Paediatric Anaesthesia 1997 7: 363–369

Review articleEthics and anaesthetics

DONALD EVANS BA, PhD

Director, Centre for Philosophy and Health Care, University of Wales Swansea,Swansea SA2 8PP, UK

Keywords: ethical values; intensive care; euthanasia; electiveventilation; advance directives; prenatal and perinatal care

Introduction and colleagues and thereby be morally objectionable.Yet moral considerations range more widely than

New technologies have placed powers in the handsthe question of professional expertise. The most

of clinicians which present them with problems abouteffective anaesthetist could practice in morally

the limits of proper practice. These problems haveobjectionable ways. This is best recognized by

led to much public discussion about medical activitiesremembering the subject matter of the

which has heightened patients’ awareness of theiranaesthesiologist’s practice—people.

rights and interests. These more critical attitudes toPeople have their own perceptions of their

medical practice, professional uncertainties and thecircumstances and conditions, their own life-plans,

threat of litigation have together encouraged thefears and hopes. As patients they are most vulnerable

growth of the new discipline of Health Care Ethics.needing the safe delivery of a healthy child, relief of

Some key concepts have emerged which togetherdebilitating pain, cure of life-threatening diseases,

cover most of the concerns of practitioners, includingamelioration of gross disfigurements and so on. All

anaesthesiologists. However, their influence in theof these are huge prizes to be sought and almost any

practice of anaesthesia will be different in importantprice will be paid for them. But should unnecessarily

respects from that in the general practice of medicinehigh prices be demanded? Once we remember that

and surgery.these are people and not simply bodies to be servicedwe invoke a range of values which mark out the

Values in medicine elements of decent human life. It is an examinationof these values with which health care ethics isWhat is a good anaesthesiologist?concerned.

There are two elements to an adequate answer tothis question. The first concerns the exercise of skills Identifying values in medicinenecessary to facilitate the aims of anaesthesia, paincontrol or intensive life support. To be effective the Much of the literature which has emerged in

health care ethics over the past twenty years hasanaesthetist must be able to identify the outcomesaimed for in practice, design adequate means for concentrated on four ideas, autonomy, beneficence,

nonmaleficence and justice (1). Most of those whotheir achievement and execute them. The nature of askill is thus understood as a means-ends relationship. have been impressed with the importance of these

ideas have been tempted to regard them as moralThe most efficient practitioner will maximize theends while minimizing the means avoiding waste principles. This is problematic for they are certainly

not ethical routes to resolving moral problems andof resources—itself an ethical consideration. Aboveand beyond this consideration however lies the vital practitioners cannot uncritically apply them as such

to resolve apparent dilemmas they might face. Forobservation that an unskilled anaesthesiologistwould constitute a hazard to the welfare of patients example: if the anaesthesiologist has the difficulty of

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deciding whether a patient should be anaesthetized anaesthesiologists this will involve sharing adequateinformation about their procedures—including datafor vital surgery when the procedure of anaesthesia

is itself extremely risky the moral problem of what about risks and alternative courses of action—inobtaining consents, and will present special problemsought to be done is created by a tension between

respect for the benefit of the patient (beneficence) in intensive care, for example, where the issues ofcompetence and identification of the authentic wishesand a concern to do no harm (nonmaleficence). If

these two considerations together create the problem of the patient arise. Anaesthesiologists also face theadded difficulty, referred to in section two below, ofit seems unreasonable to expect an application of

them to be of much assistance in deciding how to facilitating procedures for which no proper consenthas been obtained by those carrying out theact. This is not to devalue the importance of the

notions—they are clearly fundamental moral ideas procedures in question.which we ignore at our peril. Nevertheless torecognize their significance is not to place false hopes

Beneficenceupon their practical usefulness in resolving ethicalproblems.

The traditional image of the practice of medicine hasIf we are to have a rounded picture of the main

been built on this value captured in the descriptionideas which form the ethical dimensions of clinical

of that practice as ‘providing medical care’. A concernpractice we should probably add two further ideas,

for the welfare of patients or for the benefits medicalnamely dignity and truthfulness. These values are

intervention can provide to patients characterizesnot totally exclusive of each other but to delineate

the endeavour of practising medicine. Thethem helps focus attention on the origins and nature

anaesthesiologist is not excluded from this concernof ethical problems in medical practice. It is likely

facilitating such provision in making surgicalthat most, if not all, moral problems which face

interventions possible and actually providing suchpractitioners arise because of tensions between two

benefits in palliative medicine and intensive care. Yetor more of these considerations. A brief consideration

showing respect for the welfare of others is not aof each of them will illuminate most of the ethical

straightforward matter. As elsewhere in medicine itdilemmas faced by anaesthesiologists.

