PERSPE C T I V E
ing (r = 0.30 for the proportion low-quality prescribing were even
taking high-risk drugs; r = 0.25
for the proportion taking drugs
with potentially harmful interac-
tions with their underlying dis-
eases [P<0.001 for both correla-
tions]) (see the Supplementary
Appendix). In other words, the
regions in which nondrug medi-
cal spending per beneficiary was
higher were also the regions in
which beneficiaries were more
likely to be given prescriptions
for potentially harmful or high-
risk drugs — a finding that does
not support the premise that
higher medical spending leads to
higher-quality prescription use.
Our measures were adjusted for
patients’ risk scores, but because
similar patients appear to be cod-
ed as sicker in high-spending
areas than in lower-spending
areas,4 we also examined the
correlation between the quality
measures and medical or drug
spending without adjusting for
patients’ risk scores. Analyzed in
this way, the correlations between
spending and the prevalence of
Up in the Air — Suspending Ethical Medical Practice
D. Malcolm Shaner, M.D.
First I will define what I conceive
medicine to be. In general terms, it
is to do away with the sufferings
of the sick, to lessen the violence of
their diseases, and to refuse to
treat those who are overmastered
by their disease, realizing that in
such cases medicine is powerless.
— The Hippocratic Corpus
O ur plane was flying from the
East Coast to the West carry-
ing 167 passengers, including my
Comment on wife, a hospitalist and
this article at internist, and me, a neu-
NEJM.org rologist and clinical eth-
1988
The New England Journal of Medicine
Downloaded from www.nejm.org by Alba Riesgo on November 21, 2010. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.
Geographic Variation in the Quality of Prescribing
events that may require addition-
stronger and more highly signifi-
cant than they were with risk
adjustment and thus are not an
artifact of risk-coding practices.
In sum, according to HEDIS
measures of potentially danger-
ous prescribing patterns, the qual-
ity of prescribing for the elderly
varies substantially among local
markets — substantially more,
in fact, than does spending on
drugs overall. Our results do not
support the theory that high-
spending areas simply use more
of everything, including inappro-
priate drugs, since the association
between overall drug spending
and inappropriate prescribing is
weak. In addition, because spend-
ing on nondrug medical care is
positively associated with a greater
use of potentially harmful drugs,
our results also do not suggest
that more medical spending is
associated with better health care
overall. Our results are consis-
tent, however, with an association
between lower-quality prescription
patterns and more adverse drug
icist. About midflight, a woman
in the row behind us reached
frantically for the baggage bin
over our heads. I offered to help.
She was trying to get her hus-
band’s oxygen tank.
I turned and saw that he
looked to be about 70 years old.
His eyes were closed, and his right
hand was clutching his chest as
he grimaced in pain. Immediate-
ly, his grimace faded and his
right arm dropped. Leaning over
my seat, I caught his hand and
felt for a pulse while my wife
checked for the radial pulse in his
n engl j med 363;21  nejm.org  november 18, 2010
al expense to treat.
Disclosure forms provided by the au-
thors are available with the full text of this
article at NEJM.org.
From the Department of Health Policy and
Management, Graduate School of Public
Health, University of Pittsburgh, Pittsburgh
(Y.Z.); the Department of Health Policy and
Management, Harvard School of Public
Health (K.B., J.P.N.), and the Department of
Health Care Policy, Harvard Medical School
(J.P.N.) — both in Boston; and the Harvard
Kennedy School of Government, Cam-
bridge, MA (J.P.N.).
This article (10.1056/NEJMp1010220) was
published on November 3, 2010, at NEJM
.org.
1. Zhang Y, Baicker K, Newhouse JP. Geo-
graphic variation in Medicare drug spend-
ing. N Engl J Med 2010;363:405-9.
2. The state of health care quality. Washing-
ton, DC: National Committee for Quality As-
surance, 2009. (http://www.ncqa.org/Portals/
0/Newsroom/SOHC/SOHC_2009.pdf.)
3. The Healthcare Effectiveness Data and
Information Set (HEDIS). Washington, DC:
National Committee for Quality Assurance,
2010. (http://www.ncqa.org/tabid/59/default
.aspx.)
4. Song Y, Skinner J, Bynum J, Sutherland J,
Wennberg JE, Fisher ES. Regional variations
in diagnostic practices. N Engl J Med 2010;
363:45-53. [Erratum, N Engl J Med 2010;363:
198.]
Copyright © 2010 Massachusetts Medical Society.
left arm. There was none. Two
flight attendants approached. “I
am a physician,” I said. “Let’s get
him down to the floor.”
We lifted him into the aisle. I
shined a pocket flashlight on the
dimly lit scene. He had stopped
breathing; his pulse was absent.
