This Lecture was delivered at the 25th Annual Meeting of the Society of Cardiovascular Anesthesiologists.
It is a privilege to be invited to deliver the Abbott Lecture at the 25th Annual Meeting of the Society of Cardiovascular Anesthesiologists (SCA) and have the opportunity to express some opinions gained during the first four decades of my professional career. Though no longer an actively practicing cardiac anesthesiologist who tosses and turns at night, worried about causing an inadvertent harm to a patient tomorrow, as most of those who read this lecture undoubtedly still do, I shall remain one vicariously to the end of my days. Cardiac anesthesiology is an engrossing, challenging, and rewarding subspecialty of anesthesiology, and we who can claim it are privileged.
My topic is “Cardiac Anesthesiology, Professionalism and Ethics: A Microcosm of Anesthesiology and Medicine.” My overall aims include paying homage to the pioneers who made our field possible, specifying the characteristics of a medical specialty, reviewing achievements by cardiovascular anesthesiologists that qualified it for that status, defining professionalism, and indicating how cardiovascular anesthesiology has earned not only subspecialty but also professional standing. Furthermore, I shall identify deficits in our individual and collective behaviors that threaten the retention of professional status. By successfully confronting these challenges, cardiac anesthesiology has the opportunity to provide examples of behavior that could enable the entire profession to retain that presently endangered state. The concept of Civic Professionalism will be introduced as an integral part of this argument.
Beginnings of Cardiovascular Anesthesiology
The roots of cardiac anesthesiology precede open-heart surgery, but begin with the first efforts of surgery on the heart and great vessels. The anesthesiologist who managed the first successful mitral valvulotomy in 1923 (80 yr ago, and it was an isolated success) is unknown. He or she must have been thoroughly terrified as Cutler passed the valvulotome through the apex of the left ventricle and blindly excised a piece of the mitral valve (1). This model of terror was arguably the model for the next several decades, as anesthesiologists were confronted with challenges that had never before been encountered. In the late 1930s with ligation of patent ductus arteriosus (2), in World War II during removal of shrapnel from the heart (3), and shortly after that war when mitral commissurotomy (4) and systemic-pulmonary shunts (5) were developed by intrepid surgeons, anesthesiologists took up the challenge of keeping the patients both still enough to accomplish the operation and alive. Merel Harmel and Austin Lamont at Hopkins (6), William McQuiston in Chicago (7), Robert Patrick and Emerson Moffitt at the Mayo Clinic (8), and Kenneth Keown (9) in Philadelphia were among those who made these first courageous steps leading to the subspecialty. However, it was the arrival of open-heart surgery employing cardiopulmonary bypass (CPB) in the mid-1950s that stimulated anesthesiologists in sufficient numbers to confront the challenges that eventually led to a legitimate and respected subspecialty (10).
Requirements of a Specialty According to Ralph Waters
Ralph Waters, the first academic anesthesiologist of the modern age, stated that “development and recognition of a specialty is dependent upon Men, Publications and Organizations,” a pragmatic and almost poetic description (11). Today, it is inappropriate to exclude “women.” Thus, the word “people” will be substituted to include both. In addition to his criteria, a specialty needs a mission. The initial mission of cardiovascular anesthesiology was to develop a body of knowledge that would enable anesthesiologists to improve survival and decrease morbidity of cardiac surgical patients. That mission has subsequently been expanded.
People, Publications, and Organizations
In 1972, a survey published in Anesthesiology identified fewer than 50 anesthesiologists concentrating on anesthetic management of the patient undergoing cardiac surgery in the United States and Canada (12). That contrasts with over 7000 present members of the SCA, a more than 17% compound rate of growth for 3 decades! It would at that time have been wildly optimistic to predict that even several hundred anesthesiologists would eventually concentrate their efforts on this activity. In the early 1970s, rheumatic heart disease was disappearing, correction of congenital heart disease was uncommon and primitive, and coronary artery surgery was in its infancy. Many actually wondered if the numbers of anesthesiologists interested in problems related to heart disease would decrease, not realizing we were on the threshold of an avalanche of coronary artery bypass graft surgery.
