An ethical medical dilemma made the news this week, which was originally reported in the New England Journal of Medicine. It concerned an unconscious, inebriated patient brought into the University of Miami Hospital with a "Do Not Resuscitate" tattoo on his chest. The 70-year-old man had no identification, and the hospital could not find a next of kin, though the tattoo on his chest was signed, presumably with the man’s own signature.
What should the medics do? Did the tattoo represent a sane, living, up-to-date expression of the patient’s intent, or a joke – a variant of the "insert here" and "cut here" tattoos associated with youthful hi-jinks or an alcohol-fuelled night out?
Cautionary tales abound, Like the 59-year-old diabetic who went into hospital for an amputation, only to unveil a D.N.R. across his chest. He was questioned by the hospital staff: was that what he wanted? No. If necessary, he wanted the doctors to try to resuscitate him, at least for a reasonable time. The man dismissed suggestions the tattoo was confusing. He didn't think anyone would take it seriously.
For staff at the University of Miami Hospital, however, a conversation with the patient was not possible. He did not regain consciousness sufficiently for any discussion to take place. What the media coverage of this case failed to note, moreover, was that the patient was not just drunk, but in very bad physical shape. He had lived for some years with obstructive pulmonary disease, diabetes mellitus and atrial fibrillation.
Though the medical team initially decided to disregard the tattoo, they changed their minds and referred the question to an ethical advisor. Presumably, they took this decision on the basis of the man's general health. And because the medical team was impressed by what they called the 'patient’s extraordinary effort to make his presumed advance directive known'.
Why might the man have wished to be DNR? A DNR order expresses a patient's desire not to receive intubation or Cardiopulmonary resuscitation (CPR) in the event that the heart stops beating. This might seem counterintuitive, but resuscitation can cause numerous ill effects, from broken ribs and ruptured spleens to brain damage. In the case of elderly patients, and those with a serious health condition, the risks might outweigh the predicted quality of life.
However, DNR orders are emotive. This is why some areas of the United States and the United Kingdom use the term Do Not Attempt Resuscitation. Without ‘attempt’, there is an implicit suggestion that resuscitation would definitely succeed. That is an upsetting belief for the patient's family, when resuscitation is not attempted.
Unfortunately, most attempts at resuscitation in the emergency room are unsuccessful. Many doctors I have spoken to admit to attempting resuscitation when they know it is hopeless. This is because CPR is a crucial part of the spectacle of emergency care. Distraught families and friends of patients have seen CPR on medical programmes like ER, and they expect it to be carried out. They are unaware of the damage to the body that can occur, along with the limited likelihood of success.
DNRs are normally issued after discussion between the medical authorities and the patient and their family. The University of Miami Hospital staff would therefore have been in a particular dilemma. They had a moral duty to save the patient, except if he did not want them to do so. The legal issues were even more pressing.
Many countries have their own DNR rules. In Saudi Arabia, for instance, patients cannot legally sign a DNR; the decision to resuscitate rests with the physician. In the UK, it is possible to write a living will that predicts whether or not you would want a DNR order in particular circumstances. In the US, DNRs are dealt with differently by different states.
Most relevant here is that the Department of Health for Florida, which covers the University of Miami Hospital, states that a ‘Do Not Resuscitate Order (Form 1896)’ must be printed on yellow paper and signed by the patient and her or his physician. ‘EMS and medical personnel are only required to honor the form if it is printed on yellow paper.’
So, it is easy to understand the hesitation of the medics. There was no legal necessity for them to honour the tattoo, and they could not be certain that the tattoo represented genuine intent on the part of the patient. Yet the ethical advisors decided that the man had taken the time to communicate deliberately, and with forethought, to his caregivers. In respect of that, the writing on the patient's body was given the same moral and legal status as an official DNR statement.
That evening, the man died. The medical team was subsequently 'relieved' to find that there was paperwork to support the tattoo evidence in the patient's case records. They had made a choice, under difficult circumstances, and with all the available evidence. And it turned out to be the right one.
The usefulness of tattoos in conveying information about a person's health has been debated elsewhere. For there is growing trend, not only if tattoos in general, but also in people communicating existing health conditions, like diabetes. This reflects other historical usage of tattoos to communicate medical information. In World War 2, for instance, members of the SS similarly carried blood group tattoos on the underside of their left arms. This bears a terrible echo of the Nazi's tattooing prisoners of Auschwitz.
Tattooing the skin clearly provides an indelible signifier that cannot be lost, mislaid or overlooked, in the case of DNR paperwork or medic-alert bracelets. But there remains the question of intent and a change of heart. People do change their minds about being resuscitated. But they may not remove their tattoos in accordance with this re-evaluation.
I was struck by a number of other ethical and emotional issues when I read about this case. Firstly, the care and consideration exhibited by the medical team. They made an ethical decision to respect a tattoo despite the fact that this was against standard protocol. They recognised that the medical process was not always 'nimble enough to support patient-centred care'. And they wanted to ensure 'respect for patients' best interests', not just to protect the narrow limitations of the law and the hospital.
It was a brave decision, and presumably not an easy one, given the pressures on individual medics and teams working together against the clock. It was a decision that also reflected the care the patient had taken in signing the DNR statement, as though his body was a legal document.
I found that detail touching. Of course, the medical team and ethicists did not know for certain that it was the patient's authentic signature. And they must have decided the risk of litigation was reasonably low, balanced against the man's evident health and life expectancy. But the signing of the tattoo transforms what could have been a run-of-the-mill yet subversive challenge to mortality (akin to the tattooing of ‘Y’ incision autopsy scars perhaps) into something more political.
We don't talk about death enough in life. We leave important decisions about organ donation and resuscitation to others, which leaves time-pressed medical professionals and distressed families and friends, to determine what a person would have wanted, should the worst occur.
Yes, it's problematic to determine whether a tattoo can be taken as read. They have so many meanings, after all. But tattoos are also historically signs and tokens of resistance; commonly a way for people to stake their claim on their own bodies. They also take on meanings to others. At a time when our identities are increasingly commercialised and commodified, and when medicine in the UK is being privatised and seen not to care, a signed 'Do Not Resuscitate' tattoo takes on the quality of a political statement.
Transforming the body into text in place of verbal communication potentially shifts the power-balance of the physician-patient relationship. It allows the patient's otherwise silent body - unconscious or anaesthetised, speaking only through a series of objectively measured signs like the heartbeat – to retain an essence of subjectivity: Look at me, it shouts. I am here. Not just a disease, or a body, but a real person, deserving of care.
In that, the unknown man's tattoo is a statement for our time.