“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 eighth 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 Utilitarian. In each sister article released this edition, I will also approach it as a Deontologist, and a Virtue Ethicist.
Utilitarianism
A brief reminder, utilitarianism is the ethical concept that maximizing good (in the form of pleasure/happiness) for the most people IS the greatest good. The ends justify the means here, with the outcome being the most important variable. There are two subtypes, RULE and ACT utilitarianism. We will address this scenario as an ACT utilitarian, who judges morality on the summation of the good of each act. In this theory we attempt to use the “hedonic calculus,” a method of weighing variables like intensity, duration, and certainty—to calculate our pleasure vs. suffering.1 In the context of healthcare, this would mean weighing ALL aspects of care. The patient, physician, the team, the cost, the family, and the other patients who could be helped during this situation. A utilitarian must weigh the aggregate good of respecting each one of these parties and actions, to conclude what the overall best action is to take. So, does stopping the code, or continuing, produce the maximum good?
Applying It All
Remember, for the ACT utilitarian, the morally correct decision is determined not by what is possible, but by what is expected: the probability of each outcome multiplied by the amount of good or suffering it produces.
As we (the utilitarian) stand there, sweating from rounds of CPR, looking around the room to see if anyone else objects, what should we be thinking?
Starting with the patient, is there more good in continuing to do CPR? If they were to come back to life, with full mentation, and be happy, then it would seem yes. But data tells us that this is unlikely. Assuming in-hospital arrest and not accounting for type/shockable nature: after 20 minutes, chances of survival to discharge with favorable neurological outcome ~3.5%, and any survival to discharge is ~6%.2 So even if they come back, we know they may not survive to discharge anyway, and even if they do, they will likely have a poor quality of life.
What about our staff? They are tired and unable to focus on other patients that need help. Supplies? Tons of supplies are being used that could have other utility. For example, the vent being used after they get ROSC, loses utility for the new ARDS admit. Perhaps now two patients die before discharge because of this, which is certainly not maximizing goodness.
What about “invisible” patients? As mentioned above, other people could benefit from our time, resources, and medical expertise. The utility of the awaiting patient must be weighed as well, and given how sick people can be in the ED, it is likely at least someone needs our assistance urgently.
What about the family? They are hurting, watching their loved one’s chest be broken, people performing all sorts of interventions on their body, as their loved one lays there dead. Is it more “good” to have them watch this process? If they ask you to continue, is it from false hope and will it make the crash worse later?
The answer to all these individual questions is no, we should not continue. But even if the answer to the family—question was yes, and the patient—question is neutral, when you add together all the negatives on the system, staff, and financially, the net seems to be that this is not good. ACT utilitarianism tells us to stop the code.
Objections
People will object with our stance, or at least our reasoning.
First, how did we decide that the answer to those questions was no? Is it less “good” to have the patient in a coma long-term? What about when the family asks you to stop? Second, what weighs more? I said even if the family and patient questions weren’t answered no, the summation was still not a net good. How can I know that? Perhaps the good that arises from the family’s joy at the patient’s partial recovery is more than the bad from the burden on the staff and the financial burden on the system.
Critics will argue we are assigning values arbitrarily, but this is not so. We use objective metrics when possible, and although we cannot ultimately access the “hedonic calculus” and know the true values of things, many are easy to understand without it. For instance, we can observe that a patient in a coma lacks the capacity for sentience, the very vehicle for experiencing “good.” To prioritize the choice with a near-zero probability of recovery over the certain needs of waiting patients is a mathematical failure to maximize well-being. It puts an incredible burden on the staff, the hospital, and takes resources from others. The family’s emotions, while morally valid to weigh, will evolve as they heal. Keeping the patient in this state will produce years of suffering and drawn out hope with emotional swings. Through this method, we’ll miss some people along the way, but we’ll save more and net outcome is all that matters.
Caveat
As we don’t know the true value of all these actions, it is possible another ACT utilitarian would find my assessment of values to be inadequate. It is also possible that RULE utilitarianism would disagree with me, thus presenting a tension between forms of the theory. However, I do find it likely that many utilitarians would agree that with the statistics we have, this situation is costing us utility.
Conclusion
Act utilitarianism, and utilitarianism in general, is an approach used in medicine to inform decision making. A staunch ACT utilitarian would say that we SHOULD stop the code, and a RULE utilitarian would perhaps even question when and who we do codes on at all as a principle. Although most people are not staunch normative Utilitarians in the strict sense, all healthcare practitioners find themselves thinking Utilitarian sometimes, especially in these scenarios. The question then is, is Utilitarianism correct? Are we using it only sometimes when we should always use it? Is our fear of its cold nature keeping us from producing that maximum good? Or does its pursuit of the overall “good” lose track of the patient along the way? Is it risky to pursue as a concept, or brave to embrace?
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.