The first cardiac anesthesia text, written by Kenneth Keown and published in 1956, consists of 94 pages of text in 20 concise chapters (13). It contains 115 references, only 20% of which are in the anesthetic literature, and only one of which refers to CPB. In fact, there are only two phrases about CPB in the entire text. Skipping forward three decades, the 1989 SCA annual Monograph was totally devoted to the topic of CPB (14). It is larger by half than Keown’s 1956 text of the entire field, and contains more than 550 references. A dozen years later, as we entered a new century, we were confronted with a formal reference text devoted solely to cardiopulmonary bypass (15). This book on CPB contains so much information and is so heavy it is hard to lift. Edited by Glen Gravlee, your president-elect, Richard Davis, a former SCA President, one cardiac surgeon, and one perfusionist, it exemplifies the interdisciplinary nature of the required knowledge and the dramatic growth of the field. Even Amazon. com, which is not a medical bookseller, lists 23 titles of books under the heading of cardiac anesthesiology.
Journals devoted to the field have also been developed and thrived. In 1994, the SCA became the first anesthesiology subspecialty society to become an official sponsor of a leading anesthesiology journal, Anesthesia & Analgesia(16). The first section of each issue is an SCA-identified Cardiovascular Anesthesia section, with SCA member Kenneth Tuman as Associate Editor-in-Chief responsible for the editorial content. That relationship has recently been strengthened to the status of a “journal within the journal.” The Journal of Cardiothoracic and Vascular Anesthesiology, the first devoted to the subspecialty, is now in its 16th year of publication.
The first cardiac anesthesiology society, the Association of Cardiac Anesthesiologists (ACA), was founded in 1972 to provide a forum for informal presentation and discussion of important clinical and scientific issues confronting them. Membership was limited to assure that goal. The founding members encouraged formation of parallel small, informal, discussion societies when their membership limit was reached, similar to the model of the Surgical Biology Club, but that effort was not successful. The ACA is now 31 yr old, is still limited to 50 active members, and holds an annual meeting characterized by vigorous discussion.
The SCA was founded 6 yr later, after the explosive growth of cardiac surgery had begun, with different aims. Founders Robert Marino, George Burgess, and Martin Peuler deserve great credit for their foresight and the breadth of their vision. SCA membership is open to all. The society has become an international, highly respected organization, promoting excellence in clinical care, education, and research. Among its noteworthy achievements are stimulating guidelines for pulmonary arterial catheterization and transesophageal echocardiography, and initiating the steps leading to subspecialty accreditation.
Contributions to Anesthesiology and Medicine
Thus far, the contributions specified have been largely limited to the welfare of cardiac surgical patients. However, cardiac anesthesiology has also contributed importantly in a broader context to anesthesiology as a whole. I have compiled a list that is admittedly incomplete and largely subjective. This list does not begin nor claim to be comprehensive and omits many important contributors and contributions.
Contributions by Cardiac Anesthesiologists that Improved the Entire Field of Anesthesiology
Coronary artery disease was placed on the radar screen of anesthesiologists, surgeons, and referring physicians when Marjorie Topkins of New York Hospital, Cornell, in 1964 (17) showed that anesthesia and surgery in patients who had suffered a myocardial infarction was associated with a manifold increase in the rate of postoperative myocardial infarction and death. This observation has been confirmed and refined numerous times and was an important step in developing useful risk assessment of anesthesia.
The revolutionary fact that the hemodynamic factor most closely associated with perioperative myocardial infarction is tachycardia rather than hypo- or hypertension was elegantly defined by Arthur Keats and Steven Slogoff (18). This study included the first hard evidence that β adrenergic blockade decreased perioperative morbidity in patients with coronary artery disease.
The principles for safely anesthetizing patients with valvular heart disease were introduced into the domain of noncardiac anesthesiologists by a series of Refresher Course Lectures and published articles by Steven (Butch) Thomas (19).
