Anesthesiology and the Discipline of Medical Ethics: Challenges and Opportunities Perry G. Fine, MD Department of Anesthesiology, University of Utah Health Sciences Center, Salt Lake City, Utah
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onflicts resulting from rapidly advancing technology, economic constraints, shifting demographics, the medico-legal climate, and the heterogeneity of mores within our society have led to an abundance of ethical dilemmas involving health care delivery during the last several years (1). This seemingly exponential increase in medical ethics concerns has been reflected in a voluminous literature in the lay and medical press and the acceptance of "Medical Ethics" as a discipline in the sphere of academic medicine. Coincidentally, anesthesiology has experienced a parallel and concurrent meteoric increase in the ranks of clinical medicine and academics. With its progressive involvement and leadership in areas such as critical care medicine and palliative care (i.e., pain management), the anesthesia literature has been remarkably barren of contributions pertaining to ethical quandaries. This silence was broken by Martin et ale's (2) discussion of "Do Not Resuscitate" (DNR)orders in this journal, which was recently preceded by the article authored by Truog (3) in Anesthesiology. They elaborate and help to clarify the oftentimes murky and potentially disquieting issues that can arise while caring for patients who are high-risk surgical candidates with this advanced directive. They point out the important role that the anesthesiologist must serve in preoperative planning and counseling for patients (or their representatives) who have such directives. These contributions were certainly timely and helpful in their particular content. Moreover, they serve to point out one of the many seemingly hidden, yet immeasureably important, issues that routinely confront anesthesiologists. The context in which we practice medicine is as relevant as the medical expertise that we have to offer. This is what society is telling us. How do we take responsibility for this charge (4)? What makes the practice of anesthesiology unique in this way as a medical specialty? Accepted for publication October 21, 1991. Address correspondence to Dr.Fie,Department of Anesthesiology, University of Utah Health sdences Center, 50 North Medical Drive, Salt Lake City, UT 84132. 01992 by the International Anesthesia Research sodety 0003-2999/9~$5.00
General codes of conduct for physicians and even a specific ethical code that guides the professional actions and relationships of anesthesiologists are embodied, for instance, in The Hippocratic Oath, The World Medical Association Declaration of Geneva, The American Medical Association Principles of Medical Ethics, and The American Society of Anesthesiologists Guidelines for the Ethical Practice of Anesthesiology. These works, although punctuated with the flavor of their own particular historical origins, serve as the formal response to the need for a "universal" ethic. In sum, they assign the physician (anesthesiologist)a set of "behavioral" standards and help to define what that generally means. They do not direct the physician to challenge his or her own values (vis-a-vis those of the patient), and they do not charge the physician with formalizing his or her professional training with a structured means of recognizing, exploring, and resolving ethical dilemmas when they arise. The practice of anesthesiology is virtually always a team effort. Although the "captain of the ship" doctrine has some historical legal force and some practical value when rapid, critical decisions are required, there is no real ethical basis for this (traditional) assignment of hierarchical responsibility between, say, surgeons and anesthesiologists (5).Using the surgeon-anesthesiologist paradigm, if the anesthesiologist knowingly or unconsciously yields moral authority during any phase of a case to the surgeon, he or she has ceased to be a physician in the whole sense (6) and has not maintained his or her implicit contract with the patient. Perhaps there are circumstances that warrant this, but as an a priori "given," this requires some exploration. I submit that, based on the published literature, there is little guidance to be had in the form of conscious recognition and purposeful reconciliation of the difficulties inherent in this relationship (the "physician-patient relationship"). This type of conflict has been referred to in other areas of health care as the "Ethics of Interdependence" (7). A more palatable and practical terminology apropos to anesthesia practice might be the "responsibilities of shared care." Anesth Analg 1992;743274
