This Editorial View accompanies the following article: Van Norman GA: A matter of life and death: What every anesthesiologist should know about the medical, legal, and ethical aspects of declaring brain death. Anesthesiology 1999; 91:275–87.

THE practice of medicine is based on a number of ethical rules and guidelines. Many of us accepted the oaths of Hippocrates, Maimonides, or others at medical school graduation. The American Society of Anesthesiologists has adopted and published ethical guidelines, as has the American Medical Association. Within our communities we have rules based on social customs, government laws, hospital policies, and even the directives of the various organizations that pay our patients' bills. Thus, it would seem that the ethical bases of our clinical practice are founded heavily on the rules derived from these many segments of our society. However, although rules may make up an important, even predominant, component of our ethical system, it is clear that there is more involved in what we view as ethical practice.

In this issue of Anesthesiology, Van Norman writes about the application and appropriateness of brain death criteria. [1] This informative and intelligent review begins with three potentially horrifying cases in which anesthesiologists found themselves dealing with the transplantation of organs from allegedly dead (in the "brain dead" sense) patients, who were not, by standard criteria, in fact dead! Although one of these cases (case #3) seems to have been a preventable medical error, two of these cases seem to reflect the deliberate glossing over of medical findings so as to declare a patient dead who did not meet the accepted criteria. Can we understand, or explain, or perhaps even accept what those referring physicians who violated the accepted criteria for death were doing?

Much of the ethical bases of our practice are structured on principles wider than the sets of rules we have all come to accept. In part, surely, we recognize the primary of our ethical rules, but as physicians we also respond to multiple ethical criteria, some of which may be inconsistent or even in direct conflict with one another. Van Norman has given us an explication of the very popular "autonomy, beneficence, justice" trichotomous view of medical ethics. This view, as fashionable and as methodologically useful as it might be, is an incomplete analysis of the ethical problem. First, though, note that it is not based on any explicit code or set of laws. We derive the "autonomy, beneficence, justice" view from principles deeply embedded in our western culture. These implicit laws can be traced back to our Judeo-Christian culture and the philosophical system of Immanuel Kant [2] and the Enlightenment period of European culture. Philosophers refer to an ethical system based on laws, whether explicit or subtle, as a deontological system. The "autonomy, beneficence, justice" system is implicitly derived from this deontological approach.

Much of what we do in medical practice, if observed by a naive visitor from Mars, would seem to violate any reasonable guideline for behavior. We take our patients and embarrass them with questions, invade their privacy, poison them with toxic agents, cause great pain, render them insensate, even cut them open and discard or rearrange the internal parts. Here we see another ethical system coming into action. Often described as "the ends justify the means," we observe an ethic wherein the consequences determine the morality of the action. This is termed a consequentialist system, because it is the intended consequences of our actions that have important moral weight.

In medical practice in the real world, all of the aforementioned ethical principles are in action at once. In most of our daily practice, when we say that there is no ethical conflict, we mean that the principles are all in agreement. When we find an ethical problem, often we have a situation in which some of our principles are conflicting with others, principles that we would accept individually but that are inconsistent in combination. Furthermore, few of us even pretend to live our lives as philosophers-the simpler human emotions of sympathy and empathy are often part of our most profound sensibilities.

Perhaps these principles can explain what the doctors described in Van Norman's article were doing when they were breaking the rules about brain death. The conventional criteria that define brain death are not obscure; therefore, it is doubtful that the practitioners who falsely declared the patients dead were unaware. It would be unreasonable to view these two cases as simple errors and unwarranted to view them as intentionally criminal. What must have happened is that the bending of the clear rules was regarded as justifiable because of a consequentialist argument: "the ends justify the means," "no one is really hurt and lives might be saved," or "if this were my family I would want a dying and nearly dead person to be used to save a salvageable life." Here we see a direct conflict between the rules and the consequences in which physicians, imbued with a consequentialist ethic, followed a path that may break the rules but may save a life.

Obviously, the implications of these cases are more complicated than a simple consequentialist argument can resolve. Analyses of these complications may also differ because each individual has his or her own accepted moral standard. Some people may view an approach based solely on rules as complete and incontrovertible. This view is not very open to argument and is often justified by reference to religion. Within such a rule-based argument, there is no moral defense for the actions reported by Van Norman. Others of us may have scant sympathy for the outcome, may recognize the personal legal risk such rule-breaking might expose, and may avoid the act as unwise, but without significant moral overtones. Even a consequentialist might not accept the rule-breaking here as wise. For if it became known that the safeguards regarding brain death and transplantation were not inviolate, them other patients and families would avoid consenting to organ donation. So for the consequentialist concerned primarily with the long-term ends, the untoward consequence of fewer organs overall, which would affect many patients, would outweigh any benefit to the few recipients of the organs taken by violating the rules.

The cases described by Van Norman defied the accepted rules, could have bad societal consequences, and violated our medical traditions. To me that means that those actions were unethical. Yet I suspect that we all have some bit of sympathy for an outcome wherein no one is hurt and a life is saved. It may be that only by recognizing the conflict among rules, consequences, empathy, and tradition can we understand how to apply the principles of autonomy, beneficence, and justice so carefully presented by Van Norman.

Stanley H. Rosenbaum, M.D.

Professor of Anesthesiology, Medicine, and Surgery; Yale University School of Medicine; New Haven, Connecticut

Van Norman GA: A matter of life and death: What every anesthesiologist should know about the medical, legal, and ethical aspects of declaring brain death. Anesthesiology 1999; 91:275-87
Kant I: Groundwork of the Metaphysics of Morals. Translated and edited by Gregor M. Cambridge, Cambridge University Press, 1997 (original German publication, 1785)