The conflict between an individual physician’s duty to treat versus their personal issues of conscience and moral integrity has become more complex in recent years (Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 8th edition, 2015). The loss of physician autonomy due to recent societal pressures, changes in practice models, and ever-changing legal landscapes has potentially placed additional strain on the relationship between one’s professional duty to care and one’s conscience, values, and beliefs. Respect for a patient’s right of self-determination is in accordance with Principles I, II, IV, and VIII of the American Medical Association (AMA) Principles of Medical Ethics, as well as sections I.1. and I.2 of the ASA Guidelines for the Ethical Practice of Anesthesiology (asamonitor.pub/3XKmV6D; asamonitor.pub/4eiWSca; J Healthc Leadersh 2023;15:153-60). The physician’s duty to treat is not absolute, except in cases of emergency. The above documents emphasize the importance of physicians acting in accordance with their conscience while balancing professional responsibilities to patients. They stress the need for physicians to uphold ethical standards, provide care in emergencies, respect patient autonomy, and not discriminate. They also address the duty to inform patients of services that cannot be provided due to personal beliefs before establishing a patient-physician relationship. ?Additionally, the documents discuss moral complicity, factors influencing it, the duty to inform patients about treatment options, and the duty to refer patients to other providers when necessary. ?

Physicians have a moral and professional code to practice ethically and within the law. There is a need to understand the extent and impact of conscientious burdens on professional conduct and to provide recommendations for ethically navigating these potential dilemmas. This document will provide an overview of the issues facing anesthesiologists regarding their duties of care and related issues of conscience, providing strategies for resolving moral conflicts.

Advances in medicine have widened the scope of practice of anesthesiologists, resulting in an associated exponential increase in clinical duties, expectations, and responsibility. We not only provide perioperative care to surgical patients (which includes thorough preoperative evaluations, intraoperative care, including life support, and immediate postoperative care) but are also often responsible for managing critically ill patients, providing complex obstetrical care, and providing service in remote locations, pain clinics, and for complex acute pain/regional anesthesia services (asamonitor.pub/3ZswfgA). This increased scope of practice also increases the opportunity for ethical challenge.

Goals of care can vary greatly depending on the stakeholder (e.g., that of the surgeon or interventionist, hospital, care team, organization, and the patient). The ultimate burden is on the anesthesiologist who must balance these interests to make the best-informed decision (Anesthesiology 2014;120:204-17). In emergencies, we reduce risk of harm by providing the best care that we can with the tools at our disposal. In other circumstances, conflict arises when the values of providers, patients, and institutions differ. Examples include being pressured to ignore fasting guidelines, or to defer additional testing, or subspecialty consultation for the sake of efficiency (J Clin Monit Comput 2012;26:329-35). Additionally, the anesthesiologist has a responsibility in delivering a mode of care that facilitates other procedural interventions across a range of possible specialties – without which, such interventions could not be safely performed. Consequently, this creates a potential barrier to certain types of health care should the anesthesiologist refuse to participate (Pediatrics 2009;124:1689-93).

“Anesthesiologists, as all physicians, have an obligation to provide timely, compassionate, and efficient care to their patients while respecting their privacy and autonomy. In recent years, several moral issues have arisen as a result of a changing legal and political landscape and changing practice patterns within the United States.”

Burnout is a collection of symptoms, including emotional exhaustion, inefficacy, and cynicism, and may represent a much larger issue (World J Biol Psychiatry 2021;22:686-98). Distinctly, moral injury among physicians is a related, complex, and deeply concerning issue within the health care landscape. Defined as the “psychological distress resulting from actions, or the lack thereof, that violate one’s moral or ethical code,” moral injury can have profound and lasting effects on the well-being of health care professionals (J Trauma Stress 2019;32:350-62). In the context of medical practice, moral injury occurs when physicians perform, witness, or fail to prevent an act that goes against the ethical axiom of medical practice, primum non nocere (first, do no harm). Historically, the fiduciary nature of the patient-physician relationship presupposes that physicians will altruistically respect and place the autonomous interests of patients above their own. This may come in conflict with an anesthesiologist’s personal belief system, but given the collaborative nature of our profession, this may not always be possible to circumvent in a manner within our legal and ethical bounds. The toll of moral injury not only affects individual physicians but also reverberates throughout the health care system, impacting patient care and overall well-being (Obstet Gynecol 2023;141:15-21).

