Virtue Ethics, Utilitarianism, and Duty-Driven Ethics

The classic “paternalism” of medical practice was derived from virtue-based ethics. In this view, the physician is a genuinely virtuous person with inherent qualities of competence, sincerity, confidentiality, and altruism, who naturally knows and does what is correct for the patient. The patient, uneducated about medicine, has to trust the physician to decide what is best. Western society and legal systems have changed substantially since paternalism flourished, giving way to practices based in the four “pillars” of medical ethics: respect for patient autonomy, beneficence, nonmaleficence, and justice. Many different ethical frameworks are applied in modern medicine, but two of the most prominent frameworks relevant to western medicine are utilitarian ethics and deontology.

In utilitarian ethics , actions are judged right or wrong on the balance of their good and bad consequences. A “right” action produces the most good, based on a perspective that gives equal weight to the interests of all affected parties. Utilitarian theory is compelling but falls short in defining which benefits are most important. Is it the “good” that all reasonable people want or the “good” defined by the individual patient? What if the only way to maximize good is to commit an entirely immoral act? For example, what if the only way to win a war is to systematically torture children? Outcomes of actions continue to accumulate over time—when on that continuum is it appropriate to determine that an action was right or wrong? The “good” act of saving an individual’s life today may be viewed through a completely different lens when, 20 years from now, that same individual is revealed as a mass murderer.

Utilitarian theory may be best when applied to analyzing broad-based policies, in decisions regarding rationing of resources, and when attempting to resolve conflicting ethical obligations between several equally interested parties.

The premise of Kantian-based ethics (also called deontologic—or duty-based —theory) is that features of actions other than their consequences make them right or wrong. Intention is more important than outcome. Furthermore, no person should use another exclusively as a means to an end, because each person is the end for which we should act. No person should be used to further the purposes of another person without that other person’s autonomous consent. Kantian philosophy would forbid killing one innocent person to save another innocent person, for example.

Individualism and autonomy are valued highly in Western society, and people tend to turn to Kantian philosophy when ethical questions arise that balance the authority of the physician against the goals and values of individual patients.

Some of the toughest ethical questions in medical practice occur when the rights and desires of individual patients conflict with social policies. Clashes between deontologic and utilitarian principles are common in the intensive care unit (ICU), in managed care settings, in end-of-life care, in transplant medicine, in triage during civilian mass casualty events, and in the care of poor and older patients whose medical management is funded by the government. In each of these settings, the will of the individual patient may conflict with broader principles of minimizing expense, fairly allocating scarce resources, protecting the broader interests of many patients, and determining where and how society’s healthcare dollars are best spent.

The political tradition of the United States provides a clear underpinning to individual freedom, and at the beginning of the 20th century, the concept of the autonomy of patients began to emerge.

Informed Consent and Informed Refusal

Legal and moral imperatives for informed consent are based on the ethical principle of respect for patient autonomy. Autonomy refers to the ability to choose without controlling interferences by others and without personal limitations that prevent meaningful choices, such as inadequate information or understanding. Individuals have the right to determine what happens to them to the degree to which they are capable. In the United States, this right is rooted in constitutional guarantees of privacy and noninterference. In 1914, the case of Schloendorff v Society of New York Hospital established that it was the right of “every human being of adult years and sound mind to determine what shall happen to his own body.” In 1957, the term informed consent was first used in the case of Salgo v Trustees of Leland Stanford Hospital , which established that it is not sufficient for physicians simply to secure consent; physicians have a duty to inform patients about the risks and alternatives to treatment, in addition to the procedures themselves and their consequences.

Respect for the patient’s autonomy requires physicians to respect decisions made by competent patients, but also to promote autonomy by removing barriers to competent participation in decisions. Such obstacles range from incomplete or inaccurate information to reversible medical conditions that impair a patient’s ability to understand the information given to him or her.

