This document outlines key concepts in medical ethics, including: - Defining ethics as the study of concepts like right and wrong, and medical ethics as applying ethics to medicine. - Medical ethics aims to provide care for maximum patient benefit and according to basic principles. - Medical ethics can differ between countries and changes over time in response to scientific/social changes. - Individual healthcare professionals must make ethical decisions and are responsible for implementing ethical solutions.

2. Objectives
At the end of this course you should be able to;
Explain concepts of ethics and professional ethics
Analyze medical ethics and law
Describe the basic principles of ethics
Explain role of ethics in medical research
Avoid malpractice and negligence
Discuss about informed consent
Analyze the importance of anesthetic record
Differentiate hazards of Anesthesia
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3. SOME DEFINITIONS
• Ethics – is simply the philosophical study of such concepts as
Right and Wrong, Good and Bad, Rights and Duties.
• Moral philosophy is equivalent to Ethics, but takes a Latin root of
the word rather than a Greek one.
• Applied Ethics is the application of Ethical theory to practical
problems such as (for instance) Animal Rights, Environmental
Issues, Legal issues.
• Medical Ethics is a large sub-group of Applied Ethics.
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4. Definition…
• Meta-ethics is the consideration of basic questions about the
underpinning of Ethics – questions like “Is there an Absolute Right
or Wrong?”, and “Does Right and Wrong depend purely on
individuals opinions?”
• Medical Law – is the division of Law devoted to issues of Medical
importance – such as Negligence, Consent, Confidentiality, End of
Life Decisions. Medical law is often underpinned by Medical
Ethics, but can often diverge quite markedly from ethical principles
and can be quite pragmatic.
• Common law is the law derived from Judge made decisions.
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5. What is ethics?
• Is the study of moral principles governing or influencing
conduct(right and wrong).
• Is the branch of knowledge concerned with moral principles.
• Is the standard that govern the conduct of a person, especially a
member of a profession.
• is the value dimension of human decision making and
behavior which includes rights, responsibilities and virtues and
also good and bad.
• Morality is study of moral standards and how they affect conduct.
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6. Why study ethics?
• The study of ethics is important to prepare learners to recognize
difficult situations and to deal with them in rational and
principled manner.
To function at the highest professional level
To avoid legal problems
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7. What is Professional Ethics?
• Professional ethics is the personal and corporate standards of
behavior expected of the members of a particular profession.
• Many professions that are trusted by the public to apply expert
knowledge (doctors, engineers, surveyors, accountants and the
like) have a Code of ethics which sets out their expectations of a
member’s behavior and the boundaries within which members
have to operate.
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8. What is professional ethics?...
• A Code of ethics( a document created to set the standards for
ethically acceptable behavior) helps to clarify the profession’s
values provides a reference point for decision making and can be
used as a framework for discipline.
• Most Codes of ethics are principles based, providing guidance as to
the principles on which professional judgments and decisions
should be based, rather than a rigid system of rules.
• Professional ethics concerns one's conduct of behavior and practice
when carrying out professional work.
• System of conduct to guide the practice of a specific discipline.
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9. Medical Ethics
is the application of ethics to the practice of
medicine.
• Is the study of how a health professional might provide medical
care to the best of their ability and for the maximum benefit of their
patients or society.
• Medical ethics is a system of moral principles that apply values and
judgments to the practice of medicine.
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10. Medical ethics and law
• Medical ethics is closely related to law.
• In most countries there are laws that specify how HPs are required
to deal with ethical issues in patient care and research.
• In addition the medical licensing and regulatory officials in each
country can do and punish HPs for ethical violations.
• But ethics and law are not identical.
• Ethics describes higher standards of behavior than does the law
and occasionally ethics requires that physicians disobey laws that
demand unethical behavior.
• Moreover laws differ significantly from one country to another
while ethics is applicable across national boundaries.
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11. Who decides what is ethical?
• The answer to the question, “who decides what is ethical for people
in general?” therefore varies from one society to another and even
within the same society.
• In liberal societies, individuals have greater deal of freedom to
decide for themselves what is ethical although they will likely be
influenced by their families, friends, religion ,media and other
external sources. .
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12. Who decides what is ethical?...
• In more traditional societies, family and clan elders, religious
authorities and political leader have greater role than individuals in
determining what is ethical.
• Despite these differences, it seems that most human beings can
agree on some fundamental ethical principles, namely, the basic
human rights proclaimed in the United Nations Universal
Declaration of Human Rights and other widely accepted and
officially endorsed documents.
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13. Who decides what is ethical?...
The human rights that are especially important for medical ethics
include:
all human beings are born free and equal in dignity and rights
Right to life
Right to freedom from discrimination, torture and cruel inhuman or
degrading treatment
Right to medical care
Right to freedom of opinion and expression to equal access to
public service in one’s country, and to medical care.
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14. Who decides what is ethical for HPs?
• In many not most, countries medical association have been
responsible for developing and enforcing the applicable ethical
standard.
• Depending on the countries approach medical law, these standards
may have legal status.
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15. Who decides what is ethical for HPs?...
• The ethical directives of medical association are greater in nature
they can't deal with every situation that HPs might face in their
medical practice.
• In most situations HPs have to decide to themselves what is right
way to act, but in making decision it is helpful to know what other
HPs would do in similar situation.
• Medical code of ethics and policy statements reflect a general
consensus about the way HPs act and they should be followed
unless there are good reasons for acting other wise.
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16. Does medical ethics change?
• There can be little doubt that some aspects of medical ethics
have changed over the years.
• Until recently physicians had the right and the duty to decide
how patients should be treated and there was no obligation to
obtain the patient’s informed consent.
• In contrast, the 2005 version of the WMA Declaration on the
Rights of the Patient begins with this statement:
• “The relationship between HPs, their patients and broader
society has undergone significant changes in recent times.
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17. Does medical ethics change?...
• While a physician should always act according to his/her
conscience, and always in the best interests of the patient, equal
effort must be made to guarantee patient autonomy and justice.”
• Until recently, physicians generally considered themselves
accountable only to themselves, to their colleagues in the medical
profession and, for religious believers, to God.
• Nowadays, they have additional accountabilities to their patients,
to third parties such as hospitals and managed healthcare
organizations, to medical licensing and regulatory authorities, and
often to courts of law.
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18. Does medical ethics change?...
• Medical ethics has changed in other ways.
• Participation in abortion was forbidden in medical code of ethics
but now it is legalized in many countries including Ethiopia.
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19. Does medical ethics differ from one country to
another?
• Just as medical ethics change over time in response to development
in medical science and technology as well as in societal values so
does differ country to country depending on these some factors;
• On euthanasia, for example, there is a significant difference of
opinion among national medical associations.
• Some condemn it while others like Royal Duch Medical
Association and some USA states support it.
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20. Cont…
• Physicians in some countries are confident that they will not be
forced by their government to do any thing to do unethical while in
other countries it may be difficult for them to meet their ethical
obligation.
• Most other issues are similar so the similarities are more than the
differences.
• The fundamental values of medical ethics such as compassion
,competence and autonomy along with physician experience and
skills in all aspects of medicine and health care provide a sound
basis for analyzing ethical issues in medicine and arriving at
solutions that are in the best interests of individual patients and
citizens and public health in general.
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21. How do individuals decide what is ethical?
• Many ethical issues arise in medical practice for which there is no
guidance from medical associations.
• Individuals are ultimately responsible for making their own ethical
decisions and for implementing them.
• Rational and non-rational
• It is important to note that non-rational doesn’t mean irrational
simply that it is to be distinguished from the systematic reflective
use of reason in decision making.
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22. Non-rational approaches
• Obedience
• Imitation
• Feeling or desire
• Intuition
• habit
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23. 1. Obedience
• Common way of making ethical decision.
• By those who work within authoritarian structures (e.g. the
military,police,some religious organizations and many
businesses).
• Morality consists in following the rules and instructions of those
in authority whether or not agree with them.
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24. 2 . Imitation
• is similar to obedience in that it subordinates one’s judgment
about right and wrong to that of another person, in this case, a
