Death by Neurological Criteria: Caring for Families amid Tragedy

Abstract

When a patient is declared dead using neurological criteria, intense emotional and ethical challenges can follow. In our experience as clinical ethicists, consults surrounding the declaration of “brain death” can be some of the most difficult. In what follows, we describe some best practices related to death by neurological criteria (DNC). We begin with important policies hospitals need to have in place to ensure that death is properly understood by all members of the clinical team and place some limits on the authority of families to demand continued “treatment” for deceased patients. Next, we explain how best to prepare families for the diagnosis. We then discuss how to talk to families when breaking the news concerning DNC. Finally, we describe how to approach a family that is resisting the determination of death.

Summary:

This article advises clinicians on how to talk to families about brain death.

When a patient is declared dead using neurological criteria, intense emotional and ethical challenges can follow. In our experience as clinical ethicists, consults surrounding the declaration of “brain death” can be some of the most difficult. For millennia, death was determined by a lack of respiration and heartbeat or what we now call cardiopulmonary death. With the advent of the ventilator, however, oxygen can now be forced into the lungs of a patient who would otherwise have died, oxygenating organs, including the heart, and so giving the appearance of continued life, even if the patient’s whole brain has ceased to function and there is no chance for its recovery.

Death by neurological criteria (DNC) was eventually developed as a secondary criterion for death (Haas 2011). The Uniform Declaration of Death Act, which describes death as either the “irreversible cessation of circulatory and respiratory functions; or irreversible cessation of all functions of the entire brain” (National Conference of Commissioners 1980), was first drafted in 1981 and is both reflected in state laws and widely accepted within the medical community. Yet, families struggle to understand and accept DNC. Of course, skepticism around the determination of death is not new. Up until the nineteenth century, reports of premature burial were common, and rituals were devised to ensure the corpse could be observed for signs of life or putrefaction (Tomlinson 2014). DNC has reawakened a long-held fear that physicians can misdiagnose death.

Skepticism at the bedside about DNC is completely understandable. Patients who are determined to be dead under neurological criteria (brain dead) typically don’t look dead. Such patients will always be on ventilators because the damage to the patient’s brain has caused the loss of spontaneous breathing. But because the patient’s heart is still beating, the rest of the body is being oxygenated. The patient will have a pulse, may feel warm to the touch, may have normal color, and may retain some reflexes located in the spinal cord. Confusion is compounded when clinicians fail to adequately prepare families for the possibility of death, use confusing language to discuss DNC, and fail to treat the dead body as dead. The declaration of DNC will almost always be difficult for families, but adequate preparation, communication, and practices can help ease the process considerably for grieving families.

In what follows, we describe some best practices related to DNC. We learned these through our clinical work and in consultation with others who have struggled through the ethical challenges raised by these cases. We begin with important policies hospitals need to have in place to ensure that death is properly understood by all members of the clinical team and place some limits on the authority of families to demand continued “treatment” for deceased patients. Next, we explain how best to prepare families for the diagnosis. Although DNC cases are often the result of sudden trauma, this does not mean there is not time to prepare families for what may be the worst-case scenario. We then discuss how to talk to families when breaking the news concerning DNC. The words used during this meeting with the family are crucially important as are the ways the deceased body is treated after the determination. Finally, we describe how to approach a family that is resisting the determination of death. This can be one of the most challenging cases for clinicians and clinical ethicists alike. No matter how well the clinical team has prepared the family and disclosed the results of neurological testing, families may still resist the determination of death. The team will need to balance sensitivity toward the family with appropriate treatment of the now deceased patient.

Hospital Policies

It is important to have a policy in place that employs clear, current, and accepted procedures for the accurate determination of death, most especially determinations using neurological criteria. This can help avoid disputes between providers concerning how to diagnose death and the resulting mixed messages to families. Policies can also provide information on best practices for disclosing death to family members as well as mechanisms for resolving disputes when the declaration of death is not accepted by families.