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ANESTH ANALG 1992;74327-8
EDITORIALS
The DNR scenarios elaborated by Martin et al. (2) represent one of many potentially difficult situations encountered by anesthesiologists in all types of practice. For example, how does the anesthesiologist become involved in the informed consent process leading to an operative delivery of a probably unsalvageable neonate? The desire to get along and a spirit of cooperation are laudable characteristics and may help to keep strife at bay. However, and more realistically, as various members of the “care team” become more sensitive to ethical issues and the more assertive the public becomes in their demands for consideration of their values and autonomy, the necessity for constructive approaches to conflict resolution will become obvious, if, indeed, it already hasn’t. Denial, avoidance, hidden resentment, and shifting of blame are reflexive but seldom productive defenses against controversy and change. I propose that a proactive course would best serve to support the professionalism, integrity, and leadership that our specialty has worked for in so many other domains. Indeed, the roots of such thinking reach deeply into our professional origins. We can discover one source by returning to the focal article of this editorial. Martin et al. (2) begin their paper with a quotation from Wesley Bourne’s ”On the Duties of the Anaesthesiologist as a Physician” (8). These authors’ choice of whom to quote is quite poignant and appropriate in the present context. Bourne says that “The patient is not a problem; he is a person with a problem.” He attributes goodness in a physician to that quality described in Immanuel Kant’s second maxim: “Act so as to treat humanity, whether in thine own person or in the person of another, always as an end, never as a means only.” Bourne goes on to draw upon the now famous statement of Francis Peabody while addressing Harvard medical students: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caringfor the patient.” Of significance, Wesley Bourne, MD, a Canadian, was president of the International Anesthesia Research Society for two terms (1925 and 1940) and served as the only non-American president of the American Society of Anesthesiologists. So, with all of this philosophy and history setting the stage, how do
we actually move toward that lofty place to which we are directed? First, just as there is not yet a single, perfect anesthetic technique, it must be acknowledged that no one has a corner on the market for “morality” or “ethical rightness.” Then, just as we arm ourselves with well-constructed arguments (based on the “known,” the “probable,“ and the “unknown“) for choosing a specific anesthetic technique in a difficult clinical situation, a similar approach is needed in facing clinical ethical dilemmas. This requires a fund of knowledge and a structured approach to sorting out the issues. Armed with these tools, then one might consider oneself to be both responsible and entitled to an opinion. It is time, now, to integrate such material into residency training and our professional society meetings while taking some personal responsibility for informing ourselves. We can then be prepared to address cases that come to the fore in a rigorous manner-and we need to do so, honing our skills on a regular basis, in all practice settings. It would be a good beginning.
References 1. Zaner RM. The moral dimension of medicine: preliminary reflections. In:Zaner RM, ed. Ethics and the clinical encounter. Englewood Cliffs, N.J. : Prentice-Hall, 1988:2%52. 2. Martin RL, Soifer BE, Stevens WC. Ethical issues in anesthesia: management of the do-not-resuscitate patient. Anesth Analg 1991;73:221-5. 3. Truog RD. “Do-Not-Resuscitate”orders during anesthesia and surgery. Anesthesiology 1991;74606-8. 4. Ladd J. Legalism and medical ethics. VII. Responsibilities. In: Davis JW, Hoffmaster 8, Shorten S, eds. Contemporary issues in biomedical ethics. Clifton, N.J.: Humana Press, 1978:257. 5. Wasmuth CE, Wasmuth CE Jr, The anesthesiologist as a member of the surgical team. In: Wasmuth CE, Wasmuth CE Jr, eds. Law and the surgical team. Baltimore: Williams & Wilkins, 1969162-208. 6. Dunstan GR. The doctor as the responsible moral agent. In: Dunstan GR, Shineboume EA, eds. Doctors’ decisions: ethical conflicts in medical practice. New York Oxford University Press, 1989:l-9. 7. Sellers JA. Tensions in the ethics of interdependence. In: Van Eys J, Bowen JM, eds. The common bond: the University of Texas system Cancer Center code of ethics. Springfield, Ill.: Charles C. Thomas, 1986:11932. 8. Bourne W. On the duties of the anaesthesiologistas a physician. Curr Res Anesth Analg 1956;35:11522.