role model.
• Morality consists in following examples of the role model.
• Most common way of learning medical ethics by aspiring
physicians with the role models being the senior consultants.
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25. 3.Feeling or desire
• Subjective approach to moral decision making behavior.
• What Is right is what feels right satisfies one’s desire.
• What is wrong is what feels wrong frustrates one’s desire.
• The measure of morality is to be found within each individuals
and can vary individuals to individuals and even within the
some individual over time.
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26. 4.Intuition
• An immediate perception of the right way to act in situations.
• It is similar to desire in that it is entirely subjective, how ever it
differs because its location is in the mind than the will.
• It is neither systematic nor reflexive but directs moral decisions
through a simple flash of insight,
• Like feeling and desire, it can vary greatly from one individual
to an other and the some individual over time
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27. 5.Habit
• Is a very efficient method of moral decision making since there is
no need to repeat a systematic decision making process each time
a moral issue arises similar to one that has been dealt with
previously.
• However there are bad habits e.g. lying as well as good ones truth
telling.
• Moreover situations that appear similar may require significantly
different decisions.
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28. Rational approaches
• Deontology
• Consequentialism
• Principlism
• Virtue ethics
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30. 1.Deontology
• Involves a search for well founded rules that can serve as the
basis for moral decisions.
• An example of such rule is treat all people as equal, its foundation
may religious or non religious.
• Once the rules are established, they have to be applied in specific
situations and there is often room for disagreement about what the
rules require.
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31. 2.Consequentialism
• Bases ethical decision making on analysis of the likely
consequences or out come of different choices and actions.
• The end justifies the means.
• The right action is the one that produces the best outcomes.
• Decision making includes cost effectiveness and quality of life.
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32. 3.Principlism
• Ethical principles are the basis of making moral decision .
• It applies in particular cases or situations in order to determine
what is right to do taking in account both rules and
consequences.
• Four principles in particular; respect for
autonomy,beneficence,nonmaleficence and justice have been
identified as the most important for ethical decision making in
medical practice.
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33. 4.Virtue ethics
Focuses less on decision making and more on the character of
decision makers as reflected in their behavior.
 A virtue is a type of moral excellence.
Virtue is especially important for physicians to be
compassionate.
Other importance includes honest, prudence and dedication.
Physicians who possess these virtues are more likely to make
good decisions and to implement them in a good way.
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34. Virtue ethics…
Virtues;
Compassion
Honesty
Prudence-knowing how to avoid embarrassment/distress
Dedication
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35. CONT…
• Consequentialism and Deontology contrasted
• The table below gives examples of practical ethical issues and
contrasts Consequentialism and Deontology. Some situations seem
to require a Consequentialist approach, and some seem to require a
Deontological approach.
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36. CONT…
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37. Basic principles of medical ethics
• There are four basic principles of medical ethics.
• Each addresses a value that arises in interactions b/n providers
and patients.
• These are;
Autonomy/respect for persons
Beneficence
Non Maleficence
Justice
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38. 1.Respect for persons/autonomy
• People should have control over their lives as much as possible because
they are the only people who completely understand their chosen type of
lifestyle.
• People have the right to control what happens to their bodies.
• This principle simply means that an informed, competent adult patient
can refuse or accept treatments, drugs, and surgeries according to their
wishes.
• Respecting the decision making ability of autonomous persons;
tell the truth
respect patients decisions
protect confidential information
obtain consent for interventions
help others make decisions when asked
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39. Respect for persons/autonomy…
• Autonomous persons
• Autonomous choices
Autonomy includes;
 Freedom of will
 Freedom of action
 Free to choose and act
• Privacy and confidentiality
• Promotes informed consent
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40. Autonomy in Research
• Voluntary participation
• Adequate information to make informed consent
• Comprehension
• Full disclosure of risks and benefits
• No undue inducement
• Voluntary termination
• Continuing disclosure
• Legally authorized representative
• Culturally appropriate consent
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41. 2.Beneficence
• Acts of kindness or charity that go beyond strict obligation.
• Guides health professionals to do good for patients to act
always in the patients best interests.
• All healthcare providers must strive to improve their patient’s
health, to do the most good for the patient in every situation.
• Common definition – acts of kindness or charity that go beyond
strict obligation
• To do good
• Prevent evil or harm
• Ought to remove evil or harm
• Endeavor to benefit where possible
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42. Beneficence…
• In health care; an obligation to improve health
• In research; Maximize benefits and minimize risks of possible
harms
• Balance risks and benefits
• Promotes risk benefit analysis, post trial benefits etc…
• Provide benefits and balance benefits against risks and harm
• Protect and defend the rights of others
• Prevent harm to others
• Remove conditions that will cause others harm
• Help disabled persons
• Rescue persons in danger
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43. 3.Nonmaleficence
• The concept of non-maleficence is embodied by the phrase, "first, do no
harm,". Many consider that should be the main or primary consideration
that is more important not to harm your patient, than to do them good.
• In every situation, healthcare providers should avoid causing harm to their
patients.
• Nonmaleficene is a similar concept to the principle of beneficence but
deals with situations in which none of the outcomes of a treatment are
likely to benefit the patient.
• In this case, the HP should strive to do the list harm to the fewest people.
• The decision making is left to the HP, rather than the patient or others.
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44. Non-maleficence…
• Avoidance of the causation of harm
• Do not kill
• Do not cause pain or suffering to others
• Do not incapacitate others
• Do not cause offense to others
• Do not deprive others of the goods of life
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45. 4.Justice
• The principle of justice demands that HPs treat patients fairly.
• Similar patients with similar illnesses should receive similar
treatments.
• Equal treatment – Different treatment requires justification
(experience, age, deprivation, competence, merit, position, etc.)
• What is deserved – People should be treated fairly, and should be
given what they deserve in the sense of what they have earned.
• Promotes issues on subject selections, what is owed them, how
they are treated during and after research.
• Fair distribution
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46. Justice..
• Distribute benefits, risks, and costs fairly
• To each an equal share
• To each according to effort
• To each according to need
• To each according to contribution
• To each according to merit
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47. SUMMERYIN TABLE
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48. Research and Ethics
• Introduction
• Medicine is not an exact science. It does have many general
principles that are valid most of the time, but every patient is
different and what is an effective treatment for 90% of the
population may not work for the other 10%.
• Thus, medicine is inherently experimental.
• Even the most widely accepted treatments need to be monitored
and evaluated to determine whether they are effective for specific
patients and, for that matter, for patients in general.
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49. Introduction….
• All interventional medical treatments has resulted from research.
• The development of new treatments, especially drugs, medical
devices and surgical techniques are also the results of medical
researches.
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50. Historical ease of unethical research
• In the first century BC Cleopatra was reputed to have had a number
of her handmaidens impregnated and subsequently operated upon
at certain times of gestation.
• In 1932,the Japanese subjected tens of thousands of captured
Chinese subjects to a number of horrifying experiments ,some of
which involved live vivisection.
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51. Unethical…
• The Tuskegee syphilis study(1932); Was a 40 year project
administered by the US public health service .
• The government promised 400 men free treatment for bad blood
which had become an epidemic in the country.
• The study sample was made up of poor African and American men
who were told that they had “bad blood".
• They did not receive standard treatment for syphilis even when
penicillin was available later during the study.
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52. Unethical…
• The willow Brook study; This study involved a group of children
diagnosed with mental retardation ,who lived at the willow Brook
state hospital in New York .
• These innocent children were deliberately infected with hepatitis
virus ;early subjects were fed extracts of stools from infected
individuals and later subjects received injections of more purified
virus preparations.
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53. Unethical…
• The tragic history of research abuse by Nazi doctors during
World War II on Jews, gypsies and political prisoners.
• Nazi doctors’ trials for medical experiments conducted among
civilians and allied forces under the custody of the German
Reich without subjects consent committed murders, brutalities,
cruelties, tortures, atrocities and other inhuman acts.
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54. Unethical…
• Nazi medical experiments
• High altitude experiments – conducted in low pressure chambers
that approximate pressure at extremely high altitudes.
• Freezing experiments – subjects remained in ice tanks for 3 hours,
severely chilled and rewarmed.