The Jehovah ’ s Witness Patient

The classic example of a patient who refuses therapy in anesthesia practice is that of Jehovah’s Witnesses, many of whom believe that accepting a blood transfusion violates a Biblical injunction. The Jehovah’s Witness doctrine has been subject to change over time, with resulting inconsistencies in religious practice regarding which, if any, blood components may be acceptable. Individuals interpret religious doctrines in light of their own spiritual contexts, and not all believers hold to the same tenets with identical fervor. Church doctrines, like medical practices, evolve over time, and practices that are acceptable at one time may not be years later. Anesthesiologists and surgeons have cited individual and doctrinal inconsistencies as justification for ignoring the wishes of Jehovah’s Witness patients, but to do so is no more logical than assuming that every hypertensive patient needs or will respond well to identical treatment or that optimal treatments will not evolve over time. Moreover, any patient has the right to refuse blood transfusion therapy, regardless of whether this desire is founded in religious preference. Such refusals have become more common in patients who are not Jehovah’s Witnesses, as blood transfusion therapy has been connected to infection risk and other complications.

Because of the differing beliefs of Jehovah’s Witness patients, the anesthesiologist must have a thorough and detailed preoperative discussion of possible therapies with the patient, and the conclusions should be documented in the patient’s chart. A physician who cannot comply with a competent adult patient’s desire to forgo transfusion has an ethical obligation to find an alternative caregiver whenever possible.

The courts strongly support the rights of most adult patients to refuse blood products for themselves but have been inconsistent and have interfered in cases of some pregnant patients. Transfusion of pediatric Jehovah’s Witness patients by court order is common. However, this may become ethically and legally less acceptable as alternative bloodless therapies to maintain oxygen-carrying capacity evolve, as the Jehovah’s Witness church further defines its doctrines with regard to children, and as the capacity of children to consent to or refuse therapy is better understood.

The Pediatric Patient and Other Patients With Impaired Competence

The ethical practice of medicine weighs heavily toward adherence to the respect for autonomy of competent patients or advance directives of patients who were previously competent. Medical care of individuals who have never been autonomous relies on principles such as respect for human dignity, beneficence, avoidance of harm, and adherence to the principle of justice.

Children are examples of persons who may or may not yet be autonomous. Laws in each state define the age at which children become legally competent to make medical decisions (usually 18 years), but many younger children have the mental and emotional capacity to make medical decisions. Forcing such individuals to undergo treatments they do not want is unethical and could be illegal as well.

Decision-making capacity in children is variable. Most 2-year-old children are clearly not able to make medical decisions. However, the range of capability in children as young as 7 or 8 years old is wide. In one study, children 6 through 9 years of age who were invited to participate in influenza vaccine research asked pertinent questions about individual risks and benefits and whether their community and other children would benefit. Studies suggest that the average 12-year-old adolescent has capabilities that are required in medical decision-making, but differing influences of the brain’s well-developed reward system coupled with underdevelopment of the brain’s control systems suggest that decision-making capacity may in fact be diminished in specific contexts in this age group.

Most states recognize “emancipated minor” status, in which a court determines that a minor can legally make medical decisions for himself or herself. Legal exceptions to the age of consent are recognized in most states when treatment is believed to be in the minor’s best interest and when a requirement for parental consent would interfere with the child’s ability to receive medical help. The law recognizes that, tragically, some conditions for which a minor seeks therapy may even be the result of parental abuse and seeking parental permission for treatment may actually further endanger the minor. One quarter of pregnant teens are at risk for physical or sexual assault, and the most common perpetrator is a member of their family. Thus, minors are allowed in many states to consent for treatment for substance abuse, sexually transmitted disease, mental illness, and medical care affecting pregnancy, including abortion, without seeking parental consent. When a minor has decision-making capacity but is not “emancipated,” a judge may declare the child to be a “mature minor” with decision-making rights.

Ideally, individuals of any age should be involved in medical decisions to the degree that their capacity allows. Children ages 7 to 17 have been shown to desire comprehensive perioperative information, including details of the procedure and anesthesia, risks, and complications. A minor with capacity to make decisions should not be coerced or restrained under most circumstances. Determining whether a minor has such capacity may require formal consultation and assessment. The American Academy of Pediatrics has stated that physicians who care for children “should give serious consideration to each patient’s developing capacities for participating in decision making, including rationality and autonomy.” The term assent rather than consent is used to refer to agreement to treatment from children who do not fall into legal categories, such as age, that award adult rights. Recently, authors have suggested that informed consent rather than assent for medical research participation should be applied to children ages 12 and up.

When children dissent from medical care, persistent refusals may be ethically binding, particularly in the case of participation in research. Medical personnel should respect the wishes of a patient who withholds assent and should try to gain a better understanding of the patient’s situation or deal with his or her fears. “A patient’s reluctance or refusal to assent should also carry considerable weight when the proposed intervention is not essential to his or her welfare and/or can be deferred without substantial risk.”

