html xmlns=”http://www.w3.org/1999/xhtml”>
14 Informed consent for preoperative testing: pregnancy testing and other tests involving sensitive patient issues
The Case
A healthy 15-year-old girl presents for elective diagnostic ankle arthroscopy for ankle pain and swelling. She is accompanied by her mother. During the preoperative interview, she appears acutely uncomfortable with questions about whether she is sexually active (she denies it) and the timing of her last menstrual period. The anesthesiologist informs her that she will need to get a urine sample for a pregnancy test. The test is required by the anesthesia group’s policy of pregnancy testing female patients, and members of the group will not perform elective anesthesia on pregnant patients. The patient’s mother questions the necessity of the test, stating with confidence that “my daughter has never had sex.” The urine pregnancy test, however, is positive. State law prevents the anesthesiologist from informing anyone but the patient of her positive test, although the mother will surely guess the test results if the case is cancelled. Furthermore, the patient is below her state’s age of consent for sexual intercourse, and her pregnancy is therefore by legal definition the result of statutory rape according to state law – which also requires any doctor who suspects child abuse to notify state authorities.
While physicians often consider ethical issues concerning medical therapies, it is easy to overlook ethical issues regarding something as routine as a preoperative laboratory testing. Yet principles of beneficence (doing good) and nonmaleficence (avoiding harm) suggest that anytime we prescribe a medical test, ethical considerations may be relevant, since we doing such testing precisely because we hope to benefit patients and/or avoiding harm. Preoperative testing presumably benefits patients by identifying unrecognized or disguised conditions that might adversely affect anesthetic risk. But harms can also result from preoperative testing. Some harms include the risk of a false-positive test erroneously labeling a patient as having a condition they do not have; the risk of a false-negative test falsely reassuring a patient that they do not have a condition which they in fact do; the risk that erroneous results might lead to inappropriate therapy with its attendant complications; the risk that erroneous test results might deprive a patient of important therapy they would otherwise get; and the complications of performing the test itself, and monetary cost, to name a few.
Are all preoperative tests ethically equivalent? Some of the ethical problems that face the anesthesiologist in the case introducing this chapter may be obvious, and some may not. But is there really an ethical problem with obtaining an ECG, for example? This discussion will focus on issues related to common, routine preoperative tests, and also examine two preoperative tests with special social implications: HIV and pregnancy testing.
General ethical principles regarding medical testing
Physicians have ethical obligations based in principles of beneficence and nonmaleficence to make responsible and knowledgeable decisions about whether a preoperative test is even warranted. Principles of good medical practice require that physicians balance the cost of testing against the likelihood that testing will produce more benefits than harms. Physicians are also bound by an ethical principle of fidelity to their patients. Fidelity is the concept that physicians should be faithful and committed in providing good medical care, and not compromise that care in the interests of anyone else, not even for physicians’ personal interests.. This principle respects the vulnerability of patients in the doctor–patient relationship. Not only does the doctor have special medical knowledge and skills in which the patient must place their trust, but also the physician determines to a great degree how expensive medical testing and therapy will be.
The principle of nonmaleficence requires physicians to consider, in addition to the monetary costs of a test, both the medical and social harms that may result from unnecessary or poorly conceived testing. Medical harms include the discomfort and inconvenience of the test and the potential for false-positive or false-negative results that misdirect medical therapy in ways that create greater harms than benefits. Such misdirection can occur even with a simple ECG. Take, for example, a 40-year-old healthy man with no medical complaints who presents for knee arthromenisectomy. His surgeon orders a routine preoperative ECG as he has for the last few decades on all of his patients scheduled for surgery. The ECG demonstrates concerning but nonspecific ST segment changes, so the surgeon consults a cardiologist who orders stress cardiac imaging for further clarification. Imaging reveals a significant area of decreased apical uptake compatible with myocardial ischemia or possible attenuation artifact, so a cardiac catheterization is undertaken – which reveals normal coronary arteries. Ultimately, the patient suffers a femoral artery tear during catheterization and has to undergo emergency vascular surgery. The physical and financial cost to the patient is very high, although no medical decisions concerning the original surgery were ultimately altered and no surgical risks reduced as a result. In fact, this healthy patient’s risk of a major adverse event increased with each test his doctor ordered. The most recent guidelines for perioperative cardiac workup now indicate questionable utility of a preoperative ECG in this case. The subsequent stress test was also not indicated because it was unlikely to reveal anything that would favorably alter outcomes for a low risk surgery.
Good medical practice, both from ethical and medical standpoints, includes applying evidence-based guidelines in determining if a test should be done, rather than on individual experience and beliefs. Individual experiences suffer from bias, unique confounding factors, and situational conflicts of interest. Anecdotes may be useful when no systematic investigation has been undertaken that can advise physicians about the course of action most likely to lead to the best overall outcomes. But anecdotal experience, albeit a strong tradition in medical education, serves us best when it spurs systematic investigation that results in sound, evidence-based decision support for physicians., Once evidence-based algorithms are available, they should guide most decisions and replace “routine” or traditional patterns of ordering tests.
Preoperative HIV and pregnancy screening
Social risks associated with preoperative testing may not be as obvious as medical risks, but can be the source significant harm. Two examples of tests that can produce social harm but are of limited preoperative utility are HIV and pregnancy testing.
Adverse social consequences known to be associated with HIV seropositivity include employment discrimination, loss of insurance, and social isolation. Studies demonstrate that seropositive women experience high rates of marital break-up, abandonment, and verbal and physical violence when their HIV status is disclosed.1 Compulsory preoperative HIV testing is known to prevent some patients from seeking medical care. Recognition of these harms has led in the US to the inclusion of AIDS patients in the protections afforded under the Americans with Disabilities Act, and has resulted in legislation specifically protecting the privacy of a patient’s HIV status.
Revealing a positive pregnancy test may likewise have negative, even life-threatening consequences for vulnerable patients in social environments where their pregnancy is not accepted. Studies show that female patients and their fetuses are in some situations at risk of physical violence. Further, adolescent pregnancies are sometimes the result of child abuse, incest, and rape. Communication of a positive pregnancy test result to the parents of a pregnant minor can place the child in jeopardy of further physical harm, since it may be evidence of criminal behavior on the part of a family member, or family friend or acquaintance. Many states have statutory requirements for physicians to report evidence of child abuse, and some authorities recommend reporting pregnant minors to Child Protective Services for investigation of possible abuse.
In much of the US, a female patient of any age has the legal right to absolute privacy regarding reproductive matters. To reveal or even imply the results of a pregnancy test to a third party, even a parent or spouse, without the woman’s consent, would represent an overt violation of law. The anesthesiologist who discovers a pregnancy is therefore left with few comfortable legal options if they have not first obtained the patient’s voluntary informed consent for pregnancy testing and discussed both how the test results will be used and to whom they can be revealed.
Given that there are risks of both social and medical harms associated with HIV or pregnancy testing, is there evidence that routine preoperative testing for HIV or pregnancy alters outcomes in a sufficiently favorable way to justify risking such harms?
HIV testing
HIV testing is usually ordered by the surgeon or anesthesiologist to determine which patients may pose a risk to members of the operating room team, and therefore with which patients they should be particularly careful to avoid possible exposure. Studies show that most surgeons and anesthesiologists erroneously believe that: (1) compulsory routine HIV screening will reduce their personal risk of exposure; (2) ordering such tests is the prerogative of the physician; and (3) that such tests can be done without the patient’s consent.
Related posts:
Informed consent and the pediatric patient
The use of ethics consultation regarding consent and refusal
Ethical considerations in interventional pain management
Conflicts of interest in research funding
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
