Ethics in Anaesthesia(June 2004)Write Briefly on Research Ethics(Dec 2008)

7/28/2019 Ethics in Anaesthesia(June 2004)Write Briefly on Research Ethics(Dec 2008)

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-Ethics in anaesthesia (June 2004).

-Write briefly on research ethics (Dec 2008).

Classification

1)Clinical ethics-a}Informed consent-informed refusal

-special issues-i)jehovah’s witness

-ii)paediatric patient with

and

Patient with impaired

competence

-iii)consent for lab tests:HIV

& pregnancy

-iv)maternal and fetal

conflicts

-v)uncooperative patient

B}Advanced directives and surrogate decision makers

C}End of life decision making

D}Ethical issues in organ transplantation

2)Research Ethics-Human

-Animal

3)Physician participation in execution

1)CLINICAL ETHICS

- Advanced directives and surrogate decision makers



*Definition of advanced directives:-Document executed by patients before

incapacity to provide physicians with guidance in medical decision making

when the patient cannot communicate for themselves,eg living wills,DNAR

order.

*Definition of surrogate decision maker:- someone whom the patient has

appointed to make health care decision for them,eg;durable power of attorney

or an individual with other leaglly recognized authority by virtue of their

relationship with the patient.

*Hierarchy

Surrogate decision maker->family member(spouse/legally recognized

domestic partner)->children->parents->siblings->guardian

*Proxy decision making is the only option if a patient has not left specific

directives.

*medical decisions that cannot be made by surrogates-sterilizatio,electric

shock therapy

End of life decision making

*End of life issues

i)control over timing and location of death.

ii)management of symptoms such as pain,dyspnoea,anxiety,depression.

iii)financial management of medical care.

iv)maintenance of therapeutic options.

v)preference regarding primary and level of involvement of family members.

*treatment promoting patient comfort should generally be

continued,whereas those directed only at physiologic maintenance might all

be withdrawn.

*several interventions have critical implications and deserve special

consideration.



i)fluid and nutrition management

.controversial

.prolongation of the dying process

.complications

ii)administration of sedation and anarcotics that have the potential to hasten

death

iii)administration of NMBA’s

.NMBA’s have no anaesthetic,analgesic or sedative properties and have no role

in palliative care.

Physician assisted suicide/euthanasia

.provision of medication or prescriptions to patient y specific request for the

purpose of ending their life.

.primary intent is to cause death,which ends suffering

.legal only in Netherlands.

Ethical Issues in organ transplantation

-Two issues critical to the anaesthesiologist

i)Brain death

ii)Donation after cardiac death(DCD)

-i)Brain death

*the point at which all the cardiorespiratory functions had irreversibly ceased

*reasons for defining death:-

A]to allow patients to be declared dead and not maintained on machines

thereby -limiting expenses

-relocating medical resources to other salvageable patients



- allowing social rituals surrounding death to occur

*criteria for diagnosis of brain death

->cortical and brain stem function is absent in the absence of drugs,paralytic

agents,hypothermia and other reversible conditions that mimic loss of brain

function.

->Diagnosis of brain death

A}clinically absent cortical activity and brainstem reflexes

B}radiographically complete absence of cerebral blood flow.

-expensive medical interventions can be discontinued without legal

ramifications and vital organs can be donated for transplantation if the patient

or surrogate agrees

Ii}DCD

-occurs when a patient desires to have life sustaining medical therapies

withdrawn and also wishes to proceed with donation of vital organs after

death.

-controlling the time and place of death

->So that the timing of organ donation can be optimized,has

*Medical advantages:-ischaemia time can be minimized

*Ethical advantages:-discussion and informed consent

->expedient donation is the purpose of DCD;protocols call for organ retrieval

to begin only 2 minutes after the circulation has stopped.

2)RESEARCH ETHICS

A}Human subject research

-The premise that the physician always puts the best interests of the patient

first can be jeopardized when research onjectives enter the doctor-patient



relationship;therefore human subjects research is more closely

regulated,supervised and controlled than any other medical endeavour.

-regulation of research began after World War II ,with the Nuremberg Code

and the Helsinki Declaration,outlining the ethical obligation of physiciansengaged in human research.

-Ethical conduct of human research follows the principles

I}respect for autonomy and the obligation to protect subjects with limited

autonomy.

Ii}Beneficience:-with obligation to minimize risks and maximize benefits and

ensure that the research design is scientifically sound.

Iii}Justice:-the obligation to treat each person with regard to what is morally

right and to ensure fair distribution of benefits and burdens.

-disclosure to the patient ,must include:-

*risks and benefits of procedure/medications to which they will be subjected

*possibility of the commercialization of the result

*financial interests of the researchers and their institutions and beneficiaries

->subjects must be free to refuse or end participation at any time without

penalty

->mometary inducements to participate in research are probably permissible

if they do not undermine the freedom of the subject to refuse under

reasonable circumstances

->anaesthesiology research often involves the treatment or prevention of

unpleasant symptoms such as pain and nausea for which effective treatments

are already established.

->in the modern research tradition,the interests of the individual subject

always prevail over the interests of the society

->Children as research subjects:-



*children are vulnerable as research subjects because thay may

i)lack the ability to make mature decisions

ii)subject to authority of others

iii)may defer to their parents

iv)may have conditions requiring immediate decisions not consistent with

informed consent

*if a minor child is able to assent,assent must usually be obtained with the

consent of any legal surrogate decision makers.

B)Ethics of animal research

-The animal rights movement has gained significant momentum due to the

concern of human impact on environment and animal species.

-it is required to

i)establish institutional animal care

ii)use committee to oversee conditions of laboratory animals

iii)review and approve animal research protocols

iv)educate and train investigators in ethical issues and aspects of animal

handling such as anaesthesia/analgesia/euthanasia.

iv)act as community liasions.

-there are polarized views regarding animal researchers and animal welfare

activists.

-many bioethicists accept that higher animals have sufficient awareness topossess moral standing.

-researchers have obligations to provide clean and humane conditions and

appropriate veterinary care for animal subjects.

Ethics in Anaesthesia(June 2004)Write Briefly on Research Ethics(Dec 2008)

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