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Rev. Bras. Anestesiol. vol.51 no.5 Campinas Sept./Oct. 2001
Bioethical dilemmas in anesthesia*
Dilemas bioéticos en la práctica de la anestesia
José Abelardo Garcia de Meneses, M.D.
Aluno especial da disciplina MED-733 "Bioética" do Curso de Pós-graduação em Medicina e Saúde da Faculdade de Medicina da UFBa; Diretor do Sindicato dos Médicos no Estado da Bahia - SINDIMED (1998-2001); Conselheiro do CFM (1994-1999); Conselheiro do CREMEB (1998-2003); Membro da Sociedade Brasileira de Bioética; Presidente da Comissão de Sindicância de Processo Administrativo/SBA (2000-2001); Membro da Comissão de Estatuto, Regulamentos e Regimentos/SBA (1996-1998/1999-2001)
BACKGROUND AND OBJECTIVES:
Relations of human society with the universe and the application of ethical
concepts studied by philosophers to follow the evolution of biomedical sciences
gave birth to Bioethics. The aim is to deal with advances in physician-patients
relationships proposed by bioethical principles in addition to traditional Hippocratic
principles. This study aimed at encouraging and deepening bioethical discussions
CONTENT: The essay discusses limits between benevolent and non-maleficent medical acts deeply involved with patients well-being, the benefits of a paternalist medical approach aimed at preserving health and life and the respect for ill people, potential patients, and their right to free, renewable, revocable and thoroughly informed consent for any medical act.
CONCLUSIONS: Based on what is here presented, the anesthesiologist should always decide beneficially to protect individual health and the sacred right of life, understanding the limits between patients' autonomy and the physician's right to administer arbitrary treatment regardless of patients' will, in compliance with beneficence and non-maleficence principles by making available the benefits of medical science (justice) in favor of life since very often in anesthesia there is an unintelligibly subtle limit between life and death.
Key words: ANESTHESIOLOGY; BIOETHICAL
JUSTIFICATIVA Y OBJETIVOS:
Las relaciones de la sociedad humana con el universo y la aplicación de
nuevos conceptos éticos estudiados por filósofos, fundamentalmente
para acompañar la evolución de las ciencias biomédicas, originaran
la Bioética. El objetivo es tratar de los avanzos en las relaciones humanas
entre médicos y pacientes, propuestos por los principios bioéticos
en adición a los tradicionales principios hipocráticos aquí discutidos,
en particular de la práctica de esta ciencia fascinante, la Anestesiología.
El presente trabajo visa estimular y aprofundar las discusiones bioéticas
en la área de la Anestesiología.
CONTENIDO: Se discuten los límites entre el acto médico benevolente y no-maleficente, indisociablemente comprometido con el bienestar del paciente, los beneficios de la conducta médica paternalista, visando la preservación de la salud y de la vida, y del otro lado, el respeto a la autonomía del ciudadano-enfermo, potencial paciente, y su derecho al consentimiento libre, renovable, revocable y plenamente esclarecido para cualquier acto médico.
CONCLUSIONES: Con base en lo que es presentado en este trabajo, el anestesista debe siempre decidir beneficientemente en defensa de la salud del individuo y de la sacralidad de la vida, entendiendo los límites entre la autonomía del paciente y el derecho del médico a aplicar tratamiento arbitrario a rebeldía de la voluntad de aquel, en obediencia a los principios de la beneficencia y de la no-maleficencia, poniendo en disponibilidad los beneficios de la ciencia médica (justicia) en favor de la vida, puesto que, en anestesia muchas veces, hay un límite incomprensiblemente tenue entre vida y muerte.
As of the breakthrough of William Morton, at the Massachusetts General Hospital, Boston (USA), in October 16, 1846, the perspective of patients in need for surgical procedures has gained a new ally - anesthesia.
Although sharing its practice with other health professionals, namely physicians and dentists 1-3, anesthesia was given the status of independent science, which is currently called Anesthesiology. This understanding is confirmed by significant Anesthesiology advances, such as the increasing volume of therapeutic armamentarium, the development of new anesthetic techniques an new equipment for the administration of inhalational and venous agents and the introduction of sophisticated monitors.
On the other hand, it must be understood that scientific medical knowledge cannot be dissociated from Hippocratic traditions, namely: maintenance of a healthy physician- patient relationship, commitment to life, professional secret and respect to patients' right to a free and informed consent 1.
