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  1. Home
  2. Books
  3. Clinical Ethics in Anesthesiology
Publisher:
Cambridge University Press
Online publication date:
March 2012
Print publication year:
2010
Online ISBN:
9780511841361
DOI:
https://doi.org/10.1017/CBO9780511841361
Subjects:
Anesthesia, Intensive Care, Pain Management, Medicine, Medical Law, Ethics and forensic Medicine
Information

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 2 of 3

Contents
  • 21 - Revising the Uniform Anatomical Gift Act – the role of physicians in shaping legislation
    pp 123-127
  • View abstract

    Summary

    Female genital cutting (FGC) has wide acceptance in many cultures across the globe despite gender-related and more general human rights concerns raised by the practice. This chapter presents a case study on a healthy 5-year-old female patient scheduled for surgical correction of clitoral phimosis. Physicians must understand the potential medical sequelae of FGC to make reasoned decisions about whether or not to participate in the procedure. Immediate adverse outcomes of FGC include pain, post-operative infection, shock, tetanus, hemorrhage, and death. Whether an anesthesiologist should participate in FGC depends on his or her interpretation of ethical considerations. Mostprofessional societies provide only guidance, without a binding effect on members.Physician participation in FGC may prevent some health consequences but also perpetuates objectionable social practices. Physicians' decisions to participate in FGC currently rely on personal judgments, weighing adverse medical and psychological consequences against potential cultural benefits and harms.
  • 22 - Physician aid-in-dying and euthanasia
    pp 128-134
  • View abstract

    Summary

    Native Americans have views on health or strong spiritual beliefs that should be acknowledged, respected, and safely integrated into the plan for anesthesia care. The cultural effects of Native American beliefs in the medical workplace serve to illustrate problems common to the care of patients whose cultural beliefs are significantly different from that of the traditional healthcare culture with regard to autonomy, beneficence and informed consent. Native American cultures are far more communitarian than mainstream American cultures. Native Americans have historical spiritual belief systems that should not be confused with our understandings about pre-historic early human social organization. Scientific research supports the connections between spiritual and mental states and the outcomes of stressful healthcare procedures. Verbalizing respect for the concerns and spiritual needs of Native American patients and their families should be a normal part of ethical anesthesia care for these patients.
  • 23 - Ethical considerations in interventional pain management
    pp 137-142
  • View abstract

    Summary

    This chapter presents a case study of a healthy 15-year-old girl for elective diagnostic ankle arthroscopy for ankle pain and swelling. Using the study as a reference, it focuses on the ethical issues related to common, routine preoperative tests. The chapter examines two preoperative tests with special social implications: HIV and pregnancy testing. The informed consent process requires respect for informed refusal, and with rare exceptions, patients should not be coerced into undergoing screening pregnancy testing by threatening to cancel the case if they refuse. Good medical practice, both from ethical and medical standpoints, includes applying evidence-based guidelines in determining if a preoperative test should be done. Pregnancy testing and HIV testing are examples of tests with significant social implications, but little proven medical benefit as screening tests. Policies requiring such tests should be reconsidered in light of the ethical principles respecting patient autonomy and striving for beneficence and nonmaleficence.
  • 25 - Opioid therapy in addicted patients: background and perspective from the UK
    pp 148-153
  • View abstract

    Summary

    The expert management of pharmacological and non-pharmacological treatments is essential to the concept of proportionality. When physicians use appropriate analgesics and write orders to titrate medication based on evidence of pain and suffering, such as groaning, agitation, verbal complaints, diaphoresis, hypertension, or unexplained tachycardia, they demonstrate that the intention of the act is geared toward alleviating pain. Until relatively recently, dying patients were routinely under-treated for pain because physicians feared that the treatment would hasten death. This chapter explains the case study of a 58-year-old woman with widely metastatic breast cancer. In the context of caring for a terminally ill patient, the double effect (DE) allows for good pain management. DE asks physicians to carefully examine their motives and assumes that one's private moral intentions are morally relevant. The principle of double effect permits aggressive treatment of pain when death may be an unintended effect of that treatment.
  • 26 - Opioid therapy in addicted patients:
    pp 154-160
  • background and perspective from the US
  • View abstract

