Carlos Bastarache: Screen-Shot-2017-12-01-at-7.50.33-AM.jpg

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First, do no harm. It’s the most fundamental rule of medicine. But it’s also, to many, a sore spot of debate. What constitutes “harm?” Should patients define it? And if a patient defines “harm” as letting them live, what’s a doctor’s ethical obligation? All of this has suddenly been thrown into the spotlight thanks to a man with a tattoo saying “Do Not Resuscitate” written clearly on his chest.

Inside the ethical dilemma, not just of the tattoo, but of the “Do Not Resuscitate” order.

You can, in fact, tell doctors not to bring you back in the ER: It’s called a “do not resuscitate” order, or DNR order, and any doctor can draft one. A patient is allowed to refuse treatment for any reason, as long as they are in their right mind and fully aware of the results of their decision. Patients ask for DNR orders usually because they’re terminal or otherwise extremely sick, and would prefer a natural death to the rather violent revival CPR offers.

But it gets tricky when the patient is unconscious: DNR orders are usually filed for people who have long medical histories and are usually rushed to the same hospital they’re getting regular treatment in. But if a patient is, say, on vacation, or their paperwork or life-alert bracelet is lost, then doctors may not be aware that a DNR order is on file; a 2000 study found that only 46% of doctors even understood why somebody would file a DNR in the first place. Also, they can be changed at any point, so there’s the issue of a traveling patient’s order reflecting their most up-to-date thoughts. And this is where the tattoo comes in.

Tattooing a DNR order across your chest isn’t a new idea: It’s been around for a while, as a 2012 discussion of the medical ethics surrounding DNR orders and tattooing them shows. But, as the authors point out in that discussion, a tattoo isn’t legally binding, and time is of the essence:

For a responsive patient, as in the story by Cooper and Aronowitz in this issue of JGIM,4 a tattoo should provoke a conversation about the patient’s goals, values, and preferences. For an unresponsive patient, a tattoo might provoke emergency providers to search for a legally binding document, such as a Physicians Order for Life Sustaining Treatment (POLST) or a locally sanctioned pre-hospital DNR order — if there is time. But in a cardiopulmonary arrest, in the absence of such official documentation, the responding emergency provider or clinician should proceed with attempted resuscitation.

It doesn’t help that doctors would rather avoid the conversation altogether: A 2011 look at DNR orders and why they’re so often lost or ignored found that doctors don’t want to talk about it until it’s too late. Doctors are so bad at this they can’t even effectively guess what their patients might want

Which sets off a perfect ethical storm: The New England Journal of Medicine lays out what happened: The patient was unconscious, nobody had any contact information or medical records, and once they got his shirt open, they found a tattoo stating “Do Not Resuscitate,” with a tattooed signature that was, presumably, the patient’s. The problems was that tattoo wasn’t legally binding; they didn’t even know if that was his signature. Was the tattoo forced on him? Did he get it while drunk? Did he get it and then change his mind, and just never get around to getting the tattoo removed? Or was this a notification of a standing order they just didn’t have? Keep in mind, this debate unfolded while the doctors had to figure out whether or not to let this man die, with nothing but some ink on his skin to go on. The hospital staff ultimately made the call to hold off on CPR while they called in ethics advisors and searched for his paperwork. Faced with the dilemma, the ethics team weighed the likelihood of all scenarios weighed against their scant info on the patient. Ultimately they decided to take the tattoo seriously and did not resuscitate him.

Moments later, they found the DNR order and the man’s wishes were respected. But stop and consider what the doctors were facing, here. They’ve sworn an oath to do no harm, and they were ethically obligated to let the patient decide what treatment he got. But they had no idea what “harm” meant, and had to work it out on the fly.

What this underscores is that for doctors to do no harm, we as patients need to define what that means for us. It’s an issue more complicated than can be summed up in a tattoo.