Intraoperative, continuous, calibrated single precordial ST segment measurement as an online estimation of myocardial ischemia was developed independently by cardiac anesthesiologists Brian Dalton (20) and Joel Kaplan (21). This anticipated the later development of routine, continuous electrocardiographic ST segment monitoring.
Cardiac anesthesiologists have also enhanced the broader field of anesthesiology by assuming many important posts. These individuals are too numerous to name. Among these positions are the Presidency of the American Board of Anesthesiology and American Society of Anesthesiologists (ASA) and Editor-in-Chief of Anesthesiology. Others have served as Chairmen of Anesthesiology Departments and won the annual ASA Excellence in Research Award. Still others delivered the Rovenstine and Selden lectures in recognition of their contributions to anesthesiology.
Contributions by Cardiac Anesthesiologists Influencing the Broader Practice of Medicine
The acute care “stat” laboratory that operates 24/7 and provides tests that guide moment-to-moment management of critically ill patients was conceived and implemented by cardiac anesthesiologist Myron Laver (22). Now virtually all acute care hospitals have a similar facility.
Initiation of perioperative β adrenergic blockade in patients at risk for coronary artery disease has been accepted as a practice standard by the American College of Physicians after a study by Dennis Mangano demonstrating decreased long-term morbidity and mortality (23).
Preoperative evaluation was revolutionized by Michael Roizen’s demonstration that most routine tests added little benefit or actually detracted from patient care (24).
An effective patient administered treatment for breakthrough cancer pain, the opioid oralet, was developed by cardiac anesthesiologist Ted Stanley. It deserves wider utilization for this purpose (25).
John H. L. Bland (26) discovered that rapid infusion of 5% plasma protein fraction (PPF) solutions caused rather than relieved hypotension and shock when PPF was administered rapidly. He documented that albumin solutions did not produce this effect. This stimulated the organization of an international conference that led to discovering the specific responsible substances and virtual worldwide substitution of albumin solution for PPF for resuscitation.
The first incumbent as Director of the Office of Human Research Protection was cardiac anesthesiologist Greg Koski.
A substantial number of cardiac anesthesiologists have served as Deans of Medical Schools.
The foregoing convincingly establishes the proposition that the contributions of cardiac anesthesiology exceed the requirements specified by Waters. However, my topic includes professionalism, a term Waters did not include in his definition. Based upon the achievements of Dr. Waters and his students, it appears clear that he took for granted that physicians entering anesthesiology would abide by normative, ethical professional behavior, so it was unnecessary to articulate the specific characteristics which compose it. In today’s world, we must be more specific.
Definition of Profession
The word “profession” is derived from the word profess, “to declare.” Since the Middle Ages, it has referred to an occupation that is granted many privileges by society in exchange for obligations to benefit society. The terms “professionalism” and “ethics” were included in the title of this talk quite purposefully. Medicine is considered a profession, and as physicians, anesthesiologists, and cardiovascular anesthesiologists, we call ourselves professionals. The full realization of the promise of cardiac anesthesiology can only be realized if its practitioners fulfill the obligations attendant upon the professional standing granted them (us) by the larger community. The question to all of us at present is whether the preceding activities by themselves fulfill the criteria for claiming the status of profession for cardiac anesthesiology, or, is more required? A corollary is “what are the potential consequences of fulfilling or not fulfilling these criteria?”
My purpose in raising this issue is to explore the implications that devolve from the professional status granted to physicians, including cardiac anesthesiologists, by the public at large. I shall argue that in common with most physicians in the United States, even given the great benefits of our labors, we have not done enough to retain that status. We are, therefore, obligated to broaden our definition of professionalism and act upon this change. Doing so will enable cardiac anesthesiology to become an exemplar for the entire profession.
Present Status of Professionalism in Medicine
There is much talk of professionalism in medicine these days (27–29). Few would argue that the reason for this is that so many members of our society at large, including many physicians, have become suspicious of or disenchanted with many aspects of physician behavior. As trust is at the heart of the institution of profession, it is loss of trust that is at the root of these concerns (30). The perquisites of professional privilege are now under reexamination by the larger community. Just as war is claimed to be too important to be left to the generals, some now claim that health is too important to be left to the doctors. If that is so, why should doctors be considered professionals rather than simply tradesmen, like plumbers or car mechanics, who perform an important technical service but are governed by rules far different from self-directed professional codes of behavior?
