Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a hospital morgue should inform the family of a deceased patient about a corpse mix-up.
Yes: 78%
No: 22%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Corpses are sent to the wrong families frequently -- at least if one believes the media hype. For sensationalism, what can beat headlines like the Sacramento Bee's "Baby's corpse mistakenly buried with twins?" While assessing the actual incidence of such mix-ups is almost impossible, since many likely go undiscovered, the reactions of survivors generally reflect varying degrees of outrage.
A lawyer for the family of Billie Sue Smith of Tennessee, who was inadvertently buried in the grave of a man named John Hughes, summed up these frustrations as follows: "You know the adage, 'May she rest in peace?' Well, there's no peace here. To know you have ashes of the remains of a loved one that may not be their ashes? To visit the grave of a loved one and the loved one may not be in that grave? There's no peace."
The harm done in these cases is generally considered to be psychological, rather than economically or physically tangible. Followers of some religious traditions may believe otherwise, however, if they relate the fate of a corpse to their loved one's future in the afterlife. Yet widespread social customs relating to respect for the dead suggest that most victims of such a mishap will experience distress.
"Therapeutic privilege" refers to the process of withholding information from a patient or patient's family member because sharing the information is either medically contraindicated or would cause the patient great harm with no benefit. It is an example of medical paternalism, once the dominant principle in medical practice. Over the past half-century, Western medicine has rejected such paternalism as the default standard in healthcare in favor of patient autonomy. Yet there may be extreme cases in which withholding information -- at least for a period of time -- would prove justified.
Examples might include not informing an accident victim of the extent of his or her injuries for a few hours until appropriate family support can be obtained, or withholding a diagnosis that might put a severely depressed patient at risk of suicide. The American Medical Association looks highly unfavorably upon the practice, barring extraordinary circumstances. Their Code of Medical Ethics states, "Withholding medical information from patients without their knowledge or consent is ethically unacceptable."
In theory, the tragic mistake in Scarpetta's lab might justify withholding information from Bud's and Jed's families as an extension of the therapeutic privilege principle on the grounds that the revelation would likely cause considerable psychological damage and would be unlikely to provide any benefit. If the mistake were truly undiscoverable in the future and psychological distress probable, utilitarian ethicists would argue against disclosure on the grounds that it would do more harm than good.
One should note the difference in this case from one in which babies are mistakenly exchanged at birth and the mishap is later discovered. In that situation, withholding the error has considerable practical effects on the victims. They will not know their correct medical histories and may fail to connect with their "adoptive" families.
In contrast, no practical harm results from visiting the wrong grave. All the tangible damage in the case of Bud and Jed -- such as the cremation and embalming, which have undermined the late men's wishes -- has already been done.
Yet juries are likely to compensate families for the distress caused by such lapses. That may prove to be the most concrete benefit of disclosure at a societal level: if the hospital is forced to compensate the families in this case, Scarpetta will take considerably greater care in the future when allocating work while away. In the long run, such settlements may serve as powerful deterrents, reducing the likelihood of additional morgue mishaps.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Should Doc Illegally Assist Suicide in Dire Circumstance?