Clinicians’ language around death can become loose and potentially confusing to themselves, other members of the team, and especially the family. We have heard clinicians use phrases such as “basically dead,” “clinically dead,” or even “brain dead” to describe patients who are not dead but are instead in comas from which they are not likely to recover, and there is evidence that such confused understanding is commonplace (Youngner et al. 1989). While perhaps accidental, such language helps to create a climate where DNC is suspect or seen as something different than plain death. During a recent ethics consult, we discovered that our hospital’s policy was in fact riddled with errors and confusing language. The policy was not using an appropriate definition of death nor did it outline the most recent criteria for determining death. Any clinician hoping for clarity on these issues would have found our hospital policy on determination of death woefully inadequate.¹

In January 2019, the American Academy of Neurology (AAN) put out a position statement calling for uniform policies and practices regarding the determination of DNC (Russell et al. 2019). We agree uniformity among hospital policies would help providers better understand DNC as well as a standard of practice for determining death. Establishing an accepted and valid medical standard would go a long way toward resolving controversies in DNC. When reviewing your own hospital’s policy, we recommend looking out for the following:

• The definition of death matches your state law and the Uniform Determination of Death Act, which contains both the “irreversible cessation of circulatory and respiratory functions” criterion and the “irreversible cessation of all function of the entire brain, including the brain stem” criterion. In an audit of our local hospitals, we were surprised to find the second part of the definition was not written in to all hospital policies on the declaration of death.

• Policies should not insist on ancillary tests (e.g., electroencephalogram, cerebral angiography, nuclear scan, or transcranial Doppler). The AAN suggests these tests may be used when there is a dispute concerning the reliability of the clinical neurologic exam or when an apnea test cannot be performed. In our experience, however, such tests are often used when the family disputes the results of the bedside clinical exam. However, ancillary exams cannot diagnose DNC, and they do not help families to accept the DNC determination, especially when they are inconclusive.

• Hospital policies should outline who is qualified to conduct the clinical exam as well as who may make the determination. Often, this will be dictated by state law. But the AAN recommends two qualified physicians evaluate the patient for DNC.²

• A description of what must be included in the medical record once the clinical exam has been completed.

• A statement that hospital policy requires the removal of all medical interventions from patients declared dead, with some reasonable advance notice to families.

• Recommendations to consult the ethics program when a family will not accept the determination of death.

It is helpful to attach the clinical checklist that outlines the necessary steps for evaluating a patient for brain death to the hospital policy.

Before DNC Is Determined

For many families, DNC will come as a surprise. Even if the patient is in serious critical condition, many families hold out hope that their loved one will pull through. You want to allow for that hope while still preparing families for the worst. Early discussions about their loved one’s grave condition can give families time to process the severity of the situation and reduce shock and surprise when the discussion turns to DNC. Since cases of DNC are precipitated by severe brain damage, families of these patients should be counseled that their loved one has severe brain damage, and additional tests need to be done to determine the extent of the damage. You might say, “We are doing our best for your mother, but her situation does not look good.”

For families that are religious, this might be a good time to suggest meeting with a hospital chaplain or another religious authority. Some families mistakenly believe that withdrawal of ventilatory support from their loved one constitutes euthanasia. For the vast majority of religious traditions, however, this is not the case. Spiritual advisors can help families to understand what medical interventions are morally required and which are extraordinary or legitimately refused.³

It is not necessary to wait for DNC testing to commence or be concluded to begin a discussion with families about the continuation of medical interventions, especially the ventilator. At this stage—where progression to brain death is a real possibility, but not yet confirmed—families should be helped to consider the possibility that their loved one may never get any better than he or she is now and encouraged to discuss whether he or she would want to live out this sort of life on the machine. If their answer is no, any subsequent finding regarding DNC—positive or negative—becomes immaterial to that decision. If the patient is not DNC, the other results of the exam may confirm the likelihood he will not get any better. If he is dead by NC, he most certainly will not get any better. The basis for a decision to withdraw the ventilator remains, even if the family does not accept the conclusion that their loved one has already died.

Once DNC testing has begun, families should be helped to understand the tests you will be running. “We will be doing tests to see whether she can breathe on her own. We will check the pulse of the brain to see whether it is still functioning.” Physicians should explain to families that they are looking to see whether the brain has stopped working completely.