The usual understanding of profession and professional predicates an occupation based on prolonged study of a body of knowledge, self-regulation, autonomy in practice, recognized expertise, and a societally granted monopoly. These are generous perquisites granted by the larger community. The prime purpose of the occupation is to provide a public service. There are obligations to put the client’s interests foremost, for some measure of abnegation of self-interest and for normative rather than commercial behavior. Importantly, these obligations have a moral dimension (31). In medicine, the accepted ethos has been to regard the interests of the individual patient for whom the physician accepted responsibility as having priority over other patients and over societal interests in general.
The achievements by cardiac anesthesiologists itemized previously, when matched with the definition just presented, strongly suggest that Cardiac Anesthesiology has fulfilled the criteria of professionalism. The subspecialty has contributed greatly to the public service of making it possible for patients with heart disease to survive cardiac surgery, the initial justification for establishing the field. It has been the prime mover in establishing the scientific and technical bases for enhancing survival of patients with cardiac diseases undergoing noncardiac surgery, another important public service, and advanced the extended field of anesthesiology. Furthermore, members of the subspecialty have importantly changed the broader practice of medicine and contributed leaders throughout anesthesiology and medicine.
Responsibilities to Individual Patients
Although cardiac anesthesiologists are entitled to be proud of these achievements, further reflection reveals much that has been overlooked that needs to be done to truly fulfill the obligations of professionalism. For example, the issue that stimulated my formal study of medical ethics was directly related to the clinical practice of cardiac anesthesiology. The problem had to do with physician behavior towards patients who had undergone a cardiac surgical operation but did not regain their health, yet did not die. This issue is not limited to our subspecialty, but has become a major issue throughout medicine over the past four or five decades. Perhaps because scientific/technical medicine is able to “cure” so effectively, we often inadvertently devalue continued contact with, support for and relief of suffering of those who are not restored to health. In fact, it is not an exaggeration to claim that often such patients are abandoned by their physicians (32).
It is also not an exaggeration to claim that the benefit-to-burden ratio of our technical ministrations and tour de forces are at times unbalanced. At times—perhaps many times—this may even be predictable before anesthesia and operation. We have often acquiesced or distanced ourselves from involvement in the informed consent process or failed to provide information leading to genuine informed consent despite grave reservations about proposed interventions. Sometimes the patient is deprived of the ability to actively participate in the decisions that may become necessary perioperatively because an anesthesiologist prefers to remain uninvolved in the difficult patient-doctor decisions about outcome. This is a grave moral responsibility that is hard to fulfill when it results in vigorous disagreement about whether or not to operate or to continue aggressive treatment. However, it is imperative for anesthesiologists to be involved in such discussions and to actively represent his or her patient’s best interests. Interestingly, in his 1956 textbook of cardiac anesthesiology, Keown (13) deplored avoidance by anesthesiologists of participation inpatient selection for operation. He argued that because the anesthesiologist was a physician before training in anesthesia, he should always act as a physician for the patient’s welfare. The alternative was to become nothing more than a technician.
Cardiac anesthesiologists have often been derelict by “going along to get along.” A more comprehensive, enlightened involvement is what we should strive for. This will enable us to serve our patients better and may well avoid many of the unsatisfactory outcomes we observe. A role model in this area is SCA member Carl Hug, who has made it his mission to knowledgeably become involved in selection of patients for surgery to the benefit of the patients, the physician team, and the health system. More of us need to become active in this.
Of course, unsatisfactory outcomes will always be inevitable in the high-risk area in which we work. This should cause each of us to redouble our efforts to ensure that patients are not abandoned while on our services or when “lateralled” to other services. We must counter a culture that dehumanizes and depersonalizes our patients and passively or actively accepts unethical behavior. We must increase our efforts to socialize ourselves, our colleagues, and our trainees to avoid these behaviors.
