The debate rages on: physician-assisted suicide in an ethical light

The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.

The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

No Proof Found of Anesthesia Involvement in Medical Misconduct During the Nazi Period. Investigation of the Alleged Purchase of 150 Inmates From Auschwitz Concentration Camp by Bayer to Test a New Narcotic

A comprehensive investigation was undertaken to find evidence of the frequently reported, but never authenticated, "purchase of 150 inmates" from Auschwitz concentration camp by Bayer to test a new narcotic, resulting in the death of all investigated inmates. The archives of Auschwitz camp, Bayer, and the so-called former Soviet Union, where evidence of this alleged misconduct could have been saved, were investigated, but no evidence was found. Many records concerning concentration camp experiments on humans had been destroyed, but given the Nazis' meticulous record-keeping, the death of 150 inmates should have been recorded somewhere. Unethical medical research was indeed undertaken by physicians in concentration camps in many medical specialties, but no records regarding anesthesia-related medical misconduct during the Nazi period were found despite the allegations to the contrary that have been investigated here.

Reporting of conflicts of interest and of sponsorship of guidelines in anaesthesiology. A cross-sectional study

Guideline recommendations may be biased due to conflicts of interest (COI) of panel members and sponsorship of the guideline. Potential impact of COI, and their management, should be transparently reported. We analysed 110 guidelines published in ten anaesthesia journals from 2007 to June 2018. We report on the number (%) that 1) published COI disclosures; 2) in a distinct paragraph; 3) described and explained the COI of panel members, and 4) of the Chairperson; 5) reported and described the presence or absence and potential impact of a sponsor of the guideline on the recommendations; and 6) reported how COI were managed. COI were published in 70/110 (64%) guidelines; in a distinct paragraph in 25/70 (36%). Panel members reported having no COI in 27/70 (39%) guidelines, disclosed COI without describing their potential impact in 41/70 (59%), and described their potential impact in 2/70 (3%). Chairpersons were identified in 50 guidelines, 32 of which published COI disclosures; 16/32 (50%) reported having no COI, 14/32 (44%) disclosed COI without describing their potential impact, 1/32 (3%) described their impact and 1/32 (3%) made no statement regarding COI. Presence or absence of a sponsor of the guideline was reported in 40 guidelines; 12/40 (30%) declared none, 24/40 (60%) reported sponsoring without explanation of the potential impact, and 4/40 (10%) described the potential influence of the sponsor on the guideline recommendations. Seventy-five guidelines reported COI of panel members and/or sponsorship of the guideline but only seven described how the COI had been managed. Disclosures of COI of panel members and of sponsors of guidelines have increased over the 12 year period, but remain insufficiently described and their potential influence on the guidelines' recommendations is poorly documented.

Tiny tweaks, big changes: An alternative strategy to empower ethical culture of human research in anesthesia (A Taiwan Acta Anesthesiologica Taiwanica-Ethics Review Task Force Report)

For this guidance article, the Ethics Review Task Force (ERTF) of the Journal reviewed and discussed the ethics issues related to publication of human research in the field of anesthesia. ERTF first introduced international ethics principles and minimal requirements of reporting of ethics practices, followed by discussing the universal problems of publication ethics. ERTF then compared the accountability and methodology of several medical journals in assuring authors' ethics compliance. Using the Taiwan Institutional Review Board system as an example, ERTF expressed the importance of institutional review board registration and accreditation to assure human participant protection. ERTF presented four major human research misconducts in the field of anesthesia in recent years. ERTF finally proposed a flow-chart to guide journal peer reviewers and editors in ethics review during the editorial process in publishing. Examples of template languages applied in the Ethics statement section in the manuscript are expected to strengthen the ethics compliance of the authors and to set an ethical culture for all the stakeholders involved in human research.

Ethical aspects considered in doctor-patient relations: experiences of anesthesiologists

BACKGROUND AND OBJECTIVE

Ethical principles guide professional conduct, particularly in establishing the doctor-patient relationship and, therefore, require constant reflection. The purpose of this study is to analyze ethical experiences of anesthesiologists in their interaction with the patient under their care.

METHOD

This was an exploratory study involving 16 active anesthesiologists at a university hospital in João Pessoa, Paraíba. We collected data through semi-structured interviews and analyzed qualitatively using the content analysis technique.

