Autonomy

The term autonomy is best described as the ability to make deliberated or informed choices (Boylan 2013). It goes hand in hand with one’s ability to receive and weigh the information for making a choice in a given situation. In turn, it means that the accuracy and extent of information received by an individual are two of the three fundamental premises influencing one’s choices, the third being the capacity of the individual to grasp the circumstances. The ability to comprehend complex pieces of information is inherently linked to the degree of intelligence and higher mental functions of an individual. Although medical professionals could be very forthcoming in providing accurate information to their patients, the extent to which they do so and how they word the information may vary from one patient suffering from a condition to another with the same condition, depending on the belief of the doctor about the ability of each patient to comprehend the information. This may have a profound influence on the ultimate decision made by the patient.

Beneficence and Non-maleficence

The principles of beneficence and non-maleficence are interwoven. In the most literal sense the term beneficence in medical practice means “positively do good” to the patient. The question is, what is “good” for the patient? Potential answers to this question may be many and may vary according to individual circumstances (Johnson and Johnson 2006). For example, to a follower of a monotheistic religion, the term “good” may be what agrees with God’s character of love and justice and His will for a given person. A utilitarian may view “good” as what gives most pleasure, while a social Darwinist may view it as what improves the quality of the human species. For an existentialist, “good” may mean what one may feel to be good at a given point in time. An individualist may hold the view that “good” means what a person wants. Hence beneficence or “doing good” appears to be very contextual. Arguably, in the context of medicine “doing good” means promoting the health of an individual or society. Health has been defined by the World Health Organization as “a state of complete physical, mental and social wellbeing and not mere absence of disease”(WHO 1948).

The term non-maleficence simply means “do no harm”. However, the principle of non-maleficence in the context of medical ethics cannot be reduced to the oversimplified notion of avoiding harm. Many medical interventions carry an inherent risk of harm. Hence what the ethical principle of non-maleficence demands is that care providers ensure that the proposed benefit of an intervention is greater than the potential harm, that it does no direct harm and that there are measures in place to prevent harm (Johnson and Johnson 2006).

Justice

The fourth principle is that of justice. This simply means that people should be treated fairly and should not be discriminated against in provision of healthcare. The concept of justice to an individual patient could be confounded by justice to society at large, where physicians may feel the pressure of using available resources rationally. In the context of older people, overemphasis placed on societal justice might lead physicians to face a dilemma in justifying allocation of scarce resources to older people who may, by definition, have a relatively limited life-expectancy.

Medical Professionalism

Thus, there seems to be some ambiguity in the principles of medical ethics in terms of the potential for variability in interpretation and consequent actions based on those interpretations. To minimize this for care providers, the profession expects its members to behave within an agreed code of conduct. The attributes integrated into this code of conduct necessitates medical practitioners to act with integrity, honesty and compassion, to maintain trust, to maintain professional skills, to have no conflict of interests or to cultivate commitment to manage conflict of interests, to safeguard the best interests of patients, to place the interests of the patient above those of the physician, to communicate clearly with patients and colleagues, not to enforce one’s own beliefs, attitudes and values on patients and colleagues, and to be accountable, non-prejudicial, non-discriminative and altruistic. Although this is not an exhaustive list of attributes, it gives a flavor of their nature. This code of conduct is recognized as “medical professionalism” (Gregory 1772, Percival 1803, Spandorfer 2009). At the highest level of conduct, medical professionalism involves reflection on one’s own actions and self-correction (WMA 1964, GMC 2013).

Human Rights

Irrespective of race, gender, age, creed and other demographic characteristics and variables, all human beings are expected to have equal rights from the beginning of life to the end (UN 1948).

In the UK the Human Rights Act came to full effect in the year 2000. The articles which could be relevant to medical practice are shown in Box 44.1 (BMA Medical Ethics Department 2013).

Age, Frailty and Comorbidities

It is widely known that people tend to become frail as they grow older. Frailty is defined as a distinctive health state related to the aging process in which multiple body systems gradually lose their in-built reserves (Morley et al. 2013). Between a quarter and a half of those aged over 85 years could be deemed frail. Clearly, the existence of comorbidity increases one’s chances of being frail. This is especially true if an organ of the body fails. A failing organ by definition has no reserve capacity left in it.

