AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. March 2015, Volume 17, Number 3: 199-201.

From the Editor

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Ethics and the Practice of Anesthesia

Introduction to the March 2015 issue of the AMA Journal of Ethics (formerly Virtual Mentor) on the theme of ethical questions in anesthesiology.

Anesthesia began in 1846, when an American dentist administered diethyl ether to a patient undergoing neck surgery [1]. Initially, anesthesia practice was limited to rendering patients unconscious and without pain or movement during surgery. Over the course of the next century, new knowledge, technology, and drugs enabled anesthesiologists to manage physiologic derangements caused by anesthetics and surgery [1]. Although the care of patients undergoing surgery remained the mainstay of anesthesia practice, it soon expanded to include the management of all types of pain.

Rapid technological growth and the expansion of anesthesia into obstetrics, pediatrics, pain management, and critical care raised many issues—social, legal, medical, and ethical. Danish anesthesiologist Bjørn Ibsen established the first intensive care unit in Copenhagen during the 1950s [2]. Given their adeptness in physiology, pharmacology, and resuscitation, anesthesiologists were well-positioned to develop critical care, which requires expertise in airway management, continuous monitoring, cardiovascular and respiratory support, pain control, and resuscitation. Although intensive care therapy reduced overall patient mortality and improved survival, many patients on mechanical ventilation and cardiovascular support suffering from irreversible brain damage did not recover [3, 4]. Critical care medicine raised enduring questions of when to withdraw therapy, whether physicians should provide clinically unindicated care, and when to declare an unconscious person dead [3, 4].

Anesthesiologist John Bonica, who is credited with establishing the first multidisciplinary pain clinic during the 1960s, indelibly shaped the future of medical ethics when he asserted that pain was a “fundamental element of human suffering” and that pain relief was a basic human right [4].

Anesthesiologists continue this tradition of leadership in ethics and medicine [5, 6]. This issue of the AMA Journal of Ethics explores the ethical issues that anesthesiologists confront in their daily practice. Three case commentaries raise questions about informed consent and therapeutic privilege, interprofessional communication, and chronic pain management. Katherine L. Zaleski, MD, a clinical fellow in anaesthesia at Boston Children’s Hospital, and David B. Waisel, MD, associate professor of anaesthesia at Harvard Medical School, discuss whether physicians have more latitude in withholding relevant information when treating patients with severe anxiety. Gail A. Van Norman, MD, an anesthesiologist and bioethicist at the University of Washington, examines how abusive and disruptive behavior among physicians in the OR can interfere with teamwork and result in decreased patient safety. And Emory University anesthesiologist Anna Woodbury, MD, addresses conflicts between chronic pain patients and their physicians about how best to treat patients’ refractory pain.

Two other essays also deal with the social and psychological aspects of pain management. Anita Gupta, DO, PharmD, an anesthesiologist at Drexel University, argues that solutions as simple as more effective communication can improve patients’ experiences with pain management. And social psychologist Brian B. Drwecki, PhD, of Regis University, offers his views on how medical schools can partner with social scientists to study, and design educational interventions to reduce, the effects of racial bias in pain treatment in medical education.

Anesthesiologists care for patients at the extremes of health and illness, frequently employing life-sustaining technologies and procedures to restore health. Patients have the now widely recognized right to reject life-sustaining procedures, but this right once stood in conflict with the tradition of physician paternalism and authoritarianism derived from virtue-based ethics [5]. Critical care intensivists Allan B. Peetz, MD, and Nicholas Sadovnikoff, MD, of Brigham and Women’s Hospital, and Michael F. O’Connor, MD, of the University of Chicago, discuss whether it is possible for patients to give true informed consent to extracorporeal life support. Stephen Jackson, MD, of Good Samaritan Hospital, discusses the historical evolution of do-not-resuscitate (DNR) orders, and the practice of automatically suspending them during anesthesia and surgery.

Recent initiatives in health policy reform have led anesthesiologists to develop the perioperative surgical home as a counterpart to the patient-centered medical home. Jason D. Hall, JD, Lee A. Goeddel, MD, MPH, and Thomas R. Vetter, MD, MPH, of the University of Alabama at Birmingham, where a model perioperative surgical home exists, consider the ethical implications of that model. University of Chicago anesthesiologist and American Society of Anesthesiologists (ASA) chief quality officer, Richard P. Dutton, MD, MBA, discusses two arms of the ASA—the Anesthesia Patient Safety Foundation and the Anesthesia Quality Institute—and their respective approaches to patient safety and care quality.

Other parts of this issue explore anesthesiology’s history. In the podcast, University of Mississippi anesthesiologist and medical historian Douglas R. Bacon, MD, MA, discusses why anesthesia has been described as a uniquely American contribution to medicine. Kathryn E. McGoldrick, MD, an anesthesiologist at New York Medical College, narrates the evolution of professionalism in anesthesia over the past century. Donald Caton, MD, a medical historian and emeritus professor of anesthesiology at the University of Florida, reflects on how social values have both spurred and constrained the medical management of obstetric pain.

In a special contribution to this issue, David B. Waisel, MD, discusses the range of actions that board diplomates in any specialty take when they become disaffected or question a medical board’s actions. To illustrate, he recounts that in 2010 the American Board of Anesthesiology became the first physician organization to support punitive actions (including revocation of certification) for physicians who participate in capital punishment [5] and that, more recently, the American Board of Obstetrics and Gynecology attempted to redefine the scope of obstetric-gynecology care by forbidding gynecologists to care for men (a move which has now been reversed) [7].

The goal of this issue of the AMA Journal of Ethics is to provide a practical introduction to ethical questions in anesthesia. Many other ethical issues and questions remain, particularly as anesthesia practice evolves in response to a changing health care system. Whether you are an ethicist, medical student, resident, nurse, or attending physician, we invite you to explore this issue of the AMA Journal of Ethics and consider these critical ethical questions in anesthesiology.



References

  1. Caton D. The history of anaesthesia. In: Encyclopedia of Life Sciences. Chichester, UK: John Wiley and Sons; 2005. http://onlinelibrary.wiley.com/doi/ 10.1038/npg.els.0003621/full. Accessed January 29, 2015.
  2. Sykes, MK, Bunker JP. Anaesthesia and the Practice of Medicine: Historical Perspectives. London, UK: Royal Society of Medicine Press; 2007.
  3. Shephard DAE. From Craft to Specialty: A Medical and Social History of Anesthesia and Its Changing Role in Health Care. Thunder Bay, ON: York Point Publishing; 2009.
  4. Jackson SH, Van Norman G. Anesthesia, anesthesiologists and modern medical ethics. In: Eger EI II, Saidman LJ, Westhorpe RN. The Wondrous Story of Anesthesia. New York, NY: Springer; 2014:205-218.
  5. Van Norman GA, Rosenbaum S. Ethical aspects of anesthesia care. In: Miller RD, ed. Miller’s Anesthesia. Vol1. 7th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2010:209-220.
  6. Waisel DB. Legal aspects of anesthesia care. In: Miller RD, ed. Miller’s Anesthesia. Vol 1. 8th ed. London, UK: Elsevier Saunders; 2014:221-236.
  7. Waisel DB. Revocation of board certification for legally permitted activities. Mayo Clin Proc. 2014;89(7):869-872.

Matthew L. Edwards MS-3 University of Texas Medical Branch Galveston, Texas

Acknowledgement

I would like to thank David B. Waisel, MD, of the Harvard Medical School for his mentorship and support. Acknowledgement is also due to Donald Caton, MD, for nurturing my interests in medical history, and to Howard Brody, MD, PhD, for supporting my interest in medical ethics.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.