Next, assure the family that you will follow-up with them as soon as the clinical exam is complete. “We will be back in touch with you as soon as we have completed those tests and if there is any change in her condition. Please, if you have any questions, you can ask me or any other member of your mother’s care team at any time.” It is important to be as transparent as possible when conducting the DNC exam. If families think that you are hiding information from them, they will be less inclined to believe your diagnosis. It might even be beneficial to allow the family to witness parts of the neurological assessment, such as the response to noxious stimuli or pupillary reflex to bright light—or even to perform these tests themselves. In retrospect, families of patients who were declared dead using neurological criteria say they would have been more accepting of the diagnosis if they had been allowed to watch the exams performed to determine death (Davidson 2014; Tawil et al. 2014; Pugh et al. 2000). When conducting the exam, tell the family what you are testing for and why it matters. “When patients like your mother are in a coma, but their brain is not completely gone, they do not respond to us, but they still feel pain. I am testing to see whether your mother can feel any pain. If she can’t, I’ll know that the condition of her brain is worse than I feared.” Some physicians show family members the results of the patient’s apnea test. If you allow families to watch an apnea test, explain why the respirator will be reconnected after the test (Kompanje et al. 2012). Again, the physician will need to explain what the test measures and the test results in a way that is easily understood by a layperson.

After DNC Is Determined

Once death has been established, it is important to discuss the results with the family soon thereafter. Ideally, the family should be prepared for this determination, including the time frame in which the news will be delivered because the medical team was transparent with them from the beginning. If for some reason the family has not been present or involved during the patient’s hospitalization, physicians should still contact them immediately following the determination of death. When a patient dies of a cardiac arrest, few clinicians wait until the following day to alert family. Unfortunately, this is sometimes true with DNC, particularly when death is determined when the family is not present. Waiting too long to inform a family, however, may signal to the family that the determination of death is not serious or the clinician was not yet certain, otherwise the clinician would have informed them immediately. The clinical care team should treat DNC as they would a death by cardiopulmonary criteria with regard to notifying the family. The one obvious discrepancy will be the greater possibility of organ donation for DNC. For the purposes of this article, we do not want to delve into the complexities of organ donation, but it is best to alert your local organ procurement organization (OPO) when progression toward DNC is likely. Discussion of organ donation with the family should only occur after the death determination and is best discussed with the OPO representative. If necessary, assure the family that organs can only be removed from persons who are legally dead (Youngner 2016).

If possible, it is better to deliver the news of DNC in person rather than on the phone. A senior member of the care team should call the family to let them know they should come to the hospital immediately. If asked directly, providers should never conceal the fact that the patient has died. Before meeting with the family in person, the care team needs to be on the same page regarding the patient’s death. If a caregiver is not aware the patient has died, he or she may inadvertently say or do something that signals to the family that the patient is not in fact dead. It can be helpful to pull together a team to break the news to the family. Invite a member of the nursing staff, particularly if one has become well known to the family, other members of the care team who have developed a good rapport with the family, and a member of the pastoral care team. Pastoral care providers are trained to accompany families during their most difficult times. For many people, death has a religious significance, but even if the family is not religious, pastoral care can provide a comforting presence.

Next, determine who on the care team will discuss the determination in person with the family. We recommend the attending physician on the patient’s care run the meeting. The family will likely have questions regarding DNC and the patient’s condition, and the attending physician will be in the best position to answer these questions. Unfortunately, many physicians report feeling ill-equipped to discuss death with families (Barnett et al. 2007). This is unfortunate because how you break the news of a patient’s death can have a lasting effect of families, both in how they grieve and, in the case of DNC, how willing they are to accept the determination as well as how willing they are to consent to organ donation (Ormrod et al. 2005). Hospital educators should train physicians to have these sensitive conversations. We have done such training during an hour-long Ethics Grand Rounds series, followed up with simulation training with standardized family members. Physicians may also benefit from direct feedback from clinical ethicists or other hospital education staff who are invited to attend family meetings in which these conversations occur.

We recommend the following steps. First, gather the immediate family in a quiet, comfortable space. The physician running the meeting should introduce himself or herself (even if they have already met members of the family) as well as everyone else in the room, including their roles on the care team. Then begin the conversation with a direct acknowledgment that the patient has died. “We have completed the neurological tests we discussed earlier. I am sorry to tell you your loved one has died.” It is best to use words like “death” and “died” initially, so there is no confusion about the pronouncement. For families struggling to believe their loved one is dead, euphemisms such as the patient has “passed on” or “is no longer with us” may help to reinforce the nature of the determination, though they should not be used to replace “dead.” We also recommend clinicians avoid the phrase “brain dead.” “Brain death” can sometimes sound like something other than death or that the patient is alive in some other way. We do not tell families that their loved ones are “heart dead,” so the modifier “brain” can make the determination sound like something other than death. This is not to suggest all philosophical debates over DNC have now been resolved or that there is no distinction to be made in practice or in theory between a patient connected to a ventilator and one whose body is in the morgue (Shewmon 2018; Bernat 2018, Nair-Collins and Miller 2017). On the contrary, as we later suggest, there may be nonfutile reasons for maintaining ventilatory support even after DNC has been declared. Rather, we suggest clinicians refrain from using the phrase “brain death,” with families, because it is needlessly confusing to nonmedical professionals.