RESULTS

The study findings show that the classification of ethical experiences of the study participants regarding the doctor-patient relationship were classified into five categories: respect for the patient, humane treatment, equal treatment, professional secrecy, and respect for patient autonomy.

CONCLUSION

We conclude that respondents recognize the ethical and humanistic values that should guide the relationship with their patients.

A survey of healthcare industry representatives' participation in surgery: some new ethical concerns

OBJECTIVE

To provide preliminary evidence of the types and amount of involvement by healthcare industry representatives (HCIRs) in surgery, as well as the ethical concerns of those representatives.

METHODS

A link to an anonymous, web-based survey was posted on several medical device boards of the website http://www. cafepharma.com. Additionally, members of two different medical device groups on LinkedIn were asked to participate. Respondents were self-identified HCIRs in the fields of orthopedics, cardiology, endoscopic devices, lasers, general surgery, ophthalmic surgery, oral surgery, anesthesia products, and urologic surgery.

RESULTS

A total of 43 HCIRs replied to the survey over a period of one year: 35 men and eight women. Respondents reported attending an average of 184 surgeries in the prior year and had an average of 17 years as an HCIR and six years with their current employer. Of the respondents, 21 percent (nine of 43) had direct physical contact with a surgical team or patient during a surgery, and 88 percent (38 of 43) provided verbal instruction to a surgical team during a surgery. Additionally, 37 percent (16 of 43) had participated in a surgery in which they felt that their involvement was excessive, and 40 percent (17 of 43) had attended a surgery in which they questioned the competence of the surgeon.

CONCLUSIONS

HCIRs play a significant role in surgery. Involvement that exceeds their defined role, however, can raise serious ethical and legal questions for surgeons and surgical teams. Surgical teams may at times be substituting the knowledge of the HCIR for their own competence with a medical device or instrument. In some cases, contact with the surgical team or patient may violate the guidelines not only of hospitals and medical device companies, but the law as well. Further study is required to determine if the patients involved have any knowledge or understanding of the role that an HCIR played in their surgery.

[Role of an anesthesiologist-resuscitation specialist in organ donation for transplantation]

There is an annual reduction in the number of donors worldwide. An anesthesiologist-resuscitation specialist is a key figure in the whole system of organ donation. The so-called transplantation, i.e., the organization of the whole process of interaction between a healthy care facility, a local organ donation center, and ancillary laboratory and diagnostic services is one of his/her primary roles in organ donation. The organizational, legal, and ethic issues of organ donation for transplantation are discussed from the viewpoint of an anesthesiologist-resuscitation specialist. There is a parallel between the treatment of a patient with multiple organ dysfunction and the management of a donor with brain death.

Pandemic influenza: human rights, ethics and duty to treat

The 2009 influenza A/H1N1 pandemic seems to be only moderately severe. In the future, a pandemic influenza with high lethality, such as the Spanish influenza in 1918-1919 or even worse, may emerge. In this kind of scenario, lethality rates ranging roughly from 2% to 30% have been proposed. Legal and ethical issues should be discussed before the incident. This article aims to highlight the legal, ethical and professional aspects that might be relevant to anaesthesiologists in the case of a high-lethality infectious disease such as a severe pandemic influenza. The epidemiology, the role of anaesthesiologists and possible threats to the profession and colleagueship within medical specialties relevant to anaesthesiologists are reviewed. During historical plague epidemics, some doctors have behaved like 'deserters'. However, during the Spanish influenza, physicians remained at their jobs, although many perished. In surveys, more than half of the health-care workers have reported their willingness to work in the case of severe pandemics. Physicians have the same human rights as all citizens: they have to be effectively protected against infectious disease. However, they have a duty to treat. Fair and responsible colleagueship among the diverse medical specialties should be promoted. Until disaster threatens humanity, volunteering to work during a pandemic might be the best way to ensure that physicians and other health-care workers stay at their workplace. Broad discussion in society is needed.

