“Compressions are good, pulse check in 20 seconds, charge to 200!
Everybody get ready to stand back. Stop compressions! Do we have a pulse?
No pulse, that’s VFib on the monitor. Everybody clear! Delivering shock.
…I see nothing, resume compressions!
Alright, we’ve been coding for 20 minutes, after the next pulse check does anyone have an objection to stopping the code?…”
What a question to be asked in life. Do YOU object to me letting this person die? Perhaps you believe they are already dead. Perhaps you believe we shouldn’t force prolonging life and SHOULD stop. Even after being asked this question during EM or ICU, you likely don’t know. You may have a gut feeling, or have been told what is appropriate, but do you really KNOW what you believe, and why? Because, in the face of being asked if you should give up on saving someone, all the empowerment you feel by saying the words “autonomy” and “nonmaleficence” leaves your mind. What do they really mean at this moment? Which one is worth more? I have 120 seconds to decide?
Applied Ethics
Welcome back to my Medical Ethics Series for the tenth installment. Unlike the fun of the last ones, where we explored what ethical theories might be best, here we will face very real situations, and ask the hardest questions of all…What is the right thing to do?
In this article we will address the code from the perspective of a Virtue Ethicist. In each sister article released this edition, I will also approach it as a Deontologist, and a Utilitarian.
Virtue Ethics
A brief reminder, virtue ethics is the ethical concept that we want to become a virtuous person through our actions. In doing so, ideally we will achieve Eudamonia (flourishing). Virtues have two sources: First, we have our reflexive moral actions we learned as a child. Second, we have Phronesis, or practical wisdom/prudence, which we learn along the way from virtuous mentors like Dr. Beyda. Our four cardinal virtues are Phronesis, Justice, Courage, and Temperance, although there are other virtues one can use as well (e.g. Compassion).1 So, as we approach the code, we must reflect on what we think the right virtue is to invoke here, what the virtue would tell us to do, and use the guidance of our more virtuous mentors to inform us when we are lost.
Applying It All
As we (the virtue ethicist) stand there, sweating from rounds of CPR, looking around the room to see if anyone else objects, what should we be thinking?
Remember: The virtuous physician does not follow a rule or calculate an outcome, but perceives through practical wisdom what excellent medical care requires in this specific situation, and acts accordingly.
Let’s take stock:
The patient currently has a low but possible chance of survival, ~6% survival to discharge to be exact. They have a 3% chance of a good neurological outcome, too. Not great numbers, but still possible.2 How busy is our service right now? Also, what’s the staffing situation and how are hospital resources? Let’s say it’s a normal day at BUMC-P in the ED, and resources aren’t strained at this time.
The virtues to focus on in this scenario will be Phronesis, Compassion, Courage, and Temperance. Why? Phronesis overarches others, as it is what guides what virtue to adopt and how to invoke it in any situation. We also need to love our patient and show compassion without being overly sentimental. We must be courageous in saying stop or continue. And we must show temperance in our medical practice, not picking the extremes of always going on or never doing so.
Temperance: By taking the code this far, yet considering stopping, we already have shown our temperance, having attempted to avoid excess or minimalism relative to what this situation asks of us.
Compassion: The compassionate person might appear as someone who would keep going, but what about the statistics? My patient has a 1/20 chance of having a good neurological outcome? 95% chance they have a poor quality of life or die? It would seem more compassionate to let them go, as a good physician knows what appropriate care looks like. But what about the family, begging you to continue? Perhaps we go one more round for them. While it likely won’t change the outcome, if we tell them we will stop after one more round, it gives them some time to adjust to this conclusion, and creates a relationship of trust between you and them. We also must show compassion to our other patients, who may be suffering in our absence, further encouraging a time-limited code.
Courage: It is hard not continuing a code. It sounds easy to talk about, but when faced with the decision, there is a pull to try just one more round. Maybe, just maybe, today is the day for a miracle. With the family asking you to keep going, courage is even harder to show. If we talk to the family about stopping after one more round, that too, takes courage. The cowardly person would avoid the conflict, and the recklessly courageous person would stop the code without even addressing the family. Or perhaps it is the reckless person who would keep going, despite the consequences. Either way, the courageous person is not going to continue.
The virtue ethicist would say, given that we have run the code correctly to this point and ruled out all possible causes, that we should stop after one more round, letting the family know this is the final attempt. This properly invokes our virtues, our phronesis guiding us to what mattered in this situation.
Objections
People will object with our stance, or at least our reasoning.
Why are these the virtues to listen to? How can you know you are balancing them right?
Our phronesis informs us, through years of training, that compassion and courage are paramount to these situations, with temperance as a backbone. Not to mention that three of these virtues are the cardinal ones, and the one that isn’t, compassion, is essential to healthcare as an entity. The fourth cardinal virtue of justice, which we did not weigh, does not seem to be as applicable, although a secondary analysis with it is not unreasonable. But how do we know we are balancing them correctly? One might argue that it is courageous and compassionate to continue. Perhaps, but not for too long, as otherwise we would inherently lean into the extremes that leave the domain of virtues. And if we did continue for a bit longer, I am not sure it is any more or less virtuous than our current decision. Virtue ethics does not leave you only one right decision like our other normative theories. At the end of the day, we must reflect on our decisions together, collectively refining our wisdom to find the best answer, with our wiser counterparts guiding us. If we decide that wasn’t the right call, then next time we can use that conclusion to inform us. Virtue ethics leaves room for growth and discovery of what is best, we cannot guarantee we will always be right.
Caveat
As with all normative theories, the interpretation between practitioners does vary, and perhaps another virtue ethicist will find my balancing of the virtues to be missing an aspect. Perhaps Dr. Beyda will respond with his own phronesis for us to learn from and grow.
Conclusion
Virtue ethics is the normative theory concerned with living a virtuous life and achieving Eudamonia (flourishing). A virtue ethicist would say we should stop the code, and perhaps go another round while informing that family this is our last attempt. Like our other normative theories, virtue ethics is something paramount to healthcare, and something we use every day. Whether we are courageous in ending a code, compassionate in spending 10 more minutes listening to our patient complain, or just in our application of resources, virtues pop up all throughout the healthcare day. The question is, is virtue ethics correct? Does it guide us in an appropriate yet flexible manner? Or does it let us be biased, and misled? Perhaps it’s just circular? Or maybe, just maybe, following virtue ethics instead of other theories is courageous, temperant, just, and prudent.
References
Travis Seideman
Travis Seideman is a member of the Class of 2026 at UACOM-P. He attended Northern Arizona University where he studied Exercise Science and Psychology. He is pursuing Family Medicine and is passionate about increasing primary care access in Arizona, especially for underserved areas.