• Malaria experiments – infected healthy humans with infected
mosquitoes.
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55. • “Permissible medical experiment”
• Nuremberg Code
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56. Nuremberg code
• The Nuremberg code was the first set of basic principles that must
be observed in order to satisfy moral, ethical and legal concepts in
conduct of human participants in research.
• The main points included the statement that:
• That animal experimentation should precede human
experimentation.
• “Voluntary consent of the human subject is absolutely essential.“
• All unnecessary physical and mental suffering and injury should be
avoided;
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57. Nuremberg code…
• The degree of risk to participants should never exceed the
humanitarian importance of the problem and should be minimized
through proper preparations and
• That participants should always be at liberty to withdraw from
experiments.
• The Code has been the model for many professional and
governmental codes since the 1950s and has, in effect, served as
the first international standard for the conduct of research.
• The Nuremberg code was supplemented by the declaration of
Helsinki in 1964.
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58. Declaration of Helsinki
• Originally adopted 1964. was developed by the World Medical
Association for use by the medical community following
dissemination of the Nuremberg Code.
• 1st significant attempt by the medical community to regulate itself.
• Like the Nuremberg Code, the Declaration made Informed consent
a central requirement for ethical research while allowing for
surrogate consent when the research participant is incompetent,
physically or mentally incapable of giving consent, or a minor
• Who are incompetent groups?
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59. Declaration of Helsinki…
• The Declaration also states that research with these groups should
be conducted only when the research is necessary to promote the
health of the population represented and when this research cannot
be performed on legally competent persons.
• It further states that when the subject is legally incompetent but
able to give assent to decisions about participation in research,
assent must be obtained in addition to the consent of the legally
authorized representative.
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60. Declaration of Helsinki…
• The well being and interests of research participants must always
prevail over interests of science and society. (code 5)
• It is the duty of the medical professional to protect the life, privacy
and dignity of the human subject. (Code 10)
• Research must be reviewed by an independent committee (IRB)
before it is conducted. (code 13).
• The subjects must be volunteers and informed participants in the
research project. (code 20).
• Placebo acceptable only “where no proven prophylactic, diagnostic
or therapeutic method exists”.(code 29).
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61. CIOMS Guidelines
• The Council for International Organizations of Medical Sciences
(CIOMS) is an international, NGO, not for profit organization
established jointly by WHO and UNESCO in 1949.
• CIOMS serves the scientific interests of the international
biomedical community in general and has been active in
promulgating guidelines for the ethical conduct of research, among
other activities.
• CIOMS promulgated guidelines in 1993 entitled International
Ethical Guidelines for Biomedical Research Involving Human
Subjects.
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62. CIOMS Guidelines …
• The 15 guidelines address issues including informed consent,
standards for external review, recruitment of participants, and
more.
• The Guidelines are general instructions and principles of ethical
biomedical research.
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63. Research in medical practice
• All HPs make use of the results of medical research in their clinical
practice.
• To maintain their competence, HPs must keep up with the current
research in their area of practice through continuing medical
education/continuing professional development programs, medical
journals and interaction with knowledgeable colleagues.
• Even if they do not engage in research themselves, HPs must know
how to interpret the results of research and apply them to their
patients.
• The most common method of research for practicing HPs is the
clinical trial.
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64. Research in medical practice…
• Before a new drug can be approved by government mandated
regulatory authorities, it must undergo extensive testing for safety
and efficacy.
• The process begins with laboratory studies followed by testing on
animals.
• If this proves promising the four phases of clinical research, are
next:
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65. Research in medical practice…
• usually conducted on a relatively small number of healthy
volunteers, who are often paid for their participation, is intended to
determine what dosage of the drug is required to produce a
response in the human body, how the body processes the drug, and
whether the drug produces toxic or harmful effects.
•
• is conducted on a group of patients who have the disease that the
drug is intended to treat.
• Its goals are to determine whether the drug has any beneficial
effect on the disease and has any harmful side effects.
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66. Research in medical practice…
• ,
• is the clinical trial, in which the drug is administered to a large
number of patients and compared to another drug.
• , takes place after the drug is licensed and
marketed.
• For the first few years, a new drug is monitored for side effects
that did not show up in the earlier phases.
• the pharmaceutical company is usually interested in how well the
drug is being received by HPs who prescribe it and patients who
take it.
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67. Ethically acceptable research
• An ethically accepted research is conducted under the major ethical
principles.
• 1.respect for autonomy
• The involvement competent patients in research should be entirely of
their own violation.
• Participants are of free to withdraw their consent at any time and any
reason.
The three recognized components of consent are of fundamental
importance;
Voluntariness;
the study subjects participation must be entirely based on their wish.
Information;
subjects should be informed;
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68. Ethically accepted research…
What is involved in taking part
Why the research is being done
What the risks might be the subject
What the consequences of these risks might be
Competence
Is the subject competent enough to give consent
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69. International guidelines
• “Every precaution should be taken to respect the privacy of the
subject, the confidentiality of the patient’s information, and to
minimize the impact of the study on the subject’s mental integrity…
and personality…” (Helsinki, 2000)
• The investigator must establish secure safeguards of the
confidentiality of subjects research data.
• Subjects should be told the limits, legal or other, to the investigator’s
ability to safeguard confidentiality and the possible consequences of
breaches of confidentiality” (CIOMS, 2002)
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70. Medical malpractice
• Medical malpractice is improper, illegal or negligent professional
procedure or treatment in the health care service.
• Negligence is the most common medical malpractice.
• Medical negligence is a failure to give proper care over patients.
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71. Negligence
• “Negligence is one type of tort (a wrongfull act) and malpractice
is one type of negligence”
• There are four elements to negligence.
• They include:
• duty,
• breach,
• injury, and
• damages.
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72. Negligence…
• When the patient is seen preoperatively, and the anesthetist agrees
to provide anesthesia care for the patient, a duty to the patient has
been established.
• the duty the anesthetist owes to the patient is to adhere to the
standard of care for the treatment of the patient.
• So once a HPs/patient relationship has been established, the HPs
now owes the patient a certain duty of care.
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73. Negligence…
•
• After this duty of care has been established, the HPs is required to
exercise reasonable care and treat the patient as would other HPs in
his field, following procedures and actions accepted by his peers.
• In a malpractice action, expert witnesses will review the medical
records of the case and determine whether the anesthetist acted in a
reasonable and prudent manner in the specific situation and fulfilled
his or her duty to the patient.
• If they find that the anesthetist either did something that should not
have been done or failed to do something that should have been done,
then the duty to adhere to the standard of care has been breached.
• Therefore, the second requirement for a successful suit will have been
met.
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74. Negligence…
• the breach of duty may lead to the proximate cause of the injury.
• If the odds are better than even that the breach of duty led, however
circuitously, to the injury, this requirement is met.
•
• The victim must suffer damages, economic or non-economic, as a
result of the injury.
• three different types of damages.
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75. Negligence…
• General damages are those such as pain and suffering that directly
result from the injury.
• Special damages are those actual damages that are a consequence
of the injury, such as medical expenses, lost income, and funeral
expenses.
• Punitive damages are intended to punish the physician for
negligence that was reckless, wanton, fraudulent, or willful.
• Punitive damages are exceedingly rare in medical malpractice
cases. More likely in the case of gross negligence is a loss of the
license to practice anesthesia.
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76.  Informed consent is the process by which the treating health care
provider discloses appropriate information to a competent patient so
that the patient may make a voluntary choice to accept or refuse
treatment.
Consent is based on the ethical principle of respect for persons.
Acknowledge the person’s autonomy
Protect those with diminished autonomy
• Is permission to do something.
• In medicine, consent allows an autonomous patient to define and
protect his or her own interests and to control bodily privacy.
• Autonomous individuals are considered as the best judges of their
own best interests.
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77. Consent…
• The most important goal of informed consent is that the patient has
an opportunity to be an informed participant in the health care
decisions.
• Decisions are made on the basis of a current understanding of the
facts presented when evaluated in a logical manner ,with some
insight shown in to the likely consequences of the decision.
12/2/2019 ETHICS 77

