To the Editor:-We read with interest Dennis Bastron's article,  in which he gives his opinion of some of the ethical foundations and values of the ASA Ethical Guidelines for the Anesthesia Care of Patients with Do Not Resuscitate Orders or Other Directives That Limit Care. [2,3] Bastron et al. have considered the issue of perioperative care for these patients and developed a policy concerning intraoperative do-not-resuscitate (DNR) orders. We are responding to what we believe to be his overly simplistic interpretation of the Guidelines, and we disagree with most of his critical commentary regarding the ethical principles on which the Guidelines are based. Further, we question whether his “special consent” form is a sufficiently ethical means of dealing with this distinct group of DNR patients.
Bastron appears to confuse standards, policies, and guidelines. Standards are rules that are generally accepted principles for sound patient management and consist of the minimum behavior(s) that a profession requires. Policies are public (governmental) or private (professional or institutional) statements codifying these standards. Guidelines are recommendations for a particular patient management strategy or a range of such strategies. The consensus building process that produced the ASA Guidelines involved prolonged deliberations by the diversely constituted Committee on Ethics. This document then was moved through the usual ASA parliamentary stages, including a rigorous dissection in reference committee and close scrutiny by the House of Delegates. One of the current priorities of the Committee on Ethics is to develop educational materials and aids that can help our colleagues implement the Guidelines into their practices.
Whereas standards and policies represent the minimum care required, guidelines declare the ideal behavior to which anesthesiologists should aspire. The Guidelines are the ASA's statement of the ideal; however, the Guidelines also recognize that local, institutional, or situational factors may temporarily or even permanently preclude achievement of such ideal goals. These facts notwithstanding, we believe that ethical medical care should not be defined as that which is most easily achievable or convenient, but rather by what we can understand to be the most praiseworthy goals.
Most advance directives originate outside the operating room. The term resuscitate poses a semantic dilemma as it is fraught with ambiguity in the anesthesia care setting. Therefore, it behooves the anesthesiologist to clarify the meaning and consequences of “resuscitation” within the context of anesthesia care. The cornerstone of the patient-anesthesiologist relationship and its accompanying mutual trust is an unfettered preanesthetic sharing of knowledge, feelings, values, and goals that culminates in informed consent. We would expand Bastron's sentiments to state that our patients' intentions always should be understood in a goals-oriented fashion, one that goes far beyond simply focusing on the mechanics of anesthesia and resuscitation.
We believe that Bastron's “special consent” form fails to offer any meaningful choices to the competent DNR patient who presents for nonemergency surgery. This form even may be misleading to this special group of patients. Although it reads that they can choose to keep their DNR orders in the operating room, the succeeding sentence states that “the patient understands that clinical events believed to be temporary and reversible will be treated and standard anesthesia procedures will be employed.” Although this is the decision that many patients would want, we believe that this form is not the choice that it proffers to be because it offers only one other option: full suspension of the DNR request.
Bastron has emphasized that patient autonomy is only one of many ethical principles that are helpful in understanding ethical dilemmas. Although not intended to serve as a comprehensive treatise on ethical conflict resolution, the Guidelines are directed at patients who autonomously already have acknowledged their limited prognoses. They already have made a decision not to be resuscitated from an arrest, regardless of cause, unless specifically stipulated. These patients have accepted their life-limiting disease and expressed what sort of care and comfort they want provided to them. The Guidelines address this post facto scenario, in which surgical intervention may be meaningful to the quality of a patient's remaining life. Although the Guidelines are based primarily on a continued protection of a patient's right to self determination, they also concomitantly respect a physician's moral independence. The Guidelines recommend to work within the framework of safeguarding patient autonomy when no other equally compelling ethical conflict or dilemma exists.