This study aimed at encouraging and deepening bioethical discussions in anesthesiology.
Based on principles assuring freedom of expression, but with commitment and responsibility, bioethics with its pluralistic character brings to society a list of issues around beginning and end of life, new fecundation methods, cloning, transgenic food, indiscriminate use of animal models, human research, genetic engineering, organ transplantation, right to a death in dignity, euthanasia and disthanasia, therapeutic obstinacy, therapeutic privilege, arbitrary treatment, universal access to health care, progress of biological sciences, among others.
It is worth noticing that bioethics does not innovate fundamental ethical principles, but applies philosophical concepts to the update of biomedical sciences.
As of Van Rensselaer Potter's (oncologist and biologist) publication, Bioethics: bridge to the future, in 1971, human society started a new discussion cycle on men's relation with the universe, which gained a new breath with the publication of Beauchamp and Childress' work, Principles of biomedical ethics, in 1979, based on the concept that all actions should aim at the good (beneficence), not cause damage to anyone, prevent damage and remove damages otherwise caused (non-maleficence), should search for fair equitable and universal distribution of health care (justice) and the attaining of free, informed, renewable and revocable consent for any act (respect to autonomy) 2.
Our paper is based on patients' autonomy bias.
A lifes is an unavailable right and health an inalienable property, medical acts should aim at patients' welfare, their physical and psychical well-being, as well as at respecting their interests.
Physicians, based on acquired scientific knowledge, may sometimes call for a pseudo-infallibility and adopt an authoritarian behavior not allowing a more active participation of the patient in decisions related to the diagnostic or therapeutic proposal.
Anesthesiologists are no exception. However, the Brazilian Society of Anesthesiology, a body which historically has been alert in protecting the interest of its members, but at the same time leading a judicious, ethical and human practice, advises anesthesiologists to look for a healthy physician-patient relationship. This issue has been already subject of publications and discussions in scientific events by sectors especially interested in advocating a more humanized practice of anesthesia 3-5.
It is important to remind that among physicians duties: information duty, updating duty, surveillance duty and abuse abstention duty, one must also take into account patient's information duty through an open, sincere and clear dialog and especially through the understanding of the ill person, potential patient.
Along the same lines, Dias and Kfouri Neto 3 teach, respectively: "Anesthesia should not be practiced without patients' consent, which may be directly given by patients or, if impossible, by those in charge of them"... "it is his (the anesthesiologist's) special duty: a) to medically and psychologically prepare the patient; anticipate potential difficulties, calm the patient, obtain his cooperation and trust, prepare his body for the surgical procedure". Based on those legal teachings, the conclusion is that the violation of such rules supposes omission which, in case of poor outcomes, will certainly be considered negligence and imprudence 4.
Physicians should base their approach on scientific knowledge and awareness, assuring to patients the principles of justice and autonomy or the ability of citizens to decide by themselves the "law" they are willing to obey 5. From such, one may infer that patients' rights to information and active participation in decisions about them should not be minimized by physicians. This is such an important topic that the General Assembly of the World Medical Association has approved the Lisbon Declaration in 1981, about patients' rights, which was further ratified it in Bali, Indonesia, in 1995 6.
Among the Lisbon Declaration principles, it is worth mentioning patients' right to freely choose a trustful physician, the right to adequate information to their education and the physicians' right to arbitrary treatment when patients are unconscious or unable to make themselves understood.
On the other hand, the bioethical resolution - human rights with regard to biomedicine - adopted by the European Congress which gathers 15 European Union countries, advocates, among others, the principle that "individual rights are override science and society rights" 7.
The physician-citizen should not allow technological imperatives to overcome the humanistic doctrine of the medical profession. So, he should not allow his essentially technical will to be against the interests and desires of the patient-citizen, in a clear ideological conflict between autonomy and heteronomy. Siqueira 8, commenting the responsibility principle proposed by Jonas, was very clear about this issue: "...the technological imperative eliminates awareness, eliminates the subject, eliminates freedom on behalf of determinism. Science hyperspecialization mutilates and shifts the notion of humankind... This divorce between scientific breakthroughs and ethical reflection led Jonas to propose new dimensions for responsibility, because modern techniques have introduced actions of so different magnitudes and with so unforeseeable objectives and consequences that old ethical landmarks can no longer embrace them".
Bioethical principles do not establish hierarchical and absolute concepts and that is why medical paternalism in the clinical practice is admitted as an interference in citizens' autonomy and ability to decide, in a proven beneficent attitude in favor of the well-being and needs of the coerced patient and never on behalf of third parties interests, here including coercive professional interests 9.