Routine Preoperative Testing Protocols

Preoperative testing may help identify unrecognized or disguised conditions that could adversely affect anesthetic risk. All medical tests carry risks, however. False-positive and false-negative results may either label patients as having a condition they do not have or inappropriately assure patients that they do not have a condition that they do. Erroneous results may lead either to further testing or to inappropriate and unnecessary therapy associated with further complications. Errors can also cause patients to be deprived of important therapy they would otherwise receive. Tests sometimes have accompanying physical complications, and they are certainly always associated with economic costs. Systematic over-testing increases the costs of health care for entire populations, unnecessarily burdening an already costly system, and diverting badly needed funds to unnecessary enterprise. Medical tests may involve problems of conflicts of interest if the ordering physician has an economic relationship with the entity that carries out the tests. Additionally, not all medical tests are ethically equivalent. Certain tests, such as pregnancy testing and HIV testing, may have complex social consequences and can lead to serious, avoidable harms.

Modern medicine is a science that incorporates theories that are expected to be consistent and generalizable. Although all data are deeply theory laden, the practice of evidence-based medicine (EBM) is founded on the concept that conscientious, judicious, and explicit use of the best available medical evidence should be integrated with clinical experience derived from systematic research in making decisions about the medical care of individual patients. In general, nonsystematic clinical experience, anecdote, and untested theory are not sufficient grounds for clinical decision making.

EBM and medical ethics share common principles and goals: both are aimed at maximizing benefits and minimizing risks, as well as at involving the patient in shared decision making. Using EBM to guide clinical testing and therapy is supported by analysis of traditional therapies that were never subjected to rigorous testing and that, on examination, were shown to be not only unhelpful to patients but possibly harmful. One Cochrane review, for example, found that administration of human albumin, a mainstay of therapy for treatment of shock, may be associated with increased mortality. Another Cochrane review demonstrated that although mammography screening will prolong the life of 1 in 2000 women over a 10-year period, it will lead to the false diagnosis of cancer and the institution of cancer treatment in 10 women during that same period; these findings raise serious questions about the benefits and risks of routine mammography. Using systematic evaluation of medical diagnostic testing to develop principles of preoperative testing not only serves the ethical principles of beneficence and nonmaleficence, but also permits us to provide patients with accurate and up-to-date information on the potential benefits of tests to aid their understanding and input in their medical care—thus honoring the principle of respect for the patient’s autonomy.

Conversely, EBM presents potentially significant ethical concerns. In relying on traditional medical experimentation, EBM may not sufficiently account for the role of social and cultural factors (e.g., poverty, ethnicity, spirituality, and gender) in health, and instead may rely too heavily on a narrowly drawn biomedical model of the patient’s experience of health and disease. In the words of Rogers, “those with the greatest burden of ill health are disenfranchised, as there is little research that is relevant to them, there is poor access to treatments, and attention is diverted from activities that might have a much greater impact on their health.”

Despite its limitations, it nevertheless seems reasonable to believe that in trying to maximize beneficence and minimize nonmaleficence, EBM provides at least an improvement in the search for a rational, cost-effective approach to medical testing over simply adopting “traditional” therapies or protocols without evidence that they will contribute to accomplishing those goals. Applying medical tests inappropriately can cause very real harm to patients. Simply stated, if medical care is not valid, then it is not ethical.

Evidence that routine tests or traditional patterns of preoperative testing enhance perioperative outcomes is scant. Large population studies of many routine preoperative tests, such as coagulation screening, chest radiography, and electrocardiography, have, on the contrary, found that these tests increase costs without necessarily positively affecting outcomes and can even lead to detrimental outcomes. The ASA Task Force for Preanesthesia Evaluation acknowledged that most routine testing is not necessary. When evidence-based algorithms for preoperative testing are available and have been appropriately validated clinically, they should be used to guide clinical decision making.

Routine Preoperative Pregnancy and Human Immunodeficiency Virus Testing

Social risks of preoperative testing may not be as obvious to the physician as medical risks, but they can be the source of significant harm. Examples of tests that can produce social harm and are of limited preoperative utility are HIV and pregnancy tests. Both tests have serious ethical consideration; have limited, if any, beneficial impact in the setting of surgery; may have serious social and economic consequences for the patient beyond the operating room; and require the patient’s informed consent.