Of course, if the family asks how the patient died, the physician in charge of the meeting should explain how death was determined. The physician may say, “The tests showed that your mother is dead. She has no brain function and that there is no possibility of brain function ever returning. She appears to still be breathing because the machine we have her hooked up to is pushing air into her lungs, but her whole brain is dead, which means that she is dead under the law.” Physicians should explain the difference between keeping the patient’s dead body functioning and keeping the patient alive. DNC may require more explanation than cardiopulmonary death, so be patient with families who do not understand the diagnosis. In one study, only 52 percent of family members said they had an adequate understanding of DNC after the physician explained it to them and only 28 percent could define DNC when asked at a later date (Paris, Cummings, and Moore 2014). Given the complexities surrounding DNC, physicians will need to take extra time and care in explaining it to families.

In addition to “brain death,” there are a number of phrases that clinicians use which can be confusing to family members and lead them to believe their loved one is not really dead. Here are some additional suggestions:

• Don’t refer to the ventilator or other interventions as “life support.” When applicable use the term “organ support.”

• Don’t describe withdrawal of the ventilator as “withdrawing life support.” (A better phrase is “stopping the machines that aren’t helping anymore.”)

• Don’t urge the family to “let the patient die” or “let them go.” The patient has already gone.

• Do not talk to the patient as if she or he were alive, “I’m going to turn you now, Sarah.” Nursing staff often talk to unconscious patients this way, but this can be confusing to a family who has been told their loved one is dead.

After you have notified the family of the patient’s death, pause to allow the family to express their grief. Ideally, DNC is not unexpected because clinicians have done the necessary work of preparing the family for its possibility. Even when this is true, however, families are likely to have intense emotions. Inattention to emotions is one of the most common complaints from the family members of patients who had died in the intensive care unit (Lloyd-Williams, Morton, and Peters 2009). Emotions can range from shock, to anger, to guilt, to denial (Williams et al. 2000). Obviously, acts of violence cannot be tolerated, but in the heat of the moment, family members may say hurtful things out of anger and later apologize when their emotions are less intense. Allowing family members time to express these reactions will enable them to be more receptive to the discussion that follows.

Whatever you say immediately following the declaration of death will likely not be heard by a stunned family member, so the care team should remain silent at least briefly, while the family expresses their emotions. Also allow room for the family to talk. They may want to discuss their loved one or they may have questions for the care team. Physicians often have a difficult time keeping silent during encounters with families or patients, but research shows families who were given the opportunity to talk about a loved one’s death were more satisfied with their experience with the team (Wright et al. 2008). The care team should do their best to answer the family’s questions, while assuring them that they did everything they could for the patient.

Once their questions have been answered, explain to the family what happens next. If appropriate, explain that a member of the organ procurement team will come to meet the family to discuss organ donation. Let the family know when you plan on removing the patient’s ventilator. Again, it is important to let the family know that the ventilator is not keeping the patient alive. Careful explanation of how the ventilator is oxygenating the body might be necessary for some families.

The care team should allow the family some privacy to be with the patient. Not all families will want to spend time with their dead loved one, but some will need this time for closure. Rushing the family out of the hospital or on to the next steps may leave them feeling as though the care team does not have sympathy for their situation and may make them more resistant to withdrawing medical interventions later on. Offer counseling or pastoral support at this time. The family may take this time for prayer or other rituals that help them to cope with their loss (Segal 2014).

