Ethics: an essential dimension of clinical obstetric anesthesia.

Abstract

Ethics is an essential dimension of clinical obstetric anesthesia. In this article, we provide a framework for addressing ethical issues in obstetric anesthesia. The components of this framework include definitions of medical ethics and obstetric ethics, virtues and ethical principles, and the concept of the fetus as a patient (1). Medical Ethics and Obstetric Ethics Medical ethics can be defined as the disciplined study of morality in medicine (1,2). Throughout the history of ethics it has been accepted that morality concerns both character and behavior. Character involves what sort of people we should become so that we routinely identify and fulfill our duties to each other. Character is shaped by the virtues. Behavior concerns how we should act toward each other. Ethical principles guide behavior. Therefore, medical ethics begin with an account of the virtues that should define a physician as a professional and then identifies ethical principles that should guide the physician’s behavior toward patients. This approach to medical ethics can be found throughout its history (3). Obstetric ethics addresses ethical issues in obstetric practice and is of paramount importance to the anesthesiologist caring for the obstetric patient. The unique features of obstetric ethics are that the fetus is sometimes a second patient. The concept of the fetus as a patient is thus of central concern in obstetric ethics (1). It is important not to confuse medical ethics with the many sources of medical morality in pluralistic societies (4). These sources include, but are not limited to, law, various political heritages, religious beliefs, ethnic and cultural traditions, families, the traditions and practices of medicine (including medical education and training), and personal experience. The traditions and practices of medicine, including education and training, constitute the most important source of morality for physicians. These traditions and practices appeal to the general obligation to protect and promote the health-related interests of the patient (1,2). Providing a more concrete, clinically applicable account of this general ethical obligation is the central task of obstetric ethics. Four Professional Virtues of the Physician as Fiduciary. The obligation to protect and promote the patient’s health-related interests is a fiduciary obligation, which means that the physician should make the commitment to the patient’s health-related interests his or her primary concern, with self-interest a systematically secondary concern. Virtues are essential for the physician to implement this fiduciary responsibility. Virtues are those traits and habits of character that routinely focus the concern of the physician on the interests of the patient and thereby habitually blunt the motivation to act on self-interest as the physician’s primary consideration. Appealing to the medical ethics of the 18th century Scottish physician-ethicist John Gregory (1724–1773), we believe that four virtues define the physician’s role as fiduciary (5). The first virtue is self-effacement. This requires the physician not to act on the basis of potential differences between the patient and the physician such as race, religion, national origin, education, sex, manners, socioeconomic status, hygiene, or proficiency in speaking English. Self-effacement prevents biases and prejudices arising from these differences that could adversely impact on the plan of patient care. Historically, there was a violation of this virtue in medicine’s perception of obstetric anesthesia. For example, in the 19th century, biased judgment led physicians to resist the use of any anesthetic in obstetrics because they believed that the pain of childbirth was necessary. Women themselves led the struggle against this belief, resulting in the eventual acceptance of anesthesia for childbirth (6). However, some physicians took the view that, as a result of the comforts of modern life, no woman could bear the pain of childbirth, and all required anesthesia (7). The second virtue is self-sacrifice. This requires physicians to accept some reasonable risks for themselves. As one example, obstetric anesthesiologists understand that they need to be immediately available on a 24-h basis when they are on call and adjust their personal lives to meet the needs of patients. In both fee-for-service and managed care, this virtue of self-sacrifice obligates the obstetric anesthesiologist to balance their self-interest and focus on the patient’s need for relief when the two are in conflict. The third virtue, compassion, motivates the physician to recognize and seek to alleviate the stress, discomfort, pain, and suffering associated with the patient’s condition or disease. Obstetric anesthesia is a quintessential expression of the virtue of compassion in clinical practice. Integrity, the fourth virtue, requires physicians to practice medicine consistent with standards of intellectual and moral excellence. Integrity imposes an intellectual discipline on the physician’s clinical judgments about the patient’s problems and how to address them. Integrity prescribes rigor in the formation of clinical judgment. Clinical judgment is rigorous when it is based on the best available scientific information or, when such information is lacking, consensus clinical judgment and on careful thought processes of an individual physician