Hello everyone – I hope you are all enjoying summertime! Our last column touched peripherally on the concept of ethics in medicine, when we explored the question of what obligation the developed world has to assist the emerging world. In this installment, we dive headlong into the topic of perioperative ethics with our expert Alyssa M. Burgart, MD, MA, FAAP. Dr. Burgart is an eloquent, thoughtful medical ethicist who regularly engages people across medical disciplines and across the world, in no small part via her highly effective social media presence. I am delighted to have her join us and enlighten this universally applicable topic.
Welcome, Dr. Burgart! Please describe your current position and responsibilities.
Thank you for this invitation! I am a pediatric anesthesiologist at Lucile Packard Children’s Hospital at Stanford University (LPCH). I subspecialize in abdominal transplant anesthesiology, and I am part of a five-member team of anesthesiologists in one of the top pediatric transplant programs in the country. I am also the Medical Director of Clinical Ethics at LPCH, where I lead a team of four ethics consultants and co-chair the hospital’s Ethics Committee. Since arriving at Stanford, I’ve invested in building up the hospital ethics team as a trusted, high-impact service. I also provide ethics consultation at Stanford Health Care (our adult hospital). This has allowed me to maintain and enhance my ethics consultation skills across the human lifespan.
What drew you to the field of medical ethics?
As a kid, I was fascinated with Dolly the cloned sheep, advances in infertility treatment, and transplantation. The idea that there were highly emotionally charged and morally interesting things going on in science and medicine was something I wanted to know more about. When I found out I could study bioethics and also complete my pre-medical studies, I knew I’d found something that would feed my interest in philosophy long-term. My studies led to my first clinical ethics job at Cedars-Sinai Medical Center, where I learned how to navigate professional relationships and guide complex family meetings. Then I worked at UCSF in the Human Research Protection Program, learning the ins and outs of human subject research. Confident in my desire to be a physician, I went on to attend Loyola University Chicago, where I simultaneously earned a medical degree and a master’s degree in bioethics and health policy.
What ethical issue(s) do you see as most important in contemporary perioperative medicine?
The breadth of anesthesiology practice, from pain management, operative care and obstetrics to critical care, provides a plethora of ethical dilemmas. Two of the most important ethical issues facing our profession include eliminating health injustice and mitigating moral distress. These are both excellent examples of the significant overlap ethics work has with other aspects of our profession, including quality improvement, wellness, and diversity, equity, inclusion, and belonging initiatives.
First, anesthesiologists must ethically navigate societal injustice related to race, gender, disability, language, and sexual orientation for our patients, ourselves, and our colleagues. It is only through a commitment to identifying and eliminating injustice that we will be able to do our best, brightest work. What does a commitment to justice in anesthesiology look like? How will we recognize, track, and mitigate injustices in perioperative care? People tend to think of ethics as being nebulous, but we have the ability to measure the success of justice-based interventions in areas such as maternal mortality, pain management in sickle cell disease, and effectiveness of clinicians’ communication. We must examine the justice elements in our education, business, and employment practices. Does our team reflect the diversity of the population we care for? Do we compensate all anesthesiologists equitably? When the answer is “no,” we must pave the way to mitigate these injustices.
Second, our ability to recognize and address moral distress in ourselves and our teams is a critical issue in our profession. After two years of COVID-related impact, we’re seeing unprecedented levels of anxiety, burnout, and compassion fatigue in health care workers, including anesthesiologists. During the pandemic, we witnessed (and tried to mitigate) immense suffering. We have lost colleagues to illness and suicide. Many health care workers are leaving our profession. For those of us who remain, it will take years to recover and rebuild the moral confidence we need to succeed. Left untreated, distress erodes our sense of meaning and connection to our work and negatively impacts patient safety. In order to provide safe, high-quality care, we need to build, support, and maintain robust moral climates – this will take strong ethical leadership up and down our organizations.
A question that often comes up in this country is the issue of surgical versus anesthesia consent. Some institutions require two distinct documents, others allow anesthesia consent to be “bundled” into the surgical, despite the fact that there are often significant perioperative risks from anesthesia care. What is your view?