Responsibilities to Society: Civic Professionalism
Last, while the former topics are indeed important, they pale in comparison with the most serious and pervasive professional moral problem with health care in the United States. To address this, we need to consider and incorporate into our definition of professionalism the concept of Civic Professionalism (33–35). This concept states that our moral responsibilities as physicians are expanded beyond our immediate patients, as is often considered the principal professional obligation of medicine. To consider the needs of only the patient for whom a physician has accepted responsibility as separate from the needs of other patients is a philosophy with broad historical roots, which in many ways has served well. Its limitations, however, have recently been realized. Many physicians and patients alike fear a change may challenge the important focus on individual care. Balancing these potentially conflicting moral responsibilities will be difficult but necessary.
A broader basis for professionalism envisions professional authority and power arising from public contexts. Proponents of this view, to which the American Medical Association and ASA have recently subscribed in their codes of ethics (36) and with which I strongly concur, contend that services that promote health are key public goods that allow human and social flourishing. Thus, health is a truly public value. Society’s investment in expensive and elaborate institutions for financing, training, researching, and providing health care and permitting learners to practice on humans is made with the understanding that professionals will contribute meaningfully to improving civic welfare. Professional privilege for physicians is based largely upon the fact that physicians’ expertise is a means to achieving better societal health and enhanced opportunity. This relies on physicians actively using their knowledge and influence to promote the common good, rather than just satisfying the desires of its most vocal or powerful sectors, or those able to access health care at the expense of those who cannot.
Just as failure to give primacy to patient welfare in the clinical relationship represents a breach of trust and moral failure of professionalism, failure to rank the community needs above the professions’ self-interest represents serious loss of legitimacy for a profession whose mandate centers on health and alleviation of suffering.
Access to Health Care as a Moral Issue
With this as a preamble, I submit that the greatest medical ethics problem in the United States is not patient autonomy versus physician paternalism or end-of-life care, important as these may be, nor anything that can be solved exclusively by learned philosophical discussions. It is quite simply that we as physicians—including cardiac anesthesiologists—tolerate a health system that excludes a major portion of the population. The Universal Declaration of Human Rights, adopted by the General Assembly of the United Nations in 1948, declared that access to health care is a human right (37). This right was further strengthened in 1966 by the International Covenant of Economic, Social and Cultural Rights (38). The lack of even a basic form of universal health care access in the United States clearly violates this right.
We can argue about the numbers of patients excluded from adequate access: whether it is “only” the 43 million uninsured or includes the 40 million covered by a Medicaid system that is being gutted as we sit here, the uncounted undocumented aliens, the working poor with inadequate coverage, middle class families uninsured in the work place and/or the Medicare patients who cannot afford drugs. No informed person, however, could possibly deny that a substantial number of people are excluded from our health care system. Not only that, this exclusionary system costs a greater proportion of our gross national product than that of any other industrialized country, all of which provide greater access. And remarkably, we spend nearly the same amount of the medical care dollar on administration and profit as on providing care, suggesting strongly we could provide care for all without additional funds. Think about the disgrace of a mammoth bureaucracy that profits and provides only for itself and consumes such a large amount of the resources most people believe is being spent on patient care (39).
The failure of the field of medical ethics in the United States—and it has been a profound failure—is the resounding silence surrounding this issue (33). No matter how excellent our individual practices of cardiovascular anesthesiology, there is no way we should be able to sleep soundly at night when so many of our fellow citizens and noncitizen residents are thus deprived. For many self-interested, immoral, and ignoble reasons, organized medicine has not only tolerated this situation but also done all in its collective power to maintain the present, exclusionary system and oppose efforts to establish a system of universal access to health care (29). Our choices now are between universal health care and a third world system where the wealthy obtain world-class care and others receive progressively less.
In the late 1960s, I heard Robert Dripps, the distinguished Chairman of Anesthesiology at the University of Pennsylvania, exhort an audience of anesthesiologists to become active in opposing the Vietnamese War. I was quite disturbed at the time, feeling it was inappropriate, and, in fact, unprofessional for him to speak on a political issue at a medical meeting. It took me many years to realize it was a courageous act and one exhibiting the highest level of professionalism.