    Summary

    This chapter presents a case study on an 86-year-old retired accountant, experiencing worsening symptoms and signs of congestive heart failure. The patient clearly understood and accepted the balance of benefits versus risks, and gave informed consent to the procedure. Offering the operation is respectful of the ethical principle of autonomy. The patient's primary goals were to improve his functionality and reduce his symptoms even with a substantial risk of dying. The chapter discusses questions that need to be addressed when the outcome of the intervention is poor and the possibilities of achieving the patient's stated goals are virtually nil. The focus should be on the overall trend and not the minor ups and downs of vital signs, drug infusion rates, ventilatory settings, etc. It is important to recognize that it will take time, perhaps days, for the family to grasp the lack of improvement or deterioration in the patient's condition.
  • 27 - Ethics in anesthesiology research using human subjects
    pp 163-167
  • View abstract

    Summary

    This chapter considers an ethical framework to guide decision making to explore frequently encountered obstacles. It offers practical suggestions to enhance care for patients dying in the intensive care unit (ICU). To this effect, the chapter presents a case study of an 88-year-old woman with a history of diabetes, stable coronary artery disease, and hypertension, where there was consensus to switch the focus to palliation. Four basic ethical principles should guide end-of-life decision-making in the ICU: respect for the patient's autonomy; the duty of beneficence; the duty of nonmaleficence; and the obligation to ensure just distribution of care. End-of-life care, particularly making decisions to withhold or withdraw life support, is a fundamental component of critical care practice. Appropriate end-of-life decision-making hinges on the intensivist's understanding of key ethical principles. Careful, deliberate, and empathic explanations and negotiation usually lead to choices acceptable to both family members and the medical team.
  • 28 - Animal subjects research Part I: Do animals have rights?
    pp 168-173
  • View abstract

    Summary

    Disabling a device is not physician-assisted suicide. If a practitioner is uncertain about the mental health of a patient, it is reasonable to consult with a psychiatrist or psychologist. The rationale for disabling the device are based on a fundamental notion of patient autonomy, informed by patient awareness and acceptance of the consequences of the choices made. This chapter presents a case study of a 59-year-old diagnosed with idiopathic ventricular tachycardia and who requested that his ICD be turned off. Each of the three types of currently used cardiac devices pacemakers, implantable cardioverter defibrillator (ICDs), and ventricular assist devices (VADs), has different functions and a different mix of harms and benefits. They represent forms of cardiac-supportive therapies that patients may legitimately forgo or discontinue as part of end-of-life decision-making. Discontinuing cardiac device therapy should be accompanied by thoughtful discussion, discernment of patient goals, and plans for appropriate palliative care.
  • 29 - Animal subjects research Part II: Ethics of animal experimentation
    pp 174-179
  • View abstract

    Summary

    Advances in medical technology and transplantation lead to the re-defining of death to include death by virtue of brain death. The determination of whole brain death requires the demonstration of three things: an irreversible comatose state; the loss of brainstem reflexes; and brainstem inactivity leading to apnea. Protocols for the clinical determination of brain death vary among institutions but must generally be made by more than one doctor in one of several relevant specialties. Neurophysiologic determinations of cerebral circulatory arrest include four-vessel cerebral angiography as well as various scintigraphic perfusion studies. In all countries where brain death is recognized legally, the diagnosis rests with physical examination, at times supported by further medical testing. Philosophical arguments for the integrity of brain death as a definition of death rest in historic religious and social concepts of what constitutes life, or with ideas that loss of personhood may be equivalent to death.
  • 30 - Ethical function of human subjects review boards: a US perspective
    pp 180-184
  • View abstract