HIV tests are often ordered for the purpose of singling out patients for whom extra universal precautions could be taken to reduce transmission in the operating room. Most surgeons and anesthesiologists believe that compulsory HIV testing would reduce their risk of exposure, and many believe incorrectly that this testing is the physician’s prerogative and can be done without the patient’s consent.

However, HIV testing does not necessarily yield safer anesthetic management and is more costly than diligent application of universal precautions. In low-prevalence populations, testing is more likely to give false-negative results that wrongly reassure operating room workers that a patient is not infected. This may paradoxically increase the risk of HIV transmission if relaxation in vigilance is the result.

HIV tests can result in loss of employment, insurance coverage, or both. Seropositive women can experience marital breakup, abandonment, verbal abuse, and physical violence if their status is disclosed. The threat of compulsory HIV testing almost certainly would prevent some patients from seeking needed surgical care.

Routine preoperative pregnancy testing has ethical ramifications analogous to those of HIV testing. Despite pervasive beliefs to the contrary, studies do not conclusively demonstrate that anesthetic agents lead to early fetal loss, and no anesthetics have been clearly associated with teratogenic effects. Studies have also shown that even adolescent girls generally accurately report the possibility of pregnancy when asked privately. Legal ramifications of not routinely testing for pregnancy preoperatively have been virtually nonexistent, and fewer than one third of practices in the United States require such testing. A positive pregnancy test may have extremely negative consequences if a vulnerable patient is in a social situation in which pregnancy is not accepted. Up to two-thirds of sexual assault victims are minors, and some are the result of child rape within the home. Abandonment, negative family interactions, and violence to the patient or her fetus, or both, may all occur, as reactions to revelation of the pregnancy, attempts to hide a sexual domestic crime, or even in some cases as “honor killings.” Referral of pregnant adolescents to child protective services should be considered. In many states, it is illegal to disclose or even insinuate a child’s pregnancy status to her parents, regardless of her age. Therefore, the anesthesiologist who discovers an adolescent patient’s pregnancy has few comfortable or legal options.

Many patients may choose not to undergo an elective surgical procedure if they know they are pregnant. However, coercing a female patient to have a test against her wishes and that she may find insulting explicitly violates the principle of the patient’s autonomy. The physician’s self-interest is not adequate justification for disregarding a patient’s autonomy or violating a patient’s privacy. The ASA Task Force on Preoperative Testing and the ASA Committee on Ethics jointly recommended that anesthesiologists offer the choice of preoperative pregnancy testing to any female patient who may desire it, explain the potential risks and benefits, and obtain informed consent or informed refusal for the test.

Maternal-Fetal Conflicts

In general, the rights of pregnant women to refuse therapy, even if it will be detrimental to their fetuses, are protected under right-to-privacy provisions in the U.S. Constitution. Those rights are weighed against potential harms to the fetus in a decremental fashion as the fetus approaches and surpasses viable age. When the fetus is of nonviable age, the mother’s rights prevail. Court decisions have consistently upheld the rights of pregnant women to have abortions, to not be subjected to drug testing, and to forgo transfusions early in pregnancy. Attempts to charge women with child abuse, child endangerment, drug trafficking, murder, and attempted murder for activities deemed dangerous to their fetuses have almost uniformly failed. In general, women do not lose their rights to bodily integrity and informed consent when they become pregnant, and neither fetal “rights” nor state interests supersede a pregnant woman’s right as medical decision maker.

The American Academy of Pediatrics Committee on Ethics outlined conditions that in their view are necessary to override a mother’s refusal of care: (1) the fetus will suffer irrevocable harm without the treatment, (2) the treatment is clearly indicated and likely to be effective, and (3) the risk to the woman is low. The American College of Obstetricians and Gynecologists condemned the use of coercion in pregnant women and advocated counseling the patient carefully about risks, as well as consultation with an ethics committee.

Informed Consent in Laboring Women

The validity of informed consent for epidural anesthesia in laboring women is a topic of concern to anesthesiologists, who periodically raise the question whether laboring women are able to consider and weigh the risks of labor analgesia sufficiently while they are in pain. Although ideal conditions for informed consent are often lacking during labor, it is important to realize that the ideal is seldom achieved even in elective surgical patients; therefore, it is crucial to distinguish between conditions that are not ideal from conditions that are not adequate .

