Anesthesiologists Encounter Unique Ethical Issues
There currently is no standardized ethics curriculum for anesthesiology training programs in the United States. Thus, the ethics education trainees receive varies depending on the institution. “Although anesthesiologists encounter ethical challenges more frequently than practitioners in many other fields, anesthesiology training curricula in the U.S. largely do not include a formal ethics course,” says Madeline Pence, MD.
Most anesthesiology residency program directors have a standardized ethics curriculum for trainees, found a 2019 study.1 In light of those findings, Pence and colleagues wanted to know what program directors thought were high-priority ethics topics. The researchers surveyed anesthesia scholars in the biomedical ethics field in 2021 about the most important ethics topics to include in an ethics curriculum in anesthesiology training programs.2 Out of 38 ethical principles, participants prioritized these top 10 topics: Capacity to consent (with special attention to pediatrics); capacity to refuse elective vs. lifesaving treatment; application of surrogate decision-making, approach to do-not-resuscitate status in the operating room; patient autonomy and advance directives; navigating patient beliefs that could affect patient care (such as Jehovah’s witnesses and blood transfusion); “futility” in end-of-life care and when to withdraw life support; disclosure of medical errors; clinical criteria for “brain death” and consequences of this definition; and the impaired anesthesiologist.
Programs must find ways to get buy-in from trainees and maximize their engagement in the ethics content. Finding time to add content in a demanding curriculum is another challenge. “It will require programs to be creative in the way they implement and integrate this content,” acknowledges Pence.
Anesthesiology residency programs, first and foremost, should teach the basics of how to think about ethical questions, according to Michael Souter, MB, ChB, DA, FRCA, FNCS, chair of the American Society of Anesthesiologists’ (ASA) Committee on Ethics. In terms of more ethics education in anesthesiology residency programs, “the main limiting factor is time. Within a very crowded curriculum, anytime you say, ‘We need more of this element of training and care,’ somebody will say, ‘What are you going to drop?’” says Souter, a University of Washington (UW) professor of anesthesiology and pain medicine.
At UW’s anesthesiology residency program, ethics training emphasizes professionalism. Trainees learn how to talk to others (including patients, especially when there have been complications of care), and how to establish respectful relationships with colleagues. “The relationship between surgeons and anesthesiologists can vary from being great friends to being somewhat fraught. But we need to make sure that we are working respectfully and collaboratively with everybody who is working in the increasingly wide sandbox that is modern medicine,” says Souter.
Anesthesiologists routinely work with multiple specialists, such as cardiologists, neurosurgeons, orthopedists, and gynecological surgeons. Ethical issues in anesthesiology touch on all the various ethical issues that come up in those specialties. Additionally, anesthesiologists have to be aware of the pertinent issues in their area of practice. “The ASA Committee on Ethics also has to adapt to changing events, both in the political landscape and developments in medical technology,” says Souter. Souter says these are some current ethical issues that are important in anesthesiology:
• Individual autonomy of the medical practitioner in decision-making.
“This is one of the constant tensions that we are seeing, not just in our specialty, but for medicine in general. It comes up in abortion, end-of-life care, or transgender issues. Like any specialty that is composed of a lot of practitioners, anesthesiology has a diverse array of views,” says Souter. Anesthesiologists may face a conflict between doing the “right” thing by the moral and ethical standards of society in general vs. their own individual moral position.
• How to obtain informed consent properly.
In some states, anesthesiologists are required to obtain consent for anesthesia separately. In other states, consent for anesthesia is implied if patients give consent for surgery. “The ASA Committee on Ethics is currently reviewing various practices of obtaining informed consent in anesthesiology around the country,” reports Souter.
• Ethical conflicts involving patients’ do-not-resuscitate (DNR) status.
The ASA Committee on Ethics recently published guidelines for anesthesia care for patients with DNR orders.3
“Patients must be adequately informed on what their DNR status means in the context of surgery, with regard to the outcomes being different from resuscitations in the community or even on the ward,” explains Souter. During the preoperative discussion, anesthesiologists can clarify what is behind the patient’s decision by asking questions such as “What are you concerned about?” and “What are you trying to avoid?”
Patients often are focused on the risk of intellectual or physical disability that can arise from the need for resuscitation. Patients worry about the effect on their quality of life, but many do not realize that treatment delivered promptly and appropriately can greatly reduce the risks of those outcomes. “Others may already be experiencing what is for them a degraded quality of life, and even the slightest risk of further discomfort or disability is unacceptable,” says Souter.
As a result of that discussion, some patients decide to suspend their existing directives or clarify that they refuse only specific resuscitation procedures.
Others insist they do not wish to be resuscitated under any circumstance. “Anesthesiologists and surgeons may feel uncomfortable with that. Some members of either specialty may feel they can’t stand by and let somebody die,” says Souter. Institutional policies are helpful to guide anesthesiologists in these ethically complex cases. Regardless of what the patient decides, “if it’s an autonomously made decision, we have to respect that,” underscores Souter.
• Patients with greater burdens of both acute and chronic illness may be considered for potentially inappropriate procedures.
“When is it important for an anesthesiologist to say, ‘I am a medical professional, and in my judgment, this may induce an inappropriate risk of a bad outcome?’ There is a lot of subjectivity to that,” says Souter.
Preoperative discussions between the anesthesiologist and surgical and nursing colleagues are critically important. “Trying to get everybody on board is an interesting exercise. You want to deal with this well beforehand, rather than mid-procedure,” says Souter.
Emergent care always will proceed first, with resolution of questions later. However, there are times when the anesthesiologist may have to pause scheduling preoperatively to ensure that both the patient and the surgeon completely understand the risks and possible consequences of moving ahead. It can be challenging for the team to arrive at an appropriate consensus in those cases.
“These can be difficult situations, which may benefit from review by a bioethicist or similar resource. Sometimes, practitioners need to be reminded of that possibility,” says Souter.
REFERENCES
- Raymond BL, McEvoy MD, Goldstein PA, Drolet BC. Brief report – The current state of biomedical ethics education among anesthesiology training programs: A call to arms. J Educ Perioper Med 2019;21:E621.
- Pence MJ, Pla RA, Heinz E, et al. Identifying relevant topics for inclusion in an ethics curriculum for anesthesiology trainees: A survey of practitioners in the field. Camb Q Healthc Ethics 2024; Apr 29. doi: 10.1017/S0963180124000240. [Online ahead of print].
- American Society of Anesthesi-ologists. Statement on ethical guidelines for the anesthesia care of patients with do-not-resuscitate order. Reaffirmed Oct. 18, 2023. https://www.asahq.org/standards-and-practice-parameters/statement-on-ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders
There currently is no standardized ethics curriculum for anesthesiology training programs in the United States. Thus, the ethics education trainees receive varies depending on the institution.
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