It takes no courage to speak about access to health care and allotment of health care dollars, but changing the system will take political will as well as adopting and living the concept of Civic Professionalism. What can and should each of us do? First of all, gain knowledge. Valid information will convince most physicians of the immorality of our present system and create a wish to change it for the better. If you do become convinced, get active in efforts to improve it as part of your civic responsibility as a physician. Physicians for a National Health Program is one organization which can help you learn more. You may join it if you agree with its message. But if you do become persuaded that change is needed, you must not believe it is too large a problem for you to confront. Because the system is in such distress, and because increasing numbers of middle class, employed and politically empowered people are being affected, there is hope that the political will for broad change will become available and mobilized. It is our obligation as ethical professionals to spearhead such efforts.
The Power of Individuals to Effect Change
How is it possible for an individual cardiac anesthesiologist to change systems and change the world for the better? There are numerous examples of individual physicians who have acted effectively on the broad moral basis of their Civic Professionalism. One is cardiologist Bernard Lown, who certainly would have accomplished sufficient good in his life had he merely defined the electrical curves for effective, reliable DC Defibrillation. He did not stop there, however. Together with Soviet cardiologist Yevgeny Chaznov, at the height of the Cold War, he founded International Physicians for Prevention of Nuclear War. This organization mobilized peaceful segments of society throughout the world and, incidentally, was awarded the 1985 Nobel Peace Prize. It was headquartered in a bare room above a drug store, and used sweat equity as its principal resource.
Then, there is Bernard Kouchner, a gastroenterologist and one of the founders of Medecins Sans Frontiers in the 1970s. He was minister for health in his native country of France for almost a decade in the late 1980s and 1990s. At the time he assumed the position, many residents of France were ineligible for health care; when he left, all residents of France, including illegal immigrants, were entitled to it. He never tried to hide the fact that health care is expensive but persuaded his countrymen that truly universal coverage was the only just solution. He is now working for universal health care for all residents of our planet earth! Doctors Without Borders, also, was awarded a Nobel Prize.
A third person, who is not as well known, is Nancy Oriol, an academic obstetric anesthesiologist who was a pioneer of the “walking epidural” during labor and is now Dean of Students at Harvard Medical School. Disturbed by the appalling neonatal mortality in Boston’s underserved communities, she organized and successfully raised funding for a program known as the Family Van, which has effectively introduced thousands of women, children, and men into Boston’s health care system. She did this while fulfilling her duties as Director of Obstetric Anesthesia at one of the major Harvard Teaching hospitals. Not even the necessity of undergoing open-heart surgery herself and sustaining a severe postpericardiotomy syndrome were able to stop her.
Thus, individuals do have the power to effect change (40). There are over 5,000 members of the SCA in the United States. If only a portion of us became active in confronting both of the issues I have raised, the subspecialty could indeed become an exemplar to anesthesiology and to the entire profession of medicine.
The greatest challenge to us as individuals, as professionals, as cardiovascular anesthesiologists, as members of organized medicine, as academics and practitioners is not only to provide the best possible care to those who are in the health care system but also to make certain that it is a system to which all have access, even if that were to come at some cost to us. That will be the true measure of whether we belong to a profession that has fulfilled its obligation to society.
Many individuals stimulated and/or generously provided critiques of these thoughts. They include Arthur Keats, who must surely be considered as the most contributory cardiac anesthesiologist to this date; two of my colleagues on the ASA Ethics Committee, David Waisel and Chair Steven Jackson; Patrick Sim of the Wood Library Museum; anesthesiologist-historian Eugene Hessel; two of my colleagues in the Harvard Medical School Division of Medical Ethics, Marcia Angell, the former Editor-in-Chief of the New England Journal of Medicine and Russell Gruen, a surgeon who is now a Fellow in Medical Ethics; Fred Milford, a retired physicist, and my talented wife, Diane Lowenstein.
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