Ethics and Anaesthesia

Ethics and Anaesthesia

  • Issue 74

Paul McConnell 

paulmcconnel@doctors.org.uk

We all strive to be good doctors, but what do we mean by being “good”? Is this a reference to technical skill – to be able to perform complex practical procedures? Or maybe we mean to have an inexhaustible knowledge of therapies and diagnoses to best treat our patients? Perhaps we more accurately mean doing the right thing in any clinical situation. And yet as therapeutic options increase and life sustaining (though not necessarily improving) therapies proliferate, the notion of doing what is right may not always be so simple and clear cut.

The association of and need for ethical guidance in the provision of medicine dates back millennia to even before Hippocrates took his oath before before his Gods. Though ethics itself has developed along with (or as a reaction to) medical progress, it may be easy to give examples of unethical behaviour, yet deciding what is correct and ethical can prove difficult. Though we are taught and will recite our 4-pillar mantra of “beneficence, non-maleficence, autonomy, and justice” as a checklist shield when confronting any ethical monster our practice confronts us with, is this a practical defence? Can we reconcile these four sometimes disparate principals for all situations? Do we need to think in terms of populations and what benefits the most as utilitarians or work to see that those who are most disadvantaged gain most as Rawlsians? Are all our decisions relative to each scenario or are there some immutable and true rules we cannot break (and if there are, how do we know what they are)? Is ethics just a set of club rules that we all sort of agree on or are there greater underlying truths? Much like many of our difficult clinical cases the answers to this are often not clear, but through the application of experience and logic we can at least try to navigate our way through these challenges.

It is an acknowledgement of uncertainties, an appreciation of differing viewpoints, an awareness of the origins of our ethical beliefs, and an attempt to safeguard and promote safe and “good” practice that has defined the ethics programme for the 2018 Copenhagen Congress and our work around the submission and review of submitted abstracts.

In 2015, there was anecdotal evidence from abstract reviewers raising concerns regarding the ethical governance of some abstracts submitted to the Congress; that correct ethical review had not been sought. This spurred a thorough review of all abstracts submitted and evidence sought of appropriate ethical review. The surprising results were recently published in the EJA,1 and as a result the abstract submission process has been overhauled to ensure that all accepted submissions for 2018 have undergone ethical review when appropriate. The role and importance of ethics committees cannot be understated, ensuring both scientific rigor but equally important safeguarding participants from coercion, exploitation, and clinical danger. It is a testament to the resolve of the ESA that it has embraced the findings of the review and set out on a course to ensure that all abstracts adhere to not only the highest clinical, but also ethical, standards in a move that challenges other national and international societies to evaluate and reflect in their own practices.

In Copenhagen itself we will examine outcomes in Intensive Care. As we become more adept at providing life-sustaining therapies, we will look at factors that affect survival. We have increasingly become cognizant that merely because we can do something, does not necessarily mean that we should do something. We will explore how factors such as location and frailty currently affect our patients and ask whether these factors should influence our practice. We will then look to the future and the role of genetics in outcomes, whether if tests were available we should let this determine our clinical actions and ask the question “Are we more than our genes?”.

Euroanaesthesia 2018 will also see us attempt to reconcile where our own beliefs should sit within our practice with a pro/con debate on doctors’ right to conscientious objection. With many practioners and members of the public having strongly held and sometimes opposing views on organ donation, abortion, and assisted suicide, can we find a way to reconcile these and protect both parties’ interests? Are we ultimately just technicians who must put aside our own beliefs and adhere to the requests of our patients without question or do our own opinions and convictions matter equally? Should we be compelled to act in ways we believe are anathema to us to protect patient choice or is our own autonomy as important? With cases surrounding this being heard in courts all over Europe, we hope our expert speakers will help guide us through this moral maze.

Related to Conscientious Objection will be a symposium exploring religion and spirituality in medicine. How do patients’ beliefs impact organ donation and how we provide end of life care? How can we best look after Jehovah’s Witnesses; how do their beliefs impact care and how can we explore the implications of those beliefs with them? We finish this symposium by asking “Is there a place for religion and spirituality in medicine?”.

We also recognise the growing aging population and the accompanying problems of cognition. We will explore the concepts of diminishing capacity and end of life care, while providing solutions to improve treatment and well-being in the peri-operative period. This session will both challenge and educate and make us question what we mean by “best interests” and how this extends well beyond the scope of the therapies we provide.

While many of our sessions focus on the autonomy of the individual, we will also explore more macro-concerns, looking at the impact of migration on European medicine, what we can offer and do in disaster zones, what the rights of refugees are, and how we can monitor the spread of disease. With our medicine and migration symposium we will examine these issues with experts in both medicine and law from all over Europe.

Yet for all the questions we’ve asked, we will also be offering solutions, with our second pre-Congress course in ethics. This year our focus is on leadership, ethical practice, and conflict resolution, providing insight into navigating difficult ethical situations and working with colleagues and relatives to ensure best care. We will examine moral leadership, capacity, futility, and advanced planning, and integrate them into clinical scenarios with a focus on identifying difficulties and resolving conflict. With limited space and direct access to an expert faculty happy to explore complex issues, early booking is essential.

The cornerstone of medical practice lies in knowledge of the fundamentals of ethical thought and an understanding of our patients themselves. Only when we see them as more than physiology to be manipulated or conditions to be managed, and instead as people with the same hopes, fears, and defining beliefs that we have, will we ever approach being “good” doctors.

 

Reference

  1. McConnell P, Kaufman N, De Hert S, et al. Research ethics committee approval as reported for abstracts submitted to the annual Euroanaesthesia meeting. Eur J Anaesthesiol 2017;34(12):824–30.