78. 3 Components

Specific items for disclosure

 Adapt the presentation to the subject’s needs

No threat of harm (coercion) AND no improper reward (undue
influence)
12/2/2019 ETHICS 78

79. Informed consent
Protection from harm
would protect patient from an “unwise choice”
Protection of autonomy
demands:
full disclosure
comprehension
voluntary
competence to consent
12/2/2019 ETHICS 79

80. Competence
In the context of this decision
Standards of competence
decision based on rational reasons
decision leads to reasonable result
capacity to make a decision
• Competence judgments are “value laden” / weighed down
12/2/2019 ETHICS 80

81. Comprehension of information
• Comprehension-understanding the meaning of the information
• Acceptance-believing that the information is true for them.
• Appreciation-apply the information in a way that fosters
understanding of how they will feel.
12/2/2019 ETHICS 81

82. Voluntariness
• Disclosure of alternate choices.
• Influential vs.controlling inducements (influenced by
circumstances)
Coercion : - threat
Indoctrination :- repeated instruction
manipulation
seduction
rational persuasion : - reasoning
12/2/2019 ETHICS 82

83. Incompetents
• Patients competency can be affected either by age or medical
condition.
Children
16 and 17 year old children presumed to be competent to give
consent for any treatment that would otherwise constitute a
battery on them.
Children under age of 16 are presumed to be incompetent to
consent and to treatment.
12/2/2019 ETHICS 83

84. Incompetents…
•
• Mental illness may impair a patients capacity to provide valid
consent or refusal for an anesthetic intervention.
•
• Those with the greatest depth of faith refuse blood(blood product)
transfusion, even if this lead to personal harm or death, believing
that to receive transfusion will result in their eternal damnation.
12/2/2019 ETHICS 84

85. Incompetents…
• If the patient is determined to be incapacitated/incompetent to
make health care decisions, a surrogate decision maker must speak
for her.
• There is a specific hierarchy of appropriate decision makers
defined by state law.
• If no appropriate surrogate decision maker is available, the
physicians are expected to act in the best interest of the patient
until a surrogate is found or appointed.
12/2/2019 ETHICS 85

86. Incompetents…
• In rare circumstances, when no surrogate can be identified, a
guardian may have to be appointed by the court.
• The patient's consent should only be presumed rather than obtained,
in emergency situations when the patient is unconscious or
incompetent and no surrogate decision maker is available, and the
emergency interventions will prevent death or disability.
12/2/2019 ETHICS 86

87. Waiving Consent
Minimal risk studies without procedures that require consent.
Waiving consent must not adversely affect subjects rights and
welfare
Telephone surveys
Interviews
Medical record review
12/2/2019 ETHICS 87

88. Waiving Documentation of Consent
• Minimal risk studies without procedures that require consent
• When the only link to the subject is the consent document and
that link may pose risk of breach of confidentiality.
• E.g. Medical record review
12/2/2019 ETHICS 88

89. Protection of Vulnerable Subjects
• Vulnerable and Less Advantaged Persons;
• Persons who are absolutely or relatively incapable of protecting
their interests.
• Insufficient power, intelligence, resources, strength or other needed
attributes to protect their own interests through informed consent.
• Each person when measured against the highest standards of
capability is relatively vulnerable
12/2/2019 ETHICS 89

90. Involvement of Vulnerable Subjects
• “The proposed involvement of hospitalized patients, other
institutionalized persons, or disproportionate numbers of
racial or ethnic minorities or persons of low socioeconomic
status should be justified.”
• US National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research: Institutional Review
Boards: Report and Recommendation, 1978
12/2/2019 ETHICS 90

91. Special Populations
• Fetuses, pregnant women and human in vitro fertilization
• Prisoners
• Children
12/2/2019 ETHICS 91

92. Why the anesthetists are liable for law suit ?
• Liable= legally responsible
• Suit=a process by which a court of law makes a decision to
settle a disagreement.
ANSWER
Unrealistic expectation
Poor rapport and poor
communication
Greed and or litigious
society
Poor quality of care
12/2/2019 ETHICS 92

93. why do we study ethics and law
To function at the highest professional level
To avoid legal problems
 Patient injury
 Communication gap
 minimum standard not fulfilled
 Absence of License
 Manipulating and mocked records
 Not taking informed consent
 Delayed referral
 Absence from working area
 Confidentiality
 Not admitting mistakes (Apology
12/2/2019 ETHICS 93