is not always obvious what counts as a benefit,nowhere more problematic than in intensive care andresuscitation. There are also difficulties presented byAutonomythe possible gulf between the patient’s perception

This feature of human life is best understood byof benefit and that of the clinician—here tensions

considering a group of people who lacked it, viz.between autonomy and beneficence are most likely

slaves. They were reduced to chattels or instrumentsto occur.

for the purposes of others. Their own perceptions,wishes, hopes and projects counted for nothing. Whatshould be done to them or what they should do Nonmaleficencewas always decided by others on whom they weredependent and to whose authority they were subject. The Hippocratic oath incorporated a pledge that,

above all, the physician would do no harm to theIt has been argued that the practice of medicinehas been characterized by the exercise of an authority patient. Respecting this value has the same problem

as its obverse, the value of beneficence, namely, thereon matters concerning patients’ best interests andtreatment to which it is not entitled (2). Certainly may be disagreement over what constitutes harm.

For example some women regard the use of epiduralduring recent years the issue of patient autonomyhas enjoyed a higher profile and has focused on anaesthesia as an example of high tech medicine

dehumanizing the experience of childbirth whereassecuring informed consent for medical interventionsand for entering patients into clinical research it might seem obvious to the anaesthesiologist that

the relief of unnecessary pain is an unquestionableprojects. The salient feature of a regard for this valueis the need both to enhance the independence benefit (3). Nowhere is this problem of identifying

harms more evident than in the application of theof patients and to protect their freedoms. For

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ETHICS AND ANAESTHESIA 365

doctrine of double-effect in cases of palliative care by the fact that they are desperately dependent onreceiving help from others. Any action whichwhich accelerate the moment of death.reinforces that loss of self respect is to be condemned.This may be most notably observed where the mostTruthfulnessstrenuous and heroic efforts are made to extend lifeby means of new technology available to intensivists.In the history of ethics it has been argued that thisThere has been much discussion about the possibilityis an absolute value allowing of no exceptions (4)of death with dignity being denied to growingand that it is a central or fundamental moral notionnumbers of patients for whom more is done thanunderlying even the existence of language henceshould be simply because the technology is there.thought (5). What is universally recognized is thatThe same may be true even for simpler treatment—astruthtelling is a moral consideration. It is crucial toone philosopher has expressed: ‘Even when a deaththe relationship of trust which exists between doctorof one’s own is a poor consumer choice, it is a properand patient, but respecting it in clinical practiceexercise of human dignity’ (6). That is not to say theis far from straightforward. There are the practicaldecisions whether to withdraw or deny treatmentdifficulties of imparting complex and sophisticatedare ever easy but to point out the importance of notinformation to patients who may be medicallylosing sight of a value which informs the experienceuntutored and whose state of mind might militateof the patient and the patient’s family.against the comprehension of threatening

information.Sufficient information for a reasonable person to Justice

make a reasonable decision is all that is required inJustice as fairness might be thought to underlie alltelling the truth to patients. Doctors should not tryother justifications for action. Of any treatmentto hide behind the smokescreen of allegedly tryingdecision one might always ask ‘Is it fair?’. Theto impart the impossible to the incapable. Indeed noquestion arises most frequently nowadays in medicalone knows the whole truth about the outcome ofpractice in connection with the allocation ofany proposed medical intervention. Once again theresources. Given the unbridgeable gap between needgreatest challenges will arise when this moral valueand resource some form of rationing is inevitable.comes into tension with other moral values such asBut where and how is it to be applied? No practisingbeneficence. Such a tension is evident in all risk/clinician is free from responsibility for making thebenefit or harm/benefit calculations. There may bebest use of resources and avoiding waste, for whatsituations where imparting information to a patientis wasted on one patient is denied to another.could be dangerous. An example might concern the

Consider the problems the anaesthetist faces whenproposed administration of an anaesthetic wherethe choice lies between using the optimum treatmentthe parlous condition of a patient made this highlyfor the presenting patient and ensuring a servicedangerous yet where it was necessary for life-savingto the largest possible number of patients. A trialsurgery which the patient most certainly wanted.antiemetic drug, which happened to be extremelyImparting this information might well precipitate theexpensive and had been developed for use incatastrophic result which the clinicians were tryingchemotherapy, was recently proposed for use asto avoid.a prophylactic administered during anaesthesia.Imagine that its application produced nausea-freeDignityrecovery for all patients to whom it was administeredand as such constituted the best known prophylacticWhilst this value might be construed as simply being

respect for persons, a respect served by all the other treatment for the condition with all the resultantbenefits. The question still arises as to whethervalues so far considered, a more precise delineation

of the value is possible. We have already noted anaesthesiologists should insist on using it on thebasis that the doctor must do the best for the patient.the special vulnerability of patients. Their image

of themselves is often impaired by the ugliness or Such provision would be so expensive as to rule outmuch provision of necessary care to others. Thus aembarrassing nature of their condition, or merely