Despite concerns by anesthesiologists, most studies show that laboring women have the same capacity to give informed consent as the general surgical population, are able to recall details of the consent process long after labor is finished, and indicate that labor did not alter their decision making. Furthermore, studies show that the presence or absence of labor pain has minimal effect on a woman’s ability to recall analgesia risks and other elements of the informed consent process later. Some investigators argue that it is only after the patient enters active labor and she can assess for herself the severity of pain and consequences of proceeding without analgesia that she can be fully informed.

An ethical conflict can arise in the case of so-called Ulysses directives in which, before labor, a woman executes an advance directive that refuses epidural analgesia and instructs doctors to ignore her pleas for epidural anesthesia at the time of labor should she change her mind. Although some experts suggest that ignoring the Ulysses directive disrespects a woman’s long-term preferences, others argue that “information and valid experience are critical prerequisites for autonomous decision making” and that only the current wish (to receive an epidural) is ethically relevant. Such cases appear to have no clear and unequivocal ethical ground on which to proceed, and circumstances must guide the physician. However, if an anesthesia practice decides to disregard Ulysses directives routinely, this should obviously be disclosed to patients in advance of labor whenever possible.

Advance Directives and Surrogate Decision Makers

Critical decisions regarding medical care often arise when patients are too ill to formulate or express decisions regarding medical interventions. Advance directives were developed after several legal decisions affirmed that patients can refuse even lifesaving medical care and that clear and convincing evidence of the patient’s wishes is needed to allow surrogate decision makers to request withdrawal of life-sustaining therapies. An advance directive is a document executed by the patient before incapacity to provide the patient’s physicians with guidance when the patient cannot communicate for himself or herself. Such directives include the following: living wills, which detail the therapies a patient would accept or refuse in the case of terminal incapacity; DNAR orders; and any other preferences regarding medical care decisions.

A surrogate decision maker is someone whom the patient has appointed to make healthcare decisions for him or her (a durable power of attorney [durable POA]) or an individual with other legally recognized authority by virtue of his or her relationship with the patient.

A durable POA for healthcare decisions may be given by the patient to a specific person he or she designates to make healthcare decisions for them if they become incapacitated. The authority vested in a POA supersedes most other decision makers, including family members, except a court-appointed guardian.

When the patient has not designated a durable POA, doctors rely on family members to make decisions for the patient. Many states have a legally defined hierarchy of decision makers. Commonly, the surrogate hierarchy is the spouse or legally recognized domestic partner, followed by the children, if all are in agreement, then parents, if both are in agreement, and then siblings, if all are in agreement. The anesthesiologist should familiarize himself or herself with the specific laws of the state in which they practice.

Surrogate decision makers are explicitly trusted to act in “substituted judgment” to provide what the patient would have wanted and theoretically are not asked merely for their own preferences. However, surrogate decision makers at best only approximate the patient’s decisions because their interpretation is subject to their own biases, values, and psychological agendas. Incompetent patients can be emotionally and financially burdensome, and decision makers may have conflicts of interest that distort their beliefs and testimony about what the patient would have wanted.

Studies demonstrate that patients and their proxies only infrequently discuss issues and values involving life-sustaining technologies. Discrepancies between patients and proxies are often significant in the assessment of patients’ emotional health and satisfaction. Neither physicians nor proxies can always accurately predict the patient’s preferences for life-sustaining therapies. Nevertheless, with all the imperfections, proxy decision making may be the only option if a patient has not left specific directives.

End-of-Life Decision Making

A 1996 review by the AMA showed that the following end-of-life issues were of foremost importance to patients: control over the timing and location of death; management of symptoms such as pain, dyspnea, anxiety, and depression; financial management of medical care; and maintenance of therapeutic options, including physician-assisted suicide (PAS).

Terminal Sedation

“Terminal Sedation,” also known as “deep continuous sedation” (DCS), is an ethically controversial end-of-life strategy for patients who are suffering intolerable symptoms in the last stages of dying, and who do not respond well or completely to sedatives or pain medications that are being administered “as needed” in response to symptoms. In DCS, a decision is made with the patient or their appropriate surrogates to forgo reactive treatment of symptoms and to employ intravenous sedative/analgesic infusions with the intention of rendering the patient permanently unconscious until death occurs, but without the intention of causing death. While the goal of DCS—relief of suffering—is a laudable one, ethical questions nevertheless persist: the practice is plagued by vague and nonstandardized terminology and practice, a lack of outcomes research, an uncomfortable confusion with PAS and euthanasia, misunderstanding of the principle of double effect, and culturally diverse philosophies about the role of suffering and transcendence in the meaning of human life. Opponents suggest that DCS is merely euthanasia in disguise, invented to circumvent legal sanctions and moral objections. Some ethicists have argued that DCS permanently deprives the patient of morally relevant aspects of “personhood” and therefore represents a form of killing. Disturbing studies show that many physicians employing DCS actually do intend to hasten death.

