Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 22/04/2025
This article have been viewed 1540 times
Keith H. Berge, MD
Medical practice is a complex undertaking, fraught with ambiguity and uncertainty. A clinician is often forced to choose between alternate courses of action when there is little in the way of guidance for his or her actions. How, then, is a decision to be reached in the face of such ambiguity, especially if the decision creates a moral conflict for the physician? Although medical ethics focus on the “oughts” and “shoulds” of patient care, the study of medical ethics will usually fail to reveal a single “right” course of action. However, clarification of the relevant issues of the case at hand will often allow a decision to be reached in a manner that is not capricious or based on a visceral reaction to the clinical facts.
Medical ethics have been an integral part of the practice of medicine for ages. Perhaps the most famous code of ethics is the Oath of Hippocrates, which states many of the principles that still guide the modern-day physician. As modern medical practice has evolved, many ethical dilemmas have become manifest as a result of advances in technology. This has forced a rapid evolution in medical ethics from the relatively simplistic codes that have guided the “virtuous” physician for centuries. Hand in hand with this evolution has been an evolution in the laws regarding a vast array of complex biomedical issues, such as assisted suicide and euthanasia, abortion, surrogate motherhood, genetic testing of minors, withdrawal of artificial nutrition and hydration, and allocation of scarce resources. No broad consensus exists on most of these topics, reflecting the wide range of values within our pluralistic society.
The principles of autonomy, beneficence, nonmaleficence, and justice, expounded on at length by Beauchamp and Childress, are cornerstones of current ethical writings.
Autonomy is derived from the Greek root words autos (self) and nomos (rule, governance, or law). The autonomous person retains personal rule of the self while remaining free from both controlling interferences by others and personal limitations, such as coercion or inadequate understanding, that prevent meaningful choice. For example, courts and medical ethicists have long agreed that any patient with the capacity to understand the consequences of her or his actions has the right to reject any medical care, even “lifesaving” care, for herself or himself.
Beneficence is an obligation to help others further their important and legitimate interests. This requires the removal of harm as well as the provision of benefit and an effort to balance the benefits and harms of alternate plans of action so as to maximize the benefit. An example of this is the obligation for a physician to render emergency assistance when necessary.
Nonmaleficence is an obligation not to inflict evil or harm on others. It is clearly associated with the maxim primum non nocere, “above all, do no harm.” The Hippocratic Oath addresses the duty to both nonmaleficence and beneficence with the statement, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”
Justice is giving to each his or her due. This principle has been focused in medical ethics to address just distribution of medical resources. In other words, what characteristics, if any, give one person or group of persons an entitlement to more health care opportunities than others? The principle of justice lies at the very heart of the debate regarding health care reform. That is, if it is now necessary to do less than everything for some people, on what basis do we choose who gets less and how much does each of us “deserve”?
There is no societal consensus on the hierarchical ordering of these principles, but altering the priority of the principles can lead to dramatically different, and yet equally “ethical,” solutions to an ethical dilemma. As such, only a naïve person will look to these principles for absolute answers to an ethical dilemma. How, then, is one to bring any order from such seeming chaos? Common sense and an orderly approach are required.
As proposed by Jonsen and associates and outlined only briefly here, an ethical dilemma can be approached in much the same way as a routine patient history. The familiar chief complaint, history of the present illness, past medical history, and review of systems are replaced with analogous historical features. Ethical features in a clinical case include (1) medical indications (risk:benefit), (2) patient preferences, (3) quality of life, and (4) the contextual features surrounding the case, such as social, economic, legal, and administrative features. Most difficult and ambiguous patient care situations become easier to manage once these issues have been clarified.
Most of the common ethical dilemmas encountered by the anesthesiologist in the operating room or intensive care unit are primarily questions about the limits of patient autonomy. An example of such a dilemma is the patient who is a Jehovah’s Witness and who refuses a potentially lifesaving blood transfusion despite full disclosure of the risks and benefits of this decision. Another example would be the patient who demands to retain a do-not-resuscitate status throughout the perioperative period. Excellent reviews of these two topics can be found in the recent literature. In both of these circumstances, and, indeed, in any circumstance in which a competent adult rejects medical intervention for herself or himself, the courts have been consistent in requiring that the patient’s wishes be honored.
Further complexity is introduced into these already difficult situations when these decisions are being either made or related by a surrogate decision maker (e.g., a spouse or family member) on behalf of an incompetent patient. Reflecting growing societal interest and concern brought about by court decisions in so-called “right-to-die” cases, such as that of Nancy Cruzan, Congress enacted the Patient Self-Determination Act in 1991 in an effort to increase the use of advance directives. “Living wills” and “durable powers of attorney for health care” are mechanisms for a patient to give advance directives for care in the event that he or she becomes incompetent. A living will can be difficult to use because its terms can be hard to define and interpret and the conditions can change at various stages of an illness. What do “extraordinary measures” mean for this patient? The patient may have requested no mechanical ventilation, but wouldn’t the patient want to be mechanically ventilated until she or he regains consciousness after this anesthetic?
Durable powers of attorney for health care can be more workable in that decisions can be made by an appointed relative, spouse, or friend in an ongoing fashion, as judged by conditions at the time. These documents, in general, are legally binding and obligate the treating physicians to honor the requests contained therein.
In situations in which honoring patient autonomy would create a moral dilemma for the treating physician, if no acceptable compromise position can be reached with reasoned discussion (not coercion), then the physician’s only options are either to honor the patient’s requests or to withdraw from the care of that patient. The physician who, in such a circumstance, chooses to simply impose his or her values on a patient does so at the potential risk of both civil and criminal penalties. The American Society of Anesthesiologists has available on its website ethical guidelines for the anesthesia care of patients with do-not-resuscitate orders or other directives that limit treatment.
Other potential ethical conflicts encountered by anesthesia providers concern the permissibility of organ donation that is carefully timed to the withdrawal of life support and the issues raised by requests for anesthesia care providers to participate in capital punishment executions.
The study of ethics allows the physician to better recognize that not all people share common beliefs and values and to accept that a well-informed patient with decision-making capacity is the person most capable of determining the “right” course of action for him or her.
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