Bastron's arguments about the limits of patient autonomy bear some scrutiny because he evoked a limited statement from Beauchamp and Childress, but ignored a plethora of others. He is correct in asserting that respect for patient autonomy is only a prima facie principle, but he fails to acknowledge the reality that in the United States it has become an overriding principle by virtue of 30 yr of legal and social precedents. Another noted bioethicist, Albert Jonsen, stated “One of the most common ethical issues raised by the principle of respect for autonomy is paternalism. This term refers to the practice of overriding or ignoring a person's preferences to benefit them or enhance their welfare. In essence, it consists in the judgment that beneficence takes priority over autonomy. Historically, the medical profession has endorsed paternalism. Today, although still common, it is considered ethically suspect.” In accordance with this view, Beauchamp and Childress state that “such respect [for autonomy] involves respectful action, not merely a respectful attitude. It also requires more than obligations of nonintervention in the affairs of persons, because it includes obligations to maintain capacities for autonomous choice in others while allaying fears and other conditions that destroy or disrupt their autonomous actions…. Disrespect for autonomy involves attitudes and actions that ignore, insult, or demean others.” Unless Bastron can show that an overwhelming harm will result by respecting a patient's autonomy, then we believe that respect for autonomy holds priority over other considerations and obliges physicians to actively pursue means of promoting a patient's own definition and expression of their autonomy.
In the same section Bastron speaks to the fact that “All moral agents have rights.” We should emphasize that all moral agents do not have equal rights and duties. This viewpoint also is promoted by Beauchamp and Childress:“Professional fidelity or loyalty was traditionally conceived as giving the patient's interest priority in two essential respects: 1) the professional effaces self-interest in any conflict with the patient's interests, and 2) the patient's interests take priority over others' interests.” We agree that physicians' rights do not have equal standing with those of their patients. Rather, physicians are obliged to set aside their own interests and moral preferences unless an overwhelming harm to their personal integrity will occur. Physician convenience does not have equal ethical standing with the autonomous choices of patients.
Dr. Bastron also claimed that the authors of the Guidelines ignored “virtue-based ethics, casuistry, and the ethics of care.” The basis for this statement is not clear because the Committee on Ethics that developed the Guidelines did include people who favor these understandings of bioethics. The Guidelines is intentionally an amalgam of these and other approaches that represent the diversity of our American society. Unless he is able to provide an argument that any or all of these constructs suggest ignoring patient choices, he holds no reasoned base from which to evoke their mere existence as supporting evidence for his claims. Each of these constructs places a priority on respect for patients and their autonomy.
Bastron justifies his consent form and policy on the basis of practical feasibility. This would be acceptable if he did not at the same moment try to justify it as an ethical policy. Any ethical argument that relies on the nuances of feasibility for its conclusions begs caution. The boundary distinguishing feasibility from pragmatics or convenience easily becomes blurred. We believe that Bastron is mistaken when he cites Beauchamp and Childress as providing support for his commentary on the ethical and moral importance of feasibility. Consideration of feasibility as a major component of a moral system carries the potential ethical liability of increasing personal convenience to that of a moral principle. The art and the science of medicine have overcome innumerable “unfeasibilities.” Physicians are obliged to strive to protect against unethical transgressions on patient autonomy. Because our profession exists primarily to serve the needs of people who are ill and vulnerable, we should guard against prioritizing our own needs. The Guidelines permit appropriate modification of its components that are in conflict with local standards, policies, or closely held religious beliefs.
Bastron has provided an interesting discussion of the extensive range of medical ethics and his anesthesia practice. We agree that “autonomy” is not an absolute principle. Complex situations in our multifaceted and heterogeneous society necessarily include legal, ethical, and personal issues. Most life scenarios are so complex that no set of simple “rules” can be unequivocally applied. Rather, we routinely find that sophisticated interpretation is necessary. “Good medical practice” as defined by our extended community of anesthesiologists often should suffice as the prima facie guide for how we should act. Nonetheless, the contract to deliver anesthesia care is with the patient, and the patient (or surrogate) must concur with that contract. This is an ethical and a legal requirement in our society, and these mandates cannot be bypassed by either convenience or the ambiguities of pluralistic America.
We believe that competent adult DNR patients who come to the operating room can be offered real choice and that respecting their informed choice will not burden anesthesiologists in most instances.
Stephen H. Jackson, M.D.
Good Samaritan Hospital; San Jose, California 95124
Perry Fine, M.D.
University of Utah Health Sciences Center; Salt Lake City, Utah 84108
Susan Palmer, M.D.
University of Colorado Health Sciences Center; Denver, Colorado 80262
Stanley Rosenbaum, M.D.
Yale University School of Medicine; New Haven, Connecticut 06510
Robert Truog, M.D.
Childrens' Hospital; Boston, Massachusetts 02115
Gail Van Norman, M.D.
University of Washington; Seattle, Washington 98195
(Accepted for publication April 24, 1997.)