To the Editor:-Bastron [1] offers a thoughtful and sensitive analysis of a significant ethical conundrum. There are three questions we would like to address: 1) establishment of a meaningful dialogue between patient and anesthesiologist, 2) issues that arise when a competent patient's informed decision concerning do-not-resuscitate (DNR) orders in the operating room conflicts with the physician's view, and 3) the limits of patient autonomy.
Patients can understand the distinction between resuscitation from “clinical events believed to be temporary and reversible”[1] and resuscitation from events related to the terminal disease per se. In most cases, they and their anesthesiologist will agree about the use of resuscitation during surgery. However, communication of the patient's values and goals requires an intensity, focus, and duration of contact that is unlikely to occur in current anesthetic practice. Usually, the interaction between patient and anesthesiologist is limited to one short visit. Consequently, any expectation that the anesthesiologist might serve as the patient's surrogate is unrealistic. Often, there are exigencies of emergency scheduling or substitution of an anesthesiologist who has had no personal contact with the patient. It is unrealistic to expect a new anesthesiologist to be aware of those subtleties and nuances in the patient's expectations that would determine how the patient would wish him or her to act during all circumstances. We believe that the solution to this problem is not Dr. Bastron's consent form, which is designed to have “intentional vagueness.”[1] This approach simply substitutes the physician's autonomy for that of the patient.
Instead, we believe that when patients with DNR orders are scheduled for surgery, the Department of Anesthesiology should be notified well in advance of surgery. This would allow a specific anesthesiologist to interact with the patient. Our suggestion [2,3] for “required reconsideration” of DNR orders has the goal of allowing treatment consistent with each “patient's values and goals.” Such dialogue is essential if informed consent is to play a meaningful role in the anesthesiologist's actions should adverse events occur during surgery. Only during extraordinary circumstances should “the physician who obtains consent for anesthesia [not be] involved with the intra- and postoperative anesthetic management.”[1]
Dr. Bastron does not appear to allow for a situation in which patient and anesthesiologist differ. For example, although initiation of temporary therapy with vasoactive drugs may accord with the patient's values and goals, postoperative ventilatory support may be unacceptable to him or her because of the burdens of ultimately futile high-technology therapy. Should the anesthesiologist disagree in such a situation, Bastron maintains that the ASA guidelines are wrong to respect patient autonomy. Physicians can override patient autonomy or self-determination on the basis of beneficence or doing good for the patient, he maintains, citing Beauchamp and Childress' Principles of Biomedical Ethics. [4] Yet, Dr. Bastron's first citation to that book relates to a discussion directed toward negotiation and compromise in the public arena, considering “problems of feasibility, efficiency, cultural pluralism, political procedures, uncertainty about risk, noncompliance by patients, and the like.”[4] It does not address decision-making within the doctor-patient relationship. The second citation emphasizes that Beauchamp and Childress do not make their four ethical principles absolute, nor do they prioritize them morally. [4] This does not mean, however, that the physician can override patient autonomy whenever he or she chooses. Beauchamp and Childress state, “[B]eneficence provides the primary goal and rationale of medicine and health care, whereas respect for autonomy … sets moral limits on the professional's actions in pursuit of this goal.”[4]
Even so, there are some unusual situations in which doctors can override patient choices, Beauchamp and Childress acknowledge. These are circumstances when the projected benefits of the paternalistic action outweigh its risks. [4] However, Beauchamp and Childress also maintain that “techniques such as risk-benefit analysis are not purely empirical and value-free, because they involve moral evaluation….”[4] Thus, values necessarily enter the assessment of risks and benefits. But whose values? The physician should weigh the risks and benefits of not resuscitating the patient in the operating room in terms of the patient's values and goals. The informed, autonomous patient, however, presumably will have done this before he or she has made the final decision about resuscitation, thereby making paternalistic intervention unnecessary. Should the physician believe the patient has made an error, he or she is obliged to indicate this to the patient, not to override the patient's decision.
Should fundamental differences continue to exist even after a thorough discussion, case law is consistent in accepting that a competent patient's autonomy almost always will prevail. This was articulated by Judge Cardozo in 1914 [5]:
"Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent, commits an assault, for which he is liable in damages."
The right of a competent patient to refuse therapy (amputation), knowing that this would likely result in death and was offensive to her physicians, was supported 60 years later:“The law protects her right to make her own decision to accept or reject treatment, whether that decision is wise or unwise.”[6]
We certainly are not oblivious of the anesthesiologist's obligation to advocate what he or she feels is the optimum care. However, where there are fundamental differences between patient and anesthesiologist, the physician should withdraw from the case after assuring continuity of care, as sometimes occurs in the case of the competent Jehovah's Witness who refuses blood products. To provide treatment against a competent patient's wishes in most cases deviates from ethical and legal standards.
Cynthia B. Cohen, Ph.D., J.D.
Kennedy Institute of Ethics; Georgetown University; Washington, D.C. 20057
Peter J. Cohen, M.D., J.D.
National Institute on Drug Abuse; National Institutes of Health; Rockville, Maryland 20857
(Accepted for publication April 24, 1997.)
