Susan K. Palmer, M.D., 2004 Chair
Stephen Jackson, M.D., 2003 Chair
Committee on Ethics

In addition to reviewing the ethical aspects of the ASA Standards, Guidelines and Statements, the Committee on Ethics gives welcome attention to communications received from ASA members. We will discuss four of the most common current professional concerns: 1) do not resuscitate (DNR) requests in patients requiring anesthesia services, 2) expert witness/medical reviewer qualifications and testimony, 3) preanesthesia pregnancy testing and 4) conflict-of-interest declarations for ASA speakers, officers and committee members.

DNR in the Perioperative Period
It is estimated that about 20 percent of medical patients now have written advance directives, have appointed a durable power of attorney for health care and/or have specific DNR requests. The number of patients with these legal instruments is expected to rise as patients become more sophisticated about their rights to participate in medical decision-making. Nursing home patients and others with guardians are even more likely to have DNR requests.

Before caring for a patient with DNR requests, anesthesiologists must have clearly in mind whether these requests might affect the plans for anesthetic management. Surgery and anesthesia can proceed normally if the patient or patient’s surrogate agrees to a perioperative suspension of existing DNR requests. Complete suspension of DNR orders should not be assumed because patients have the right to maintain these requests during their anesthetic and surgical care. ASA’s policy is that there should be “required reconsideration” of DNR status before any anesthetic <www.ASAhq.org/publicationsAndServices/standards/09.html>. An agreement between the anesthesiologist and the patient or patient’s surrogate — based on the patient’s values and goals — should be reached when the anesthetic is planned and then be reflected in the anesthesiologist’s record or progress notes as well as in the orders. Note that ASA has made a consent form available for such situations, and ASA members have praised its usefulness (Waisel DB. What’s new in perioperative DNR orders. ASA Newsl. 2002; 66(10):32-34).

If the existing DNR order is agreed to be suspended, a reinstatement plan should be decided upon. The American College of Surgeons used our ASA document as a template for its own similar statement on DNR-status patients; therefore, there should be no conflict with surgeons over the necessity for the reconsideration of existing DNR orders.

Surgery and anesthesia must be abandoned or modified when a patient’s DNR requests are not compatible with good anesthetic care; for example, requesting to proceed with thoracic surgery or abdominal adhesiolysis without an endotracheal tube. When DNR requests cannot be honored because of an anesthesiologist’s closely held moral beliefs, a substitute anesthesiologist should be sought. This is similar to other situations when anesthesiologists have professional limitations or moral objections to requested nonemergency care.

Expert Witness/Medical Reviewer Conduct
The Committee on Ethics believes that an anesthesiologist who serves as an expert witness in medical malpractice litigation is obliged to educate the jury/judge by providing accurate and dispassionate testimony. That testimony should be honest, unbiased and reflective of scientifically supported data and professional standards of care that are relevant to the medical practice and judgments in dispute. The committee is recommending an addition to the “Guidelines for the Ethical Practice of Anesthesiology” <www.ASAhq.org/publicationsAndServices/standards/10.html>, which makes it unequivocal that ASA members acting as legal witnesses must follow the ASA’s “Guidelines for Expert Witness Qualifications and Testimony” <www.ASAhq.org/publicationsAndServices/standards/07.html>. Because all ASA members are bound to adhere to ASA’s ethical guidelines, a member acting as an expert witness whose behavior does not conform to the guidelines could, in the future, be disciplined or denied ASA membership.

Expert witnesses and medical reviewers are obligated to be practicing anesthesiologists familiar with the medical issues and willing to submit their testimony for peer review. Legal testimony must serve the best interests of the public and the medical profession and not be influenced by financial pressure (such as contingency fees). Physicians must maintain honesty as a valued medical ethic and not adopt the legal profession’s practice of client-advocacy regardless of medical merit.

Preanesthetic Pregnancy Testing
Members of the Committee on Ethics and the Committee on Practice Parameters were appointed to a joint task force to resolve differences of opinion regarding testing for early pregnancy. The Committee on Ethics maintains that a blanket policy of nonconsented testing for pregnancy cannot be ethically justified. This opinion is fortified by the fact that there are no scientific data to support that any anesthetic drug can harm an early human pregnancy.

State of pregnancy is very personal information that belongs to the patient, and it does not alter her right to proceed with anesthesia and surgery if she so desires. Therefore, pregnancy testing should be offered to patients but should not be required by physicians unless there is a compelling medical reason to know whether the patient is pregnant. Beyond not being ethical, it also may not be legal to test a patient for pregnancy without her consent. Minors are even more complex in this regard because states have disparate statutes defining whether parents are entitled to the results of their minor child’s pregnancy testing.

The joint task force has recommended that the Practice Advisory for Preanesthesia Evaluation be amended to reflect the above concerns. Blanket policies to test for (and bill) patients for nonconsented pregnancy testing in an effort to “protect” anesthesiologists from future legal claims are not ethically, scientifically or legally supportable.

Conflicts of Interest for ASA Speakers, Officers and Committee Members
Apparent and real conflicts of interest are a fact of daily life. Conflicts cannot be eliminated, so they must be systematically managed. ASA members have a right to know whether invited speakers have competing interests regarding the subject of their presentation. Listeners can then make up their own minds regarding the veracity or completeness of information presented to them. The Committee on Ethics has recommended stronger wording for the current speakers/officers/committee members’ conflict of interest statement. We also recommended that both oral and written information be presented at Annual Meeting programs rather than the current practice of a generic indication in the program book.

ASA officers and appointees have an obligation to separate their own opinions from the appearance of “speaking for” ASA. Officials within ASA should not imply that their opinions are anything more than personal ones.

All ASA Standards, Guidelines, Statements and Practice Parameters can be found on the ASA Web site at <www.ASAhq.org> or obtained from ASA Executive Office in Park Ridge, Illinois.

Susan K. Palmer, M.D., is Chair, Department of Anesthesiology, Providence Milwaukie Hospital, Milwaukie, Oregon.

Stephen H. Jackson, M.D., is Staff Anesthesiologist and Chair of the Bioethics Committee at Good Samaritan Hospital, San Jose, California.