The Unexpected Death of a Patient in the Clinical Setting: Some Ethical Reflections

Introduction

The death of a patient is always a significant event; however, the unexpected death of a patient is immeasurably more significant and can strike the physician with devastating force, stressing her or his ability to cope to the very limit. There are several reasons for this. They range from professional (Was the death a result of incompetence or negligence? Were other professional factors involved that could have been foreseen, dealt with, or avoided?) to psychological (Was the professional psychologically attached to her patients, in general, and to this patient, in particular?) to spiritual (Did her personal beliefs and values affect her outlook on death in a way that might cause personal turmoil?). However, there is one factor that is almost invariably overlooked, yet it goes to the very heart of the situation. It concerns the ethical legitimacy of the feelings that are being experienced, and centers on 3 notions that are basic to medicine as a profession: the notion of a patient, the concept of healthcare, and the nature of medicine itself. What follows is a brief sketch of how these factors function, how they are interrelated, and how they may be resolved.

Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email: glundberg@medscape.net

Conceptual Frameworks and Values

In order to explain the ethical forces that are operative, it is necessary to begin with some general remarks about what a conceptual framework is and what role it plays.

Everyone, whether physician, administrator, or patient, perceives the world through her or his senses. However, what comes through the senses are merely raw data that, in and by themselves, are meaningless. What gives them cognitive significance are concepts. The totality of concepts that someone has and that categorize experience constitute that person's conceptual framework. People from different cultures or subcultures have different conceptual frameworks.[1] Consequently, the world as perceived by them is different because the concepts that structure their experiences are different. This fact is illustrated most graphically by considering the arctic tundra as perceived by an Inuit as opposed to an average Western person. The Inuit experiences the frozen tundra as being full of different kinds of snow, different kinds of ice, etc, whereas the average Western person merely sees a frigid, barren landscape. Similarly, the world as perceived by those who believe in a creator deity is cognitively quite different from those who don't. Believers quite literally experience traces of God in everything that they see, and they experience the world as an inherently value-laden place; by contrast, nonbelievers, whose conceptual framework lacks the structuring concept of a creator deity, experience the world as a totality of material objects and of causally interrelated processes that are devoid of inherent moral significance, and view the world as a place that is simply governed by the laws of physics.

Physicians are immersed in a subculture of their own, complete with professional language and a distinctive conceptual perspective that centers on providing healthcare. In a word, it is medically oriented. Physicians acquire this conceptual framework during their training.[2] In fact, probably the most important part of their training consists in providing them with these new concepts and with building up this conceptual framework. Even more than the manual skills that they acquire, it is this that turns them into physicians. That is why the world as perceived by physicians is different from the world as perceived by nonphysicians.[3–7]

This phenomenon itself has been the subject of detailed study because it has profound implications for meaningful physician-patient communication.[3–5] However, what is particularly important for the present context is that the concepts that one learns when one becomes a physician – when one acquires a medical conceptual framework and worldview – are not learned alone. They are acquired with attitudinal sets and dispositions that surround these concepts, as a halo.[8] These attitudes and dispositions are automatically called into play whenever the relevant concepts themselves become active. They are called values. Values are the psychological gradients that motivate someone in a negative or positive fashion.[9,10] It follows that if these values are inconsistent or contradictory, the individuals who hold them will experience emotional turmoil when the concepts to which they are attached are activated. On such occasions, psychological and affective problems arise for that person.

These considerations provide the basic tools for understanding the stress and difficulties that may assail physicians when they are faced with the unexpected death of a patient. As was indicated in the beginning, there are 3 key concepts that structure the physician's perceptual framework and that condition her or his worldview. They are the concept of a patient, the concept of health, and the concept of medicine itself. Unfortunately, these concepts are often surrounded by conflicting ethical values. To show how this is the case, I begin with the concept of a patient.

The Concept of a Patient

What exactly is a patient?

