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Clinical Ethics in Anesthesiology
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Book description

Ethical issues facing anesthesiologists are more far-reaching than those involving virtually any other medical specialty. In this clinical ethics textbook, authors from across the USA, Canada and Europe draw on ethical principles and practical knowledge to provide a realistic understanding of ethical anesthetic practice. The result is a compilation of expert opinion and international perspectives from clinical leaders in anesthesiology. Building on real-life, case-based problems, each chapter is clinically focused and addresses both practical and theoretical issues. Topics include general operating room care, pediatric and obstetrical patient care, the intensive care unit, pain practice, research and publication, as well as discussions of lethal injection, disclosure of errors, expert witness testimony, triage in disaster and conflicts of interest with industry. An important reference tool for any anesthesiologist, whether clinical or research-oriented, this book is especially valuable for physicians involved in teaching residents and students about the ethical aspects of anesthesia practice.

Reviews

'Rather than attempting to provide simple answers to … complex ethical problems, this book sets out to identify the principles underlying a wide variety of issues that a practising anaesthesiologist may encounter … [a] must-read textbook for all readers interested in addressing ethics issues in practice with the information essential to form proper and moral decisions.'

Martin Dauber Source: Journal of the American Medical Association

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Contents


Page 1 of 3


  • 10 - Ethical use of restraints
    pp 61-63
  • View abstract

    Summary

    The ethical principle of respect for patient autonomy is firmly grounded in western ethical principles valuing individual freedoms. This chapter talks about autonomous choices, presenting a case of a 35-year-old man with colectomy. Of the four foundational principles in medical ethics: beneficence, nonmaleficence, respect for autonomy, and justice, the principle with the strongest influence in the United States is respect for personal autonomy. Three conditions must be met in order for an act (or choice) to be autonomous: a person must act with intention, with understanding, and without controlling influences. In the informed consent process, physicians have ethical obligations to avoid controlling influences that invalidate autonomous choice. Generally speaking intentional acts require planning, although not necessarily reflective thought or strategy. Coercion and manipulation are unethical because they violate the principle of respect for patient autonomy, and because manipulation often involves deception and violates physician obligations of veracity.
  • 11 - The use of ethics consultation regarding consent and refusal
    pp 64-68
  • View abstract

    Summary

    Do-not-resuscitate (DNR) orders may be written if cardiopulmonary resuscitation (CPR) would be physiologically futile, or at the request of patients who feel that CPR would result in poorer quality of life. Pre-hospital DNR policies have emerged recently and serve three primary purposes: to provide continued respect for patient autonomy following hospital discharge, prevent futile resuscitation efforts in the field, and protect the well-being of emergency medical service (EMS) personnel. This chapter explains this concept citing the case study of a 67-year-old male with oxygen-dependent COPD requiring a series of electroconvulsive therapies (ECT) for severe depression refractory to medical therapy. Patients with preexisting DNR orders often require anesthesia for surgical procedures necessitated by the need to improve quality of life. The American Society of Anesthesiologists and the American College of Surgeons have drafted guidelines for the management of the patient with a presurgical DNR order.
  • 12 - Consent and cultural conflicts: ethical issues in pediatric anesthesiologists’ participation in female genital cutting
    pp 69-73
  • View abstract

    Summary

    This chapter presents a case study of a 41-year-old female with hepatitis C cirrhosis complicated by hepato-pulmonary syndrome. Adults with appropriate decision-making capacity express their autonomy through the informed consent process. Physicians demonstrate respect for the autonomy of competent patients by accepting their informed decisions, whether or not they consent to medical treatment. Key questions arise in most cases involving Jehovah's Witnesses (JWs) and others who refuse certain types of treatment on religious or other grounds. Due to strongly-held beliefs, most practicing JWs patients refuse transfusion of blood and many blood products. Respect for patient autonomy is the primary ethical principle applied in the United States, while the principle of beneficence is more strongly held in many other countries. Respect for autonomy supports the concept that adult, competent patients have the right to refuse blood transfusions, as well as any other therapy.
  • 13 - Communitarian values in medical decision-making: Native Americans
    pp 74-78
  • View abstract

    Summary

    This chapter explains the burdens of surrogate decision-making decision-making citing a case study of an 80 year-old widowed woman admitted for elective total hip replacement but post-surgery loses the decision-making capacity. Many European countries have autonomy-based models of decision-making for competent patients, and hierarchies for surrogate decision-making for incapacitated patients that are similar to that in the US. It may be possible to prevent confusion about the appropriate surrogate by asking all hospitalized and preoperative patients with decision-making capacity to identify their preferred surrogate decision maker(s) early in their hospital stay. Ethics and palliative care consultants can help evaluate apparent discrepancies. Decision-making capacity is assessed by evaluating patients' abilities to understand information about their condition and treatment options; appreciate that the decision at hand will affect them; explain their reasoning; and arrive at a choice consistent with their values and beliefs or a discussion of the patient's life and values.
  • 14 - Informed consent for preoperative testing: pregnancy testing and other tests involving sensitive patient issues
    pp 79-84
  • View abstract

    Summary

    Anesthesiologists should choose to involve children in medical decision-making with the ethical objective of enhancing the child's self-determination, while keeping the child engaged in their care. Anesthesiologists can use the patient's age as a first approximation of a patient's cognitive and emotional development. This chapter discusses the issues raised by incorporating the ethical concept of pediatric patient assent into the traditional process of parental (surrogate) informed consent. Competency is a legal term while decision-making capacity is the ability to make a specific decision at a specific time. It is important to resolve disagreements among the pediatric patient-parent-physician triad about the appropriate clinical plan. Response to requests for nondisclosure by parents must weigh the goal of the best Znterests of the patient. Emancipated minor and mature minor status pose distinct ethical and practical issues. Confidentiality must be honored, and failure to do so may be harmful to the patient.
  • 15 - The principle of double effect in palliative care: euthanasia by another name?
    pp 87-91
  • View abstract