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366 D. EVANS

tension arises between the respect for the welfare of hands of the reponsibility for such unacceptablestandards of care by appealing to a division of labourthe presenting patient and the unfairness of denying

treatment to future patients. according to which he is seen to be responsible onlyfor a limited range of occurrences relating to thesustaining of vital functions? In some cases the

Special problems for the answer to this question is clearly no, for those vitalanaesthesiologists functions may themselves be threatened by the

negligence of the surgeon. Consider cases whereHaving made these general remarks about the valuesthe poor condition of a patient calls for the mostwhich inform the practice of all health careconservative intervention and the shortest possibleprofessionals we need now to note the peculiartime is theatre. Here, a complex and unnecessarilycontext in which they apply in the practice ofextended procedure would be unjustified. Yetanaesthesia and the differences this can make.temptations to proceed—maybe in the interests ofresearch, or a doctrinaire attachment to a favoured

The anaesthesiologist/patient relationship regimen—do exist. For the anaesthesiologist toremain silent on the matter ethically compromises

This relationship is akin to the standard doctor/him and calls into question the standards of his own

patient relationship in some areas of practice butpractice.

significantly different in others. Indeed it is in theThere are more difficult cases however, where the

most traditional role of the anaesthesiologist that thelong term welfare of the patient might be threatened

differences are greatest.by substandard execution of acceptable surgicalprocedures. Here the anaesthetist’s responsibility forsustaining vital functions is not compromised at all.The context of surgeryYet such harm as might result from such episodes

Anaesthesiologists are directly responsible to the are also inflicted by courtesy of anaesthetic activity.patient for the interventions made in anaesthesia and The ethical picture is complicated by rival obligationsthe sustaining of vital bodily functions in the course of the anaesthesiologist to professional colleagues,of the anaesthetic and this is the normal doctor/ the reputation of the health care professions and topatient relationship. However, their activity extends the patient. Whilst whistleblowing might be thebeyond these parameters. In rendering the patient option of last resort for respecting the doctor/patientunconscious they are facilitating the activity of relationship—consultation with surgical colleaguesothers, most notably the surgeon and thus become and refusal to proceed with such procedures beingaccomplices or aiders and abettors of what is done exhausted—there might be no other way for anin surgery. However, it does place a peculiar moral anaesthesiologist to go in responsibly discharging hisburden on them, viz. a partial responsiblity for the duty of care to the patient.welfare of the patient with respect to interventionsmade by others. It is worth pointing out precisely

Researchhow this occurs and its implications. There are threemajor situations where there is need for vigilance Special problems are created by the treatment ofand where the anaesthesiologist might be placed in patients in the interests of others but all clinicalan invidious position. research activities do involve such activity. We shall

later canvass a particularly worrying set of such casesin which intensivists have been invited to participateNegligenceand which involve no research interest. Indeed thereis a good argument that therapeutic research is anIf the surgeon performs procedures which fall below

acceptable standards and consequently jeopardizes empty notion and all clinical research, where a nullhypothesis is being tested, is in the interests only ofthe welfare of the patient he does so under the

auspices of but not with the consent of the future patients (7). It is thus crucial that such researchbe scrutinized by independent ethics reviewanaesthesiologist. Can the anaesthesiologist wash his

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ETHICS AND ANAESTHESIA 367

committees to protect the interests of research of technology in medicine with the attendantproblems of how these new powers ought tosubjects and the issue of informed consent of the

research subject to the procedure will be top of its exercised. From this role many problems arise whichdeserve greater discussion beyond the scope of thislist of priorities. Difficulties are created where the

line between research and practice is not easy to paper. These are bound up with ideas such as futilityand quality of life, the adoption and applicationdraw (8). This is especially the case in surgery where

new techniques often emerge as a result of a series of brainstem death criteria, the identity of clinicaltreatments, the distinction between active and passiveof incremental changes each of which might be small.