that can withstand peer review. Accountability for the quality of obstetric anesthesia and reduction of uncontrolled, and therefore unjustified, clinical variation becomes obligatory on the basis of the virtue of integrity. Integrity is thus an antidote to the pitfalls of bias, subjective clinical impressions, and unexamined clinical common sense. Consider the current use of dilute epidural local anesthetics rather than the more concentrated solutions that had been previously used (8). Some anesthesiologists still routinely initiate or top-up an epidural with large concentrations of bupivacaine (e.g., 0.5%) as opposed to continuous infusions of dilute combinations of local anesthetics plus opioids, although it is common knowledge that motor block is not in the patient’s clinical interest. The practice of routinely using large concentrations of local anesthetics that produce motor block in laboring women, in the absence of a valid scientific justification, should be discontinued because it violates the scientific excellence required by the virtue of integrity. If the rationale offered is that dilute concentrations of local anesthetics require too much attention from the anesthesiologist, then self-sacrifice is violated. None of these four virtues is absolute in its ethical demands. The task of medical ethics is to identify both the application and the limits of these four virtues. The concept of legitimate self-interest provides the basis for these limits (9). Legitimate self-interest includes protecting the conditions for practicing medicine well, fulfilling obligations to persons in the physician’s life other than the patient, and protecting activities outside the practice of medicine that the physician finds deeply fulfilling. For example, in a community that does not have the resources to provide for continuous in-house anesthetic coverage and if parenteral opioids are considered an acceptable but less than desirable form of pain relief, it is ethically justified for the lone anesthesiologist working in a small community to refuse to come to the hospital to perform a neuraxial block for all intrapartum patients. This practice would be consistent with integrity and protects the anesthesiologist’s legitimate interest in avoiding an overwhelming demand on time and family life. However, there seems to be no ethical justification for responding to a patient’s request for neuraxial analgesia, and then after arriving at the patient’s bedside, to refuse to proceed with the procedure until payment in cash is made because the level of financial self-sacrifice in performing one epidural is not overwhelming. This is in contradistinction to the scenario where the level of financial self-sacrifice is overwhelming and would thus preclude fulfilling obligations to one’s family or other patients. Ethical Principles as Guides to Clinical Behavior. Professional virtues direct the physician’s attention and concern to the health-related interests of the patient. Specifically, clinically applicable guides for behavior toward the patient are provided by ethical principles, three of which play a central role in medical and obstetric ethics: beneficence, respect for autonomy, and justice (1,10). The principle of beneficence requires one to act in a way that is expected to reliably produce the greater balance of goods over harms for others who will be affected by one’s behavior (1,2,10). To put this principle into clinical practice requires a reliable account of the goods and harms relevant to the care of patients and of how those goods and harms should be reasonably balanced against each other when not all of them can be achieved in a particular clinical situation. In medicine, the principle of beneficence requires the physician to act in a way that is expected to produce the greater balance of clinical goods over harms for the patient. Beneficence-based clinical judgment has an ancient pedigree. Its first expression in Western medical ethics can be found in the Hippocratic Oath and accompanying texts. Beneficence-based clinical judgment claims the authority to interpret reliably the health-related interests of the patient from a rigorous clinical perspective (1,2). This perspective should be based on accumulated scientific research, clinical experience, and reasoned responses to uncertainty. It should not be the function of the individual clinical perspective of a particular physician and, therefore, should not be based merely on clinical impression or intuition of an individual physician. Beneficence-based clinical judgment identifies the goods that can be achieved for patients based on the competencies of medicine. The goods that medicine is competent to seek for patients are the prevention and management of disease, injury, handicap, and unnecessary pain and suffering and the prevention of premature or unnecessary death (1). Pain and suffering become unnecessary when they do not result in achieving the other goods of medical care. Thus, the relief of unnecessary pain is a fundamental, beneficence-based obligation in obstetric anesthesia. This obligation needs to be balanced against other beneficence-based obligations to the pregnant woman and fetal patient. Beneficence-based obligations are not absolute; they have justified limits (1). The beneficence-based obligation to provide pain relief has such limits, including economic limits such as hospitals that cannot supply full-time obstetric anesthesiologist