    Summary

    Do not resuscitate (DNR) orders developed in response to the realization that cardiopulmonary resuscitation (CPR) is not appropriate for all patients, particularly those with terminal illness and otherwise dismal prognosis. Pediatric patients may or may not have the capacity to participate in medical decision making. Parents function as surrogate decision-makers, acting in the overall best interest of the child. This chapter explains CPR, citing the case study of a 4-year-old boy with metastatic neuroblastoma undergoing stem cell transplantation following intensive chemotherapy and radiation. CPR became a nearly ubiquitous final procedure for all hospitalized patients experiencing cardiopulmonary arrest, regardless of circumstances. Automatic suspension of DNR orders in the setting of anesthesia and surgery does not sufficiently recognize patients' rights to self-determination. When patients or their surrogate decision-makers, such as parents, do not wish to suspend DNR orders in the setting of surgery, few ethical arguments support ignoring their wishes.
  • 16 - Surgical interventions near the end of life: “therapeutic trials”
    pp 92-96
  • View abstract

    Summary

    Principle-based medical ethics focuses on the four concepts of autonomy, beneficence, nonmaleficence and justice. Informed consent requires several elements: capacity of the patient to make a decision, freedom or voluntariness of the patient in decision-making, disclosure of adequate information to the patient, understanding of that information by the patient, and consent by the patient to the procedure. Ensuring that these elements have been addressed and obtaining consent for procedures in laboring patients can be extremely challenging. Every labor carries the risk of maternal-fetal conflicts. Cultural and religious beliefs may complicate care of the laboring patient and require consideration in managing ethical conflicts. When a laboring woman refuses critical intervention, all efforts should be made to inform her of the risks and benefits of refusal of treatment, including the use of interpreter services if needed to a conduct careful and complete discussion.
  • 17 - Withholding and withdrawing life support in the intensive care unit
    pp 97-102
  • View abstract

    Summary

    The principle of respect for patient autonomy supports a pregnant woman's rights to refuse recommended medical treatments, even if such refusal may be detrimental to her or to her fetus. The incidence of cesarean delivery without medical or obstetrical indications is increasing in the US, one component of which is cesarean deliveries at maternal request (CDMR). Principles of beneficence and nonmaleficence are particularly challenging with CDMR, since they must balance benefits and harms for both mother and baby in a situation where there is a lack of reliable authoritative data, physicians' own personal views may vary widely, and there is heated political as well as medical debate. The anesthesiologist probably would not have been directly involved in the patient's and obstetrician's decisions regarding mode of delivery. When patients request unnecessary interventions, additional ethical considerations include issues of distributive justice.
  • 18 - Discontinuing pacemakers, ventricular assist devices, and implanted cardioverter-defibrillators in end-of-life care
    pp 103-107
  • View abstract

    Summary

    This chapter focuses on the concept of patient consent for ansthesia for psychosurgery and electroconvulsive therapy (ECT) using the case of a 20-year-old patient with severe psychiatric disorders. Psychosurgery has a controversial history, in which medical, moral, social, and political considerations intermingle. The main ethical issues connected to these interventions involve the scientific validity of the therapy and its evaluation, the validity of patient consent, and the possibility of conflict between the interests of the patient and those of society, particularly in the case of dangerous or violent individuals. Psychosurgery raises fundamental questions, such as those linked to the definition of person and free will, concepts of dignity, integrity, and the validity of true consent. Ultimately, decisions regarding psychosurgical interventions and ECT must be made on a case-by-case basis, taking into account patient suffering and disability, and balancing these considerations with patient autonomy.
  • 19 - Brain death
    pp 108-113
  • View abstract

    Summary

    Restraint therapy is instituted to prevent injuries to patients or others by restricting a patient's movement. Used appropriately, restraint therapy reduces patient risk and improves outcome. Otherwise, restraint can cause accidental injury or even death. Physicians are ethically obliged to limit the use of restraints to clinically and adequately justified situations so that associated risks can be reduced. Physicians should consider whether the benefits of restraint therapy are worth the harms. This chapter presents two case studies on the appropriate use of restraint therapy. In the first case, the desire for the restraints may have been misguided. The second case exhibits the effects of restraint therapy on the family. The ethical principles of respect for patient self-determination (including informed consent obtained from surrogate decision-makers), beneficence and non-maleficence should weigh heavily in the decision to employ restraint as a mode of treatment.
  • 20 - Ethical issues in organ donation after cardiac death
    pp 114-122
  • View abstract

    Summary

    This chapter presents a case study of a 63-year-old female unconscious patient involved in an MVA and brought urgently to the O.R for repair of bilateral femur fractures. With reference to this study, the chapter highlights that religious freedom does not guarantee the free practice of religious behaviors, if such behavior is harmful to others or to society. At times, conflicts between religious behavior and societal interests occur in the setting of medical care. Ethics consultation services can be useful when unusual or seemingly irresolvable conflicts between patient wishes and physician professional standards arise. An ethics consultation requires the participation of all interested parties, including the patient, patient's caregivers, family, religious support if available, the physicians, and hospital representatives. Ethics consultation includes a process of outlining the medical situation, legal considerations, ethical concerns, and a range of acceptable ethical and medical outcomes.

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