C
onflicts resulting from rapidly advancing technology, economic constraints, shifting demographics, the medico-legal climate, and the heterogeneity of mores within our society have led to an abundance of ethical dilemmas involving health care delivery during the last several years (1). This seemingly exponential increase in medical ethics concerns has been reflected in a voluminous literature in the lay and medical press and the acceptance of "Medical Ethics" as a discipline in the sphere of academic medicine. Coincidentally, anesthesiology has experienced a parallel and concurrent meteoric increase in the ranks of clinical medicine and academics. With its progressive involvement and leadership in areas such as critical care medicine and palliative care (i.e., pain management), the anesthesia literature has been remarkably barren of contributions pertaining to ethical quandaries. This silence was broken by Martin et ale's (2) discussion of "Do Not Resuscitate" (DNR)orders in this journal, which was recently preceded by the article authored by Truog (3) in Anesthesiology. They elaborate and help to clarify the oftentimes murky and potentially disquieting issues that can arise while caring for patients who are high-risk surgical candidates with this advanced directive. They point out the important role that the anesthesiologist must serve in preoperative planning and counseling for patients (or their representatives) who have such directives. These contributions were certainly timely and helpful in their particular content. Moreover, they serve to point out one of the many seemingly hidden, yet immeasureably important, issues that routinely confront anesthesiologists. The context in which we practice medicine is as relevant as the medical expertise that we have to offer. This is what society is telling us. How do we take responsibility for this charge (4)? What makes the practice of anesthesiology unique in this way as a medical specialty? Accepted for publication October 21, 1991. Address correspondence to Dr.Fie,Department of Anesthesiology, University of Utah Health sdences Center, 50 North Medical Drive, Salt Lake City, UT 84132. 01992 by the International Anesthesia Research sodety 0003-2999/9~$5.00
General codes of conduct for physicians and even a specific ethical code that guides the professional actions and relationships of anesthesiologists are embodied, for instance, in The Hippocratic Oath, The World Medical Association Declaration of Geneva, The American Medical Association Principles of Medical Ethics, and The American Society of Anesthesiologists Guidelines for the Ethical Practice of Anesthesiology. These works, although punctuated with the flavor of their own particular historical origins, serve as the formal response to the need for a "universal" ethic. In sum, they assign the physician (anesthesiologist)a set of "behavioral" standards and help to define what that generally means. They do not direct the physician to challenge his or her own values (vis-a-vis those of the patient), and they do not charge the physician with formalizing his or her professional training with a structured means of recognizing, exploring, and resolving ethical dilemmas when they arise. The practice of anesthesiology is virtually always a team effort. Although the "captain of the ship" doctrine has some historical legal force and some practical value when rapid, critical decisions are required, there is no real ethical basis for this (traditional) assignment of hierarchical responsibility between, say, surgeons and anesthesiologists (5).Using the surgeon-anesthesiologist paradigm, if the anesthesiologist knowingly or unconsciously yields moral authority during any phase of a case to the surgeon, he or she has ceased to be a physician in the whole sense (6) and has not maintained his or her implicit contract with the patient. Perhaps there are circumstances that warrant this, but as an a priori "given," this requires some exploration. I submit that, based on the published literature, there is little guidance to be had in the form of conscious recognition and purposeful reconciliation of the difficulties inherent in this relationship (the "physician-patient relationship"). This type of conflict has been referred to in other areas of health care as the "Ethics of Interdependence" (7). A more palatable and practical terminology apropos to anesthesia practice might be the "responsibilities of shared care." Anesth Analg 1992;743274
327
328
ANESTH ANALG 1992;74327-8
EDITORIALS
