“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 ninth 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 Deontologist. In each sister article released this edition, I will also approach it as a Utilitarian, and a Virtue Ethicist.
Deontology
A brief reminder, deontology is the ethical concept that we have duties to rational beings that we must honor, regardless of the outcomes. Unlike utilitarianism, people are a means in and of themselves, NOT ends, as they are rational agents. The possession of this capability earns them such treatment even if they are not capable of reason at this moment (e.g. dead during a code). As we have discussed in my prior paper on this concept, there are subtypes (e.g. Agent vs. Duty),1 so for this paper we will be Kantian duty-based deontologists. When considering this scenario, we must ask ourselves if we are treating the patient, the family, our team, and ourselves as means, or an end. And we must make sure we are fulfilling our duties to them, without consideration of the consequences of those actions.
Applying It All
As we (the deontologist) 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 continuing to do CPR respecting them as a rational-being? While at first it would seem giving up on them fails our duty, we might actually be going too far in the other direction. As we continue to code them we might try to force them back alive, simply for the sake of being alive. But that is an end, which is not what we want to treat them solely as. What matters here is our why. Why are we still going? Is it to return this person as a rational agent, or just simply to “bring them back” because that’s what we do. Although Kantians don’t care about outcome statistics the way most people do, stats can inform us if our why is still plausibly directed toward restoring rational agency. At this point in our code, survival to hospital discharge is 6%, which is not insignificant. Further, 3% will have favorable neurological outcomes.2 We could still return this patient to their existence as a rational being, and therefore we should continue to code them until statistics tell us that our intent is not rationally coherent with returning this patient to their rational-being state. This could be because of another problem that arises, or simple “length of code” statistics (e.g. 0% neurological recovery). Continuing CPR at that point would now violate the patient’s dignity, as we are bringing them back simply to achieve the goal of bringing them back (they are now a means to an end).
Should we consider our staff and the family, too? While we do have a duty to them as well, the patient is whose body is being acted upon, so they take the primary focus in this analysis.
Objections
People will object with our stance, or at least our reasoning.
What if they come back with a poor quality of life? What if continuing causes resource waste and therefore other patients can’t be helped. At what percentage of likelihood of survival would we say we are no longer coherent in our intent?
They may come back with a life deemed of poor quality, but are they a rational-being again? If yes, I think that is what matters to us. Poor quality of life doesn’t invalidate their dignity if rational agency remains. We have a duty to return them to that state out of respect for them. If they come back but are simply in a coma, the vent can be turned off later, when we determine keeping them on it is not serving the person as a rational agent. Just because we tried to restore them and failed doesn’t mean we shouldn’t have tried. Resource waste and not helping other patients is not our concern at this very moment, patients are not a line-item. We are in a code, and our patient is being acted upon, so we analyze our duty to them right now. When should we stop? Data that shows that at 32 minutes neurological recovery approaches 0%.2 At this point, as discussed above, they move from an end to a means. Therefore, we would stop before 32 minutes if the scenarios were the same. However, certain codes have certain characteristics that affect outcomes, such as shockable vs. non-shockable rhythms, and in the cited study you can see the survival curve variances. We would use the data pertaining to each case to let us know if we are pursuing the right goal and that is coherent with respecting them as a rational-being. Deontology in this scenario is a case-by-case analysis, so one could never answer with “I will always stop at X time.” Rather, our maxim would be “I will continue CPR to restore this person as a rational agent,” with data informing us if we are holding true to this maxim. In this scenario, this informs us that we should tell our attending to keep going.
Caveat
Now, there is a good chance another deontologist would argue why the code should be stopped to respect the patient. Perhaps they think waiting until the percentage of returning neurological function is nearly 0% is too extreme and still violates dignity. Even among these normative theories, there is argument on the best way to interpret and use them. However, the idea of focusing on the rational-agent, and not the outcome, remains the same.
Conclusion
Deontology, specifically Kantian deontology, is concerned with how we treat rational beings and if we respect them as such. Kant’s Formula of Humanity states: Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end. In medicine, we do this a lot, but we turn it off when it is convenient. We consider resources, outcomes, and other ends that fail the formula. The question is, is that ok? Is deontology too strict? Would it fail our other patients? Would it fail the system? Or perhaps, thinking of it as failing the system misunderstands our duty to one another in the first place?
References
- https://plato.stanford.edu/entries/ethics-deontological/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC10847985/
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.