    Summary

    The transplantation program in the US is an altruistic program based on the premise that organ donation is a gift, and relying on ethical principles of autonomy, respect for persons (beneficence, nonmaleficence), and justice. Organ donation after cardiac death (DCD) is controversial because it combines two ethically complex events: withdrawal of life-supportive therapies as part of end-of-life care of the dying patient, and the altruistic gift of organ donation. Firewalls should separate the three key decisions involved in DCD: the decision to forgo resuscitation, the decision to withdraw life-sustaining therapies, and the decision to donate organs after death. The dead donor rule presents ethical problems for expansions of DCD, and some legislative and practice changes to counteract these limitations may have presented even greater ethical problems than the dead donor rule itself. Resolving conflicts in the DCD process may require revisiting the dead donor rule.
  • 31 - Research with vulnerable persons such as children and prisoners
    pp 185-192
  • View abstract

    Summary

    The original Uniform Anatomical Gift Act (UAGA) is model legislation for states to emulate, and promote uniform laws among states. A revised version of the UAGA 2006 has now been adopted in most of the US, but the story still serves to remind us that ethical responsibilities do not end at the hospital doors, but include a duty to help shape healthcare legislation. Respect for patient autonomy requires that patients be fully informed about implications that organ donation may have for other aspects of end-of-life (EOL) care. Anesthesiologists have ethical duties to understand legislation that may affect their patients, to publicize concerns, and to press for legislation that adequately protects the rights of all patients. Legislative change requires the actions of just a few knowledgeable persons. This chapter also presents the case study of a man in critical condition, who wishes to be an organ donor.
  • 32 - The ethics of research on pain and other symptoms for which effective treatments already exist
    pp 193-198
  • View abstract

    Summary

    This chapter presents a case study which analyzes whether physicians can end a patient's life at his or her request (as in euthanasia), or otherwise collaborate with the ending of life at a patient's initiative (as in assisted suicide). A request for euthanasia or assisted suicide is an emotionally taxing situation, where a thoughtful and respectful response is particularly important. Requirements for legal euthanasia or assisted suicide include that patients need to be capable of decision making and persistently requesting death, and that there be otherwise intractable suffering. Requests for aid-in-dying should be taken seriously and carefully listened to. Screening for and treatment of problematic symptoms and depression may lead to withdrawal of the request. When a request for aid-in-dying persists and no life-sustaining treatments are being employed, the response will depend on the legal status of euthanasia or assisted suicide, and on the physician's own convictions.
  • 34 - Conflicts of interest in research funding
    pp 204-208
  • View abstract

    Summary

    Despite the intrusion of insurance forms and changing reimbursements, medicine in general and pain medicine specifically continues to be a humanitarian pursuit with goals of relieving suffering and restoring function. Pain is a subjective patient experience, and one of the greatest limitations of pain management is a lack of objective diagnostic tests that identify and quantify pain. The use of interventional procedures to diagnose and treat pain involves ethical concerns of beneficence and nonmaleficence as well as potential financial conflicts of interest for the physician. Complications may be mitigated by performing procedures in the safest environment possible, with the most up-to-date equipment, and by an experienced, highly-trained pain specialist. Pain management providers must deal with competing problems in pain management: under treatment of pain and opioid abuse. In pain management, patient vulnerability is a prominent feature of the doctor-patient relationship.
  • 35 - Publication ethics: obligations of authors, peer-reviewers, and editors
    pp 209-216
  • View abstract

    Summary

    A one-size-fits-all approach to pain management is not practical, nor ethically justifiable. This chapter explains pain management using the case study of a 61-year-old woman with metastatic colon cancer and intractable abdominal pain, as an example. Technological advancements within science and medicine have enabled prolongation of the lifespan for those patients with incurable diseases. Interventional techniques may be especially useful because of their capacity to effectively reduce pain, make patients more amenable to other therapeutics, and enhance patients' quality of life. Interventional pain management techniques and integrative pain medicine are underutilized, due to misperceptions by hospital operators and insurance companies about cost effectiveness. Employment of collaborative interventional techniques, however, has been shown to be both cost and time effective. Physicians should advocate policy development that is directed toward developing and enabling the profession and practice of pain/palliative care.
  • 36 - The impaired anesthesiologist – addiction
    pp 219-223
  • View abstract

