As an anaesthesiologist with an interest in professional and clinical ethics, I have always been fascinated by the ethical labyrinth that we navigate in our daily practice. We are clinicians to the patients, service providers to the surgeons and stakeholders to the operating room management team. Anaesthesiologists thus have ethical responsibilities to their patients, medical colleagues as well as the healthcare facilities in which they practise.
PROFESSIONAL RESPONSIBILITIES TO THE PATIENTS
The framework for the care of our patients is rooted in the principles of patient welfare and respect for their autonomy. The main challenge is the difficulty in establishing an anaesthesiologist-patient relationship. This is primarily due to the fact that anaesthesiologists are not the primary physicians for the patients under their care. Surgical patients do not come to the hospital seeking anaesthesiologists, but they will inevitably need one to participate in their management. Many patients think of their anaesthesiologists as just the person behind the mask — the person who puts them to sleep and wakes them up when it's over. They often do not realise the comprehensive medical care the anaesthesiologist provides preoperatively and beyond.
Our professional duty begins preoperatively. Anaesthesiologists carry the responsibility of providing preoperative evaluation, optimisation and also the facilitation of informed decision-making, especially with regard to the choice of anaesthetic technique.
Oftentimes, we find that the contact time with patients while they are awake ends up being very brief. This then forms an imbalance in the trust and depth of relationship between the patient and their anaesthesiologist, and with their surgeon. By the time patients are presented to the anaesthesiologist for assessment and risk discussion, they would have been through multiple sessions with surgical colleagues and are then understandably more focused on the surgical risks. It can be difficult for patients to grasp the concept of a separate set of risks for a single surgery, and that the risks of anaesthesia may sometimes be higher than those of the surgery itself. This may lead to downplaying of the anaesthesiologist’s risk discussion and estimation with the patient. It is also challenging to assess if the patient is really able to understand, retain and process all the complex information given within that short preoperative assessment visit.
A dedicated outpatient preanaesthetic evaluation clinic allows anaesthesiologists to be able to spend time interacting with their patients in a comfortable environment, weeks before the surgery. This could help to enhance the patient’s understanding of the discussion, build rapport and trust with the anaesthesiologist, and act as mitigation against the last minute rush to assess patients the night before, or even morning of, the surgery. One can even arrange for further follow-up or revisits for truly complex cases. This would be an improvement from the traditional workflow of visiting patients the night before their surgery. To further strengthen this understanding, general conversation and dissemination of information on the anaesthetic process could even be started earlier at the surgeon’s office. After all, it is in the best interest of our patients that the surgeons and anaesthesiologists work as a team to care for each patient.
On the part of the anaesthesiologist, offering a full risk-benefit discussion in the best interest of the patient would require an understanding of their values, medical and surgical condition, as well as prognosis and healthcare access. This should also be placed into a wider context beyond the aim to get the patient through one surgery. Anaesthesiologists should resist the temptation to use medical jargon to restrain or coerce patients who have adequate decision-making capacity.1 The patient’s right for self-determination in the presence of informed consent should be respected. In challenging circumstances, multiple engagements over time or seeking the help of surgical colleagues may be better options.
Intra-operatively, the major professional and ethical consideration would be that anaesthetised patients are extremely vulnerable. Ethical practice should motivate us to step up as the patient’s advocate and care for the patient’s physical and psychological safety, comfort and dignity. Examples are wide-ranging — from protecting the anaesthetised patient’s modesty to ensuring that the patient’s consent and wishes are respected. This would again require anaesthesiologists to know their patients well enough while they are awake so that a custodial relationship can be forged. Anaesthesia training programmes should not only focus on producing anaesthesiologists with good clinical competence, but also those who are aware of surrounding ethical and professional issues.
THE ANAESTHESIOLOGIST AND CONSCIENTIOUS OBJECTION
Invocation of conscientious objection does not exonerate physicians from duties to their patients. Hence, disclosure of personal ethical beliefs to the institution might be needed for the purpose of ensuring the availability of cover. Anaesthesiologists should not abandon or compromise the care of patients whose beliefs clash with their own, but instead arrange for a transfer of care. In an emergency, the patient’s safety and best interest would be paramount. Arrangement for another anaesthesiologist could be carried on concurrently with lifesaving measures which should be provided without prejudice.