A particularly controversial aspect of DCS is whether it can and should be allowed when the patient is suffering from severe and intractable existential suffering: fear, loneliness, anxiety, spiritual crises, and so forth. Professional guidelines regarding DCS and existential suffering at end of life differ greatly in their recommendations: the American Academy of Hospice and Palliative Medicine and the American College of Physicians do not make specific statements about DCS in existential suffering; the AMA Council on Ethical and Judicial Affairs opposes DCS for existential suffering; the Royal Dutch Medical Association and the Harvard University Community Ethics Committee support the use of DCS in cases of existential suffering; and the Veterans Health Administration does not exclude it, but weighed against use of DCS for existential symptoms in their discussions. Even more questions arise when DCS is instituted in pediatric patients.

Neuromuscular Blocking Drugs

Neuromuscular blocking drugs have no anesthetic, analgesic, or sedative properties. Such drugs should not be initiated if withdrawal of ventilatory support is anticipated. Paralyzing the patient to comfort the family so that they see no disturbing movements or respirations as the patient dies is not justifiable. Even worse, it can mask symptoms and signs of distress and can thus prevent relief of suffering during the dying process. When withdrawal of ventilator support is anticipated in a patient already receiving such drugs, they should be withheld in all but extraordinary cases.

Implantable Cardiac Devices

When a patient who has a cardiac device requests withdrawal of life-sustaining interventions, questions can arise about whether it is ethical to deactivate or even explant such devices at the patient’s request. In the case of ICDs, the question might well be whether it is ethical to continue such therapy in a patient who has opted for palliative care. Recent studies provide concerning information: in the MADIT II trial, only 15% of patients who died had their ICD deactivated, after receiving “many” shocks at the last days of their lives. A post-mortem device interrogation study indicates that 31% of patients received shocks in the last 24 hours of life. It is likely that patients receiving shocks in the final hours of their lives may be unable to communicate that they are suffering this painful experience and ask to have it stopped. In another study, only 27% of patients had discussed deactivation of the ICD at end-of-life, raising concerns that failure to deactivate the device was due largely to failure of physician-to-patient communication that this was possible and should be considered. In some cases, physicians may lack the expertise or equipment to promptly deactivate such devices when inappropriate shocks are being delivered.

Some experts have said that that these devices must be treated differently from other medical interventions because by virtue of implantation they have become a “biofixture,” or literally a part of the patients themselves. Such arguments are difficult to sustain when we consider that many people undergo implantation of medical devices and subsequent explantation of them when the devices are no longer working or do not serve the patient’s purpose. Common examples include artificial joints, intraocular lenses, medication delivery devices, and orthopedic hardware. Furthermore, these devices are never uniquely a part of the patient in the same sense as DNA or their native organs. In fact, the ethical distinction between disabling a pacemaker in a pacer-dependent patient and turning off a ventilator for a ventilator-dependent patient is minimal if the request comes from a competent patient or the surrogate decision maker. Both actions involve discontinuance of artificial therapies that the patient no longer desires, and both may be followed by rapid death.

Consensus statements and guidelines by the Resuscitation Council of the UK, British Cardiovascular Society, and National Council for Palliative Care, the European Heart Rhythm Association, and Heart Rhythm Society, and the Canadian Cardiovascular Society all recommend discussion with the patient of deactivation of implantable cardiac devices in end-of-life care.

The presence of a do-not-resuscitate order should not be taken as an automatic request by the patient to discontinue implantable device therapy. As with other end-of-life therapies, discontinuance of such devices should include due consideration of whether the decision is made by a competent patient and with full informed consent. Management of discontinuance of device therapy should always include planning for treatment of distressing symptoms and administration of appropriate comfort measures.