However, there are several caveats. Currently there are two widely accepted frailty models, namely deficit (Fried et al. 2001) and phenotype (Rockwood et al. 2005). These models specify that a certain number of criteria have to be met before conclusions are drawn as to whether a person is frail or the degree of frailty. Therefore, existence of one or two markers of frailty in a person may not be firm and unequivocal evidence of the existence of frailty severe enough to deny surgery. Understanding that every single older person is neither frail nor has comorbidity is vital. Suffering from comorbidity does not necessarily make one frail. Some frail people may neither be regarded as “old” nor have comorbidity. There is a complex interaction between these three elements (Figure 44.1). Therefore, each individual needs a totally unprejudiced approach to the assessment of fitness for surgery and needs consideration on personal merits.

Figure 44.1 Interactions between comorbidity, frailty and older age.

Ageism

Ageism is a complex notion. At an individual level, ageism attributes certain age-based group characteristics to an individual, regardless of the actual personal characteristics of that particular person (Macnicol 2005). The prejudice, stereotyping and discrimination embedded in ageism appear to be based on the belief that there is inevitable frailty in old age (Thornton 2002) even though there is wide variation in the physiological reserve capacity amongst people who have reached a given chronological age. Chronological age has been misinterpreted as the sole foundation of physiological or biological variation between people of different ages (Bytheway and Johnson 1990), but also society seems to nurture the idea that even pathological processes observed in older people are inevitable consequences of old age itself. Ageism reaches out beyond the individual level and emerges as an ideology that serves the dominant groups of the society (Bytheway 1995) to justify denial of available resources to certain groups of people, in the medical context mostly based on potentially poor cost-effectiveness, averting harm and futility of treatment.

In spite of growing awareness, ageism continues to be a dominant feature in healthcare in the UK (Fernando et al. 2011). However, ageism in surgical specialties has been subtle and more difficult to measure (Healthcare Commission 2006). A review of care received by older people undergoing surgery, published by NCEPOD in the UK, highlighted several major shortcomings in postoperative care for older people (Wilkinson et al. 2010). Poor assessment and treatment of postoperative pain, lack of intensive and high-dependency care to match the severity of illness and the profile of surgery, lack of knowledge of the resident medical staff to deal with complex comorbidity and paucity of timely interventions by expert specialists trained in geriatric medicine in this cohort of patients were highlighted in this report (Wilkinson et al. 2010). Expert reviewers found that only one-third of patients who had died within 30 days of surgery were deemed to have received only an ‘‘acceptable’’ level of care, let alone the best possible care (Wilkinson et al. 2010).

Evidence-based Medicine and Surgery in Older People

Clearly, the ethical dilemma is to make an individualized, holistic, non-discriminatory care plan for a given patient, taking into consideration the unique circumstances, both medical and otherwise, of the individual, while balancing it with the public duty of the doctor, where there is an obligation to justify utilization of public funds. The way forward seems to be the application of evidence-based medicine to the unique circumstances of the individual needing treatment.

Unfortunately, the evidence is grossly lacking, predominantly because of lack of clinical trials involving older people (Fernando et al. 2014). The representation of older people in clinical trials has not been in keeping with disease prevalence and incidence. Discrimination against older people on various grounds under the guise of exclusion criteria is the key reason for the dearth of evidence (Crome et al. 2011).

A Cochrane systematic review on anesthesia for hip fracture surgery in adults, which included 22 clinical trials, but only 2567 participants, comparing regional anesthesia with general anesthesia, stated that there was insufficient evidence available from trials to arrive at a conclusion on the best mode of anesthesia for these patients (Parker et al. 2004). The mere fact that it took 22 trials to gather a cohort of 2567 in spite of an annual incidence of 70,000 hip fractures occurring in the UK alone (NHFD 2011) is good evidence to demonstrate the lack of research with regard to conditions predominantly affecting older people.

Evidence-based medicine has limitations in older people. Denial of interventions due to lack of evidence is not necessarily scientific as the absence of evidence is due to absence of clinical trials to establish the evidence. Even where there are trials, the outcome measures employed in many of them, such as disease-free survival are illogical for older people who inherently have a limited life expectancy (Dimick et al. 2003, Hermans et al. 2010, Bhangu et al. 2014, Nicolini et al. 2014, Soreide and Desserud 2015). Besides, what matters to older people is mostly quality of life, as perceived by themselves, an outcome which has not yet been extensively considered by researchers, but which could have given a wholly different set of conclusions in a clinical trial, rather than using the length of survival. Therefore, practicing evidence-based medicine rigidly in older people could even be seen as a way of systematic discrimination against older people at present. The absence of evidence of effectiveness of an intervention thus does not equate with evidence of absence of effectiveness of the intervention in older people.