94. Anesthetic record
• It is of little benefit in legal terms to have delivered good
anesthesia care if it is impossible to identify each component of an
anesthetic agent and when it was performed.
• The record may have to be defended years after the case was
completed, and case has been forgotten.
• A general rule “if it was not written it was not done”
When an incident occurs
Facts should be documented
Avoid using terms such as inadvertently that convey message of
guilt or negligence
Simply record the relavant facts about the incident like
auscultatory findings, spinal level of somatic block
12/2/2019 ETHICS 94

95. When an incident occurs
• Facts should be documented
• Avoid using terms such as inadvertently that convey message of
guilt or negligence
• Simply record the relavant facts about the incident like
auscultatory findings, spinal level of somatic block
• A frequent complaint is that there is no time to write notes while
responding to a emergency situation
• The solution is to write a perioperative note as soon as possible
making reference to the approximate times of the events
• such records are invaluable in distinguishing b/n a known
complication and actual negligence
12/2/2019 ETHICS 95

96. Respond appropriately an incident occurs
• The anesthetist should continue to maintain professional contact
with the patient during hospitalization after any incident that might
be related to anesthesia.
• Failure to do so might be interpret as a rejecting the patient.
12/2/2019 ETHICS 96

97. Recognize malpractice prodromes
• Receiving letters from a previous patient
• Getting request for medical record from attorneys.
• Response should not be hostile & goals are to explain why there is
no liability for the claim to reduce the chance of a lawsuit being
filed.
• Direct correspondence with the patient should be kept to a
minimum.
• Best to work through the insurer or attorney.
12/2/2019 ETHICS 97

98. Avoid vicarious liability
• If anesthetist supervising anyone who is incompetent, supervision
must be very close such as double checking preoperative findings,
being present in the operating room during the entire case.
• Do not agree to supervise more simultaneous cases than you can
safely handle.
• Issues of inadequate supervision and pt abandonment are hard to
defend.
12/2/2019 ETHICS 98

99. Notification of a lawsuit
• An anesthetist may receive a notice of intent to sue within a
specified period of time or may receive a summons.
• There is finite period of time for a response to the summons and an
assistance of an attorneys will be required.
• Failure to respond within time will result in a directed decision for
the plaintiff.
• Anesthetist should avoid from discussing the case with anyone
other than the attorney, as certain statements may be discoverable
and used by the plaintiff during the trial.
12/2/2019 ETHICS 99

100. CONT…
• Access to the patient’s medical records is
• permissible, but the temptation to add
• notes must be avoided.
• plaintiff’s attorney has already obtained
• a copy of the medical record, and any
• alteration after the notification of a
• lawsuit will be introduced as evidence of
• negligence.
12/2/2019 ETHICS 100

101. Discovery
• After the complaint is answered, both sides begin the process knows
as ‘discovery’.
• The purpose of discovery is to ascertain the “facts” of the case in
preparation for trial.
• It is the responsibility of the jury to decide which facts to believe.
• So juries are, for this reason ,called “triers of fact”
• A strength is a fact that is favorable and a weakness is a fact that is
unfavorable.
• The Medical record is the primary (FIRST) source of the facts.
• A trier of the fact will believe what is written before believing what
is said.
• The notes were completed before any adverse outcome was known,
so records are trusted.
12/2/2019 ETHICS 101

102. CONT…
• Second source of facts is the testimony of those who witnessed the
event
• Anesthetist may testify that something that was not recorded was
done or seen.
• It is not as believable as medical records because it relies upon
specific recall of events that may have happened in the remote past.
• Third source of facts is the usual practice pattern of the anesthetist.
• If anesthetist has done something it must be because that is part of
a routine.
12/2/2019 ETHICS 102

103. CONT…
• Fourth source of the fact
• It is the expert witness testimony.
• Expert are necessary because the subject of medicine is held to
be beyond the knowledge or understanding of lay jurors.
• Expert will review entire medical record
12/2/2019 ETHICS 103

104. Order of credibility
• 1) The anesthesia record and notes
• 2) The expert’s interpretation
• 3) Specific recall
• 4) Usual and customary practice
12/2/2019 ETHICS 104

105. Deposition testimony
• The defendant anesthetist testimony is conducted by the plaintiff’s
attorney.
• The plaintiff attorney will attempt to uncover facts favorable to the
plaintiff to ascertain the defense position on the issues in question.
• Prior to the deposition, the defense attorney should meet the
anesthetist to explain the conduct of the procedure, what to bring.
12/2/2019 ETHICS 105

106. CONT…
• There will be a series of questions .
• There is need to speak slowly and clearly, understanding the
questions, and waiting until the question is fully asked before
answering .
• Answer should be brief and to the point.
• It helps to have a familiar with the dates of training, licence, and
certifications.
12/2/2019 ETHICS 106

107. Expert witness
• Courts demand that witnesses be called so that the jury can benefit
from the expertise and opinions of uninvolved parties.
• Witnesses who are allowed to give opinions are called expert
witness.
12/2/2019 ETHICS 107

108. Malpractice suit
To be successful in malpractice suit four elements must be proved
by plain tiff attorney
Duty –the anesthetist owed him or her a duty
Breach of duty-anesthetist failed to fulfill his or her duty
Causation-close causal relation ship exists between the acts of the
anesthetist and the resultant injury
Damages –the actual damages resulted because of the acts of the
anesthetist.
12/2/2019 ETHICS 108

109. Why anesthetists are sued ?
Unrealistic expectations
Poor rapport and poor communication
Greed and or litigious society
Poor quality of care
What to do when sued ?
Specific actions
Don't discuss the case with any one
Never alter any records
Gather together all pertinent records
Make notes recalling all events
Cooperate fully with the attorney provided by the insurer or other
bodies.
12/2/2019 ETHICS 109

110. The Do’s
• Review record
• Analyze the case
• Look for other relevant documents
• Review literature
• Identify experts in the field
• Make a list of fact witness
• Educate your attorney
• The Don’ts
• Don’t discuss the case with any one
• Don’t change the records
• Don’t accept any calls from other attorneys or patient or
family members
• Don’t talk to media
12/2/2019 ETHICS 110

111. • Euthanasia - is the intentional bringing about of the death of a
patient (by killing or allowing to die) where this is done for the
patient's own sake.
• Note the three parts to the definition
• Intentional
• Killing or allowing to die
• Done for the patient's sake
• Active Euthanasia - is taking of some action in order to cause
death, for the patient's own sake
• Passive Euthanasia - is omitting to take some action which
would prevent or avert death, for the patient's own sake
12/2/2019 ETHICS 111

112. CONT…
• A patient who refuses treatment (even if that refusal may
shorten the life of the patient) This sounds like Passive
Euthanasia, as defined above.
• However, it is d/t even though the difference is subtle. In Passive
Euthanasia the patient says, "Please don't give me Treatment X,
because I want to die".
• In Refusal of Treatment, the patient says "Please don't give me
Treatment X, it's my right to refuse treatment, and I'll take my
chances" (which may or may not include death) The Doctor's reply
is d/t too - in Passive Euthanasia he may say "It's my duty to
prevent death, I can't go along with this plan - you must have the
treatment" (or he may say "Okay, I agree you’ve had enough
suffering" In Refusal of Treatment, he says, "Well, it's your right
to refuse treatment if you wish, but I need to advise you that I
strongly recommend the treatment I suggested"
12/2/2019 ETHICS 112