Nevertheless patients need to consent to become euthanasia, the use of advance directives and oforders not to resuscitate. For example, the Tony Blandresearch subjects. Where there is doubt whether a

procedure is research or part of clinical practice then case raised most of these issues (9), including thecontentious matter of whether feeding should bethe matter should be decided by the independent

authority. In other cases it will be clear that a regarded as a clinical treatment, if so whether it wasfutile in his case, whether he died in his accident threeprocedure does constitute part of an ongoing

research project. If the anaesthesiologist has any years before his vital functions ceased in hospital andwhether withdrawal of care constituted killing. Fordoubts about the willingness of the patient to be a

research subject then, again a morally compromised the purposes of illustrating the difficult terrain inwhich intensivists are called upon to practise Iposition exists with similar options open as in the

negligence cases. propose to consider the issue of elective ventilation,an activity exclusively the responsibility ofanaesthesiologists.

In these cases we are presented with patients whoseEducationcondition is so grave that treatment is thought to be

It is obvious that all surgeons have to make a firstfutile and is thus witheld. A subsequent decision to

incision, perform a first organ transplantation,ventilate the patient with a view to harvesting organs

appendicectomy, by-pass or whatever according tofor transplantation to other patients is then envisaged.

their speciality. This entails that someone is destinedOn a purely consequentialist analysis this might seem

to be the first subject upon whom they will practiseto be perfectly justifiable—some lives may be saved

their imperfect skills. General consent forms do notand others enhanced, the death will not seem

usually guarantee to the patient the identity of thepointless for those who mourn, and nothing is lost

personnel performing any part of their surgery whichas the patient is already irreversibly unconscious

allows for such teaching and learning to proceed.with no prospects of a meaningful life. But matters

Whether it should be more specific is a moot point.are not as straightforward as they appear. The patient

It is certainly the case, however, that the interests ofis not yet certified dead—indeed harvesting cannot

patients should be properly safeguarded if they areoccur until brainstem-death criteria are satisfied—is

to be used for the purposes of clinical education.not being treated for his benefit and has not consented

Thus proper supervision and the presence of suitableto being treated for the sake of others. To treat at all

senior practitioners are the sine qua non of acceptableon this basis amounts to battery. Additionally

practice in this area. Where anaesthesiologiststhere are consequentialist reasons for resisting

facilitate such education but are dissatisfied with thesuch procedures—the relationship of trust between

standards of supervision or the degrees ofpatients and medical professionals might be

responsibility devolved to hands-on practitionersweakened if patients cannot be reassured that in all

they are once again in an ethically sensitive positioncircumstances their interests will take precedence

and might be forced to intervene in order to properlyover the interests of others with respect to their own

discharge their responsibilities.treatment. Also it will be impossible to separateclearly and properly responsibilities for care of the

The context of intensive care patient and care of other patients in a unit where thepolicy of elective ventilation operates. Consent byThe role of the intensivist has placed

anaesthesiologists at the sharp end of the application relatives in circumstances of such emotional pressure

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368 D. EVANS

may be regretted on reflection and so be regarded of them (13). The problems for the practitioner lie inthe application of these apparently objective tests. Itas unsafe and harmful. The major problem for

anaesthesiologists is that the welfare of the ventilated is almost impossible to divorce the doctor’s valuesfrom the business of assessment of competence. Forpatient in these cases is their responsibility yet their

activity vis-a-vis that patient is wholly disinterested example there might be radical disagreement overwhat is thought to constitute a reasonable outcome.in that patient’s welfare and is taken up with

maximizing the possibilities of restoration of health This is precisely the problem involved in a patient’srefusal to consent to what the practitioner clearlyto other patients. These problems exist over and

above the problems associated with the worries some believes to be a beneficial intervention. The dangeris that the patient will be in a situation wherehave about the removal of beating hearts from donors

on the strength of certification of death by means of agreement to a treatment will result in its applicationand refusal to agree will also result in its applicationthe application of brainstem death criteria.on the grounds that the refusal demonstrates theincompetence of the patient (14). Similar problemsPeculiar problems for the paediatricare faced by practitioners dealing with other groupsanaesthesiologistof supposed incompetents.

Finally, I wish to draw attention to a developingThe paediatric anaesthesiologist has to tackle all theethical challenges alluded to above in a context which area of ethical difficulty faced by the paediatric

anaesthesiologist facilitated by the developments ofintensifies them. The focus of this special area ofethical concern is the issue of consent. modern medicine. It is not at all clear whose

responsibility the welfare of the viable fetus is withChildren have traditionally been categorized asincompetents with respect to the giving of consent respect to surgical interventions to treat the fetus.