coverage. Neuraxial block may be considered the “gold standard,” but does beneficence obligate the anesthesiologist to provide the gold standard to every patient? In such cases, the best should not be the enemy of the good. Whereas it is clear that denying a parturient labor analgesia is unethical because it would be inconsistent with beneficence-based obligations, there are other forms of effective pain relief than this gold standard. Beneficence requires that pain relief be provided, but relief comes in degrees of effectiveness. As long as the analgesia being provided to every patient is effective, beneficence-based obligations are met. Substitution of effective pain relief for marginally more effective pain relief in a subset of patients is consistent with the anesthesiologist’s and hospital’s beneficence-based obligations to the patient, provided that the hospital’s economic shortfall is real. For hospitals with the economic resources to provide full-time coverage, it would be inappropriate not to provide such coverage, unless hospital management could document that the resources are required to meet more basic patient needs such as adequately staffing the emergency department. When basic needs are being met throughout the hospital, it would be appropriate for obstetric anesthesiologists to advocate for the resources required to provide full-time coverage, and this advocacy could not reasonably be interpreted by hospital leadership as the expression of mere self-interest or special pleading. In addition to the principle of beneficence, there has been increasing emphasis in medical and obstetric ethics on the principle of respect for autonomy (1,10). The pregnant patient brings to her medical care her own perspective on what is in her interest, which can range beyond health-related concerns. The principle of respect for autonomy translates this fact into autonomy-based clinical judgment. Because each patient’s perspective on her interests is a function of her values and beliefs, it would be inappropriate to specify in advance the goods and harms that she should judge to be significant. Conversely, the physician in beneficence-based judgment balances clinical goods and harms. However, the woman’s perspective is broader than these clinical goods and harms. Respect for autonomy is implemented in the clinical setting through the informed consent process (1). A signed operative and anesthetic consent form should never be considered as entirely satisfying the obligation to obtain informed consent. A consent form mainly documents the patient’s acceptance of a plan of care. In the informed consent process, the obstetric anesthesiologist should present the beneficence-supported alternatives for analgesia and elicit the patient’s preferences regarding pain relief and willingness to accept the iatrogenic risks. The woman’s judgment about the level of pain she is willing to accept is a function of her values and beliefs. The obstetric anesthesiologist functions as an authority (4), i.e., a physician with expert knowledge about medically reasonable alternatives for pain relief and their iatrogenic risks. The pregnant woman is in authority (4), i.e., she has the right to accept or refuse obstetric labor anesthesia. Ethical challenges arise when patients’ decisions seem to be inconsistent with their health-related interests. For example, some patients insist on being allowed to eat solid food during labor and may express indifference to the risk of aspiration. These preventable risks of aspiration include death and serious injury to the woman and are inconsistent with beneficence-based clinical judgment and practice. The informed consent process is not understood in either ethics or law to be one in which the patient can exercise autonomy in the expectation that the physician will violate the professional integrity of beneficence-based clinical judgement. It follows that requests to eat solid food should be denied and that orders in the chart denying solid food are justified. These orders should include efforts by nurses and other members of the care team to discourage patients from obtaining solid food on their own and immediate notification of the anesthesiologist should such efforts fail. In that case, the anesthesiologist should make a vigorous effort, underscoring the risks, to aggressively persuade the patient to forego eating until after delivery. In contrast, a patient may refuse epidural or spinal anesthesia for cesarean delivery and request general anesthesia, which is associated with greater risks of mortality (11), even after being informed about these risks. The question to ask in all such cases is whether the patient’s preference is medically reasonable, i.e., consistent with beneficence-based clinical judgment, or unreasonable, i.e., not consistent with such judgment. We believe that the request for general anesthesia involves acceptable levels of risk, although the risks of spinal and epidural anesthesia are smaller. Refusal to provide general anesthesia in such cases is not supported by an appeal to professional integrity but to individual judgments about one’s comfort level with the patient’s preference. The anesthesiologist is certainly justified in attempting to persuade such patients to reconsider and change their minds and to seek aid from their obstetric colleague in trying to convince the patient to accept a neuraxial technique. If, however, such good-faith efforts fail, it is appropriate