In Reply:-The authors of these letters raise several issues that need clarification.
The Scott & White Clarification Form:“Resuscitation” means different things to different people, a situation which is not clarified by the ASA Guidelines. Drs. Berry and Heitman believe “consent for … anesthesia implies consent for all of the component parts,” yet the ASA Guidelines specifically mentions as issues to be negotiated with patients: tracheal intubation, vasoactive drug administration, therapeutic modalities to correct deviations of hemodynamic and respiratory variables predictably resulting from anesthetic agents and techniques, establishment of intravenous access, maintenance of intravenous volume with nonblood products, and treatment with supplemental oxygen.
One choice on the Scott & White clarification form leaves the do-not-resuscitate (DNR) order in effect but gives explicit, rather than implicit, consent for all the component parts of the anesthetic; the other choice suspends the DNR order perioperatively. We believe the choices are clearly different and that there is no deception.
The ASA Guidelines: Jackson et al. say the ASA Guidelines is a statement of the ideal. I believe it is neither ideal nor praiseworthy to ask for permission from a patient for “the appropriate use of therapeutic modalities to correct deviations of hemodynamic and respiratory variables predictably resulting from anesthetic agents and techniques.” I am pleased that Jackson et al. agree that our discussions with surgical patients who have DNR orders in place should be goal-oriented. The Guidelines not only fail to make that clear, they provide a menu from which our patients may choose, thereby focusing on the means, rather than an end. I do not know what principle, ethical theory, or philosophy guided the members of the committee that wrote the Guidelines, but what is written is easily interpreted as making respect for autonomy an absolute principle.
Feasibility: Berry and Heitman and Jackson et al. seem to have slid down a slippery slope from feasibility to convenience. (Does “feasible” in section VIII-C of the Guidelines really mean “convenient”?) Our policy of required reconsideration (a policy recommended by the Guidelines) is considerably less convenient than our previous policy of automatic suspension of DNR orders in surgical patients. Jackson et al. caution against feasibility as a consideration in ethical policy. Any ethical system that is not feasible is doomed to fail. My statement about feasibility in the article refers to the ASA Guidelines and our institutional policy, not to patient-physician interactions.
Drs. Cohen's acknowledgment that “often, there are exigencies of emergency scheduling or substitution of an anesthesiologist,” is in direct conflict with their belief “that when patients with DNR orders are scheduled for surgery, the Department of Anesthesiology should be notified well in advance of surgery.” This conflict highlights the importance of planning for feasible solutions in anticipation of the exigencies. We have not had a situation in which the patient and anesthesiologist differ because all of our staff agree to accept either option on the clarification form.
The anesthesiologist as the patient's surrogate: Drs. Cohen claim it is unrealistic for an anesthesiologist to serve as a patient's surrogate. Anesthetized or sedated patients lack, or have decreased, decision-making capacity. If the anesthesiologist is not the anesthetized patient's surrogate, who is?
Autonomy: I do not maintain it is wrong to respect patient autonomy; I maintain it is wrong to make respect for autonomy an absolute rather than a prima facie principle. It is easy to show how unbridled respect for autonomy can be harmful. We have people living on the streets because it would not respect their autonomy to put them into institutions. Children are born with AIDS because it would not respect the mothers' autonomy to be tested for AIDS.
For a hypothetical example in anesthesiology, consider an elderly man who executes a DNR order after watching his spouse vegetate with the aid of ventilatory and circulatory support in an intensive care unit. His goal is not to have a prolonged death. He is scheduled for repair of a large strangulated inguinal hernia that is causing severe pain and bowel obstruction. Given the Guidelines menu, he refuses tracheal intubation and vasoactive drugs. A subarachniod block is administered, and as a result of the predictable sympathetic blockade, he becomes hypotensive and suffers a stroke. He survives with total hemiparesis, urinary and fecal incontinence, and aphasia. His worst nightmare has occurred. A libertarian anesthesiologist could proudly explain to this patient and his family that the patient's autonomy had been honored and respected.
Most anesthesiologists would behave like physicians and would give a vasopressor to avoid potentially great physical harm. It is ethically more sound to make the patient aware of that possibility before, rather than after, the event. Excluding the libertarians for whom autonomy trumps all other ethical principles, many ethisists agree that during such circumstances, beneficence should take precedence over respect for autonomy. I agree with all the authors of the letters that such cases should be uncommon.
The patient-physician relationship: I do not suggest that patients misunderstand their desires. Patients are medically unsophisticated, which is why the patient-physician relationship is, and should be, a fiduciary relationship. I am disheartened that six distinguished leaders in our specialty would reduce that nearly sacred relationship to a contract. Should that relationship become contractual, we will have lost our status as a profession. Although a minority of philosophers would make the relationship contractual, the law recognizes the fiduciary nature of the patient-physician relationship. When the physician fails to perform the duties required by the fiduciary nature of the relationship, one runs afoul of the law.
There is rarely a right answer to ethical problems. I do not claim to have the answer, and I am pleased that the article stimulated so much discussion. Ethical issues are cloudy, and it is through disputation that they become a little clearer.
R. Dennis Bastron, M.D.
Professor of Anesthesiology; Scott & White Hospital; 2401 South 31st Street; Temple, Texas 76508
(Accepted for publication April 24, 1997.)
