Ethics Goes Beyond Self Interest!

By Robert W. Ninker, CAE
The most challenging situations are those in which we seemingly have to put our own best interests aside in order to adequately serve a grieving family. Their interests, and those of the community, need to take precedence. No, I don’t think those two sentences are either enlightened or inspired. The key word is “seemingly,” because, in the long run, the wishes of the well served family are always our best interests.

Organ and Tissue Donations

We have long known that organ donations, autopsies or body donations have been a challenge for both funeral directors and embalmers. Because an organ or tissue donation can delay release of a remains, and involve additional preparation of the body, professionals have to struggle to put a proper perspective on the way families are counseled.

On the one hand, a family is entitled to know that there may be a delay of a day or more. At the same time, unless you put the best construction on the importance of allowing the greater community to benefit from the availability of organs and tissue, other dying patients will be denied desperately needed replacements for their heart, kidneys, skin or long bones.

The sad thing is that you, as a professional, can turn a donation, desired by the deceased and the family, into a routine funeral without saying one word! That is right, and it happens everyday, somewhere, with or without the knowledge of the licensee. Your leadership is respected by families you serve, more than you can ever believe. Lacking any experience in such matters, a family will look to you for whatever guidance they seek, or which you choose to offer.

Purse your lips, raise an eyebrow or simply hesitate before responding to an inquiry and you send a positive or negative perception to the family. You are that powerful, friend. The esteem in which you are held, in these matters, causes those you serve to react based upon the message you are perceived to be sending.

Such control potential makes it essential that you respond in a wholesome, informative and positive way.

Why wouldn’t you do that automatically? You may very well, unknowingly, convey a negative message even when you are attempting to give judicious counsel. Should a family at a hospital call you after being asked to allow a donation of their son’s organs as a result of an auto death, they may want to know the implications.

If you say, “Typically, the funeral is delayed and sometimes the securing of the maximum organ and tissue also results in further delay and increased cost,” you’ve essentially been honest. But, have you been ethically fair? You can state the facts and close with encouragement by saying, “Mr. and Mrs. Jones, even with these minor inconveniences, you should do what you feel would be best for your own personal satisfaction and the good that can come from your decision. I’ll handle the details, just let me know what you decide.”

You may be thinking that’s so much Pollyanna and that you are a funeral director and embalmer who cares for the dead and you know how some of the physicians, in their rush, don’t leave sufficient arteries so you can do your work effectively. That is true and calls for an educational process with regional organ banks, Red Cross and others. But, it doesn’t give you ethical license to indirectly deny a family or community the benefit of life extending organs or tissue.

Autopsy is Different, Though!

Yes, your influencing of an autopsy is a lot easier to achieve because you might not have the same level of guilt about informing a family that the autopsy will cause a delay, will cost more and, besides that, they should know the facts. It is “disclosure,” isn’t it, to say, “We know the hospital said it is just a small necessary incision but you should know what really takes place,” as you let your finger mark a large X across your chest.

At what point does a licensee cross the threshold of his or her ethical responsibility to balance fact versus the possible positive benefit of furthering medicine in the search for increased knowledge on how to prolong life by understanding what causes deaths? Ethically, you cross the bounds when you inject opinion, or fact, that has the effect of discouraging a family from authorizing an autopsy.

If you have read this far and we haven’t hurt your feelings or disturbed your conscience, congratulations. On the other hand, if you are thinking it’s easy for someone to be highfalutin ethical when they don’t have to deal with the arrogance or ineptness of a pathologist who ignores his responsibility to contain invasion of the scalp or other areas which will inhibit the proper presentation of the deceased for funeral visitation purposes.

Every funeral director has a war story about an ear being lacerated through pathologist carelessness and other more insensitive actions. However, that is a professional education problem and not justification for referring to pathologists as “butchers” as some have done in discussing autopsy decisions with a family.

The FUNERAL ETHICS ASSOCIATION’s manual of professional practices addresses the ethical issue with this policy:

Attitude Toward Autopsy

Post-mortem examination of the human body is an essential tool in the advancement of medical knowledge. Unwarranted discouragement of autopsy by funeral directors is to be considered unprofessional.

It is true that the performance of autopsies will frequently cause delay and inconvenience to the family and to the funeral director. Nevertheless, these difficulties can be minimized through cooperation between funeral directors and pathologists in understanding each others problems.

Questions relating to autopsy should be referred to the family physician, pathologist, coroner or medical examiner.

As Executive Director of the FUNERAL ETHICS ASSOCIATION, without a funeral director or embalmer’s license, where do I get the temerity to imply that funeral licensees may not be acting ethically? The answer is, from a professionally conducted survey of Illinois funeral directors, printed in the Archives of Pathology and Laboratory Medicine by Paul S. Heckerling, M.D. and Melissa Johnson Williams, LFD, LE, in November, 1992. It revealed that “Although 80.3% believed that autopsy served a useful purpose, 46.4% had counseled families not to permit autopsy, and 16.6% did so more than half the time.

The article offers a detailed, analytical presentation of the reasons why funeral directors and particularly embalmers act in that way. For a copy, you may write to the FUNERAL ETHICS ASSOCIATION. The report is exceptionally enlightening.

As a follow-up to the published article, co-author Melissa Johnson Williams was asked if the article could be reproduced. In the discussion, she also confirmed that a number of medical journal articles have been published which accuse funeral directors or embalmers of being partly responsible for the decline in the percentage of autopsies which are being performed. That is a sad commentary we should reverse.

The fact is, until we as a profession can get beyond self-interest, animosity toward pathologists and personal bias, we lose respect as professionals.

As a way of encouraging each licensee to address autopsies professionally, following is the joint recommendation of the College of American Pathologists and the National Funeral Directors Association:

1. Encourage the performance of arterial embalming prior to autopsy except in those cases in which microbiological or toxicological studies are indicated.
2. Reduce procedural delays in an effort to minimize the time interval from death to release of the remains, preferably to a period of four to six hours.
3. Suggest and encourage the use of autopsy techniques which will eliminate technical difficulties for the embalmer.
4. Establish a joint CAP (College of American Pathologists)-NFDA Educational Program.
5. Seek legal permission for pathologists to sign death certificates following the completion of an autopsy.
6. Encourage the adoption of a simplified, non-technical autopsy consent form.
7. Encourage both professions to cooperate with and promote organ donor programs.

Perhaps it is time for the National Funeral Directors Association and others to assemble joint meetings of pathologists, organ banks and eye donor organizations for a candid, open dialogue on how licensees can act professionally and ethically in cooperation with physicians and pathologists. It is a two way street, friends.

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