The Cambridge textbook of bioethics

While there are no doubt ethical principles and concepts that extend across all aspects of bioethics, it is now becoming common to find separate treatments of specialty fields emerging in the bioethics literature and in clinical ethics areas of specialization. In most academic fields and interdisciplinary areas of study, it is not uncommon to find scholars and practitioners focusing on developing particular areas of specialty. What is fairly unique about bioethics, however, is that we find that its speciality areas are not just reconceiving central disciplinary questions or using different ways of looking at issues but are bringing to light the importance of examining the ethical issues specific to their areas of clinical and research practice.

It will always be the case that considerations such as informed consent, confidentiality, minimizing harm, and priority setting, among other considerations, will be central ethical issues that clinicians will confront in all areas of practice. Nevertheless, the development and study of various speciality fields of bioethics places us in a better position to be able to give a more nuanced and pertinent analysis of the distinctive ethical issues faced by particular clinical areas of practice, especially where the traditional application of overarching ethical theory or bioethical methodologies may have been found to be limiting.

The chapters in this section provide an overview of the most pressing and relevant ethical issues unique to their clinical speciality. For instance, in Ch. 57, Gail Van Norman examines the distinctive

ethical issues that arise because anesthesia routinely alters the patient’s consciousness, sometimes affecting a patient’s competence and autonomy, and that there are instances where anesthesiologists can be expected to use their knowledge and skills to abolish patient resistance. These issues are made stark in her examination of the special role of anesthesiologists in participating in state executions (in jurisdictions where it is required by law) and in upholding do-not-resuscitate orders in the operating room. Similarly, in Ch. 64, Margaret Eaton examines the singularity of ethical issues faced in pharmacy practice by virtue of several facts. For example, pharmacists are one step removed from the diagnostic aspect of the therapeutic encounter and are usually the last healthcare professional the patient has contact with before drug treatment commences. Numerous issues also arise from the fact that pharmacists often control the drug formulary in healthcare institutions.

Some areas of specialization within bioethics will be driven by scientific progress and technological advancement. For example, the specialty area of neuroethics has recently exploded and we find the ethical issues surrounding the brain, mind, and consciousness becoming one of the predominant areas in bioethics literature and ethical issues that are discussed more widely outside of clinical medicine. In Ch. 63, Eric Racine and Judy Illes discuss the importance of the ethical issues surrounding clinicians acting as gatekeepers in the marketing of neuroimaging and therapeutic products to treat neurological and psychiatric diseases.

Other areas of specialization within bioethics are driven by immediate societal threats that require prompt and effective responses. For instance, with the increase threat of pandemics and bioterrorism, we have seen rapid development of treatment and institutional structures related to infectious diseases. In Ch. 61, Jay Jacobsen examines the distinctive ethical tension that arises in the practice of infectious disease medicine between respecting patient preferences and preventing harm to others in society.

There will also be times where the development of different areas of bioethics specialization will depend on factors surrounding the expanding scope of what constitutes medical care. For instance, in Ch. 65, Michael Cohen examines how the integration oftherapies such as acupuncture, chiropractic, herbal

medicine, massage therapy, and so on concurrent to conventional medical therapies presents new ethical challenges with respect to whether and how clinicians should acknowledge a pluralistic foundation of healthcare that contains multiple modes of legitimate therapeutic interventions.

We additionally have chapters on emergency and trauma medicine (Ch. 59), critical and intensive care medicine (Ch. 58), surgery (Ch. 56), psychiatry (Ch. 62), and primary care (Ch. 60). All these provide both a basis from which to explore further developments in specialty fields of bioethics and, for clinicians who work with colleagues in these specialties, a better understanding of how the clinical issues specific to their area of practice presents and informs the ethical issues they must deal with on a daily basis.

Mrs. A is a 72-year-old woman suffering from coronary artery disease. Upon angiography, the medical team diagnoses triple vessel involvement and determines that Mrs. A requires surgical management. She then meets with her surgeon, Dr. B, to discuss treatment options, and together they decide upon triple bypass surgery. Aware of the associated risks, Mrs. A does not relish the thought of surgery, but she desperately wishes to ‘‘put these heart troubles behind her.’’ In the operating room the following week, when Dr. B exposes the heart he discovers an obvious dissection of the ascending aorta. The lesion must be repaired, but the risks are much greater than those discussed with the patient and family.

What is surgical ethics?