    Summary

    Ethical problems presented by opioid-dependent patients suffering from pain are challenging, but can be guided by simple principles of ethical medical practice. This chapter presents three case studies on opioid therapy for addicted patients. The first is of a 35-year-old woman with chronic leg pain secondary to vascular damage from previous recurrent groin infections associated with intravenous opioid use. The second deals with a 34-year-old man with acute alcohol poisoning. The third focuses on a 40-year-old man with a significant history of drug misuse. The chapter then explains their resolutions from the UK perspective. A major problem with pain management in the patient with opioid dependency is lack of physician knowledge about appropriate prescribing; education of physicians is key to developing reasonable prescribing practices. A principle like that of "double effect" might be useful in defining appropriate physician behavior in relieving pain in the potentially dependent patient.
  • 37 - The impaired anesthesiologist – sleep deprivation
    pp 224-229
  • View abstract

    Summary

    This chapter discusses opioid therapy for addicted patients based on the three cases studies. Differences in history, culture, healthcare systems, laws, and attitudes have significantly affected perspectives on the ethical management of opioid use between the US and the UK. The present state of affairs is that abuse of prescription opioids is more prevalent in the US than abuse of "street" heroin. Opioid treatment of pain has periodically come under intense scrutiny in the US, resulting in fluctuations between under- and overtreatment of pain. Fears of civil or criminal prosecution may unduly influence physicians in the US, placing self-interest ahead of the traditional prioritization of beneficence and respect for patient autonomy. Differences between the US and UK in healthcare provision additionally influence opioid prescribing. The paternalistic approach more predominant in universal healthcare systems is not appropriate in the US, thus producing ethical dilemmas for the US physicians.
  • 39 - The abusive and disruptive physician
    pp 235-239
  • View abstract

    Summary

    This chapter presents a case study which contains a number of ethical issues of concern that could arise in other clinical anesthesiology research. A group of anesthesia researchers undertook a research project to determine if injection of a sedative drug into the subarachnoid space would improve effectiveness of pain control post-operatively for labor and delivery. The chapter focuses on the ethics of conducting research involving human subjects, in particular, some of the main ethical issues that arise with the kind of research conducted by anesthesiologists in clinical settings. It discusses the three areas where these issues are especially important for the ethical conduct of clinical anesthesiology research: enrollment and consent, potential conflicts of interest, and the balance of risk and benefit. Subjects should be given sufficient time to reflect on the information they are given about the research study.
  • 40 - Sexual harassment, discrimination, and faculty–student intimate relationships in anesthesia practice
    pp 240-244
  • View abstract

    Summary

    This chapter considers what it means to say that a being deserves moral consideration. It addresses the question what it means to say that a being has a right to life. The chapter explores the meaning of a right to life and considers the claim that, even if a being lacks a right to life, it deserves to have its interests taken into account. It considers three distinct answers: the conservative view, liberal view, and the moderate view to the issue of moral distinctiveness about humanity. Despite the fact that Immanuel Kant's philosophy encourages the humane treatment of animals, critics charge that it gives insufficient regard to animals. The chapter presents Peter Singer's seven ideas of argument against certain forms of animal experimentation. For Singer, the ethically crucial requirement is that our actions produce as much pleasure and happiness and as little pain and misery as possible for all beings.
  • 41 - Conflicts of interest – industry gifts to physicians
    pp 245-249
  • View abstract

    Summary

    Most reviews addressing the ethics of animal research describe this debate as a war of wills between scientists and animal rights activists. Ethical arguments favoring animal experimentation generally fall into two categories: humans have higher moral standing than animals and have a right to use animals in experiments that better human lives, and the benefits of animal experimentation outweigh the harms, and that animal experimentation is sometimes the only way in which science can answer important questions necessary to human well-being. Mainstream scientific study has now challenged long-held beliefs that animals are fundamentally different than humans in many morally relevant ways. The 3Rs of animal research ethics: replace, reduce, and refine have been adopted internationally in legislation and regulations regarding animal research. Animal researchers have ethical obligations to seek alternative models whenever possible, to offer humane care that reduces pain,distress and harm when using animals in research.
  • 42 - Disclosure of medical errors in anesthesiology practice
    pp 250-254
  • View abstract