Anesthesiologists, as all physicians, have an obligation to provide timely, compassionate, and efficient care to their patients while respecting their privacy and autonomy (asamonitor.pub/4eiWSca). In recent years, several moral issues have arisen as a result of a changing legal and political landscape and changing practice patterns within the United States (Anesth Prog 1995;42:1-6). The nature of the practice of anesthesiology often places practitioners at the crossroads of these moral dilemmas (Camb Q Healthc Ethics 2017;26:97-08). Patient autonomy and shared decision-making involve incorporating, to a reasonable extent, a patient’s values, preferences, and beliefs in the proposed plan of care. Examples include refusal of well recognized or proven standard therapies, demands for nonbeneficial or unproven therapies, expectations regarding end-of-life care, and abortion.

Historically, physician autonomy was respected by arranging case assignments such that those physicians who morally objected to caring for a patient were not involved in their care (J Nerv Ment Dis 2021;209:174-80). The problem occurs when such a replacement cannot be found (asamonitor.pub/3XKmV6D). Recent changes in the practice model, where increasing numbers of anesthesiologists have become employees either by direct hiring or by the purchase of practice groups and/or hospitals by large medical or other corporate entities, will no doubt impact individual physician autonomy (J Healthc Leadersh 2023;15:153-60). Corporations have shifted to increasing profit by heavily supporting revenue-generating procedures and improving innovative and lucrative procedures while limiting unprofitable patient care (J Public Health Manag Pract 2012;18:E1-3).

The burden of moral injury weighs heavily on physicians, who often enter the profession with a deep sense of altruism and a commitment to healing. This may be compounded by adverse patient outcomes within the standard of care and medical errors, as well as the criminalization of medical errors leading to profound self-doubt (Ann N Y Acad Sci 2014;1330:19-37). These emotions can have far-reaching consequences, contributing to burnout, depression, and even suicidal ideation. Conflict also arises in the realm of informed consent. While we strive for full disclosure, the complexity of anesthesia and the acuteness of surgical or other interventional settings can make this challenging. Balancing the need to provide comprehensive information without inducing undue fear or misunderstanding is difficult. Another ethical challenge is the management of high-risk procedures in patients with a poor prognosis. The decision to proceed with anesthesia in such cases involves weighing the risks and potential burdens versus the benefits, the patient’s quality of life, and their autonomy (J Clin Ethics 2017;28:15-29).

Anesthesiologists today face an evolving landscape of societal expectations and moral complexities. Navigating these challenges requires a blend of strong communication skills, ethical decision-making, and adaptability to changing societal norms. By maintaining a patient-centered approach and engaging in continuous professional development, anesthesiologists can adeptly manage these societal burdens and moral dilemmas, ultimately enhancing patient care and trust in the specialty. In discussing these questions well in advance, and being better prepared for when they arise, we avoid consequential reflexive crisis management. Collaboration and compromise within the bounds of ethically appropriate norms often yield a solution (Intensive Crit Care Nurs 2022;70:103206). Emotional intelligence and active listening are essential in practicing some of the suggestions described below (Nurs Ethics 2015;22:91-02):

  • It is often helpful to establish ground rules for respectful communication and to create a safe space from which limited non-essential information will be released.
  • In-person meetings are usually ideal as they allow for greater understanding of tone, intent, and body language.
  • Structured dialogue techniques such as reflective listening and paraphrasing can facilitate constructive conversations (Healthcare 2021;10:46).
  • Reviewing cases or role-playing exercises can help participants conceptualize how different scenarios may present (Front Psychol 2022;13:935773).
  • Institutional buy-in is essential, and the provision of legal and potentially financial counsel can be an invaluable resource to add context to these discussions.
  • Diversity of thought must be considered, and the perspectives of groups that may be at higher risk for worse health outcomes should be valued.

Physicians should distinguish between deeply held moral objections and personal distaste or prejudice. Legally, the right to decline provision of care may be limited by employment contracts. Balance must be maintained between risks to health care workers and the benefits to the patient, and health care workers should not be asked to forsake moral beliefs as a condition of practice, such as in conscientious objections to abortions/contraception. At the same time, physicians cannot refuse to treat certain groups of patients out of a conscientious objection stemming from bias against that group. Finally, patients deserve to be informed of the medically feasible options for care – and to have equitable access to medically appropriate care delivered in a timely manner – when physicians are unable to perform their duties due to issues of conscience. This responsibility should rest with both the physicians and the institution to have such safeguards and protocols in place in order to deliver seamless care for our patients.