Knowledge and practices of obtaining informed consent for medical procedures among specialist physicians: questionnaire study in 6 Croatian hospitals

AIM. To assess physicians' knowledge and practices for obtaining patients' informed consent to medical procedures. METHODS. An anonymous and voluntary survey of knowledge and practices for obtaining informed consent was conducted among 470 physicians (63% response rate) working in 6 hospitals: 93 specialists in anesthesiology, 166 in internal medicine, and 211 in surgery. RESULTS. Only 54% physicians were acquainted with the fact that the procedure for obtaining consent was regulated by the law. Internists and surgeons were better informed than anesthesiologists (P=0.024). More than a half of respondents (66%) were familiar with the fact that a law on patient rights was passed in Croatia; there were no differences among different specialties (P=0.638). Only 38% of the physicians were fully informed about the procedure of obtaining consent. Internists and surgeons provided detailed information to the patient in 33% of the cases and anesthesiologists in 16% of the cases (P<0.050). Internists reported spending more time on informing the patient than anesthesiologists and surgeons (P<0.001). There were no differences in knowledge and practices for obtaining informed consent between physicians working in university and those working in community hospitals (P> or =0.05 for all questions). CONCLUSION. Physicians in Croatia have no formal education on informed consent and implement the informed consent process in a rather formal manner, regardless of the type of hospital or medical specialty. Systemic approach at education and training at the national level is needed to improve the informed consent process.

Student-to-student local anesthesia injections in dental education: moral, ethical, and legal issues

This article reports the findings of a survey-based study conducted to determine U.S. dental schools' institutional protocols regarding the practice of students' administering local anesthetic injections to fellow students as part of their process of learning this skill. The majority of schools ask students to practice local anesthetic injections on each other without obtaining informed consent.

Guidelines for safety and quality in anaesthesia practice in the European Union

Anaesthesia is a medical specialty that is particularly concerned with the safety of the patient who is undergoing a surgical procedure. This is a prerequisite in order to provide quality of care, which is based on good clinical practice, on a sound organization, on an agreement on best practice and on adequate communication with other healthcare workers involved. Providing a safe environment for those working in healthcare is at least as important as other factors serving that objective. A working party on Safety and Quality in Anaesthesiological Practice in the Section and Board of Anaesthesiology of the European Union of Medical Specialists (EUMS/UEMS) has prepared guidelines that were amended and approved recently.

The meaning of technology in an intensive care unit—an interview study

BACKGROUND

Previous research has suggested technology may dehumanise patient care and also that technology may restrict nurses' freedom of action. This raises questions about the relationship between technology, care and medicine in units where the patient's need for treatment is often an emergency.

AIM

The aim of the study was to explore how staff members in an intensive care unit (ICU) make sense of technology in their everyday practice.

METHOD

Twelve staff members from one ICU were interviewed about their understanding of technology in their everyday practice.

RESULT

Three main findings emerged from the analysis: Technology seems to be considered decisive as it directs and controls medical treatment and results in the patients' well being; technology is seen as facilitating everyday practice because it makes treatment more secure and decreases workload; however technology can complicate the staff members' everyday practice as it is not completely trustworthy, is not easy to handle and can cause ethical dilemmas.

CONCLUSION

Contrary to previous findings this study shows that technology seems to be embedded in care and medical treatment. Furthermore, the meaning of technology appears to be dependent on the different staff members' accounting practices.

Perception of training needs and opportunities in advanced airway skills

BACKGROUND AND OBJECTIVE

We surveyed delegates at the Group of Anaesthetists in Training (UK) meeting to investigate evidence of a training-gap (number of fibreoptic intubations believed to bestow competence vs. number actually performed).

METHODS

Questionnaires were distributed to and collected from delegates in person. Questions covered six areas, including experience of fibreoptic intubation and cricothyrotomy, fibreoptic intubation as a specialist skill and ethical issues.

RESULTS

We received 221 replies (76%). All trainees believed competence to be achievable with 10 intubations (interquartile range (IQR) 10-20); the median number performed was 2 (IQR 0-4). This was statistically significant for the groups' senior house officers, 1st and 2nd year registrars and 3rd and 4th year registrars; P < 0.0001. Many final year trainees (12/20, 60%) also failed to achieve their competency target. Few trainees had seen or performed any cricothyrotomies (medians 0, IQRs 0-1 and 0-0). Most (195/208, 94%) believed that fibreoptic intubation was a core skill and 199/212 (94%) believed that all should be competent by completion of training. Ten percent (n = 208) felt it unethical to perform an awake training intubation with full consent and 10% believed it acceptable without explanation. Most (82.7%) would fibreoptically intubate an asleep patient (requiring intubation) without consent.

CONCLUSION

Trainees reported a gap between their perception of competence and achievement in awake fibreoptic intubation. Simple and complex simulations and structured training programmes may help. Anaesthetists must address the ethics of clinical training in advanced airway management.