We tore open his shirt to reveal
a well-healed thoracotomy scar.
A flight attendant brought an
automated external defibrillator
(AED), an Ambu bag, and other
equipment. Three other passen-
gers — an oncologist, an anes-
thesiologist, and a surgeon —
PERSPECTIVE
joined us. My wife ran the code,
I provided chest compressions,
the anesthesiologist bagged the
patient, the oncologist managed
the equipment, and the surgeon
attempted venous cannulation and
then intracardiac injection of epi-
nephrine. We confirmed that there
was a femoral pulse only with
chest compressions.
We followed the protocol sug-
gested by the AED. The device
did not discharge, since its auto-
matic rhythm-detection program
had found no rhythm that might
be treated with defibrillation. The
monitor eventually showed a wide
complex bradycardia with which
we could not associate a palpa-
ble pulse.
Our resuscitative efforts were
taking place in full view of the
passengers and the man’s wife,
who stood beside us. Five previ-
ously rambunctious children were
now silent.
After 25 minutes of basic car-
diac life support, there was still
only pulseless electrical activity.
The five physicians agreed that
it was time to stop the code and
declare the patient dead. But the
flight attendant explained that if
we stopped CPR, the airline’s pro-
tocol would require the cabin crew
to continue it in our stead. “This
is futile,” muttered the surgeon,
and without discussion, he re-
turned to his seat, leaving four of
us facing a dilemma: If we turned
the resuscitative efforts over to the
crew, who would look after the
passengers? But if we continued
CPR, we would be treating a pa-
tient who had clearly been “over-
mastered” by his disease.
The proper practice of medi-
cine does not include treating ir-
n engl j med 363;21  nejm.org  november 18, 2010
The New England Journal of Medicine
Downloaded from www.nejm.org by Alba Riesgo on November 21, 2010. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.
Suspending Ethical Medical Practice
reversible disease when patients
are overcome by illness. This prin-
ciple holds true even when fam-
ily members request futile inter-
ventions or when physicians are
following a well-meaning proto-
col. To prolong CPR under the cir-
cumstances in which we found
ourselves would be to subvert
medicine’s goal from the good
of the patient to the benefit of
the community. Given this under-
standing, we could not consider
our actions to be within the
scope of the practice of medi-
cine; rather, as we continued ad-
ministering CPR, we were acting
less as physicians than as skilled
passengers assisting a flight crew.
The pilot announced that he
was diverting the plane to a small
airport. The crew calmed the
passengers, addressed their oth-
er needs, and attended to land-
ing preparations. As we descended
steeply, the pilot ordered every-
one to be seated. The anesthesi-
ologist and oncologist complied.
We were down to two physicians
administering CPR. A flight at-
tendant took over the use of the
Ambu bag and required coaching
on technique. I was instructed to
hold onto my wife as she contin-
ued chest compressions, both of
us half-strapped into stretched
safety belts to allow us to con-
tinue CPR during the landing.
We landed with a light bump,
then braked and taxied along the
6500-ft runway to a stop. The
resuscitative efforts had contin-
ued for some 35 to 40 minutes.
Firefighters and paramedics ar-
rived and carried the patient to
the door and down a fire-truck
ladder. He died that day, accord-
ing to news reports we later
found online. As it turned out,
he had also been a physician.
We had knowingly delivered
medically ineffective CPR. But we
did so because of practical con-
cerns arising from the demands
of the airline’s protocol. CPR was
going to go forward whatever we
decided, and we chose to contin-
ue it ourselves so that the four
flight attendants could attend to
their duties during an emergency
landing.
On solid ground, I believe that
medical policy and protocols
should preclude such dilemmas.
The responsibility for deciding to
stop CPR should rest with a phy-
sician who is focused solely on
the good of the patient. CPR
should be deemed ineffective
when it cannot be expected to
meaningfully alter the natural
course of the disease; it should
be deemed futile when it no lon-
ger serves the patient. We should
ensure that our medical policies
and protocols exclude consider-
ations such as mitigation of lia-
bility or the exclusive interests of
third parties from playing a role
in resuscitative decisions. Such
policies will help support the ef-
forts of physicians to act always
for the good of the patient and
within the bounds enunciated in
the Hippocratic Corpus.
The views expressed in this article are
those of the author and do not necessarily
reflect those of the institutions with which
he is affiliated.
Disclosure forms provided by the author
are available with the full text of this arti-
cle at NEJM.org.
From the Department of Neurology, Kaiser
Permanente Medical Care Program, West
Los Angeles Medical Center; and the Depart-
ment of Neurology, David Geffen School of
Medicine, UCLA — both in Los Angeles.
Copyright © 2010 Massachusetts Medical Society.
1989