KEYPOINTS | |
1.Ethics: Ethics are a vital component of all health care. Anesthesiologists and patients may differ in their perception as to optimal treatment, creating an ethical dilemma. Before making a medical or ethical decision, all of the facts must be ascertained. 2.Informed consent: Informed consent requires consent be given and the consent be informed. Informed consent honors, and in law, enforces the woman’s autonomy. Consenting is a process, and written consent by itself is not enough. Women have the right to give consent, withdraw consent, refuse consent, and to delegate that right to another. Women lose that right if incapable, but informed consent is still required. 3.Communication: Good communication is an essential part of ethics and informed consent. 4.The law: Informed consent, in law, enforces patient autonomy. The patient must consent to the proposed treatment and that consent must be informed. Failure to obtain consent will normally constitute a battery or an assault. Failure to properly inform will normally constitute negligence. The patient must be capable to give informed consent. Even if the patient is incapable, informed consent is still required unless it is an emergency and there is no one present legally to consent. 5.Maternal autonomy and fetal beneficence: Occasionally, the interests of the woman and her fetus may differ, presenting the physician with a dilemma. In most circumstances, legally and ethically, the woman’s autonomy should be respected. | |
I.Introduction to ethics
A. Ethical decision making in health care in the Western world is based mainly on the application of the four prima facie ethical principles:
1. Autonomy (choice)
2. Nonmaleficence (do no harm)
3. Beneficence (prevent harm, remove harm)
4. Justice (be fair, treat like cases alike) to the facts of the particular health care case.1 This method replaced the older way of “doctor knows best” decision-making (strong paternalism).
B. Remember that not all choices are ethical in nature. Whether to use a 16 or 19 gauge needle for an epidural may require a decision, but the decision is solely a medical one.
C. Ethical decision-making is not done in a vacuum. The facts are essential. Knowing which facts are relevant can only be determined after ascertaining all of the facts available. This includes not only the patient’s pertinent medical facts but also social, economic, and cultural facts that may influence the decision. An ethical dilemma may seem to appear when one does not know all of the facts but may disappear once sufficient facts are available.
D. Questions to ask when assessing the facts
1. What will the proposed treatment accomplish?
2. What happens if there is no treatment?
3. Are there alternatives to the proposed treatment?
4. What are the risks and benefits of the proposed treatment, the alternate treatments, and no treatment?
5. What does the patient want? (This is where nonmedical facts enter into the decision-making.)
6. What other considerations are there in the case?
E. Jonsen et al.2 suggest setting out the facts under the headings of “medical indications,” “patient preferences” (autonomy), “quality of life” (including with and without treatment), and “contextual features” (other factors such as religion and allocation of resources).
F. The facts will identify the possible choices of action. It may be that when applying the ethical principles to the choices, the principles will align with one choice and there is no ethical dilemma. The patient chooses an epidural for labor pain (autonomy), the recommended treatment (beneficence and nonmaleficence), and therefore no dilemma exists (provided the ethical principle of justice is not wronged).
G. However, the ethical principles may conflict. If more than one principle applies and, in choosing one, the other(s) cannot be followed, there is an ethical dilemma. An example is the laboring parturient who is in pain. The physician wants to relieve the pain (beneficence) and the parturient refuses (autonomy). The result is, whichever one is chosen, the other is excluded. When facing an ethical dilemma, the challenge for the practitioner is determining which ethical principle to follow.
H. Each of the prima facie principles is applied to the relevant facts. The principle that discloses the stronger obligation, or as stated by Beauchamp and Childress,1 the “strongest right” on those facts is the principle to be followed. Notwithstanding this, the law is very clear on the importance of autonomy. “Every human being of adult years and of 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.”3
II.Informed consent
A. Background
1. Informed consent underlines and legally enforces the principle of patient autonomy—the woman chooses (hopefully in consultation with the anesthesiologist) what she wants after she has been fully informed. This legal requirement consists of two separate parts. The first is the requirement of consent.
2. Consent must be:
a. Voluntary
b. For the proposed procedure and who will do it
c. Given by a capable patient
3. Care must be taken not to confuse lack of knowledge of the world, intellectual disability, or mental illness or instability with a lack of capability to consent to health care. If the woman understands:
a. The nature and purpose of the proposed treatment
b. The condition for which the procedure is proposed
c. The risks and benefits of the procedure
d. The consequences of consenting or not consenting
e. That the procedure applies to her situation, then, unless there is law in a particular jurisdiction to the contrary, she has capability to give or withhold consent
CLINICAL PEARLThe fact that someone is incapable of that understanding in regard to a complex procedure does not preclude her of being capable of that understanding for a simple procedure. Indeed, she may be incapable of consenting during a contraction but capable of doing so between contractions.
4. Consent must be informed. The physician is responsible for:
a. Providing full information about the proposed intervention
b. Taking reasonable steps to ensure the woman understands the proposed intervention
c. Informing the woman
(1) How the procedure is done
(2) Why it is done
(3) The benefits and the risks associated with doing it
(4) Any alternative treatments and their benefits and risks
CLINICAL PEARLThe woman should be given the opportunity to consider her choices and to ask questions. If there are any concerns about her understanding, she should be asked to repeat the information in her own words.
d. Finally, the anesthesiologist should document the discussion, including any concerns expressed by the woman and information given in response to those concerns.
B. Can laboring women give informed consent?
1. Some question whether women having severe labor pain can assimilate the information in order to provide informed consent.4 Not only might pain interfere with the woman’s understanding, but opioids, such as morphine, given to alleviate pain, also might interfere. Pattee et al.5 examined this question and found that women felt that the ability to give consent was not affected by opioid premedication, anxiety, or the amount of pain. This ability to consent was confirmed in two other studies.6,7 In the latter study, more than 90% agreed that they had received sufficient information to make a decision and were satisfied with the process.7
2. Other studies have examined what a patient recalled about the risks provided during the consent discussion to see if they were informed. The patients were asked to recall certain risks within 24 hours,8 on postpartum day 1,9 36 to 48 hours later,10 and 5 to 7 months later.11 They used the number of risks recalled as a measure of whether informed consent was obtained. The results did not differ from studies of recall in nonobstetric patients.8,11
CLINICAL PEARLIt is important to remember that although information may not be recalled, it does not mean that the patient did not understand it at the time.12
C. Implied consent
This can occur from either the action or the words of a patient indicating consent. A note as to how that determination was made should be added to the patient’s chart.
CLINICAL PEARLImplied consent is only consent. The requirement that the consent be informed has not been met.
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