Three Cheers for the DNR Tattoo

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Tom Tomlinson, PhD

A Letter to the Editor published at the end of November in The New England Journal of Medicine excited a lot of comment and mass media coverage. The letter by Holt and colleagues, “An Unconscious Patient with a DNR Tattoo,” made the news throughout the U.S., and internationally.

This was treated as an unusual oddity, but DNR tattoos are a lot more common than one might think. Try searching for images of them. The first I heard of them was a news report in the late ’80s of an ICU nurse who had one done, to guard against a fate that had befallen too many of her patients.

DNR tattoos in Google image search results

Image description: a screen shot of Google image search results for “DNR OR “do not resuscitate” “tattoo”” captured January 9, 2018.

Acting on the advice of their ethics consultants, the University of Miami physicians decided to honor the tattoo and wrote a DNR order for the patient, but in the article they studiously avoided taking any position for or against DNR tattoos.

I think they were right to honor the tattoo, but maybe more timid than they needed to be on the general question. I’ll put up three cheers for DNR tattoos.

First, once I’ve got that tattoo, my advance directive goes wherever I go, always there when I need it. Unlike written directives, which are virtually never found in the ER, too seldom presented on admission, and often devilishly hard to get into the medical record for those patients who purportedly have one.

Second, unlike state-authorized advance directives, the DNR tattoo does not require anyone to witness my signature as evidence that the wishes expressed therein were indeed mine. Unless you imagine I was somehow unconscious or blind drunk when I got my tattoo, the wishes expressed thereupon are undoubtedly mine. And getting a witness for a state-authorized advance directive can be more difficult than it sounds, with all the people prohibited from serving under many statutes. Still, for the legally scrupulous among you with high pain tolerance, it may still be possible to have your DNR tattoo witnessed.

Third, “do-not-resuscitate” on the chest is no more ambiguous a directive than “do-not-resuscitate” in a written document. Neither of them provides a clue regarding the motivation for that instruction. What circumstances did the person have in mind at the time? What fate did they hope to avoid? Is the medical situation they are now in similar enough to what they had in mind? These may have been the “uncertainties” the University of Miami team had in mind when they initially decided not to honor the tattoo, deferring to “the principle of not choosing an irreversible path when faced with uncertainty.”

As I’ve just pointed out, these are not uncertainties unique to tattooed advance directives. Just as importantly, these are uncertainties that can be resolved by two factors that can tip the balance in favor of honoring the tattoo. First is knowledge of the circumstances in which the patient got the tattoo. Was it sometime during the course of a progressive, worsening illness? Then it is entirely reasonable to infer that the patient did not want to be resuscitated from the cardiac arrest waiting at the end of that decline. Second (and related) is prognosis. Given the severity of the patient’s condition, what are the chances of a successful resuscitation that at least might return them to their pre-admission baseline? If the chances are small, then consideration of their best interest does not carry enough weight to justify acting against the literal meaning of their tattoo. A little reading between the lines suggests that this combination of considerations is what persuaded the team at the University of Miami to honor their patient’s tattoo, just as it would have had the same directive been documented on paper.

Of course, there are some advantages to the paper version, and it would be irresponsible for me not to mention them.

First, unless I’m willing to tattoo a lot of skin, the paper version gives me the space I might use to elaborate on my preferences, not only about specific interventions, but more importantly about my goals, especially those outcomes I want to avoid.

Second, since the tattoo probably won’t meet the requirements as to form set under state statutes, it is an advance directive that won’t offer the liability immunities such statutes provide. Not an ethical objection, I note, but a powerful motivator for risk management departments to be more skittish than they need to be in most circumstances, making it less likely that my wishes will be honored.

Finally, a not inconsiderable factor favoring the paper version is the significantly lower risk of getting a nasty infection.

Looks like a virtual tie on paper, but on balance, I’m not about to toss out my paper advance directive for a tattoo. If I see one as an ethics consultant, however, I will give it very serious consideration.

Tom Tomlinson photoTom Tomlinson, PhD, is Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Tuesday, January 23, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

Click through to view references

Posted in Bioethics in the News, Uncategorized | Tagged , , , , , , , | 2 Comments

February webinar to address Michigan’s vaccine waiver education policy

bbag-blog-image-logoWhat’s the point of Michigan’s vaccine waiver education requirement?

Event Flyer

Since 2015, Michigan parents have had to attend education sessions at public health offices if they want their unvaccinated or under-vaccinated children to attend school or daycare. This policy seems to have succeeded: the state’s nonmedical exemption rate declined by 35% from 2014 to 2015. But what explains this apparent success? Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions? Also, does vaccine education promote additional public health goals, i.e. other than short-term vaccination compliance? This presentation will attempt to answer these questions by drawing on immunization records, interviews with public health staff, and surveys of health department leaders, with the goal of informing arguments about the value of Michigan’s vaccine waiver education policy.

Feb 15 date iconJoin us for Dr. Navin’s lecture on Wednesday, February 14, 2018 from noon till 1 pm in person or online.

Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University. His recent work is primarily in bioethics and public health ethics. His book, Values and Vaccine Refusal, was published by Routledge in 2015.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

Posted in Bioethics Events, Brownbag & Webinar Series, Center News, Outreach, Uncategorized | Tagged , , , , , , , , ,

Announcing the Spring 2018 Bioethics Brownbag & Webinar Series

green brownbag and webinar iconThis year’s Bioethics Brownbag & Webinar Series resumes in February. You are invited to join us in person or watch live online from anywhere in the world. Information about the spring series is listed below. Please visit our website for more details, including the full description and speaker bio for each event.