PROFESSIONAL DUTIES TO OTHER MEDICAL COLLEAGUES
With the patient’s best interest in mind, anaesthesiologists should also bear the responsibility of promoting a cooperative and respectful relationship with other professionals involved in their care. One should strive to maintain an environment where good quality management can be given. This can be challenging especially when there are differing professional opinions, which can be common when dealing with medically complex cases that require multidisciplinary input. Portraying another colleague in a bad light or allowing disagreements to become apparent in front of the patient would erode the patient’s trust in medical providers and their ability to work together.
The anaesthesiologist-surgeon relationship can often be strained in the face of disagreements, especially over the extent of medical interventions in medically challenging cases. When an anaesthesiologist finds the surgeon’s decisions to be in conflict with his or her own moral or professional beliefs, there should be an attempt to reconcile these differences diplomatically, which may include escalation of the issue to a higher level or getting a second opinion from a neutral colleague. If the situation is irreconcilable, the anaesthesiologist should withdraw in a non-judgemental fashion and provide an alternative for care in a timely fashion.2 However, if an anaesthesiologist finds certain intervention decisions to be in conflict with the accepted professional standards of care, ethical practice or institutional policies, the anaesthesiologist should then voice such concerns and present the situation to the appropriate institutional body. In no instance however, should a patient be inconvenienced or have his or her care compromised due to unresolved differences between the anaesthesiologist and the surgeon — patient care should always be at the forefront of any professional interaction. Maintaining a healthy collegial relationship is the responsibility of all physicians caring for their patients.
CONFLICTS OF INTEREST IN ANAESTHESIOLOGY
Most anaesthesiologists in private practice are dependent on surgeons to provide patients for anaesthesia and it is rare for patients to request for an anaesthesiologist unless they have positive experiences from a previous surgery. As such, the anaesthesiologists may end up beholden to the surgeon, which can lead to conflicts of interest — pitting patient advocacy against loyalty to the referring surgeon. Furthermore, as service providers, the practice of financial kickbacks, undercutting and price-fixing are always a temptation. Those who participate in fraudulent business practices often do so due to ignorance rather than intent. Hence, it is our ethical obligation to learn and understand the various forms of inappropriate business practices in order to avoid becoming unintentionally implicated.
THE ANAESTHESIOLOGIST AND PRACTICE-BASED IMPROVEMENT
Anaesthesiologists throughout the world have established themselves as leaders in patient safety and quality improvement. I know of many anaesthesiologists who serve within hospital or specialty committees. Much of our training revolves around patient safety and acute care; hence, using our skill set to help develop departmental or hospital guidelines as well as reviewing the practice of colleagues, in good faith, are part of our ethical responsibility. Cooperating with both clinical and administrative colleagues to improve the quality, effectiveness and efficiency of the care given would only serve to improve the patient’s outcome. This may consist of being present and taking part in the surgical safety checklist, as well as taking lead in patient safety issues in the operating theatre.
As an acute care physician, we are also ethically obliged to be present during emergencies in our institution when contracted to do so, and to ensure that we are able to handle such emergencies. This would include measures to maintain our state of readiness, such as attending continuous medical education sessions and refresher courses.
Due to our unique role which requires the personal handling of controlled and dangerous drugs, we also carry the responsibility of keeping these substances safe from abuse and illicit use. We should be vigilant about the signs of possible substance abuse among our colleagues and learn how to handle such cases discreetly and ethically.
Conclusion
Every specialty will have its own unique ethical responsibilities and challenges. Anaesthesiologists, being clinician service providers, encounter many. These are obviously on top of the myriad of ethical responsibilities which are common among all physicians. It can be a daunting prospect to try and keep within ethical parameters. However, as long as we practise in the best interest of our patients and keep to the common pillars of medical ethics — we should be secure in the knowledge that we are on the right track.
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