I work at an organization that allows documentation of anesthesia consent to be built into the surgical consent form. However, this approach doesn’t mean that I am abdicating the consent conversation. A form can serve to codify that both patient and clinician agree to move forward, but there is often a false sense that the signed paper alone is sufficient. It’s not! Regardless of whether a regulatory agency or hospital requires a separate document, it’s our responsibility to do our best to ensure that patients understand the risks, benefits, and alternatives in anesthesia care. Documenting these conversations effectively is critical.
Medical futility is another hot topic for ASA members, specifically the idea of performing high-risk, resource-intensive surgery on patients of extreme age or with significant cognitive impairment (e.g., Alzheimer’s) or both. Readers (and me) would love to get your take on this.
Potentially medically ineffective treatment (previously called “futility”) is a hot topic in all specialties participating in high-intensity, life-prolonging care and is a significant source of moral distress in intensive care units. Anesthesiologists are in a position where we often play little role in the discussions and decisions that lead to surgery, yet we have valuable experiences that inform our intuitions of what is “right.” Additionally, sometimes the medical team is unified in believing treatment offers no benefit, but the patient’s decision-makers see things differently and insist on continuing intense, uncomfortable interventions. One thing I often ask is: whose values have been considered so far? Are we actively centering the patient’s values (to the degree we know them)? It’s critical to recognize that there are many perspectives on what constitutes a meaningful quality of life, and I may have a different view of that than the patient, their family, or, for that matter, their surgeon or oncologist. Patients and families are often making decisions in the context of the information they have received from a trusted source or possibly the source who presented information in the most accessible, least painful way. Each of these cases is unique and benefits from respectful, compassionate communication to understand the patient’s or family’s goals and values and help them navigate a usually tragic situation. It is always preferable to reach a shared decision on treatment plans, which can take time and commitment from the medical team. If there is ongoing conflict, it can be valuable to ask for advice from ethicists, risk management, spiritual care, or other counselors in your practice setting.
Another important question for ASA members is how to deal with a surgical colleague who one judges to be unsafe or excessively unprofessional in their practice, yet no one else has spoken up about.
This is an extremely difficult situation, especially for those in marginalized positions. The hierarchy and production pressures we face can deeply impact what we see as viable options in the moment. Given that no one else has spoken up, the stakes may be very high, and individuals may fear professional consequences. Bullying, retaliation, and abuse are significant issues that negatively impact not only our experience as caregivers but also can result in patient safety events. We all deserve a safe work environment. My thoughts:
- Document your experiences for reference.
- You’re likely not alone in your concern. Escalating concerns with others can diffuse anxiety about going it alone against a powerful person in an organization.
- Learn about resources at your organization. Which trusted individual(s) might offer confidential advice? What administrative resources exist? Is there an ombudsperson or other option through human resources? If you are at a university, the Title IX office or harassment office may provide additional resources.
- If you feel safe to do so, escalate your concerns to relevant administrators – and in particular, relay your concern that the unprofessional behavior may impact patient and staff safety.
- It is critically important that everyone on staff is trained to recognize hostile behavior in the workplace and understand what resources there are to combat it.
What ASA resources are available for members dealing with ethical questions/conundrums?
The ASA Committee on Ethics offers several valuable resources on the ASA website, including Guidelines for the Ethical Practice of Anesthesiology and guidance on specific issues such as caring for patients with do-not-resuscitate orders, transplantation, ethical considerations with drug shortages, and physician non-participation in legally authorized executions. These resources won’t be sufficient for all your ethical conundrums, but they are a start in understanding some of the serious issues anesthesiologists face. I am interested to hear from readers about what issues they would like the Committee on Ethics to address.
Many practice environments have access to an ethics committee and/or ethics consultants, though the extent of these resources will vary widely.
Can you share a notable ethical dilemma from your own practice and how you managed it?
Catch me at the next ASA or Society for Pediatric Anesthesia meeting, and I’ll happily share some de-identified tales of ethics at the bedside.
What are your interests, outside of clinical medicine and medical ethics?
Playing guitar and singing are deeply meaningful to me. I’ve taken up surfing since moving back to California. Our family loves spending time outdoors enjoying the ocean and mountains.
Any parting words for our readers?
We don’t all need to become clinical ethicists, but every anesthesiologist has a role in promoting an ethical environment. Trust yourself and your moral compass – if you feel like something is not in alignment with your values, it’s worth exploring with a trusted colleague and understanding your options. Anesthesiologists do high-risk, exceptionally challenging work. Promoting a morally robust climate will allow us to do the work we do best for years to come.
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