    Summary

    Regulation of human subjects research has evolved in the wake of scandals involving mistreatment of human research subjects. In practice modern Institutional Review Boards (IRBs) are responsible for assuring that investigators are in compliance with the regulations regarding human subjects research. One of the principal obligations of IRBs is the determination of the level of risk posed to a participant and assuring that the risks are both acceptable and minimized by appropriate research design risk. A frequent complaint leveled against current IRBs is the tendency to review the scientific design of a research proposal. Early declarations regarding the ethical treatment of human research subjects include the Nuremberg Code, and the WMA Declaration of Helsinki. The description of the Tuskeegee Experiment was a watershed event in the history of US human research ethics, leading to the publication of the Belmont report elaborating the ethical principles in treatment of human subjects research.
  • 43 - Physician conscientious objection in anesthesiology practice
    pp 257-260
  • View abstract

    Summary

    This chapter focuses on two specific populations of individuals often vulnerable in the conduct of research: children and prisoners. With children, prisoners, and other vulnerable populations, the challenge is to find the right balance between protection from abuse and the need to grant vulnerable populations access to participation in research. Necessary protections have two components: fair subject selection, and the specific care required to minimize wrongs to vulnerable persons once they are enrolled in research. As a group, prisoners are vulnerable due to their particular situation: being detained and therefore being deprived of the freedom to move freely. Several prison-related factors are relevant for ethical considerations about research involving prisoners. Studies designed to address health problems specific to a vulnerable population are needed to improve care for this very population, and often cannot be conducted on others.
  • 44 - The ethics of expert testimony
    pp 261-265
  • View abstract

    Summary

    Research on the management of pain and other symptoms is crucial to provide better care for acute, postoperative, and chronic symptoms, as well as better symptom management at the end of life. Some aspects do present difficulties more specific to the context of symptom management studies. These include difficulties related to scientific methodology, fair subject selection, obtaining a favorable risk/benefit ratio, and informed consent. Researchers always have the obligation to obtain informed consent from research subjects. Even with explicit patient consent, the researcher has the obligation to minimize risk and discomfort to the patient. Research involving symptomatic relief at the end of life is ethical, but requires special considerations. Particular attention to subject comfort and safety is important in placebo-controlled trials. Patient assessment of benefits and burdens may shift during the trial and require reconsideration.
  • 45 - Ethical principles regarding physician response to disasters: pandemics, natural disasters, and terrorism
    pp 266-269
  • View abstract

    Summary

    Quality improvement (QI)/quality assurance (QA) has evolved from an informal retrospective review of individual cases involving critical incidents, to large retrospective analyses and evaluation of physicians, departments, hospitals, and healthcare systems. Some forms of QI activity actually represent human subjects research, with potential for patient harm. As such, similar ethical imperatives should apply in protecting patients from unconsented research when QI initiatives involve significant changes in patient care. As rationing and cost-containment efforts increase, institutional review boards (IRBs) may come under increasing pressure, and therefore experience conflicts of interest, with regard to evaluation of cost-containment QI activities. The Electronic Medical Record (EMR) carries powerful potential as a tool in QI and cost-containment efforts. Use of patient records carries risk for future privacy conflicts necessitating revision of the Code of Federal Regulations (CFR) and OHRP's regulatory authority in federal policy creation.
  • 46 - Triage in civilian mass casualty situations
    pp 270-274
  • View abstract

    Summary

    One of the most harmful adverse consequences of conflicts of interest in research is the potential introduction of bias into the science of medicine and the denigration of the integrity of scientific research. A number of facts support the concerns that financial conflicts influence the integrity of medical research. The potential for conflicts of interest can never be eliminated, but conflicts of interest can be managed and, in some cases, reduced. Strategies for doing so are most useful when they are matters of institutional and editorial policies that are focused on preventing the adverse effects of conflict of interest and are not unduly burdensome. Disclosure is the most common first step in managing conflicts of interest. Public disclosure of raw scientific data and independent monitoring of research are additional mechanisms for managing conflicts of interest. Policies and guidance on conflicts of interest are changing rapidly.

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