Physician-Assisted Suicide and Euthanasia

PAS is defined as the provision of medication or prescriptions by a physician to a patient at their specific request for the explicit purpose of ending their life. PAS requires a patient who is both competent and capable of communicating the request, as well as capable of self-administration. Euthanasia is defined as the administration of medication by someone other than the patient for the express purpose of causing death in the belief that this would be best for the patient, but not necessarily at the specific request of the patient. Both practices differ ethically from withdrawing or withholding life-supporting medical treatments. In withdrawal or withholding of life-supporting treatment, the primary intention is to discontinue treatments that are causing suffering with an understanding that death may or probably will result. In PAS and euthanasia, the primary intention is to cause death, which secondarily ends suffering.

Currently, euthanasia is legal only in the Netherlands, Belgium, and Luxembourg. Some confusion exists about the status of euthanasia in Colombia, which has been labeled as allowing “euthanasia,” but appears in fact to have legalized PAS, reflecting a common misconception in the press about differences between the two practices. In the United States, euthanasia remains illegal regardless of circumstance, but PAS is legal as of 2018 in the states of Oregon, Washington, Montana, Vermont, Colorado, California, and the District of Columbia. It narrowly missed ratification in New Mexico after being passed by both state houses in 2017, and it passed the Hawaii State House of Representatives in March of 2018. It is also under consideration in other states. Thirty-seven states have specific laws that make PAS illegal, and four states have no specific laws regarding PAS. Internationally, PAS is legal only in the Netherlands, Belgium, Luxembourg, Germany, and Switzerland.

Supporters of PAS argue that the right to privacy and respect for autonomy support a patient’s right to determine the time, location, and circumstance of his or her own death. Patients consistently rate loss of autonomy and control, inability to pursue previously valued activities, and loss of dignity as the major concerns at the end of life. Adequate control of pain, anxiety, dyspnea, and other symptoms at the end of life remain a challenge to the medical profession, thereby fueling the desire for a means to end life when suffering cannot be controlled. Opponents argue that PAS “medicalizes” death, overly idealizes the physician-patient relationship, ignores possible personal and professional conflicts of interest, and leads to erosion of trust between dying patients and their doctors. Although many ethicists acknowledge that individual circumstances may make assisted suicide an ethically permissible action, most express concerns about potential abuse. Vulnerable members of society, such as the poor, old, and handicapped, could be pressed by financial and social factors into a suicide option in preference to palliative care. An additional argument against PAS or legalized euthanasia is that these approaches could provide solutions to the medical, social, and economic problems common to older and poor patients that are simpler and less expensive than seeking and requiring more difficult but definitive remedies.

Twenty years have passed since Oregon legalized and enacted PAS in 1997 and the Netherlands legalized both PAS and euthanasia, and significant data now provide some insights into whether these concerns about PAS and euthanasia are materializing. In recent polls, more than two thirds of the U.S. population polled favored legalizing PAS, and approximately 70% favored legalization of euthanasia. The percentage of U.S. oncology patients favoring a PAS or euthanasia option in end-of-life care is approximately 65%, whereas physicians frequently involved in end-of-life care, such as intensive care specialists, oncologists, and palliative care specialists, are the most uniformly opposed specialists. This finding represents a significant discordance between physicians and their patients.

In Oregon, where PAS has been legalized for the longest period in the United States, data from 2015 (the most recent year available) remain consistent and show that patients who requested PAS were more likely to be white and had generally higher economic status and education. More than 99.2% were insured, and 92.2% were enrolled in hospice care. Most were more than 65 years old (78%), and 72% were suffering from cancer. As of 2015, 36% of patients receiving prescriptions for PAS (a total of 1545 patients over 20 years) never used them and ultimately died of their underlying disease—with many surviving significantly longer than predicted. More than 92% of patients enrolled in the Oregon program cited loss of autonomy as a primary reason for pursuing the option. Some authors have suggested that the possession of a means to end their lives legally and humanely prevented “preemptive” suicides that could have occurred earlier and thus may have prolonged lives.

Concerns regarding abuses of PAS and euthanasia will undoubtedly continue, but thus far, evidence of systematic abuse is lacking in places where PAS is legalized and regulated. As the population ages and patients desire greater control over end-of-life care and circumstances, debate over PAS and euthanasia in the United States can be expected to continue to grow.

Ethical Issues in Organ Transplantation

Two issues critical to vital organ transplantation that confront anesthesiologists are the concept of brain death and the linkage of withdrawal of life-sustaining therapies with organ retrieval and transplantation after cardiac death (DCD).