The truly defining institution of surgical medicine is the operation itself. Ultimately, that which distinguishes surgery, in practice and in ethics, from the other medical specialties arises in the operating room. Whether referred to as a simple ‘‘room,’’ or more grandly as a ‘‘suite’’ or ‘‘theater,’’ mystery has always enshrouded this sacred ground where surgeons practice their art. Here, amidst secrecy and sterility, surgeons confront fundamental ethical quandaries unique to their practice. Surgical ethics, thus, captures the unique ethical dilemmas that arise in the operating room.

Why is surgical ethics important?

The surgeon, unlike other clinicians, confronts first and foremost the ethical dilemma that any

operation performed harms before healing. Postoperative side effects, such as pain, a wound, and scarring, represent not an undesirable possibility for the patient but rather a near certainty. Consequently, by striving to minimize this necessary temporary injury to the patient while maximizing the therapy’s curative potential, surgeons have forever engaged in ethical deliberations. Once in the operating theater, the patient literally surrenders his or her body to the surgeon’s expertise. The surgeon serves as the patient’s advocate in the purest sense, responsible for protecting not only the patient’s physical wellbeing but also his or her values and beliefs.

Our discussion of surgical ethics begins with the patient–surgeon relationship, then deals with issues associated with the preoperative conference – informed consent and disclosure – and finally ends with decisions involving patients presenting as emergencies.

Patient–surgeon relationship

Certain ethical considerations distinguish the patient–surgeon relationship from interactions between patients and clinicians in non-surgical specialties. An ultimate trust exists on the part of patients when they confide their entire beings to a surgeon during the operation. Indeed, Palmer (1982, p. 2) in the Bulletin of the American College of Surgeons characterized this special rapport as a:

. . . physical interaction, including the act of making an intentional, permanent ‘‘wound,’’ in which the therapy produces measurable pathophysiologic change and mixes

with the disease process . . . creat[ing] unique bonds. This extraordinary contact cannot but influence how you feel about the patient and how he or she feels about you.

The ultimate trust that surgeons must cultivate with their patients comes to the fore in the operating room. For, here patient’s immediate control ends. The balance of power shifts such that now essentially all authority resides with the surgeon. This increased authority naturally engenders increased responsibility and liability.

Reduced to its essence, the patient–clinician relationship is a fiduciary contract, founded on both trust and loyalty (Beauchamp and Childress, 2001a). The physician pledges, either implicitly or explicitly, to protect the patient’s rights. A complete discussion of these rights is beyond the scope of this chapter. However, to differentiate between positive and negative rights is useful. Traditionally, liberal individualist societies more readily justify negative rights (Beauchamp and Childress, 2001b). For example, few North Americans would argue against the patient’s negative right to refuse surgery, but they would be more reluctant to grant that patient the positive right to demand a given operation.

To respect the patient’s autonomy, the surgeon should always disclose who will perform each step of the operation and who will be responsible (McCullough et al., 1998a). For surgeons practicing in universities and teaching hospitals, disclosing the role of trainees, residents, and medical students is essential. The surgeon in academia balances two responsibilities: to provide trainees the practice they require, and to offer patients optimal care. When properly informed of the students’ involvement, patients often report a positive benefit (York et al., 1995). Furthermore, the American Medical Association Council on Ethical and Judical Affairs (1994a) condemned the substitution of the surgeon without the patient’s consent claiming: ‘‘A surgeon who allows a substitute to operate on his or her patient without the patient’s knowledge and consent is deceitful. The patient is entitled to choose his or her own physician and should be permitted to acquiesce or to refuse the substitution.’’ The

patient specifically agrees to allow the surgeon to whom consent was granted to perform the operation. To betray that agreement undermines the patient–surgeon relationship and is both deceptive and unprofessional.

Informed consent

The preoperative conference affords the patient and the surgeon the opportunity to discuss viable treatment options and to decide together which option best suits the needs, both medical and practical, of the patient. The patient’s values, beliefs, and preferences factor prominently in this discussion. Principles that form the basis of a successful conference include effective communication, assessment of competence, and sufficient disclosure. Many of these issues fall under the more general heading of informed consent, a pivotal topic in surgical ethics. He´bert et al. (1997) rightly argued that ‘‘[t]he candid disclosure and discussion of information not only helps patients to understand and deal with what is happening to them but also fosters and helps to maintain trust.’’ Indeed, informed consent is the basis for the therapeutic patient–surgeon relationship, fostering mutual trust and promoting shared responsibility for decision making.