Ethical aspects of triage in mass casualty

PURPOSE OF REVIEW

There is a growing awareness that, not only in war, but also in relation to natural disasters, we may have to face situations of mass casualty. Little has been said about the philosophical aspects of the triage problem arising in anesthesiology in these circumstances, however. There are only a few articles where these problems are addressed in a fruitful manner. These articles are reviewed here.

RECENT FINDINGS

Even though important triage problems have been identified in the recent literature, they have not been solved in the discussion. Furthermore, there is no unanimity about how they should be solved in principle or in practice.

SUMMARY

The implications of the discussions reviewed here are mainly for policy making and only indirectly for the clinic. When the problems have been sorted out in the political process, however, one would hope that a result should surface in the form of clear guidelines for clinical application. One of the reviewed articles puts forward suggestions to this effect. This, however, could only be the beginning of an important discussion to come.

Ethics in research

PURPOSE OF REVIEW

This review will examine research ethics in the context of globalization of clinical trials and recent rapid developments in bioscience. It will focus on international ethical guidelines and the functions of research ethics review boards in research governance. Consent issues in genetic research, which must comply with privacy laws by protecting confidentiality and privacy of personal health data, will be discussed.

RECENT FINDINGS

There has been a rapid expansion of genomic and proteonomic research and biotechnology in the last decade. International ethical guidelines have been updated and the bioscience industry has developed ethics policies. At the same time, problems in academic anesthesia in the US and UK have been identified, leading to recommendations to train physician-scientists in anesthesia to stimulate research activity in the future. Anesthesiologists are joining interdisciplinary research teams and the concept of evidence-based translational research is emerging.

SUMMARY

Anesthesiologists are moving towards participation in interdisciplinary research teams. They are well placed to speed the translation of research discovery into clinical practice and provide evidence-based perioperative care. This review provides the ethical framework that anesthesiologists will need to meet the challenges of this changing pattern of practice.

Sedation in palliative care

PURPOSE OF REVIEW

Palliative sedation, the conscious induction of sleep in patients with a very short life expectancy who suffer intractable physical and existential distress, may offer the patient and his or her relatives a more peaceful dying. This technique is still subject to several ethical and medical controversies justifying a review of the recent literature on this subject.

RECENT FINDINGS

The available evidence consists of few prospective trials and mainly retrospectively collected case reports. Two guidelines are published in the period under review. The most important points stressed in these reviews are the careful information exchange with the patient, if possible, and his or her proxies, a gradually increased sedation allowing respite if possible to evaluate the effect of the sedation and the need for consultation with colleagues, preferentially physicians experienced in palliative care. Stopping artificial nutrition and hydration is a medical decision that should be taken after evaluation of the potential side effects and consultation with the patient and relatives.

SUMMARY

Palliative sedation may be considered for terminally ill patients who suffer intractable symptoms. Ideally it should be included in the patient's trajectory that has been described and discussed earlier when the disease was judged to be incurable. The main goal is to offer comfort.

Ambulatory anesthesia and the lack of consensus among Canadian pediatric anesthesiologists: a survey

BACKGROUND

The purpose of this study was to assess the current selection criteria for outpatient surgery in children among Canadian pediatric anesthesiologists.

METHODS

A survey specifying 20 different medical situations was sent to 120 members of the Canadian Pediatric Anesthesia Society. Members were asked to indicate if they agreed or refused to provide anesthesia for children with one or more clinical condition or symptoms. Consensus was defined as a >70% majority opinion.

RESULTS

Sixty-four pediatric anesthesiologists replied (53.3%). For 13 conditions there was no consensus among members. Seven scenarios resulted in a consensus of either providing or not providing anesthesia in an outpatient setting. The majority of members would agree to provide anesthesia for the following scenarios: (i) an asymptomatic child with recurrent otitis media, rectal temperature of 38 degrees C; (ii) the same child with chronic nasal discharge for bilateral myringotomy and tube placement; (iii) an asymptomatic child with sickle-cell disease (SCD) for cast change; (iv) an asymptomatic child with asthma and fever for bilateral myringotomy and tube placement (BMT); (v) a morbidly obese child with congested nose for BMT; and (vi) a child with well controlled insulin dependent diabetes mellitus for magnetic resonance imaging (MRI). Most members would refuse to provide outpatient anesthesia in an asymptomatic child with SCD for tonsillectomy.

CONCLUSION

Further studies are needed to establish evidence-based medicine to support guidelines that would allow one to select children safely for ambulatory surgery.