113. 12/2/2019 ETHICS 113

114. Do not resuscitate’orders
• Again, no statutory law exists. The guidelines that inform clinical
practice in the UK are those provided by the BMA, Royal College
of Nursing and the UK Resuscitation Council joint statement of
2002.
• This may be summarized as follows:
• Principles
• support for patients and people close to them, and effective,
sensitive communication are essential; decisions must be based on
the individual patient’s circumstances and reviewed regularly;
information about CPR and the chances of a successful outcome
needs to be realistic.
12/2/2019 ETHICS 114

115. CONT…
• In emergencies
• If no advance decision has been made or is known, CPR should be
attempted unless:
• the patient has refused CPR;
• the patient is clearly in the terminal phase of illness;
• the burdens of the treatment outweigh the benefits.
• Advance decision-making
• competent patients should be involved in discussions about
attempting CPR unless they indicate that they do not want to be;
where patients lack competence to participate, people close to them
can be helpful in reflecting their views.
12/2/2019 ETHICS 115

116. CONT…
• Legal issues
• patient’s rights under the HRA must be taken into account in
decision-making; neither patients nor relatives can demand
treatment which the health care team judges to be inappropriate, but
all efforts will be made to accommodate wishes and preferences; in
England, Wales and Northern Ireland, relatives and people close to
the patient are not entitled in law to take health care decisions for
the patient; in Scotland, adults may appoint a health care proxy to
give consent to medical treatment; health professionals need to be
aware of the law in relation to decision-making for children and
young people.
12/2/2019 ETHICS 116

117. CONT…
12/2/2019 ETHICS 117

118. 12/2/2019 ETHICS 118

119. Causes of action most relevant to anesthetist
• Medical negligence:- Breech of a duty of a standard of care causing
harm
• Wrongful death:- One that occurs earlier that it would have
otherwise.
• If negligence causes death, survivors may sue for damages
• Lack of informed consent Obligation to provide information
material to a reasonable person
• Abandonment-- Obligation to provide continuity of care once a
physician assumes responsibility for the patient
12/2/2019 ETHICS 119

120. • Vicarious liability – Obligation for reasonable oversight of those
working for the physician
• Loss of chance of recovery or survival- The patient must show that
recovery was likely except for the action of the physician
• Battery- Touching a person without express or implied consent.
There is no need for the plaintiff to prove harm in battery cases
• Assault -The attempt to touch another person.
• There is no need to prove actual harm
12/2/2019 ETHICS 120

121. • Jehovah’s Witnesses are an international religious organization and
comprise approximately 0.6–0.8% of the adult population in the
US with the greatest percentage residing in the South (36%) or
West (29%).
• Interestingly, the majority of Jehovah’s Witnesses (63%) have no
children.
• However, Jehovah’s Witnesses have the lowest retention rate of
any religious group with only 37% of individuals raised in the faith
as children keeping this religious affiliation into adulthood
12/2/2019 ETHICS 121

122. CONT…
• Though JWs started in 1870, it was not until 1945 that a ban on blood
transfusions was placed for JW’s.
• This ban on blood transfusions was based on quotes from the Bible,
especially the following: ( New World Translation of the Holy Scriptures –
2013 Revision ).
• Genesis 9:3 - …. Only flesh with its life – with its blood – you must not eat
• Leviticus 17:10–12 - ‘If any man of the house of Israel or any foreigner who is residing
• in your midst eats any sort of blood, I will certainly set my face against the one who is eating
• the blood, and I will cut him off from among his people (Leviticus 17:10). For the life
• of the fl esh is in the blood, and I myself have given it on the altar for you to make atonement
• for yourselves, because it is the blood that makes atonement by means of the life in it
• (Leviticus 17:11). That is why I have said to the Israelites: “None of you should eat blood,
• and no foreigner who is residing in your midst should eat blood” (Leviticus 17:12).
• Acts 15:28–29 - …to keep abstaining from things sacrificed to idols and from blood…
12/2/2019 ETHICS 122

123. • A 1951 Watchtower article explained the reasoning that led to
this ban on blood
• transfusion: “when sugar solutions are given intravenously, it is
called intravenous feeding. …The transfusion is feeding the
patient blood and …(the patient) is eating it (blood) through his
veins”.
12/2/2019 ETHICS 123

124. • It is a common misconception that if you give a JW blood
against his or her will, then the JW is still subject to eternal
damnation.
• Another misconception is that if a JW accepts blood then he or
she, too, would be subject to eternal damnation with no chance
of repentance.
• Neither of these is true. According to an e-mail communication
with the JW lead office:
12/2/2019 ETHICS 124

125. • In fact, since 2000 JWs are not “disfellowshipped” for accepting
blood.
• JWs are considered to have voluntarily “disassociated” from the
Church.
• This means that if a JW does repent he or she can remain in the
fold.
• In order to keep up with advances in medicine (for example,
renal dialysis; cardiopulmonary bypass; blood harvesting
including cell saver (cell salvage), acute normovolemic
hemodilution and autologous blood donation; and organ
transplant), new guidelines for JWs have been developed to aid
members in addressing these clinical situations.
12/2/2019 ETHICS 125

126. • “A forced blood transfusion would not be viewed as a sin.
• Also, if under extreme pressure & while experiencing undue stress
a JW was to compromise their belief and accept blood transfusions,
in other words, if they caved in at a moment of spiritual weakness
yet still held to their beliefs, that individual would not be ostracized
by the JW community, rather, kindness would be shown and
pastoral help offered. Nevertheless, a forced transfusion or a
compromise with one's conscience may leave the patient with deep
emotional scars.”
12/2/2019 ETHICS 126

127. • The ethical and legal right of capacitated adults to make medical
decisions for themselves is well-established.
• Autonomous decision making provides adults with the leeway to
make authentic choices consistent with their beliefs and values.
• If an adult patient makes a “bad decision,” the clinician may
confirm capacity and attempt to use gentle persuasion to redirect
the patient, but little precedent exists to override their refusal.
• It may even be considered battery if consent is not obtained from
a capacitated adult patient and his or her known preferences are
overridden.
12/2/2019 ETHICS 127

128. • When adult patients are unable to make medical decisions on their
own behalf, clinicians try to identify a person to act as the
patient’s “surrogate” and make decisions as his or her proxy.
• In other words, clinicians ask the surrogate to make decisions
based on the patient’s previously expressed wishes (if known), or
to make decisions consistent with the patient’s known values and
interests.
• In pediatrics, children have developing and evolving decisional
capacity as well as beliefs and values.
• Parental authority and familial autonomy over their developing,
vulnerable child creates a unique dynamic that is different from
the moral space in which surrogates make medical decisions.
12/2/2019 ETHICS 128

129. • Infants and children lack the ability to make autonomous medical decisions and
• therefore parents (or legal guardians) are presumed to have a liberty interest in the “care,
custody, and management” of their children.
• Furthermore, as children age and mature they are able to play an increasing role in the
medical decision making process creating a triangle of decision making between patient,
parent, and provider, which may raise additional complexities.
• While parents are allowed broad discretion in medical decision making, this right is not
absolute.
• As was noted in the case of Prince v Massachusetts , “…Parents may be free to become
martyrs themselves.
• But it does not follow they are free, in identical circumstances, to make martyrs of their
children before they have reached the age of full and legal discretion
12/2/2019 ETHICS 129