Disclosure, another pivotal component of adequate informed consent, dictates that during the preoperative conference the surgeon discusses with the patient the available treatment options, the expected outcomes, and the risks and benefits of each. Each option should be evaluated as to how well the choice aligns with the patient’s medical needs, lifestyle preferences, and values. For example, during a preoperative meeting with an orthodox Jew needing heart valve replacement therapy, the authors had to determine whether or not he was comfortable receiving the recommended porcine valve (Zaroff, 2005a). After discussing the viable options, the surgeon may then document the conversation in the patient’s medical record.

In addition to evaluating treatment options within the context of patient preferences, surgeons

also encounter patients who insist that treatment be carried out in a manner that entails increased risk. A commonly cited example is the Jehovah’s Witness patient who refuses to receive a blood transfusion during surgery (Zaroff, 2005b). Such requests place the surgeon in an ethical position where a decision must be made whether or not the risk to the patient is too great to justify operating as the patient wishes.

Conflicts of interest

The surgeon also needs to disclose any potential conflicts of interest. These conflicts of interest are often financial, as George Bernard Shaw (1946) lamented in the following oft-quoted passage from

The Doctor’s Dilemma: A Tragedy: ‘‘That any sane nation having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.’’

However, we wish to highlight conflicts of interest arising in the context of surgical innovation. The quest to further knowledge through scientific research creates a troubling ethical dilemma for the surgeon–scientist. The surgeon has the primary obligation to do whatever is best for the patient’s health (Frader and Caniano, 1998). But history has demonstrated, at times quite tragically, that deciding whether this fiduciary contract is violated by an experiment can prove anything but straightforward (Lefall, 1997). Moreover, as no centralized body exists for evaluating new surgical procedures, new operations are sometimes implemented without prior proof of their efficacy. McKneally (1999, p. 786) offered the following pessimistic condemnation of surgical innovation: ‘‘When innovative surgeons who take unaccredited courses return with uncertified skills to introduce non-validated treatments in trusting patients, we have a recipe for disaster.’’

Lastly, one should remember that the control procedure in surgical trials is often quite invasive to the patient. The use of so-called ‘‘sham surgeries’’

as controls, for example, continues to provoke heated ethical debates (Macklin, 1999; Albin, 2005). One recent example debated in the literature involves the drilling of burr holes in the skull as a control treatment for the evaluation of new Parkinson’s disease therapies (Albin, 2002; Kim et al., 2005).

Emergency patients

Many of the most compelling ethical dilemmas that surgeons face come to the fore while treating the urgently ill patient. The preoperative conference becomes an irrelevant luxury, and disclosure and informed consent are often partially overlooked. When faced with a patient in urgent need of treatment, the surgeon must assume not only great authority, but a great deal more as well. Firstly, he or she assumes that the immediacy of care is important and will benefit the patient. Secondly, the literature refers to three classic assumptions used to justify treating emergency patients before obtaining their informed consent: the life-preserving goal of medicine, the premise that most patients would want their life saved, and the condition that the benefits outweigh the risks (Mattox and Engelhardt, 1998).

Finally, surgeons, despite the breadth of their craft, are limited in their ability to heal. They deal with emotionally and morally wrenching decisions about when to forgo further surgical treatment. Selzer’s ‘‘Sarcophagus,’’ part of his anecdotal anthology The Doctor Stories (1998), insightfully portrays the emotional trials of an operating team accepting the futility of further intervention. In many cases, patients have decided in advance how they would like their surgeon to proceed in given dire situations. The main challenge for the surgeon then becomes deciding whether or not the patient’s advance directive applies to the current situation. Many resources exist to assist the surgeon in deciding, but if there is any doubt and the benefits of treatment outweigh the risks, then the surgeon is best advised to treat (Emanuel et al., 1994; King, 1996).

450J. Andrews and L. Zaroff

How should I approach surgical ethics in practice?

The preoperative conference

McCullough et al. (1998b) have proposed a schema, which we adapt here, for facilitating the patient– surgeon conference and subsequent decision making. Firstly, the surgeon must identify the relevant facts, particularly the viable treatment options and what is important to the patient. Then, the ethical analysis is undertaken, wherein one must consider the fiduciary responsibilities of the surgeon towards the patient, the relative benefits and risks of each option, the patient’s rights and values, and the obligation to allocate limited resources with justice and equality. The final step asks the surgeon to arrive at and justify a conclusion within the context of the above considerations.