Patients who challenge

Individuals have different values. They seek to express their individuality even when receiving medical care. It is a part of modern medical practice and respect for patient autonomy to show respect for different values. We give an account of what it means to respect different values and challenging patients in medical practice. Challenging choices are often choices which are perceived by many to be either irrational or against a person's interests, such as engaging in harmful or excessively risky activities. When the medical profession is involved in such choices, the basic medical principle of acting in a person's best interests is challenged. Often doctors refuse to respect controversial choices on paternalistic grounds. We should all respect and facilitate the controversial choices of competent individuals, subject to resource limitations, our own and others well-being and autonomy, and the public interest. But more importantly, sometimes such choices make for a better, more autonomous life. Sometimes, such choices reflect considerations of global well-being or altruism, or idiosyncratic attitudes to risk. Sometimes, they reflect unusual values. However, in some other cases, controversial choices are irrational and are not expressions of our autonomy. Doctors should assist patients to make rational if individual choices. The patient also bears the responsibility for bringing his beliefs to the attention of the clinician.

The pregnant and the parturient

Society and the culture of health care delivery have radically changed over the last thirty years, the rate of change increasing exponentially towards the present time. Maternity care has been part of that change. Previously paternalistic obstetricians told women whether they should or should not become pregnant, advised hospital confinements, kept women in hospital for days after their confinements, and discussed little of their management with the women themselves. Now women have choice and they exercise that choice. There is choice as to the kind of antenatal care women wish to have, where they will deliver their baby and who will look after them during their pregnancy and delivery. This was, and to a certain extent still is, threatening to obstetricians. But there are also genuine concerns as to whether these changes will adversely influence the morbidity and mortality of mother and child. This chapter deals with issues of maternal choice from pre conception through to the post natal period, looking at how the exercise of maternal choice may conflict with the advice of the medical profession, potentially leaving accountability and responsibility a very grey area and how all this impinges on the anaesthetist.

Confidentiality, ‘No blame culture’ and whistleblowing, non-physician practice and accountability

Confidentiality is a core tenet of medical professionalism, which enables the maintenance of trust in a doctor-patient relationship. However, both the amount of personal data stored and the number of third parties who might access this data have increased dramatically in the digital age, necessitating the introduction of various national data protection acts. Paradoxically, the Freedom of Information Act 2000 allows United Kingdom citizens to access information held by public bodies, including hospitals. Furthermore, the Public Interest Disclosure Act 1998 actively protects physicians who breach their duty of confidentiality in the name of public interest ('whistleblowing'). This article explores the evolution of the law and ethics in this area, and draws attention to the difficulties in balancing confidentiality against freedom of information. In addition, the role and responsibilities of the non-physician anaesthetist are examined.

[Is training on basic skills and management of critical events responsible of ethical considerations in anaesthesia and intensive care?]

OBJECTIVE

To provide information on morbidity and ethical questions associated with learning of invasive techniques (tracheal intubation, positioning of central venous or epidural catheters) and management of anaphylactic shock.

STUDY DESIGN

Retrospective survey.

METHODS

Written questionnaire to 54 anaesthesiologists and 55 residents.

RESULTS

Training was primarily performed by residents having a 6 months-experience for general anaesthesia and by more experienced residents for epidural analgesia. Residents observed first two or three procedures performed by seniors, but did not have theoretical lectures in 30 to 50% of cases. Dead bodies or manikins were rarely used. Despite the presence of experienced anaesthesiologists during the first attempts, there was a high morbidity rate which was considered by 22 to 37% of the interviewed anaesthesiologists a loss of benefit for the patients. Despite a high level of coaching, a high morbidity rate was associated with the first attempts. However, only few residents explicitly stated to be concerned by ethical questions. Among anaesthesiologists, who had yet to manage anaphylactic shock, 21 and 35% of them reported that diagnostic and treatment could have been performed faster. Virtual learning was misunderstood but 46% of anaesthesiologist described numerous advantages in using simulator of anaesthesia.

CONCLUSION

Despite an apparent morbidity with a loss of benefit, informed consent of the patients were rarely obtained.

Medico-legal aspects in anesthesia: how to lead a happy life

This article discusses medico-legal aspects in anesthesia. It underlines the standards of care by which anesthesiologists should abide by, as well as define malpractice, its causes, and ways to avoid it. The role of the expert witness is explained and the ethical guidelines to follow are outlined.