130. • The “best interest of the child” standard is based on the ethical
principles of beneficence, or the “moral obligation to contribute
to the good of others”.
• In the context of medical decision making, it aspires to identify
the medical care (decision) that is in the best interest of the child.
• When parental decision making aligns with a proposed medical
therapy, the care is often delivered without deliberate
consideration of this ethical standard.
12/2/2019 ETHICS 130

131. • When differences of opinion exist, the standard may be invoked to
substitute the views of a third party (the physician, the courts) over the
views of the parents.
• One expects that most parents do not seek to make decisions they
perceive as harmful, so why do clinicians and families sometimes
collide over what interventions are best for the pediatric patient?
• The best interest standard and the evaluation of the benefits and harms
of alternative medical pathways are inherently subjective, value-laden
judgments.
• Consider a patient with osteosarcoma – based on tumor location and
the response to chemotherapy, the oncologist and surgeon may
recommend amputation rather than a limb sparing technique, but after
evaluation of the information and consideration of their personal
preferences and beliefs, the family may still elect to pursue limb-
sparing.
12/2/2019 ETHICS 131

132. • The teenager may feel that it is in his long-term best interest to
not have a prosthesis and is willing to accept any increased risks
associated with declining amputation (amputation being what the
physicians consider to be his present day best interest).
• Finally, children are highly dependent on their parents who bear
the burden of their care.
• Parents are likely to consider familial needs – this is the balancing
and rank ordering of the interests of the parents, siblings, and
their child who is the patient in order to reach a determination of
what is the best medical decision
12/2/2019 ETHICS 132

133. Assent and Children’s Role in Medical Decision
Making
• As children mature, they develop an increasing ability to evaluate
proposed medical interventions and consider the risks and benefits of
the alternatives.
• Children are not treated as rational, autonomous adults but allowed
to participate in decisions in a manner consistent with their
developing capacity.
• Meaningful pediatric assent, which is less stringent than consent,
allows children the opportunity to state their preferences within the
context of their developmental abilities and desire to participate.
• It may be helpful to consider the practical
• The “rule of sevens” can provide general guidance for clinicians
assessing developmental capacity in pediatrics.
12/2/2019 ETHICS 133

134. • Children under the age of 7 are presumed to lack capacity,
children 7–13 years of age have an evolving sense of capacity
and should be evaluated on a case-by-case basis, and children
over 14 are presumed to have capacity unless evidence exists to
the contrary. example of a common pediatric intervention,
vaccination. A 4-year-old is unlikely to want to receive a shot,
but most all 4-year-old children will be unable to articulate a
meaningful decline, and may actively cry or hide in anticipation
of the intervention.
12/2/2019 ETHICS 134

135. • A 10-year-old is unlikely to want a shot, and may protest against it
because it may hurt, but will usually sit cooperatively for
administration of the immunization.
• A teenager may not want the shot, but realize that it is beneficial
and not protest, or they may articulate a reasonable response for
declining the immunization.
• It is important to remember that there will be older children who
lack developmental maturity to participate meaningfully and
younger children who have significant illness experience
prompting greater consideration of their opinion.
• If the child does not have a true choice in the final medical
decision, then they should not be offered a false choice.
12/2/2019 ETHICS 135

136. Evaluating Transfusion Refusals in Pediatric
Jehovah’s Witness Patients
• Refusals of transfusion should be evaluated in a manner similar to
other refusals.
• Providers should consider if alternative interventions (or
nonintervention) exist and evaluate the risks and benefits of the
treatment being refused against other proposed alternatives.
• It may be helpful to solicit the reason for the refusal and engage in
an open discussion to see if the refusing party can be gently
persuaded through assuasion of fears or misperceptions.
12/2/2019 ETHICS 136

137. • In our local experience, families have sometimes presented with
inaccurate information, such as vastly overestimating infection
risks associated with transfusion or expecting more immediate
(within days) benefit from the use of erythropoietin.
• If the intervention refused is not essential or can be deferred
without substantial risk, the refusal may be binding.
• In considering adolescent refusals, it is important to note the low
retention rate in the religious tradition and consider that the 16-
year-old refusing transfusion today, may be unlikely to hold the
same beliefs as an adult.
• This may be a consideration when there are high risks of harm to
the adolescent if the declination of transfusion is honored.
12/2/2019 ETHICS 137

138. • Families often understand that physicians have a fiduciary
responsibility to their patient, the child.
• Some families may be willing to sign an “acknowledgement
statement” which documents that the parents have been informed
that emergency transfusion will not be withheld regardless of
parental refusal to sign official transfusion consent.
• Acknowledgement statements may allow for the avoidance of state
intervention.
• Due to variability in legal precedent between states, we recommend
conferring with institutional legal counsel for appropriate language.
• In some circumstances it may not be possible to avoid state
intervention.
12/2/2019 ETHICS 138

139. • Some physicians believe that caring for a patient who refuses
standard care in the OR (for example, blood transfusion) puts them
in a situation of not being able to fully carry out their professional
responsibilities.
• The ASA has developed Guidelines for the Anesthesia Care of
Patients with Do- Not-Resuscitate Orders or Other Directives that
Limit Treatment.
• These guidelines should be applicable to surgeons as well.
• These guidelines state When an anesthetist finds the patient’s or
surgeon’s limitations of intervention decisions to be irreconcilable
with one’s own moral views, then the anesthetist should withdraw
in a nonjudgmental fashion, providing an alternative for care in a
timely fashion.
12/2/2019 ETHICS 139

140. 12/2/2019 ETHICS 140

141. • Anesthetists spends longer time in an environment which is filled
with many hazards.
• There is a potential exposure to vapors from chemical radiations
and infectious agents.
• Their is also psychological stress.
Physical hazards
Infectious hazards
Psychological stress
12/2/2019 ETHICS 141

142. Physical hazards
• The effect of chronic exposure to anesthetic gases was not
recognized early.
• Reports on the effects of chronic exposure to anesthetic gases
have include;
• 1.Epidemiologic studies
• 2.Reproductive studies
• 3.Cellular studies
• 4.Studies on laboratory animals and humans
12/2/2019 ETHICS 142

143. 1.Epidemiologic studies
• Were the first to suggest the possibility of hazards of exposure to
trace levels of anesthetics.
• There is high potential error in data collection and interpretation to
prevent this there should be an appropriate control group.
• Avoid misleading questions.
• Use medical records which provides reliable data.
12/2/2019 ETHICS 143

144. 2.Cellular studies
• At clinically useful concentration, volatile anesthetics interfere
with cell division in a reversible manner.
• This may due to reduction in O2 intake by mitochondria.
• Although chronic exposure to trace level of N2O doesn’t affect
cellular activity, in abusers of N2O there will be inhibition of
methionine synthesis ;this will result in anemia and
polyneuropathy.
• Many studies have been performed in animals to asses the
carcinogenicity of anesthetics.
12/2/2019 ETHICS 144

