Is it ever right to practice on the dying?

Early in 1998 a student approached Lauris C. Kaldjian, M.D., HS ’91, with a question about something disturbing seen on the wards. The student, said Kaldjian, wondered if it was ethical to use a dying patient to practice inserting a femoral-vein catheter, even though the procedure offered no therapeutic value. “There was enough of a concern to do a proper study of the question,” said Kaldjian, a clinical instructor in medicine who co-directs a program on ethics for hospital residents and is pursuing a doctorate in ethics at Yale’s Department of Religious Studies. In the fall of 1998 Kaldjian surveyed 234 residents at three training programs encompassing five hospitals in Connecticut. “I was surprised that as many as a third of the respondents thought it was appropriate to use one patient for the sake of other patients,” he said. “The important thing to remember is that the people who believe this is OK are doing this for noble reasons. The question is, ‘Can one have good motivations and still be doing something that is inappropriate?’”

In a paper published in the Dec. 30 issue of The New England Journal of Medicine, Kaldjian reported that 34 percent of respondents believe it is sometimes appropriate to insert femoral-vein catheters for practice during cardiopulmonary resuscitation, 26 percent had observed such insertions and 16 percent had attempted the procedure themselves. “We don’t see any reason to doubt that results would be different elsewhere,” Kaldjian said. The dilemma, he says, is to reconcile the needs of the patient with the larger need of society to have well-trained doctors. “I would argue that, as a clinician, my first responsibility is to the patient who is immediately in front of me. We cannot use one patient to serve other patients,” he said, noting that there are alternatives to this way of training. “You learn to do this procedure on people who have to have it done.”