If we look beyond the immediate triteness of the question and avoid the temptation to give an equally trite answer – perhaps something, such as “A patient is someone who has entered into a more or less formalized relationship with a healthcare professional” – we see that deep down this is really a question about the nature of the concepts that structure the experiences of the physician and that allow the physician to see a particular individual as a patient. Once the matter is put this way, it becomes obvious that the answer to the question of what is a patient very much depends on how the physician became a physician, ie, professional training, and on the acculturative process that integrated the physician into the professional subculture to which she or he belongs.

In other words, a physician's training has 2 distinct parameters: one that is technically or scientifically focused and one that is person-oriented. Each of these orientations potentiates a different perspective of what constitutes a patient. If the technical or scientific aspect of the training predominates, the physician will come to see the patient mainly as a biological organism that exhibits – in fact, that is defined by – a constellation of symptoms, conditions, needs, etc. Therefore, the concept of a patient that arises under these circumstances will be an objectively oriented concept; correspondingly, the notion of what is and what is not professionally appropriate – what will count as discharging one's professional duty – will be defined in essentially technical terms that focus on the attainment and/or maintenance of some technically defined optimal state. Therefore, the measure of how well or ill the physician fulfills her or his duties as a physician will be centered mainly on standards of what is possible, feasible, or appropriate in technical terms. Any deviation from these standards as adjusted to the particular occasion will automatically mean failure in the physician's fiduciary obligation toward her or his patient.

If the training places more emphasis on the human side of the physician's activities, then the focus will not be technical in orientation – although technical expertise will by no means be neglected. Instead, rather than essentially presenting the patient as a biological organism with a constellation of symptoms and conditions, the optics become person-oriented. The patient is seen as someone with values and hopes, strengths and weaknesses, and abilities and foibles who happens to suffer from a certain set of medical conditions. And because this person-oriented approach spills over into a general respect for individuals as persons, it also affects the self-perception of the physician. The physician will come to see herself or himself as someone who is more than merely a purveyor of technical services and expertise but as someone who, as a person, is subject to the same ethical rules and principles that govern all other members of society. Most importantly, the physician will understand that there is no fiduciary failure in not being able to guard against the unforeseeable because one cannot be required to do what is impossible.[11] All that can be required is that one do one's best.

The patient-as-object and the patient-as-person orientations are present in the training of physicians. Consequently, both are part of the conceptual framework that governs physicians' actions. Clearly, the implications when a patient unexpectedly dies are tremendous, because the conflicting fiduciary expectations that are engaged by the distinct perspectives set up seriously conflicting ethical strains.

The Notion of “Healthcare”

The second important notion is the concept of healthcare. This notion is central to what physicians are all about. In providing medical services to their patients, they are fulfilling their unique mandate as healthcare providers.

That may sound trite; however, the notion of healthcare is not a simple concept. It has 2 components: that of health and that of care. How these are interpreted determines how the notion of healthcare itself is understood – and it is here that the problem arises. Although physicians tend to shy away from giving formal definitions of “health,” the notion of health that predominates in medicine is essentially similar to the one advanced many years ago by the World Health Organization: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (Preamble to the Constitution of the WHO).[12] This definition has been amended many times, but its thrust always has been and continues to be the same: It is an outcome-oriented notion.

Similar remarks apply to the concept of care. Although originally not curative in orientation, with the advent and success of modern medicine it has increasingly evolved into an outcome-focused notion that identifies providing care not with what used to be called “caring,” but with providing appropriate services, in which “appropriate” is defined in terms of positive outcomes. When these 2 notions are integrated into the concept of healthcare, the result is a conceptual framework that is inherently outcome-oriented. We see evidence of this in the very tools that physicians and institutions use to measure the quality of healthcare delivery. The language of outcome measures is all-pervasive, and the concept of evidence-based medicine that predominates modern medicine is largely focused in this direction.

The implications for the physician who is confronted with the unexpected death of a patient are patent. Although the death of a particular patient may be considered acceptable from a caring perspective, it does not fit well with the success-oriented notion of health, and if the physician's duty to provide appropriate healthcare is measured in successful outcomes, then the unexpected death of a patient will automatically call into question the physician's ability to provide appropriate care. In view of the physician's fiduciary obligations, this would constitute an ethical stressor.