If Family Is Resisting DNC

Difficult ethical challenges arise when families resist the determination of death. If the news of death has been delivered in a straightforward and compassionate manner, this can help families to accept DNC. Even when providers have done their best to do so, however, some families will still object that the patient is not actually dead. Although such situations can be frustrating to providers, they should try to resist overly negative judgments on these families. In addition to general confusion about DNC, there have been many news stories of families who have successfully resisted the determination of death, such as the family of Jahi McMath, moving their loved one to another state that allow for exceptions to the death determination (Goldschmidt 2018). There have also been news stories of providers misdiagnosing death and patient’s “recovering” from DNC. Originally, many on the Harvard committee conflated persistent vegetative state with DNC. If specialists once struggled, we can sympathize with grieving families who are also struggling to understand what has happened to their loved one.

At the same time, sympathy for a grieving family should not mean that providers are willing to do whatever the family wants. Most providers do not struggle with such demands when placed on a patient who has died of heart failure. Yet, when a family resists removing medical interventions from a patient who has died by neurological criteria, hospitals often comply. A hospital in our region kept a dead patient on ventilatory support and artificial hydration and nutrition for nearly a month after the patient had died. This created an incredibly stressful working conditions for providers, particularly nurses, who were expected to care for the dead person as they would a sick (alive) patient. The fallout from this decision lasted for years. Even today, physicians do not believe they will be supported by the institution if they withhold or withdraw any treatment from a patient, even treatments they know will not be beneficial. If the administration would not allow physicians to withdraw treatment from a dead patient, then why would they allow physicians to withdraw a treatment from a live patient? Families now believe they can demand any treatment for their loved one, and providers are obligated to provide it.

Continuing to sustain the bodies of dead patients is harmful to all parties involved. Families are given false hope that the determination of death is inaccurate, which will likely complicate their grief. Providers are asked to treat dead persons, which can feel morally wrong and futile. Arguably, the act can also be seen as a wrong to the deceased, whose body is now being traumatized for the sake of the living.

At the same time, it would be wrong to immediately withdraw all medical treatments at the time death is determined. The family needs to be notified first, so that they can gather around the patient to say their goodbyes. It can also be a necessary courtesy to allow forty-eight hours for family from out of town to come to the hospital. Circumstances will vary, but we recommend waiting no longer than three days to withdraw all medical interventions from a deceased patient. When discussing the withdrawal of medical treatments, physicians should discuss when the machines will be removed not whether they will be removed (Mitra 2014). Obviously, no new treatments should be started. Such a time frame should be specified in the hospital’s death policy, that way physicians can point to the policy when describing what needs to happen next.

For families resisting the determination of death, it is important that the clinical team provide a clear and consist message that the patient is dead and that the machines are only sustaining the patient’s body. The patient is gone and cannot come back. If the care team believes resistance is likely or ongoing, an ethics consultation is appropriate. Clinical ethicists can ensure that the concerns of all stakeholders are heard and considered. Families often feel as though clinicians are running roughshod over them and have not given them adequate time to come to terms with what has happened. Ethics consultants can help discern what circumstances and values are in conflict, such that the family is not accepting the diagnosis of brain death. If the family is religious, the care team might also consider involving a clergy member the family trusts. This should be done with some caution, however. All religions distinguish between the living and the dead, but not all religions accept DNC as death. Court cases arguing against DNC have been brought by some Orthodox Jews (Rastogi 2008), Buddhists (Tench 2006), and Pentecostals (Kerr 2017). And, as already indicated, some states allow for religious exceptions to their DNC statutes.

Conclusion

Breaking the news that a patient has died is one of the most difficult conversations providers can undertake. This responsibility is made more complicated when death is determined through neurological criteria. Despite its entrenched legal authority, DNC does not align with a “commonsense” cultural understanding of death shaped by centuries of experience. It is not surprising then that families will struggle to accept DNC, making the provider’s task even more difficult. Yet we believe the steps outlined here can help to ease some of these struggles, without becoming ensnared in the ongoing philosophical disputes surrounding “brain death.” Communicating with sympathy, clarity, and consistency can help to reduce the chances that families reject providers’ determination of death and help families to begin the grieving process. Hospitals can better prepare clinicians for this task through training. Practitioners who are taught to deliver the tragic news of DNC will be in a better position to help families understand what is happening as well as help them through the grieving process. Educational tutorials, simulated training, and peer-to-peer feedback after the fact can help practitioners improve their skills in this important arena.

Discussing DNC Quick Sheet

When DNC Is suspected

Follow AAN criteria for determination of DNC. Early discussions about the patient’s grave diagnosis are a good way avoid surprising the family with news of the patient’s death. The family will have time to process the severity of the situation.