As it is well known, anesthesia has unique features, in some aspects common to intensive care, neonatology, emergency and urgency, among others, where the medical paternalism may be admitted.
This exceptional paternalism faced to an unconscious patient or unable to make himself understood, does not override the previous knowledge of the proposed anesthetic technique for a certain surgical procedure or investigation. So, understanding that preanesthetic evaluation is a non transferable responsibility of the anesthesiologits 10 and that the patient has the right to such evaluation, there is a consensus of the Federal Council of Medicine as to best anesthesia practices 11,12.
There are daily situations where the anesthesiologist can immediately decide between doing good against patients will and, in not doing it to contribute by omission for the possibility of an irreparable damage. With such, we are not advocating the free arbitration of the medical authority, on the opposite; we advocate that, during preanesthetic evaluation performed in the office or upon visiting the admitted patient, different practices should be very clearly explained and the consent be obtained with total freedom of the patient or his legal guardian on the proposed technique, never going against his will, respecting the principle of patient's autonomy and, of course, within the limits imposed by the medical science, including patient's right for freely choosing a trustful professional.
The issue presented in this paper is the autonomy limit of the patient-citizen and the right of the physician-citizen to apply arbitrary treatment against patient's will but in strict compliance with the principles of beneficence and non maleficence, making available the benefits of medical science (justice) in favor of life, as in anesthesia, very often there is an incomprehensibly blurred limit between life and death, situation in which the physician should decide on behalf of the individual's health and of the sacred gift of life.
01. Código de Ética Médica. Resolução CFM nº 1.246/88. Diário Oficial da União, 26 de janeiro de 1988. [ Links ]
02. Beauchamp TL, Childress JF - Principles of Biomedical Ethics. 3rd Ed, New York, Oxford University Press, 1979; 67-119. [ Links ]
03. Kfouri Neto M - Responsabilidade Civil em Anestesiologia, em: Kfouri Neto M - Responsabilidade Civil do Médico. 3ª Ed, São Paulo, Editora Revista dos Tribunais, 1998;136-149. [ Links ]
04. Conselho Federal de Medicina. Parecer nº 56/99. Sessão Plenária de 29 de setembro de 1999. [ Links ]
05. Schramm FR - A autonomia Difícil. Bioética, Conselho Federal de Medicina, 1998; 6:27-37. [ Links ]
06. Associação Médica Mundial. Declaração de Lisboa sobre os direitos do paciente, 1981. [ Links ]
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08. Siqueira JE - O imperativo Tecnológico e as Dimensões da Responsabilidade, em: Siqueira JE - Ética e Tecnociência. Londrina, Editora UEL, 1998;23-42. [ Links ]
09. Fortes PAC - Direitos dos Pacientes, em: Fortes PAC - Ética e Saúde: Questões Éticas, Deontológicas e Legais, Tomada de Decisões, Autonomia e Direitos do Paciente, Estudo de Casos. São Paulo, Editora Pedagógica e Universitária, 1998;18-22. [ Links ]
10. Vieira ZEG, Pereira E, Saraiva RA - Visita pré-anestésica, responsabilidade intransferível do anestesiologista. Rev Bras Anestesiol, 1977;27:337-353. [ Links ]
11. Conselho Federal de Medicina. Resolução nº 1.363/93, Diário Oficial da União de 22 de março de 1993, seção I. 1993;3439. [ Links ]
12. Conselho Federal de Medicina. Parecer nº 56/99. Sessão Plenária de 29 de setembro de 1999. [ Links ]
Correspondence to: Submitted for publication January
15, 2001 *
Received from Disciplina Bioética, conceito 10,0 (dez), do Curso de Pós-Graduação
em Medicina e Saúde (CPgMS) da Faculdade de Medicina da Universidade Federal
da Bahia (FAMED - UFBa), dezembro/2000
Dr. José Abelardo Garcia de Meneses
Address: R. Martins de Almeida, 60 - Jardim Apipema
ZIP: 40155-060 City: Salvador, Brazil
Accepted for publication April 12, 2001
Submitted for publication January
* Received from Disciplina Bioética, conceito 10,0 (dez), do Curso de Pós-Graduação em Medicina e Saúde (CPgMS) da Faculdade de Medicina da Universidade Federal da Bahia (FAMED - UFBa), dezembro/2000