The DNR scenarios elaborated by Martin et al. (2) represent one of many potentially difficult situations encountered by anesthesiologists in all types of practice. For example, how does the anesthesiologist become involved in the informed consent process leading to an operative delivery of a probably unsalvageable neonate? The desire to get along and a spirit of cooperation are laudable characteristics and may help to keep strife at bay. However, and more realistically, as various members of the “care team” become more sensitive to ethical issues and the more assertive the public becomes in their demands for consideration of their values and autonomy, the necessity for constructive approaches to conflict resolution will become obvious, if, indeed, it already hasn’t. Denial, avoidance, hidden resentment, and shifting of blame are reflexive but seldom productive defenses against controversy and change. I propose that a proactive course would best serve to support the professionalism, integrity, and leadership that our specialty has worked for in so many other domains. Indeed, the roots of such thinking reach deeply into our professional origins. We can discover one source by returning to the focal article of this editorial. Martin et al. (2) begin their paper with a quotation from Wesley Bourne’s ”On the Duties of the Anaesthesiologist as a Physician” (8). These authors’ choice of whom to quote is quite poignant and appropriate in the present context. Bourne says that “The patient is not a problem; he is a person with a problem.” He attributes goodness in a physician to that quality described in Immanuel Kant’s second maxim: “Act so as to treat humanity, whether in thine own person or in the person of another, always as an end, never as a means only.” Bourne goes on to draw upon the now famous statement of Francis Peabody while addressing Harvard medical students: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caringfor the patient.” Of significance, Wesley Bourne, MD, a Canadian, was president of the International Anesthesia Research Society for two terms (1925 and 1940) and served as the only non-American president of the American Society of Anesthesiologists. So, with all of this philosophy and history setting the stage, how do
we actually move toward that lofty place to which we are directed? First, just as there is not yet a single, perfect anesthetic technique, it must be acknowledged that no one has a corner on the market for “morality” or “ethical rightness.” Then, just as we arm ourselves with well-constructed arguments (based on the “known,” the “probable,“ and the “unknown“) for choosing a specific anesthetic technique in a difficult clinical situation, a similar approach is needed in facing clinical ethical dilemmas. This requires a fund of knowledge and a structured approach to sorting out the issues. Armed with these tools, then one might consider oneself to be both responsible and entitled to an opinion. It is time, now, to integrate such material into residency training and our professional society meetings while taking some personal responsibility for informing ourselves. We can then be prepared to address cases that come to the fore in a rigorous manner-and we need to do so, honing our skills on a regular basis, in all practice settings. It would be a good beginning.
References 1. Zaner RM. The moral dimension of medicine: preliminary reflections. In:Zaner RM, ed. Ethics and the clinical encounter. Englewood Cliffs, N.J. : Prentice-Hall, 1988:2%52. 2. Martin RL, Soifer BE, Stevens WC. Ethical issues in anesthesia: management of the do-not-resuscitate patient. Anesth Analg 1991;73:221-5. 3. Truog RD. “Do-Not-Resuscitate”orders during anesthesia and surgery. Anesthesiology 1991;74606-8. 4. Ladd J. Legalism and medical ethics. VII. Responsibilities. In: Davis JW, Hoffmaster 8, Shorten S, eds. Contemporary issues in biomedical ethics. Clifton, N.J.: Humana Press, 1978:257. 5. Wasmuth CE, Wasmuth CE Jr, The anesthesiologist as a member of the surgical team. In: Wasmuth CE, Wasmuth CE Jr, eds. Law and the surgical team. Baltimore: Williams & Wilkins, 1969162-208. 6. Dunstan GR. The doctor as the responsible moral agent. In: Dunstan GR, Shineboume EA, eds. Doctors’ decisions: ethical conflicts in medical practice. New York Oxford University Press, 1989:l-9. 7. Sellers JA. Tensions in the ethics of interdependence. In: Van Eys J, Bowen JM, eds. The common bond: the University of Texas system Cancer Center code of ethics. Springfield, Ill.: Charles C. Thomas, 1986:11932. 8. Bourne W. On the duties of the anaesthesiologistas a physician. Curr Res Anesth Analg 1956;35:11522.