Surgery in Older People Who Lack Mental Capacity

The incidence and prevalence of cognitive impairment is higher in older people. Cognitive impairment is not synonymous with dementia unless it compromises one’s ability to function independently. The presence of dementia is not of course a contraindication for surgery. However, it may make obtaining valid consent, which is a necessity in terms of respecting the autonomy of an individual, a challenge. How such situations are best handled is laid down in law in some countries and the Mental Capacity Act 2005, which is applicable to England and Wales is an example.

The Act sets out five “statutory principles” – the values that underpin the legal requirements of the Act. These principles are (UK Government 2007):

1. 
   

   1. A person must be assumed to have capacity unless established otherwise.

   
   
2. 
   

   2. Do not assume a lack of capacity to make a decision unless all practicable steps to help a person to do so have been taken without success.

   
   
3. 
   

   3. An unwise decision does not mean a person lacks capacity.

   
   
4. 
   

   4. An act done or a decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.

   
   
5. 
   

   5. Before an act is undertaken, or a decision is made, consider whether the purpose for which it is needed can be as effectively achieved in an alternative way that is less restrictive of the person’s rights and freedom.

These principles are self-explanatory and it is obvious that the spirit of the law is well in line with the four prime facie of medical ethics and also with basic human rights. It suffices to conclude that in the light of the law and ethics, the presumption is in favor of prolonging life and maintaining the health of a given individual, where there is any ambiguity.

Surgery and End of Life

As much as the right to life, not being subjected to derogative treatment is a basic human right. Hence, allowing death with dignity is an essential part of healthcare. The same ethical principles of autonomy, beneficence, non-maleficence and justice apply to palliative and end-of-life care for surgical patients reaching the end of life. The principle of autonomy dictates that the patient is given options. Offering and undertaking surgery could certainly be a necessity for a dignified death. Thirty-day mortality and mortality in the first year following hip fracture surgery in the UK is between 8–9% and 33%, respectively (Castronuovo et al. 2011). Nearly 70% of the patients are ASA grade 3 or 4 on presentation (NHFD 2011). Nearly 88% of the patients who are ASA grade 4 are no longer alive one year later (NHFD 2011). Nevertheless, it is only 2% of patients who do not undergo surgery following a hip fracture in the UK (NHFD 2011). Essentially there has been wide recognition over the years that emergency surgery for hip fracture is a palliative procedure.

However, the decision to operate may not be clear cut in some circumstances. Symptom relief from intestinal obstruction due to an inoperable tumor with a defunctioning stoma may be welcomed by one patient who wants to buy time to bid goodbye to family, whereas another patient may loathe the idea of collecting feces in a bag attached to the body under any circumstances. Therefore, understanding priorities, as deemed by the patient, is absolutely essential in providing palliative and end-of-life care (Fried and Bradley 2003). The essence of provision of successful care is good communication and maintaining a patient-centered approach under all circumstances. Empowering the patients to make decisions is fully in line with basic ethical principles. However, in patients who lack capacity to make decisions, it is important to recognize that the situation needs to be handled sensitively in such a way that the kith and kin do not carry feelings of guilt and the burden of making the decision about letting go of their loved one.

Cardiopulmonary Resuscitation

One of the key dilemmas in surgical patients is making decisions about cardiopulmonary resuscitation. The guidance on this can be vague and ambiguous. In the UK, doctors are expected to respect the patient’s decision, but are also expected to hold off futile treatment (The Resuscitation Council 2014).

Where there is a Do Not Attempt Resuscitation (DNAR) decision, the options for managing it are (AAGBI, 2009):

1. 
   

   1. Reversal of the decision.

   
   
2. 
   

   2. Modification to permit the use of drugs and techniques commensurate with the provision of anesthesia.

   
   
3. 
   

   3. No change. This is not compatible with the provision of general anesthesia or surgery under most circumstances.

The DNAR management options are to be applied mostly during the period that the patient is in the operating theater and recovery areas. The ethical principles are there to guide us through these difficult circumstances.