For the last decade or more, physicians practicing perioperative medicine and many other specialties have constantly confronted two competing demands: the desire to alleviate patients’ pain and the urgent need to avoid fueling the opioid epidemic. In her presentation “Ethical Considerations in Perioperative Pain Medicine,” now available for CME credit through AudioDigest, anesthesiologist Dr. Emily H. Garmon offers a wealth of practical insight into medical ethics and its direct application to the practice of pain control.
By elaborating on the four primary principles of medical ethics — autonomy, beneficence, nonmaleficence and justice — Dr. Garmon illuminates the underpinnings for ethical decision-making in anesthesia and pain management. However, the application of these principles is not limited to perioperative medicine. Rather, they serve to guide physicians of all specialties as they make treatment decisions together with their patients.
The Nature and Purpose of Medical Ethics
The principles of medical ethics direct physicians by giving us tools that empower us to behave with the highest integrity in the context of a pluralistic and multicultural society. None of the four principles below holds primacy over the others; all are equally important. In fact, it is frequently in situations where the principles appear to come into conflict with one another where the interface among them often becomes most useful.
As Thomas R. McCormick, DMin, writes in “Principles of Bioethics,” “[I]n both clinical medicine and in scientific research … these principles can be applied, even in unique circumstances, to provide guidance in discovering our moral duties within that situation.” Dr. Garmon agrees, indicating that the four principles offer a framework physicians can use in a wide array of circumstances to resolve ethical dilemmas and select appropriate care in collaboration with patients and families.
The 4 Principles of Medical Ethics
1. Respect for Autonomy
The principle of autonomy highlights our responsibility to respect the patient’s values and their right to make voluntary decisions regarding their healthcare. As Dr. Garmon notes, a treating physician and their patient are strangers at first. Each will need to learn about the other if the physician is to understand the patient’s needs and the patient to understand what the physician has to offer them. A healthy respect for the patient’s right to self-determination dictates taking the time to have that conversation.
Perhaps the most obvious application of the principle of respect for autonomy arises in the context of “informed consent.” When we invite the patient into a clear discussion of risks and benefits of a given treatment, the likelihood of success and alternatives to that treatment, we acknowledge their right as a unique individual to make decisions consistent with their own values and wishes.
Naturally, we have the duty to convey information in language the patient can comprehend as well as to assess the patient’s capacity to understand the information and make a reasonable choice. Additionally, we have a responsibility to consider the patient’s cultural and religious beliefs and avoid undue coercion. Dr. Garmon encourages us to maintain a spirit of openness, even after obtaining consent, and to honor the patient’s right to change their mind at any time.
Providing benefit and reducing harm to patients and populations is perhaps the most salient aim of healthcare. In order to take action in the best interest of an individual patient, however, we again need to explore their values and goals. Without that conversation, we may miss the mark in seeking beneficence.
Dr. Garmon elaborates that we further enhance our capacity for beneficence by expanding our skills over the course of our careers. The wider the variety of up-to-date treatment options we offer, the greater the support we offer the patient as they exercise their right to choose the option best suited to their individual needs.
Hippocrates captured the principle of nonmaleficence in the words “First, do no harm.” Although nearly all medical treatment entails risk in some form, it is a fundamental principle of medical practice that we seek to do as little harm as is possible.
In the realm of anesthesia, standardized pain management order sets and procedural checklists are some of the most effective tools for preventing violations of the principle of nonmaleficence, says Dr. Garmon. Similar tools to minimize error now exist in virtually every medical specialty.
She additionally points to the need to plan for the unexpected. In the surgical suite, that might mean taking steps such as having rescue medications available for use in the event of unexpected complications, using adequate monitoring equipment and having IV access in place before it is needed. Whatever the context, each and every action that serves to reduce risk of harm supports our aim of nonmaleficence.
At its core, the principle of justice insists that we promote fairness and equity for all patients. As fundamental as this principle is to medical practice, its application can be challenging. At a basic level, justice insists that we make similar treatment options available to patients in similar circumstances without regard to ability to pay or other factors irrelevant to the patient’s health. Additionally, as Dr. Garmon notes, justice demands that we consider the allocation of limited resources in ways which both protect the vulnerable among our patients and ensure that maximal benefit is derived from limited resources.
The complexities of medical practice among patients with widely diverse backgrounds, preferences and needs ensure that we will always face ethical challenges as physicians. However, considering these fundamental principles can empower us to engage in collaboration with patients, their caregivers and our colleagues to ensure that patients receive the best and most satisfying care we have to give.