Whilst in postnatal care clearly the paediatricto treatment, however, the matter has beencomplicated by various judgements in the courts anaesthetist will be responsible, in perinatal care the

situation is not obvious. It partly depends upon theover the past ten years or so. Following the Gillickjudgement (10) a person under the age of sixteen identity of the patient. If the fetus is to be regarded

as the patient then it would seem that somecould consent to a treatment as long as that personwas thought to understand the nature of the responsibility should be borne by the paediatric

anaesthetist. On the other hand treatment of fetaltreatment which was being proposed. But ‘Gillickcompetence’ has been subjected to challenges in patients inevitably involves treatment of another

patient, viz. the carrying mother. Whilst no consentsubsequent judgements (11).However, a refusal to consent to treatment by a can be sought from the fetal patient the competent

mother cannot be ignored. But is her refusal ofminor does not carry the same weight as anagreement even when the competence of the minor intervention to assist the fetus to be regarded as

final? Until recently the answer was an obvious yes,is not doubted (12). There are ethical problemsattached to this restriction arising out of tensions but this is no longer clear following the decision in

the case of Re F (15) where the refusal of the motherbetween the judgement which embodies it and theGillick judgment. The paediatric anaesthesiologist to consent to a Caesarian section for religious reasons

was overruled by the courts in the interests of thehas this difficulty with respect not only to the consentto anaesthesia but also the consent to the facilitated fetus which sadly died in spite of the procedure. It

is possible only to speculate about possiblesurgery.Notwithstanding this extra complication in the case judgements in cases where it is in the interests of

the fetus to undergo some surgical procedureof refusal, the legal judgments leave the clinician withthe responsibility for determining the competence of which would necessitate anaesthesia and surgical

intervention for the mother, though it is of interestthe minor and there is no universal agreement onwhat constitutes competence. The most familiar to note that court orders for intrauterine blood

transfusions have been granted in the United States.criteria are evidence of choice, reasonable outcomeof choice, good reasons for choice, patient capacity Maybe this is a new frontier of ethical problems the

paediatric anaesthesiologist will be called upon toto understand the issues and actual understanding

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ETHICS AND ANAESTHESIA 369

of Morals, (Trans. Mary Gregor), Cambridge: Cambridgetackle which will call for conceptual clarificationUniversity Press, 1991: 225–227.about the identity of the fetus as a patient (and 5 Winch P. Nature and Convention. In: Ethics and Action, London:

possibly as a paediatric patient) and the question of Routledge & Kegan Paul, 1972: 61–69.6 Hollis M. A death of one’s own. In: Bell JM, Mendus S,the legal rights of fetuses before the ethical issues

eds. Philosophy and Medical Welfare, Cambridge: Cambridgecan be properly addressed.University Press, 1988: 15.

7 Evans D, Evans M. A Decent Proposal: Ethical Review of ClinicalResearch. Chichester: John Wiley & Sons, 1996: 43–46.

References 8 Evans D, Evans M. op cit.: 51–61.9 Airedale NHS Trust v Anthony David Bland, (1993) 1 All E R

1 These principles have figured in philosophical ethics for many 821.years. (For example, Ross WD. The Right and the Good, Oxford: 10 Gillick v West Norfolk and Wisbech Area Health Authority, (1986)Oxford University Press, 1930: 21.) They were taken up by the AC 112.National Commission for the Protection of Human Subjects of 11 McCall-Smith A. Consent to treatment in childhood. ArchBiomedical and Behavioural Research in the United States in the Disease Childhood, 1992; 67: 1247–1248.1970s from which the classic application to Health Care Ethics 12 Re R. (1991) 3 WLR 592.was produced by Beauchamp TL, Childress F. In: Principles of 13 Roth, LH, Meisel A, Lidz CW. Tests of competency to consentBiomedical Ethics, Oxford: Oxford University Press; 1979. to treatment. Am J Psych 1977; 134: 279–284.

2 In: Kennedy I. The Unmasking of Medicine. A sustained polemic 14 Ethicist and Patient: What is their relationship? Gillon R, ed.against medical paternalism. London: George, Allen & Unwin; In: Principles of Health Care Ethics. Chichester: John Wiley &1981. Sons, 1994: 387–397.

3 Faulder C. Whose Body Is It? The troubling issue of informed 15 Re. F (1992) 4 All ER 671.consent, London: Virago, 1985.

4 Kant I. The Metaphysical First Principles of the Doctrine of Virtue,I, Part I, Book I, Chapter II, Section I. In: The Metaphysics Accepted 6 May 1997

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