During my 3rd year medical school intensive care unit (ICU) subinternship, I took care of a young man who had become a quadriplegic from a gunshot wound several years earlier. Because of an array of complex psychosocial and medical issues, he had required bilateral amputations to the hip and developed severe stage IV sacral ulcerations so deep that muscle and bones were exposed. He was admitted for overwhelming sepsis and his prognosis was grim. Multiple members of the team including me, the house staff, and the attending, explained to him his extremely poor prognosis and the fact that he would likely not survive resuscitation; however, it was unclear whether or not he had the capacity to make decisions, and, therefore, our attempts at a Do Not Resuscitate (DNR) order were stalled by difficulties in finding his next of kin.

Before we had time to confirm his resuscitation status, he had a cardiac arrest. Rather than stopping the resuscitation when it was clear he would not survive, seeing this as a perfect teaching opportunity, our attending encouraged the three interns to rotate leading a code that lasted well over an hour. Staring intently at their pocket cards, they slowly and thoroughly went through each step in the advanced cardiac life support (ACLS) algorithm. Although it was clear to all of us that the patient would never survive the resuscitation, his heart was tenacious. With every jolt of epinephrine, asystole would temporarily convert to ventricular fibrillation. During the relentless chest compressions I subjected him to, his sacral ulcers and rotting flesh became increasingly one with the hospital bed.

As a medical student, I was engrossed by the medical facts and did not think twice about the ethical issues surrounding this patient’s care. However, as my training progressed, I began to revisit this moment with growing disquiet. In an interview study I conducted at American academic medical centers regarding attitudes and beliefs surrounding resuscitation at the end of life,^{Footnote 1,Footnote 2} institutionalized rationalization of resuscitation that is highly unlikely to succeed as a potential learning opportunity for physician learners was not an uncommon theme. A physician described the self-interested aspect of medical learning as a justification for futile resuscitation for the sake of medical education:

An attending who frequently supervised residents similarly commented:

These “teachable moments” are at the core of the trainee learning experience. Patients are generally aware that a teaching hospital team is composed of trainees who use their admission as learning opportunities that are integral to their development into competent physicians. However, the line between teaching moments and situations in which informed consent and beneficence touch the boundary of ethical permissibility can be treacherously thin.

The American Medical Association (AMA) Code of Medical Ethics states that the “physician shall, while caring for a patient, regard responsibility to the patient as paramount.”^{Footnote 3} Teaching hospitals have an additional responsibility toward the education of health professionals; however, I believe that this should not be at the expense of the patient. In the preceding quotations, futile resuscitation was justified by some as an important teaching tool, as it gave trainees opportunities to practice.

However, this practice violates the principle of informed consent, as the patient agreed to resuscitation for the purpose of potentially prolonging life rather than as futile resuscitation as a teaching opportunity. Justifying futile resuscitation in order to practice normalizes deceptive and nonconsensual teaching cases in medical training. The lack of disclosure can cause false hope and emotional harm, if families believe that physicians are providing this care because it might actually help.

Fred Hafferty recognized the ethical tensions between training and patient care when describing the hidden curriculum, “The ethical dilemmas created by the structure of the educational experience itself, including…the requirement that students function in multiple—and often conflicting—roles (e.g. students simultaneously functioning as learners and as providers of care).”^{Footnote 4} Attending physicians are role models for moral conduct, within a broader cultural milieu that socializes trainees to internalize the ethical norms inherent in their particular institutional system.^{Footnote 5} Several articles published in this journal, including the Romanell Report on the essential role of medical ethics education in achieving professionalism, have emphasized the critical importance of recognizing the hidden curriculum in undermining professionalism, and a need to change the culture of medicine as a whole to promote ethical behavior in learners.^{Footnote 6,Footnote 7}

These teaching moments have been shown to affect professional behavior. In the case of futile resuscitation, one could argue that the patient is already dead and, therefore, would not experience suffering or pain. However, condoning these behaviors as ethically acceptable trains generations of physicians into believing that core ethical principles are relative and fluid to suit one’s purpose. This goes against the foundation of medical ethics, which is in part derived from Kantian ethics whereby, a person should “never merely [be treated] as a means to an end, but always at the same time as an end.”^{Footnote 8} Similarly, using a dying patient as a teaching moment is antithetical to many definitions of physician professionalism, which often include subordinating one’s needs to the interests of others.^{Footnote 9}

Studies have shown that medical students were ethically troubled by potential harms to patients caused by the educational process.^{Footnote 10} Other studies have shown that participating in ethically compromising activities promotes beliefs that are unethical. Students who practiced pelvic examinations on anesthetized patients without specific informed consent had a statistically significant decrease in their belief that informed consent was important.^{Footnote 11} Although teaching is necessarily a part of the medical student experience, the profession must be careful about the manner and extent to which we use futile resuscitation as a teaching strategy. Further studies should explore whether these situations may contribute to a loss of empathy by further depersonalizing patients as instruments of teaching rather than people who are about to die.^{Footnote 12}

The culture of medicine necessarily has a complicated relationship with dehumanization, which is a necessary first step in ethically justifying using patients for learning purposes. To a degree, dehumanization is crucial from the day medical students step into the anatomy laboratory and cut into their first body.^{Footnote 13} Moral distancing allows students to learn on bodies, turning the body from a human being into a practical learning tool. Recognition of the effect this has on physician humanism, many medical schools have instituted donor memorial ceremonies to remind students of their donor’s humanity.^{Footnote 14}

Medical training programs have a duty to foster not only skilled, knowledgeable physicians, but also humanistic physicians with a strong moral compass. The transition from cadavers to human patients provides key learning opportunities that can either counter or promote dehumanization. Using dead or dying patients as teaching material speaks volumes to the respect we believe our patients deserve and its subordinate position relative to medical education. Providing nonbeneficial and potentially harmful treatments for the sake of teachable moments may help train a competent physician, but are the effects of these experiences on the moral education of physicians worth it?