9 Ethical Aspects of Anesthesia Care Gail A. Van Norman, Stanley H. Rosenbaum Key Points History of Ethics in Medicine and Ethical Theory Medicine is a respected profession with codes of behavior and definite rules of conduct. In modern times, medical practitioners have tremendous powers, recognized social import, and powerful financial interactions that touch nearly everyones lives. It is in the context of long-held and highly developed rules and practices that we examine the ethical bases of the practice of medicine and its implications for anesthesiologists. Ethical Theory Virtue Ethics, Utilitarianism, and Duty-Driven Ethics The classic style of medical practice, called “paternalism,” is derived from “virtue-based ethics.” In this view, the physician is a genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism who naturally knows and does what is correct for the patient. The patient, who is not knowledgeable in the art of medicine, should trust the physician to decide what is best. Our society and legal system have changed substantially since paternalism flourished, but some patients and physicians still see this style as a desirable component of medicine. In utilitarian ethics, actions are judged right or wrong on the balance of their good and bad consequences. A “right” action produces the most good, based on a perspective that gives equal weight to the interests of all affected parties. Although utilitarian theory is compelling (who would not want to do the most good and minimize evil?), it falls short in defining which benefits are most important. Is it the “good” that all reasonable people want or the “good” defined by the individual patient? What if the only way to maximize “good” is to commit an entirely immoral act? Suppose, for example, the only way to win a war is to systematically torture children? Utilitarian theory may be best when applied to analyzing broad-based policies, in decisions regarding rationing of resources, and when attempting to resolve conflicting ethical obligations. 1. Anesthesiologists have ethical obligations to promote patients abilities to make medical decisions, as well as obligations to respect those decisions. 2. Competent patients have the right to refuse medical treatments or tests, even if it appears to be a “bad” decision. Coercing or restraining competent patients is unethical. 3. Children should be involved in medical decision-making to the degree that their abilities allow, and their wishes should usually be respected. 4. Advance directives and decisions by surrogate decision-makers are legally binding. 5. Do-not-attempt-resuscitation orders require reconsideration before anesthesia and surgery and cannot be automatically suspended. 6. Withdrawal or withholding of life-sustaining treatments at the end of life requires specialized training or experience. 7. Anesthesiologists play a pivotal role in caring for both brain-dead and nonheart-beating organ donors and must be familiar with the medical, legal, and ethical issues involved. 8. Human and animal research carries special obligations to protect the subjects from inhumane treatment. Whenever possible, alternatives to human and animal research should be sought. 9. “State-sponsored” activities such as executions (1) are not the practice of medicine, (2) undermine the medical profession, and (3) place the physician on dubious moral grounds. 10. Although physicians have a right to withdraw from some situations in which patient care presents them with personal moral conflicts, this right is limited, and professionally accepted standards and obligations usually prevail (e.g., well-established standards, such as informed consent). 页码，1/17(W)w 2011/5/26mk:MSITStore:C:UserslenovoAppDataLocalTempRar$DI00.919Miller_s_Anes. 323 The premise of Kantian-based ethics (also called “deontological theory”) is that there are features of actions other than their consequences that make them right or wrong. Intention is more important than outcome. Furthermore, no person should use another exclusively as a means to an end because each person is the end for which we should act. Each person is uniquely valuable and should not be used to further the purposes of other persons without their autonomous consent. Kantian philosophy would, for example, forbid killing one innocent person to save another innocent person. Deontological and utilitarian theories are both applied to varying degrees in modern medical ethics. Individualism and autonomy are highly valued in Western society, and people tend to turn to Kantian philosophy when ethical questions arise that balance the authority of the physician against the goals and values of individual patients. When broad-based social issues are at stake, such as allocation of scarce medical resources, utilitarian arguments are often used. Some of the toughest ethical questions in medical practice occur when the rights and desires