Legal and Ethical Aspects of Anaesthesia, Critical Care and Perioperative Medicine.

Abstract

Mayo Clinic, Rochester, Minnesota. mkumar@mayo.eduLegal and Ethical Aspects of Anaesthesia, Critical Care and Perioperative Medicine. By Stuart White and Timothy Baldwin. Cambridge, United Kingdom; New York, Cambridge University Press, 2005. Pages: 216. Price: $43.00.Often there is no single best answer to an ethical question in medicine. A multitude of factors, including the physician’s own morality, religious beliefs, and the prevailing laws in the community shape the nature of one’s answer. In their new book, Legal and Ethical Aspects of Anaesthesia, Critical Care and Perioperative Medicine , Stuart White, a practicing anesthesiologist, and Timothy Baldwin, a barrister, provide readers with a set of analytical tools to examine critically and resolve legal and ethical issues.The 13 chapters in the book loosely follow the General Medical Council’s 1998 proposed core curriculum for medical ethics and law. The first few chapters provide an introduction to the organization of the legal system in the United Kingdom and the basic tenets of medical ethics. The 1998 Human Rights Act and its relevance to contemporary medical ethics are discussed in chapter 4. Subsequent chapters are dedicated to issues of consent, negligence, confidentiality of medical records, abortion, product liability, research, death, organ procurement, professional regulation, and resource allocation. In each chapter, the authors clearly frame the issues, state the relevant case laws and statutes, provide alternative arguments, and suggest reasonable courses of conduct. In the appendix, the authors describe seminal cases in legal brief format and provide hypothetical questions for group discussion.The authors trace the roots of current patient-centered medical ethics to the principles embodied in the 1998 Human Rights Act and its predecessors: the Nuremberg Code (1947), the United Nation’s Universal Declaration of Human Rights (1948), and the European Convention of Human Rights (1950). This patient-centered approach forms the basis of the authors’ treatment of topics involving consent, confidentiality, abortion, death, and organ procurement.Regarding patient consent, the authors argue that respect for patient autonomy lies at the core of contemporary medical law and ethics. Contrary to the paternalistic Hippocratic ethic, in patient-centered decision making, choices are placed in the hands of patients rather than physicians. Capacity to consent or not, based on age, mental health status, and religious beliefs, is discussed at length.The elements of negligence—duty, breach, causation, and damages—are well illustrated with examples and actual legal cases. In the United States, where physicians often supervise the administration of anesthetics by nurses and other allied health personnel, vicarious liability may attach to the physician for the negligent acts of the other. Under such circumstances, the physicians can be sued under the legal doctrines of Respondeat Superior, Res Ipsa Loquitur , or Joint and Several Liability . Because supervisory practice is limited in Europe, the authors provide little, if any, discussion of these forms of tort liability.Britain’s National Health Service was among the first to push for protecting sensitive patient information in the age of the Internet. The authors discuss confidentiality and medical records in light of the 1997 Caldicott Committee Report. American readers will find that many of the Caldicott Committee recommendations are mirrored in the Health Insurance Portability and Accountability Act 1996.Abortion is legal in the United Kingdom. Without taking sides, the authors discuss the “pro-choice” and “pro-life” arguments regarding abortion at various stages of gestation. Ultimately, the authors present abortion in terms of patient-centered ethics: The choice is the patient’s to make within the local legal framework.In chapter 9, the authors spare the readers the soporific complexities of product liability law and focus on answering two questions: (1) When a defective product causes injury, who is liable, and (2) can a physician accused of negligence raise the defense of defective product? In both circumstances, the liability of the manufacturer under the doctrines of breach of contract, negligence, and statutory provisions of the Consumer Protection Act 1987 are succinctly discussed.Is it ever ethical for a physician to help a patient die? The authors describe a spectrum of physician involvement from suicide to voluntary euthanasia to involuntary euthanasia to murder. They provide the legal and ethical principles relevant to the various degrees of involvement and leave it to the reader to apply these principles and formulate the rationale for what he or she believes is ethical.The final chapter of the book explores the thorny issue of resource allocation. Cost-effectiveness analysis and “needs” theories of resource allocation are compared and contrasted. American readers will find this chapter particularly enlightening since the United States spends 14% of its GDP on health care, which is twice that of most Western nations for a comparable level of services.International readers must bear in mind that the British case laws and statutes quoted in this book may not apply to their jurisdiction. For example, in the United States, outside holdings from common law countries, such as the United Kingdom, may influence the court and constitute persuasive precedent, but not mandatory precedent. American courts rely on persuasive precedent when their own case laws do not cover the issue or they are outdated because of legal developments elsewhere or new legislative actions have overturned existing case law.As medical technology has progressed, the number and complexity of ethical quandaries have increased. This text is a timely and much-needed discussion of emerging ethical issues in a concise, readable, and engaging format. It is suitable as a textbook for medical students in a medical ethics course or for busy residents and consultants as an overview of important ethical issues.Mayo Clinic, Rochester, Minnesota. mkumar@mayo.edu