care. She rubbed his feet with lotion every night to prevent the growth of fungus. She put his bib on before every meal so that he could eat without staining his clothes, and then cleaned it so that he would be able to sit at the table with dignity. She told me stories about his life so that, long after he lost his ability to communicate with the world, I would remember the great man he truly was. Eventually, she gave in to my family’s pleas that she accept the help of in-home hospice care, because lifting him in and out of his wheelchair was rather difficult for her 85-year-old frame. Her decision to use CPR, therefore, represents only one in a series of loving, thoughtful choices made entirely on my grandfather’s behalf.
I am proud of the ways in which my grandmother strayed from the Kantian ideal that might have allowed him to die in a hospital bed, without his two children by his side. By letting my grandfather die not a hospital, but at home, my grandmother created a reality that the majority of Americans wish for, but fail to achieve. As I think about the small smile on my cadaver’s face, I can only hope that he died knowing that someone like my grandmother was watching out for him, making sure that he was treated well despite the medical, ethical, or social quandaries that stood between them and the right decision. Did he get to die at home?
I know that physicians train, not only for a minimum of eight years but also for an entire career. But the ability to view the patient holistically, empathetically, and with care is a crucial aspect of treatment, and one that is often best delivered with the help of those who know the patient well. Doctors should strive to treat their patients as ends-in-and-of-themselves. I can only hope that, like my grandfather, my cadaver died surrounded by competent, caring physicians, friends, and family, who viewed him not as a set of statistics, but as an end-in-and-of-himself.