Secondly, and early in the preoperative interview, the surgeon should determine the degree to which the patient wishes to participate in this decision-making process. While the actual degree to which the patient desires to participate may vary, encouraging the patient’s comfortable involvement has been shown to improve not only patient– surgeon rapport but also the overall health outcome (Siegler, 1996). The patient may choose to participate more or less in the decision-making process, but the presentation of options always occurs. In addition to the degree of desired participation, the surgeon must also determine whether the patient is competent to make decisions regarding treatment. We simply point out that surgeons, in particular, must remember that as the cost to the patient of refusing treatment increases, so too does the burden to prove competence (Mattox and Engelhardt, 1998).

Lastly, the surgeon has both an ethical and a legal obligation to ensure that the patient understands the information that has been discussed. Often the emotional impact of the information compromises the patient’s ability to register what has been discussed. Having a family member or close friend of the patient present during the conference

facilitates an effective conversation. The com-

for patients, and the surgeon is obligated to help the patient to overcome these difficulties. As an example of one such misunderstanding taken from the authors’ experience, consider a devoutly Catholic patient, a nun, who greatly feared that when her Jewish surgeon spoke of ‘‘cardioversion’’ and ‘‘converting’’ her irregular heartbeat, she was in grave danger of having her religious faith converted against her will (Zaroff, 2005c). Clearly, effective communication can alleviate great potential for misinterpretation and can engender a more effective patient–surgeon relationship.

For patients to make the best decision possible, the surgeon is also ethically obliged to provide information on the expected outcomes of each treatment option. Most surgeons openly disclose statistics on the industry-wide outcomes of a procedure, whereas our experience suggests that few surgeons routinely present their personal outcome statistics. In the USA, many national medical associations, such as the American College of Surgeons and the American Medical Association, sidestep this question of complete disclosure with non-specific statements such as: ‘‘Eligibility to perform surgical procedures as the responsible surgeon must be based on an individual’s adequate education and training, continued experience, and demonstrated proficiency,’’(American College of Surgeons, 1997) and ‘‘Only through full disclosure is a patient able to make informed decisions regarding future medical care’’ (American Medical Association, Council on Ethical and Judicial Affairs, 1994b).

Many have criticized the medical establishment’s continued quiet ambivalence on this matter. Bosk, over 25 years ago, insightfully studied perceptions and repercussions surrounding error in surgical practice in his Forgive and Remember: Managing Medical Error (Bosk, 1979). More recently, Clarke and Oakley (2004) cogently championed increased patient access to surgeons’ comparative clinical performance. Furthermore, this reluctance on the

part of surgeons to disclose individual outcome statistics has ultimately led many patients and health professionals to call for the creation of public databases of surgeon-specific outcomes as a means of achieving greater transparency. However, as Lo (2000) pointed out, making such information available raises additional ethical debates about how most accurately to represent the data and who should have access. Until a more widespread consensus is reached, the individual surgeon will continue to be responsible for adequately disclosing personal outcome information.

Emergency patients

When making assumptions regarding the treatment of emergency patients, the surgeon risks arriving at an ethically unjustifiable decision. Among the determinations to be made, the surgeon must first decide whether the chosen course of action best benefits the patient and aligns with the patient’s wishes. Moreover, if the surgeon concludes that the patient cannot be helped by the available treatment options, then ethical reasoning does not justify proposing an operation (Halevy and Brody, 1996). Lest the surgeon appear alone in making these weighty ethical decisions, various surgeons and ethicists have devised patient classification schemes based on the degree of urgency to facilitate decisions regarding when to treat (Mattox and Engelhardt, 1998). Finally, many authors concur that surgeons should consult their peers often and regularly. However, doing so does presuppose a willingness to seek help from others.

The inability to engage the urgently ill in the consent process poses yet another dilemma. In situations of the utmost urgency, the surgeon may opt to treat the patient without consent or may assume the patient’s consent. This scenario, borne of necessity, occurs regularly. Yet clinicians must recognize one important limitation to this assumption: clinicians may not administer emergency treatment without consent if they believe that the patient would refuse such treatment if he or she were capable (Etchells et al., 1996). Alternatively,

for patients with limited competence or in situations where time is exceedingly precious, surgeons may apply a truncated version of the consent process. In the ideal situation, when time permits, the surgeon identifies a surrogate to stand in the patient’s stead during the consent process. In the majority of cases, this solution offers the best means of honoring the patient’s autonomy. The two chief concerns in surrogate decision making are identifying the most appropriate surrogate and determining how the decision should be made (Buchanan and Brock, 1989; Lazar et al., 1996). Finally, when complications arise during the operation, the surgeon has to decide, and oftentimes rather precipitously, whether or not to step away from the operating table to consult with the patient’s loved ones regarding the patient’s wishes.