Medicine as a Profession

Finally, there is the notion of medicine as a profession. As Parsons, Freidson, and others have pointed out, professions tend to see themselves in a peculiar ethical light. Specifically, they tend to see themselves as ethically unique in that they believe that the ethical rules and principles that apply to them when they are engaged in their work are more stringent than those that apply to the remainder of society.[13–15] In particular, they tend to assume that when individuals function as professionals, they must leave behind all private values and embrace the values of the profession itself.

Medicine is a profession, and fits this mould of professionalism very well.[13,15] It is easy to see that if beneficence and nonmalfeasance are considered central to the concept of medicine as a profession, the conceptual framework that then determines physicians' attitudes may well lead to an otherwise unwarranted paternalism toward their patients.

However, there are other consequences. The notion that everyday ethical rules and principles apply more stringently in the case of medicine and the assumption that beneficence and nonmalfeasance become central to the profession can easily lead to the belief that physicians are ethically required to engage in superhuman efforts in order to fulfill their obligations toward their patients. However, this is a mistake. Ethically, there are limits to what may legitimately be expected of any member of society – and physicians are no exception. No one can have a duty to do the impossible.[16] Even beneficence and nonmalfeasance have their limits. Therefore, the failure to guard against the unforeseeable is not malfeasance of duty: It is inherent in the limits of human ability itself. Likewise. the failure to achieve a positive outcome is not necessarily a violation of beneficence and nonmalfeasance. If the physician has done her or his best, then the unexpected denouement is a function of the human condition. To forget this is to elevate unreasonable values to the status of principles. It is then easy to characterize the failure to guard against the unforeseeable as an ethical failure.

Synthesis

A conceptual framework that is structured around the concepts of patient, healthcare, and profession as these have been sketched is a conceptual framework that carries the seeds of internal turmoil. Inevitably, it will raise conflicting psychological forces in the mind of the physician who is acculturated in this fashion. A physician will vacillate between the conviction that she or he has performed her or his duties properly even though the patient has died and is therefore morally blameless, and the feeling that she or he has failed in her or his duties and is therefore ethically to blame. If the situation remains uncorrected, it will tear the physician apart psychologically. This will manifest itself not only in terms of emotional stress, but also in terms of cognitive and functional repercussions – and possibly even burnout. Therefore, both from a professional and a human perspective, it is desirable to avoid it.

If the preceding analysis is correct, then the solution does not lie in increased technical education for physicians or in professional counseling, but in appropriate ethical training. That training should include 3 things: First, it should include an appropriate ethical focus on the concept of a person – both with respect to the patient as well as the physician. The same orientation that sees the patient as a constellation of symptoms paints the physician as a technician. Both are morally demeaning. Both patient and physician are persons. To forget this is to set the stage for professional disaster.

Second, it should include an appropriate concept of healthcare. Instead of being purely outcome-oriented, the concept should be more functional in nature. In other words, it should focus on what is reasonable and appropriate given the condition of the patient and limitations that obtain. This means that rather than single-mindedly focusing on attaining a cure or a state of perfect well-being, the goal should be to achieve what is appropriate and possible for this patient under these conditions at this particular point in time within a framework of care. This, in turn, will trigger the realization that if the patient unexpectedly dies, it does not constitute failure if the care that the patient received was human in orientation and above reproach.

Finally, it should include the realization that even though medicine is a profession, this does not mean that it is subject to special ethical principles. Most importantly, it does not mean that the principles of beneficence and nonmalfeasance have unlimited force. The principle of impossibility applies to physicians just as much as it does to everyone else. Not to include this basic moral fact in the medical curriculum is to acculturate the nascent physician into a culture of omniscience and perfection. No more need be said.

Incorporating these concepts into the physician's conceptual framework will not do away with the element of shock that attends the unexpected death of a patient. Nor should it. After all, the physician as person will never leave her or his emotions behind. However, it will allow the physician to deal with the situation and the shock without turning it into a moral crisis – which, in the end, has little to do with the death of the patient but stems from the contradictory nature of the ethical glasses through which she or he has been trained to see the world.