• Counsel the family that there is severe brain damage, and additional testing needs to be done to determine how bad the damage is, along with assuring the family that they will know as soon as you do.

• Offer pastoral care services.

• Initiating discussions with a statement, such as “The situation does not look good” may help family members to be more receptive of the prognosis.

• Explain the neurological tests that you will be running. Consider saying “We will be doing tests to see whether she can breathe on her own. We will check the pulse of the brain to see whether it is still functioning. We will be back in touch with you as soon as we have completed those tests and also if there is any change in her condition. Please, if you have any questions, you can ask me or any other member of your mother’s care team at any time.”

• Invite family to witness easily understood and apparent clinical exams, which could include no response to painful stimuli; no pupillary reflex to bright light.

• Show the family the results of the apnea test. Seeing a definitive rise in PaCO₂ can provide closure.

Before Meeting with the Family with the Results of the Positive Tests

After death has been established, it is important to discuss the results with the family soon thereafter. Waiting too long (until the following day) can signal to the family that the determination is not serious, otherwise they would have been informed immediately. When breaking the news to the family, however, take a few minutes to assemble the team that will talk with the family, to ensure a consistent message is delivered.

• Ensure that all members of the care team understand the diagnosis and what will happen next.

• Put together a team that will break the news to the family. If any of the nursing staff, pastoral care, or other members of the team have developed good rapport with the family, invite them to the meeting. Members of this team should have a full understanding that DNC is no less death than is cardiorespiratory death.

• Since death has a religious significance for many families, pastoral care should routinely be consulted.

After DNC Is Determined

• Notify the appropriate organ procurement agency.

• Gather the family together in a quiet comfortable space.

• Introduce yourself to everyone in the room (even if you have already met some members of the family).

• Start the conversation honestly and directly. Tell the family you have run the tests that were discussed, and the patient is dead. Let family know the testing is complete and definitive.

• Pause to allow for expressions of grief, consolation, and questions.

• Allow the family the opportunity to ask questions and express their concerns.

• Explain what happens next regarding the removal of machines and where the patient’s body will go.

• Offer pastoral care or other counseling services.

If Family Is Resisting Determination

Some families will not accept the determination of death, especially since the patient does not “look dead.” Discussions with a grieving family at the time of death can be very difficult. While the aim of the clinician is to comfort the family, many families are looking for any evidence that their loved one is not really gone.

• It is important to have a clear and consistent message from all members of the team that the patient is dead and that the machines are only sustaining the patient’s body. The person is gone and cannot come back.

• Consult ethics to help lead a meeting between family and providers.

• Consider inviting clergy to the family meeting.

Phrases/Actions to Avoid

Saying the wrong thing can lead to a very awkward situation where the family takes hope from a phrase not meant to give hope. For this reason, avoid the following phrases when discussing the death of a loved one by DNC with families:

• Physicians should not use the phrases “brain death” or “brain dead” after the family has been told that the patient is dead. If necessary, physicians can explain that under the law, there are two ways to determine whether someone is dead.

• After the determination of death, don’t use language or engage in behaviors that suggest the patient in still alive:

  • Don’t refer to the ventilator or other interventions as “life support.”

  • Don’t describe withdrawal of the ventilator as “withdrawing life support.” A better phrase is “stopping the machines that aren’t helping anymore.”

  • Don’t urge the family to “let the patient die” or “let them go.” The patient has already gone.

  • Do not talk to the patient as if she or he were alive, “I’m going to turn you now, Sarah.”

Biographical Notes

Devan Stahl, PhD, is an assistant professor of ethics at Baylor University. She has experience teaching bioethics and medical humanities to undergraduates, medical students and residents, nursing students, and veterinary students. She has worked as a clinical ethicist in tertiary hospitals and has trained as a hospital chaplain. Her research interests include end-of-life care, medicine and the visual arts, theological bioethics, and disability studies.

Tom Tomlinson, PhD, is a professor and the Director Emeritus, the Center for Ethics and Humanities in the Life Sciences, Michigan State University, and the chair of the Ethics Committee at Sparrow Hospital, Lansing, MI. His research interests have included criteria for determining the irreversibility of death, demands for nonbeneficial treatment, consent for research uses of deidentified clinical specimens and data, and critiques of methods in bioethics. He has taught medical students, residents, nurses, veterinary students, and doctoral students in philosophy.