Spring 2018 Series Flyer

Feb 15 date iconWhat’s the point of Michigan’s vaccine waiver education requirement?
Are parents changing their minds as a result of mandatory vaccine education, or are they choosing to vaccinate rather than be inconvenienced by education sessions?
Wednesday, February 14, 2018
Mark Navin, PhD, is an Associate Professor of Philosophy at Oakland University.

March 14 calendar iconPain But No Gain: Pain as a Problematic and Useless Concept?
Do references to pain help us with anything, or should we perhaps abandon pain as a “useless concept?”
Wednesday, March 14, 2018
Marleen Eijkholt, JD, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Obstetrics, Gynecology and Reproductive Biology in the Michigan State University College of Human Medicine, and Clinical Ethics Consultant at Spectrum Health System.

April 11 calendar iconEthical Issues Related to Fundraising from Grateful Patients
How should the process of philanthropic development be structured in order to demonstrate respect for all persons involved?
Wednesday, April 11, 2018
Reshma Jagsi, MD, DPhil, is Professor and Deputy Chair in the Department of Radiation Oncology, and Director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan Medical School.

In person: These lectures will take place in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

Posted in Bioethics Events, Brownbag & Webinar Series, Center News, Outreach, Uncategorized | Tagged , , , , , , , , , ,

Episode 5: Public Perception of Psychiatric Interventions

No Easy Answers in Bioethics logoEpisode 5 of No Easy Answers in Bioethics is now available! This episode features guests Dr. Laura Cabrera, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine, Dr. Robyn Bluhm, Associate Professor in the Philosophy Department and Lyman Briggs College, and undergraduate research assistant Rachel McKenzie. Together at Michigan State University they have collaborated on research regarding psychiatric interventions, including pharmacological interventions as well as neurosurgery, like deep brain stimulation. In this episode they share some highlights from their internally-funded Science and Society at State project, which focused on the public perceptions of such psychiatric interventions.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Posted in Center News, Outreach, Podcasts, Uncategorized | Tagged , , , , , , , , , , ,

Dr. Fleck co-authors ICU article in new ‘Cambridge Quarterly of Healthcare Ethics’

Leonard Fleck photoCenter Professor Dr. Leonard Fleck has a new article in the January 2018 issue of Cambridge Quarterly of Healthcare Ethics. The article, “First Come, First Served in the Intensive Care Unit: Always?,” was written by Dr. Fleck and Timothy F. Murphy.

Abstract: Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.

The full text is available online through Cambridge University Press (MSU Library or other institutional access may be required to view this article).

Posted in Articles, Publications, Uncategorized | Tagged , , , , , , ,

Dr. Eijkholt and co-authors published in ‘Narrative Inquiry in Bioethics’ winter issue

Marleen Eijkholt photoCenter Assistant Professor Dr. Marleen Eijkholt has a new article in the Winter 2017 issue of Narrative Inquiry in Bioethics. Authored by Dr. Eijkholt, Jane Jankowski, and Marilyn Fisher, the article is titled “Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online.”

Abstract: Social media sites and their relationship to health care is a subject of intense debate. Common discussions regarding social media address patient privacy, or e-professionalism. This case study explores the tensions that arise for health care providers when negative patient statements surface in social media and blog forums. Recognizing that patients and families often find relief in sharing personal illness narratives, we contemplate if, and how, individual health care professionals and institutions should address complaints aired in public, unmoderated media. Our discussion begins by presenting a case of a family blogging on the Internet to share grievances (to deidentify the case, we have changed some details). Next, we offer an exploration of the impact on health care delivery when professionals become aware of specific criticisms published online. Strategies for managing electronic criticisms are then proposed. We conclude by proposing a novel E-THICS approach to address negative patient expressions via electronic word of mouth (eWOM). Our examination of this evolving issue focuses on maintaining satisfactory relationships between health care providers and patients/families when dealing with health care narratives published in open online media.

The full text is available online through Project MUSE/Johns Hopkins University Press (MSU Library or other institutional access may be required to view this article).

Posted in Articles, Publications, Uncategorized | Tagged , , , , , , ,

Episode 4: Comparing Chinese and American Bioethics

No Easy Answers in Bioethics logoEpisode 4 of No Easy Answers in Bioethics is now available! This episode features guests Dr. Guobin Cheng, Adjunct Associate Professor with the Center for Ethics and Associate Professor at Southeast University in China, and Center Director and Professor Dr. Tom Tomlinson. Freshly back in East Lansing from the annual meeting of the American Society for Bioethics and Humanities (ASBH) held in Kansas City, Missouri, they sat down together to discuss differences and similarities observed in American and Chinese bioethics. Based in part on work they presented at the ASBH meeting, they discuss specific case examples as they relate to patient autonomy, family and individual identity, and the patient’s right to know or right not to know diagnosis and prognosis.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics—clinical ethics, evidence-based medicine, health policy, medical education, neuroethics, shared decision-making, and more. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

Posted in Center News, Outreach, Podcasts, Uncategorized | Tagged , , , , , , , , , ,