for the anesthesiologist to administer general anesthesia as an alternative having acceptable risk and therefore consistent with beneficence-based clinical judgment. Justice is an ethical principle that obligates us to allocate scarce resources in ways that are fair, both in the process of deciding about allocation and the outcome, what each individual will receive as his or her due. Concerning obstetric anesthesia, there is an ethical obligation of hospitals and payers to fund accepted standards of care for the administration of obstetric anesthesia as a matter of fairness to all patients regardless of source of payment (1). Anesthesiologists and obstetricians should continue to advocate for financial support from insurers, managed-care providers, and hospitals for obstetric anesthesia services. Justice and beneficence help address the ethical challenges of different levels of insurance that patients have. Beneficence requires the administration of effective pain relief. So long as the pain relief is effective in every case, the obstetric anesthesiologist’s practice may vary from patient to patient on the basis of the source of payment because beneficence-based obligations, and therefore fiduciary obligations, are not violated. Justice in the allocation of scarce resources is permissible as long as it does not result in any patent being denied the baseline standard of care, as defined in that hospital or community. It is crucial that all substitutions of less expensive for more expensive analgesia be evidence-based to protect the anesthesiologist’s professional integrity. The Fetus as a Patient The concept of the fetus as a patient is the next major component of this framework for ethics in obstetric anesthesia. This concept is shaped by the interaction of the principles of beneficence and respect for autonomy applied to both the pregnant woman and the fetus. The physician obviously has beneficence-based and autonomy-based obligations to the pregnant patient (1). The physician’s perspective on the pregnant woman’s interests provides the basis for the physician’s beneficence-based obligations to her, whereas her own perspective on those interests provides the basis for the physician’s autonomy-based obligations to her. Because of an insufficiently developed central nervous system, the fetus cannot meaningfully be said to possess or have possessed values and beliefs. This is in contradistinction to the comatose patient. Thus, there is no basis for saying that a fetus has a perspective on its interests. Therefore, there can be no autonomy-based obligations to any fetus (1). The language of fetal rights has no meaning and therefore no application to the fetus in the ethics of obstetric anesthesia. Obviously, the physician has a perspective on the fetus’s health-related interests, and the physician has beneficence-based obligations to the fetus, but only when the fetus is a patient. The physician’s obligations to the fetal patient are exclusively beneficence based. The absence of fetal rights from this account does not in any way diminish the weight of these obligations (1). The concept of the fetus as a patient understood in terms of beneficence-based obligations is essential to obstetric anesthesia. Developments in fetal diagnosis and management strategies to optimize fetal outcome have become widely accepted, encouraging the development of this concept. This concept has considerable clinical significance. When the fetus is a patient, directive counseling, i.e., recommending a form of management, for fetal benefit is appropriate. In contrast, when the fetus is not a patient, nondirective counseling, i.e., offering but not recommending a form of management, is appropriate. However, these apparently straightforward roles for directive and nondirective counseling are often difficult to apply in obstetric anesthesia because of uncertainty about when the fetus is a patient. One approach to resolving this uncertainty would be to argue that the fetus is or is not a patient because the fetus is a person or has some other form of independent moral status. Independent moral status for the fetus means that one or more properties that the fetus possesses in and of itself and, therefore, independently of the pregnant woman or any other factor generate and therefore ground obligations to the fetus on the part of the pregnant woman and her physician (1). Some have argued that the fetus has independent moral status from the moment of conception or implantation. Others have held that independent moral status is acquired in degrees, thus resulting in graded moral status. Still, others hold, at least by implication, that the fetus never has independent moral status so long as it is in utero. There has been no agreement on a single authoritative account of the independent moral status of the fetus for all of the markedly diverse theological and philosophical schools of thought involved in this continuing debate (1). Therefore, we suggest that obstetric ethics should abandon these intellectually futile attempts to understand the fetus as a patient in terms of independent moral status of the fetus. Our account of the concept of the fetus as a patient begins with the recognition that being a patient does not require that one possesses independent moral status or be able to generate rights, a view that protects many vulnerable patients, not just the fetal patient (1). Put more precisely, a human being becomes a patient