145. Cellular studies…
• Corbett’s pilot work indicated that isoflorane produced hepatic
neoplasia when administered to mice during early stage of gestation
but a subsequent well controlled study disproved this
• Other studies in mice and rats found no carcinogenic effect of
halothane,N2O or enflurane.
• There is no proof that there is a relationship between anesthetic
exposure, cellular ultra structural changes and functional
abnormalities.
12/2/2019 ETHICS 145

146. 3.Reproductive outcome
• Vaisman ,in 1975 surveyed 303 Russian anesthesiologists(193 men
and 110 women)
• The majority of them used N2O and ether without scavenging
waste anesthetic gases.
• The anesthesiologists reported increased incidence of headache,
irritability and fatigability.
• There were 18 abortions among 31 pregnant women in the survey.
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147. Reproductive …
• Although Vaisman’s study had no control group and done on
extremely small group of people, he finally concluded that these
occurrence were due to factors in the working environment
including;
chronic exposure to anesthetics
high level of emotional stress
excessive work load
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148. Reproductive…
• After the work of Vaisman, other investigators also began to survey
on anesthetic effects on reproductive system.
• One of the largest study was conducted by one committee of the
ASA.
• Questionnaires were sent to 49,585 OR personnel with potential
exposure to waste anesthetic gases whereas, 23,911 from the
American academic of pediatrics and the American nurse
association served as a control group.
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149. Reproductive outcome…
• The association finally concluded that, there is an increased risk
of abortion in women working in the operating area and
increased risk of congenital abnormalities in wives whose
husbands works in the operating room.
• But a Swedish study clearly demonstrates the inaccuracy
encountered when using mailed questionnaires.
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150. Reproductive outcome…
• All spontaneous abortions in the exposed group were accurately
documented in the responses to the questionnaires.
• But a review of hospital records revealed that one third of
spontaneous abortions went unreported.
• When verified data were analyzed, there was no statistically
significant difference b/n reproductive outcome in the exposed and
non-exposed.
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151. Infectious hazard
• Risk of infection is not unique to anesthesia.
• Every hospital personnel are at risk of infection.
• Anesthesia personnel can acquire infection during clerking the
patient, administering anesthesia and during post anesthesia care.
These includes;
Respiratory viruses
Viral hepatitis
HIV/AIDS
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152. I. Respiratory virus
• These are infections which are responsible for community acquired
infections.
• These viruses are usually transmitted by two routes.
• Small particle aerosols produced by coughing and sneezing.
• e.g. influenza viruses
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153. Respiratory viruses…
• Viruses transmitted by close person to person contact.
• e.g. Rhino virus
• II. Viral hepatitis
• hepatitis B virus (HBV) is a significant occupational hazard for
medical personnel who contact blood and blood products.
• Hepatitis B is highly infectious and the risk of transmission after
occupational exposure is higher than for HIV.
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154. Viral hepatitis…
• There are several modes of transmission of HBV that put
anesthesia personnel at risk for accidental infection.
• Percutaneous transmission can occur with contact with blood
products and body fluids.
• HBV is a hard virus that may be infectious for at least one week in
a dried blood.
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155. Viral hepatitis…
• An effective vaccine exists to prevent the transmission of hepatitis
B and all anesthetists should ensure that they are up to date with
their immunization schedule.
• Anesthetists in whom no antibodies are present and who suspect
exposure to hepatitis B should be immunized passively with
hepatitis B immunoglobulin and receive a series of three injections
of hepatitis B vaccine.
• Prior vaccination with seroconversion eliminates the need for
immunoglobulin.
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156. III.HIV/AIDS
• Risk of HIV infection is another infectious hazard.
• The risk of acquiring HIV after an occupational exposure to HIV-
infected blood is low.
• Epidemiological studies have indicated that the risk for HIV
transmission after percutaneous exposure to HIV-infected blood in
health care settings is 0.3%.
• After a mucocutaneous exposure, the risk is 0.03% and if intact
skin is exposed to HIV infected blood there is no risk of HIV
transmission
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157. HIV/AIDS…
• If occupational exposure does occur, the site of exposure should
be washed immediately with soap and water and the
occupational health department informed.
• Post-exposure prophylaxis has been shown to be maximally
effective if taken within an hour after an exposure, but benefit
may remain if commenced up to 2 weeks after exposure.
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158. Types of exposure with a significant
potential to transmit HIV
• Percutaneous injury from needles, instruments, bone fragments and
bites which break the skin
• Exposure of broken skin (eczema, cuts, abrasions) to contaminated
blood
• Exposure of mucous membranes including the conjunctivae
• Deep injury
• Visible blood on the device which caused the injury
• Injury with a needle or device which had been placed directly into
a source patients artery or vein
• Terminal HIV-related illness in the source patient
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159. HIV/AIDS…
• Exposure to larger volumes of blood, especially if the patients viral
load is high Because many patients may carry the AIDS virus and
not officially carry the diagnosis, anesthetists should consider all
patients to potentially have the disease
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160. Stress
• Stress is an inevitable factor in professional and personal life and
can lead to negative health effects, both mental and physical.
• Moderate levels of stress are an important driving factor in
optimizing performance, but prolonged and excessive levels of
stress, coupled with inadequate coping mechanisms, can lead to
decreased job satisfaction, impairment of decision making and
even suicide.
• Stress is a well recognized potential health hazards in the OR.
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161. Stress…
Causes of stress in anesthetists
Excessive work load
Process of difficult decisions
Night duty, fatigue
Interpersonal tension, relation
Lack of control of the work environment
Sleep deprivation and disruption of circadian rhythm
Continuing medical education and professional development
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162. Other occupational hazards
• Drug abuse and addiction
• Suicide
• Radiation
• Allergic reaction, etc..
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163. Sources of gas spillage in the OR
• Leakage of the scavenging system;
• During pediatric anesthesia
• A poorly fitting mask
• Un cuffed endotracheal tube
• Turning on the vaporizer before connecting breathing system to
the patient.
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164. Methods of reducing pollution with the volatile
anesthetics in the OR
• Use scavenging system
• Ventilate operating room well, especially after filling the vaporizer
with volatile agents
• Turn off vaporizer at end of surgery
• Select appropriate endotracheal tube size
• Fill vaporizer during night
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165. CASE-I
• 57 year old woman arrives in an Emergency Department comatose and bleeding
extensively (car accident)
• The ER physician feels she needs a blood transfusion to survive
• She has an unsigned and undated card in her wallet identifying her as a Jehovah’s Witness
and refusing blood products
• The court found him guilty of battery (assault) as he ignored her prior expressed wishes
(no blood transfusion)
• No one can speak for her
• The ER physician gives her blood in spite of the card
• She survived only to sue the doctor
• What are the issues here?
• What do you think of the doctor’s actions?
• What do you think of the court decision?
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166. CASE-II
• Acute perforated appendicitis which needs immediate
surgery but the patient refused to sign a consent which
was not documented was not operated and died next day.
What are the issues here?
What do you think should be the Doctor’s actions?
If the patient dies after the operation what is the liability?
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167. REFFERANCE
• Ethical Issues in Anesthesiology and Surgery, Barbara
G. Jericho Editor
• Clinical Anesthesia, Paul G. Barash, 8th edition
• Clinical ethics: a practical approach to ethical
decision in clinical medicine,7th edition 2010
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