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Ethical Issues in Anesthesiology and Surgery

Waisel, David B. MD

doi: 10.1213/ANE.0000000000001488
Books, Multimedia, and Meeting Reviews
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Department of Anesthesiology, Perioperative and Pain Medicine, Institution Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, david.waisel@childrens.harvard.edu

Anesthesiologists, surgeons, other physicians, nurses, and technicians confront similar ethical issues but from different perspectives. Knowing only 1 perspective (or worse, assuming that there is only 1 perspective) leads to false assumptions, ineffective communication, and suboptimal care. Dr. Jericho has wisely prioritized interdisciplinary understanding in assembling this book. The 17 chapters include contributions from anesthesiologists, surgeons, pediatricians, radiologists, lawyers, and clinical ethicists.

Ethics books written for students, nurses, residents, attending physicians, and hospital ethics committees should include (1) basic information necessary for the novice; (2) advanced concepts for the knowledgeable reader; (3) vigorous and intellectually honest treatment of alternative positions; and (4) clear instructions for applying ethical concepts to clinical practice.

All chapters include basic information, most chapters include advanced concepts, and some chapters present alternative positions with vigor. The chapters on perioperative resuscitation and on the ethics of high-risk innovative surgery present alternative views with particular grace. The chapter on conscientious objection deftly explores the range of positions held on the emotionally laden topics of abortion, torture, lethal injection, and physician aid-in-dying. Unfortunately, other chapters either do not review alternative positions or review them listlessly. If this were intended to be a how-to manual or an introductory text, it would be understandable. However, for a book that wants to be a go-to reference, I would have preferred more spirited defenses of alternative positions.

To earn a busy clinician’s time, clinical ethics must give practical tools to address dilemmas. The chapters on Jehovah’s Witnesses and on spirituality notably succeed here. The chapter on Jehovah’s Witnesses includes a diagram that explains in a stepwise manner how to approach parental refusal of potentially life-sustaining transfusion to a child. The chapter on spirituality provides resources, standardized tools, strategies, and specific phrases to explore and optimize the spiritual experience of patients, especially those who are critically ill.

In addition to the chapters mentioned, I recommend the chapters on fatigue, drug shortages, and publication and research. Categorizing spirituality, fatigue, and drug shortages as ethical issues is welcomed and should become the norm.

Chapters are well referenced, although at times, particularly when discussing patient and physician attitudes about decision-making, apology and disclosure, end-of-life care, and education, citations are dated. Attitudes have changed in part because patients have greater access to information, patients and doctors have become more comfortable prioritizing the preferences of the patient, particularly in regard to end-of-life care, and the influx of younger physicians has more closely aligned the informal curriculum with recommended practice. The recommendations in response to these older data are conventional and likely still valid, but authors should alert the reader that older data may not fully reflect current conditions.

The book takes a standard approach of using clinical case scenarios. Case scenarios are designed to hook the reader, to show clinical application, and to reinforce central points. For the most part, case presentation is at the beginning of the chapter and case resolution is at the end of the chapter. Most of the chapters do not integrate the cases throughout the discussion. Although the case presentations are useful, I suspect that the lessons would be more effective if relevant aspects of the case were weaved into the text.

Physical books have page limitations (thus the beauty of electronic books), and page allocation requires tough choices. That said, I would have liked to see a more thorough exploration of potential conflicts of interest as it relates to daily practice (although the discussion about the potential conflicts of interest brought about by drug shortages is a “must read”), business ethics from the perspectives of the individual and the organization, and Physician Orders for Life-Sustaining Treatment. Given the intimate teamwork among nurses, anesthesiologists, and surgeons, a book designed to improve understanding across disciplines should include authors from nursing and a chapter about nursing perspectives.

Readers of Ethical Issues in Anesthesiology and Surgery will develop the crucial ability to recognize ethical dilemmas and to understand that complexities underlie superficially obvious situations. This alone makes the book worth reading. It is a well-written and thorough survey, and it is a terrific book to base an introductory course in perioperative ethics. I recommend it to those who are beginning to participate in clinical ethics. Because most chapters can stand alone, this book is well suited for the episodic nature of trainee education found in academic medicine.

David B. Waisel, MDDepartment of Anesthesiology, Perioperative and PainMedicineInstitution Boston Children’s HospitalHarvard Medical SchoolBoston, Massachusettsdavid.waisel@childrens.harvard.edu

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