Clinical Ethics in Anesthesiology. A Case-Based Textbook


Anesthesiologists have broad representation in private and academic clinical practices, clinical and laboratory research settings, intensive care units, palliative care facilities, pain treatment centers, journal review boards, and expert panels charged with legislative initiatives and practice guidelines, to name a few. Ethical questions abound in all walks of anesthesia practice; this is abundantly clear to the editors of this book, all of whom have been members and/or chairs of the American Society of Anesthesiologist’s Committee on Ethics since its inception in the early 1990s*. The committee receives a steady flow of communications from anesthesiologists seeking answers to questions, wanting someone to vent their frustrations to, and/or asking for reassurance that they “did the right thing.” It is moving testimony to the importance ethical principles hold for most members of the specialty.

But while the importance of physician understanding of ethical principles in the practice of medicine is almost universally recognized, few resources exist specific to anesthesia practice or the issues facing anesthesiologists in other settings. This textbook respectfully follows the footsteps of such books as Draper and Scott (Ethics in Anaesthesia and Intensive Care, Butterworth-Heineman 2003), and Scott, Vickers and Draper (Ethical Issues in Anaesthesia, Butterworth-Heineman, 1994).

While the ethical issues facing anesthesiologists are a numerous and varied as anesthesia practice itself, some general themes emerge. We considered issues roughly (and admittedly artificially) divided into 6 categories. In Section 1 (Informed consent and refusal), common issues such as Do-not-resuscitate orders, and the Jehovah’s Witness patient are covered as are more controversial issues, such as anesthesiology involvement in female circumcision. Maternal-fetal issues are explored in the context of “Ulysses directives” and maternal demand for cesarean section delivery. Consent issues in non-Westernized cultures where autonomy may not be the dominant principle are reviewed. In Section 2 (End-of-life issues), withholding and withdrawing treatments includes considerations of discontinuing cardiac assist devices, organ transplantation issues such as donation-after-cardiac death (DCD) and the legislative efforts of anesthesiology experts, and euthanasia. Section 3 (Pain management) includes different considerations in management of addicted patients in the UK and US settings. In Section 4 (Ethical issues in research and publication), controversial topics concerning the treatment of animals and animal rights are included, as are the relatively new debates around quality improvement initiatives as research, and the pivotal roles of authors, editors and reviewers in publishing medical information. Dealing with the addicted or disabled provider, sleep deprivation, industry gifts to physicians, disclosure of errors to patients, and physician conscientious objection are covered in Section 5. Section 6 concerns anesthesiologists in their roles and duties within the state: expert testimony, response to disasters, ethical issues in the military, torture, and physician involvement in lethal injection of prisoners.

Physicians are educated in their art by study and contemplation, but also, if not primarily, by involvement in and discussion of cases and their management. Highly abstract analyses of ethical issues is not always well understood or received because physicians deal in real-life situations, and seek both practical understanding and advice. For the most part, we have tried to imitate and emphasize the case-based nature of medical education throughout the book. Chapters begin with a case example. By reading the case and subsequent discussion, the authors have attempted to discuss the major issues and principles involved in each case. Where possible, they have proposed some example resolutions, and a list of important points close each chapter. While it is not possible to anticipate the entire scope of complexity of ethical issues that might present in any one case, it is our goal that the discussion fosters thoughtful reflection and aids the physician in future case management.

Because even among Western countries, the perspectives on ethical controversies in medicine are not always in agreement, we have purposefully sought authors from different nationalities, educational backgrounds, and practice experiences to provide international breadth to the book. Whenever possible, resources are cited regarding management in both US and European settings.

The chapter discussions are not meant to provide an exhaustive list of references for each and every issue’to do so would add unnecessarily to the volume of the book, and distract from the main purpose, which is both philosophical and practical discussion. Where needed, we have supplied in the References at the end of each chapter any key resources. Other important, but non-cited readings are included in a “Further reading list” to aid readers in expanding their knowledge of specific topics. In both of these lists, those readings felt to be especially helpful, historic, or even controversial are highlighted with an asterisk.

I would like to personally acknowledge all of the wonderful people who contributed so substantially to the creation of this book. Stephen Jackson and Susan Palmer introduced me to the discipline of medical ethics through their brilliant and compassionate teaching and leadership. Stanley Rosenbaum has been the intellectual and ethical foil, and wonderful friend that all students should be as lucky as I was to find early in their studies. Not only has each been a teacher and friend to me for many years, each has worked tirelessly to write, edit, and provide “moral” support throughout the production of this book. Sadek Beloucif has graciously and patiently providing insights about the different perspectives in Western medical ethics. A host of learned authors and ethics experts willingly and generously contributed their time and effort’many of them meeting last-minute requests and short deadlines to provide chapters and changes. They all have my heartfelt thanks.

From Cambridge University Press, thank you also to Nick Dunton, who embraced the idea, and to Deborah Russell, Laura Wood, Rachael Lazenby, Nisha Doshi and Mary Sanders, who kept it going, to Jonathan Ratcliffe who didn’t complain about all of the changes, and everyone of the wonderful production staff who made this book possible. Gail A. Van Norman MDSeattle, WA USASummer, 2010