The case

Faced with an unexpected finding, the aortic aneurysm, Dr. B must decide how to proceed. Should he perform a less risky but incomplete repair of the aortic tear, or a more invasive and complete repair in which the ascending aorta is replaced with a graft and the ostia of the diseased coronary vessels are incorporated into the graft? Dr. B should first consult the referring physician and cardiologist. Then, if possible, the surrogatedecision maker should be informed of the reasons to proceed despite the increased risks. By helping this individual understand the risks and benefits of each option, he or she is better equipped to offer advice as to what Mrs. A would prefer.

Inasmuch as possible, foreseeable scenarios should be discussed with patients in advance. When unanticipated complications arise intraoperatively, however, the ultimate trust that the patient has granted the surgeon guides all decision making. Dr. B must take into consideration the opinions of his peers and determine which option best aligns with Mrs. A’s wishes. But finally the problem is surgical, and the surgeon makes the

Etchells, E., Sharpe, G., Walsh, P., Williams, J. R., and Singer, P. A. (1996). Bioethics for clinicians: 1. consent. CMAJ 155: 177–80.

Frader, J. F. and Caniano, D. A. (1998). Research and innovation in surgery. In Surgical Ethics, ed. L. McCullough, J. Jones, and B. Brody. New York: Oxford University Press, pp. 216–41.

Halevy, A. and Brody, B. A. (1996). A multi-institution collaborative policy on medical futility. JAMA 276: 571–4.

He´bert, P. C., Hoffmaster, B., Kathleen, C., and Singer, P. A. (1997). Bioethics for clinicians: 7. truth-telling. CMAJ 156: 225–8.

Kim, S. Y., Frank, S., Holloway, R., et al. (2005). Science and ethics of sham surgery: a survey of Parkinson disease clinical researchers. Arch Neurol 62: 1357–60.

King, N. (1996). Making Sense of Advance Directives, rev edn. Washington, DC: Georgetown University Press.

Lazar, N. M., Greiner, G. G., Robertson, G., and Singer, P. A. (1996). Bioethics for clinicians: 5. substitute decisionmaking. CMAJ 155: 1435–7.

Lefall, L.-S. D. (1997). Ethics in research and surgical practice. Am J Surg 174: 589–91.

Lo, B. (2000). Resolving Ethical Dilemma: A Guide for Clinicians, 2nd edn, Philadelphia, PA: Lippincott, Williams and Wilkins, pp. 294–301.

Macklin, R. (1999). Ethical problems with sham surgery.

N Engl J Med 341: 992–6.

Mattox, K. L. and Engelhardt, H. T. (1998). Emergency patients: serious moral choices with limited time, information, and patient participation. In Surgical Ethics, ed. L. McCullough, J. Jones, and B. Brody. New York: Oxford University Press, pp. 78–96.

McCullough L., Jones J., and Brody B. (1998a). Informed consent: autonomous decision making of the surgical patient. In Surgical Ethics, ed. L. McCullough, J. Jones, and B. Brody. New York: Oxford University Press, pp. 15–37.

McCullough L., Jones J., and Brody B. (1998b). Principles and ethics of surgery. In Surgical Ethics, ed. L. McCullough, J. Jones, and B. Brody. New York: Oxford University Press, pp. 3–14.

McKneally, M. F. (1999). Ethical problems in surgery: innovation leading to unforeseen complications.

World J Surg 23: 786–8.

Palmer, M. (1982). Ethics of a professional surgeon. Bull Am Coll Surg 67: 2–5.

Selzer, R. (1998). Sarcophagus. In The Doctor Stories. New York: Picador.

Shaw, G. B. (1946). The Doctor’s Dilemma: A Tragedy. Baltimore, MD: Penguin Books.

Siegler, M. (1996). Identifying the ethical aspects of clinical practice. Bull Am Coll Surg 81: 23–5.

York, N. L., DaRosa, D. A., Markwell, S. J., Niehaus, A. H., and Folse, R. (1995). Patients’ attitudes towards the involvement of medical students in their care. Am J Surg 169: 421–3.

Zaroff, L. (2005a). Two worlds of rituals are joined in the operating room. New York Times, 11 October (late edn), F5.

Zaroff, L. (2005b). A physician’s challenge: cancer surgery, but ‘‘no blood’’. New York Times. 8 November (late edn), F5.

Zaroff, L. (2005c). In the operating room, matters of heart and mind. New York Times, 21 June (late edn), F5.