when two conditions are met: that a human being (a) is presented to the physician and (b) there are clinical interventions that are reliably expected to be effective, in that they are reliably expected to result in a greater balance of clinical goods over harms for the human being in question (12). We call this the dependent moral status of the fetus. It has been argued elsewhere that there are beneficence-based obligations to the fetus when it is reliably expected later to become a child and subsequently to achieve independent moral status (1). That is, the fetus is a patient when the fetus is presented for medical interventions that reasonably can be expected to result in a greater balance of clinical goods over harms for the child or person the fetus can later become. The ethical significance of the concept of the fetus as a patient, therefore, depends on links that can be established between the fetus and its later achieving independent moral status. One such link is viability. Viability must be understood in terms of both biological and technological factors. When a fetus is viable, i.e., when it is of sufficient maturity so that it can survive into the neonatal period and achieve independent moral status given the availability of the requisite technological support and when it is presented to the physician, the fetus is a patient, and the physician and pregnant woman both have beneficence-based obligations to it. The physician’s beneficence-based obligations to the fetal patient must in all cases be balanced against the physician’s beneficence-based and autonomy-based obligations to the pregnant woman (1). Viability exists as a function of biomedical and technological capacities, which are different in different parts of the world. As a consequence, there is, at the present time, no worldwide, uniform gestational age to define viability. In the United States, the authors believe, viability presently occurs at approximately 24 wk of gestational age (13–15). When the fetus is a patient, directive counseling for fetal benefit is ethically justified. For example, cesarean delivery of an extremely premature fetal patient may justifiably influence the mode of anesthesia for this especially vulnerable fetal patient. Obviously, any strategy for directive counseling for fetal benefit that takes account of obligations to the pregnant woman must be open to the possibility of conflict between the physician’s recommendation and a pregnant woman’s autonomous decision to the contrary. Such conflict is best managed preventively through informed consent as a continuing dialog throughout the pregnancy, augmented as required by negotiation and respectful persuasion (1). Discussions about obstetric anesthesia should become a routine element of prenatal care and not be postponed until labor, when the informed consent process is inevitably rushed and under stress. The only possible link between the previable fetus and the child it can become is the pregnant woman’s autonomy. This is because technological factors cannot result in the previable fetus becoming a child. Thus, the link between a previable fetus and the child it can become can be established only by the pregnant woman’s decision to confer the status of being a patient on her previable fetus. Therefore, the previable fetus has no claim to the status of being a patient independently of the pregnant woman’s autonomy. In our view, the pregnant woman is free to withhold, confer, or, having once conferred, withdraw the status of being a patient on or from her previable fetus according to her own values and beliefs. The previable fetus is presented to the physician solely as a function of the pregnant woman’s autonomy. Counseling the pregnant woman regarding the management of her pregnancy when the fetus is previable should be nondirective in terms of continuing the pregnancy or having an abortion if she refuses to confer the status of being a patient on her fetus. Clinical judgment about anesthesia during abortion therefore takes account only of beneficence-based obligations to the pregnant woman. Physicians morally opposed to abortion, as a matter of individual conscience, are not obligated to participate in the procedure. Emergency termination of pregnancy that is life-threatening to the mother, for whom no other anesthesiologist is available, might be an exception. Full consideration of this topic is beyond the scope of this paper. At the same time, obstetric anesthesiologists with such conscience-based objections to abortion are obliged, as a matter of professional ethics, not to interfere with the woman’s autonomous decision in this matter (1). In conclusion, the practice of obstetric anesthesia is incomplete and inadequate without identifying and addressing its ethical dimensions. The purpose of this article has been to provide a clinically applicable framework based on ethically sound concepts, specifically ethical virtues and principles. Whereas it is possible that this paper may provoke interesting debate, we believe that the framework identifies and organizes these virtues and principles in a way that enables obstetric anesthesiologists to identify, prevent, and manage ethical conflict that can arise in the clinical setting. We hope that we have convinced the reader that ethics is an essential dimension of obstetric anesthesiology that enables obstetric anesthesiologists to fulfill their ethical obligations to pregnant women and fetal patients.