Key points

Introduction

Charles Bosk, the noted sociologist who studied surgeons, pointed out in his seminal work Forgive and Remember that “the postgraduate training of surgeons is above all things an ethical training… The moral and ethical dimensions of training are not bracketed from all other concerns but are instead built into everyday clinical life.” By that he meant that surgical decision making entails not only making a diagnosis and considering treatment options but also making a host of other judgments that require the prudential weighing of values. If ethics is defined as “disciplined reflection on moral ambiguities” then surgeons do not engage in much of the reflection, because they are actively sorting through the ambiguities of complex situations in pursuit of doing the right thing for their patients. What then can ethics offer surgeons who are taking care of burned patients? Fundamentally it represents a large body of literature that has taken a principled approach to closely examining the conflicts in values that clinicians experience as ethical dilemmas. Knowledge of the content and process of ethical deliberation can help clinicians to navigate these situations.

The issues of informed consent, surrogate decision making, and withholding or withdrawing interventions at the end of life are commonly encountered in burn practices. The following 3 cases examine practical solutions to these issues. Burn surgeons also must be familiar with the ethics of innovation and research in the surgical setting, what to do with a do-not-resuscitate (DNR) order in the operating room (OR), and what to disclose to the patient when a harm-causing error occurs.

Introduction

Charles Bosk, the noted sociologist who studied surgeons, pointed out in his seminal work Forgive and Remember that “the postgraduate training of surgeons is above all things an ethical training… The moral and ethical dimensions of training are not bracketed from all other concerns but are instead built into everyday clinical life.” By that he meant that surgical decision making entails not only making a diagnosis and considering treatment options but also making a host of other judgments that require the prudential weighing of values. If ethics is defined as “disciplined reflection on moral ambiguities” then surgeons do not engage in much of the reflection, because they are actively sorting through the ambiguities of complex situations in pursuit of doing the right thing for their patients. What then can ethics offer surgeons who are taking care of burned patients? Fundamentally it represents a large body of literature that has taken a principled approach to closely examining the conflicts in values that clinicians experience as ethical dilemmas. Knowledge of the content and process of ethical deliberation can help clinicians to navigate these situations.

The issues of informed consent, surrogate decision making, and withholding or withdrawing interventions at the end of life are commonly encountered in burn practices. The following 3 cases examine practical solutions to these issues. Burn surgeons also must be familiar with the ethics of innovation and research in the surgical setting, what to do with a do-not-resuscitate (DNR) order in the operating room (OR), and what to disclose to the patient when a harm-causing error occurs.

Case 1

A 48-year-old man is admitted to the burn intensive care unit (ICU) with a 30% total body surface area (TBSA) full-thickness flame burn and inhalation injury. During his resuscitation he develops respiratory distress and requires ventilator support. He requires extensive debridement and split-thickness skin grafting, and you approach his wife for her signature on the consent form. She states that she will consent to the operations, but refuses to accept any blood transfusions because they are Jehovah’s Witnesses. You decide to stage his excision and grafting to minimize blood loss. After surgery his hemoglobin level is 5 g/dL and you are concerned that his unexcised burns are making him septic but that he cannot tolerate further excisions without a transfusion. The patient’s son arrives from out of town and informs you that the patient is not a Jehovah’s Witness and that he will accept a blood transfusion. It seems that the patient’s wife and he are recently married and she has been trying to convert him; however, per report of the son, your patient is not a practicing Jehovah’s Witness. The son demands a blood transfusion and excision and grafting as soon as possible, despite protests from the patient’s wife.

Discussion

There are several issues at play in this case that intertwine to make it more difficult than usual. One issue is a religion-based refusal of a lifesaving medical intervention. The second is a conflict between family members about the appropriate course of action. The third issue, which relates to respect for patient autonomy, is the concept of surrogate decision making.

In this case the patient is intubated and sedated, and therefore cannot express his wishes relative to his care. Therefore, someone has to make decisions on his behalf. The standard that must be applied is called substituted judgment; what the person would choose for himself if he was able. Some patients have appointed a durable power of attorney for health care to make these decisions for them. Most patients, especially those who have traumatic injuries, have not executed such documents and surgeons routinely turn to next of kin for guidance. Some states have laws and some hospitals have policies that delineate the hierarchy to be followed; for example, court-appointed guardians, spouse, partner, adult children, parent (if living), and close friend. The overriding principle is that the person who speaks on behalf of the patient should have demonstrated an intimacy with the patient to know what the patient would want to be done.

Patients generally have the right to refuse treatment, and Jehovah’s Witnesses have had a long and well-defined refusal of blood transfusions based on their interpretation of certain passages in the Bible. Although many surgeons disagree with their interpretation of these passages, or disagree with religion-based decisions in medicine generally, they accept the refusal of blood out of respect for the patient’s autonomy. A different standard is used in children, in whom, rather than substituted judgment, a notion of best interests is followed. A court order is obtained to transfuse these children. Simply put, society’s interest in the flourishing of children overrides the parent’s religious convictions to make martyrs of their children. Because this patient is an adult, the best-interests standard is not invoked, so answer D is incorrect. In emergency situations in which the patient lacks decision-making capacity and there is no surrogate decision maker available, it is ethically permissible for surgeons to treat the patient with presumed consent using a reasonable-person standard. The idea is that a reasonable person would choose to undergo a life-sustaining intervention, and delaying implementation of the intervention while trying to get consent would render the intervention ineffective. This standard does not apply in this case, because 2 potential surrogate decision makers are readily available.

In this case, answer C is the most prudent choice. The hospital ethics committee may be more familiar with state laws or hospital policies on surrogacy. The committee may also be equipped to facilitate a family meeting and be able to arbitrate between family members. The right course of action in this case depends on several details that are not readily available. Specifically, the claim that the patient is not a practicing Jehovah’s Witness needs to be investigated. If the patient is not a Jehovah’s Witness, then the wife’s refusal of a blood transfusion for him is not ethically permissible. She is imposing her values onto him and potentially risking his life. Even if state law or hospital policy indicated that the patient’s spouse should be the surrogate decision maker, the deviation from making the decision according to the substituted-judgment standard weakens the spouse’s authority. In that case option A would be the correct course of action. Option B is only the right answer if, after further investigation, the son’s claims are found to be false and refusal of blood transfusion is indeed consistent with the patient’s deeply held religious beliefs.

Although surgeons have the professional responsibility to understand the basics of informed consent, refusal of treatment, and surrogate decision making, involving the hospital ethics committee in complicated cases like this is a judicious path to take. Ethics committees can help sort through the issues of conflicting values when a patient’s life is at stake and family members disagree to make sure that all perspectives are examined. Typically, informed consent is just a box that must be checked in order to proceed with doing what clinicians propose is the right thing for the patient. Cogent arguments could be made in favor of each of the proposed courses of action. Clinicians must guard against taking the easiest option or the path of least resistance in these cases. Taking these ethical issues into consideration helps to ensure that the right operation is performed on the right patient at the right time for the right reasons.

Case 2

A 63-year-old woman sustains a 10% TBSA full-thickness burn to her abdomen and part of her dominant forearm during a minor explosion in her kiln. She is an ex-smoker, has mild chronic obstructive pulmonary disease, and was intubated for respiratory distress from presumed inhalational injury. She is widowed and lives independently, making a living from her husband’s pension and selling her pottery. On hospital day 3 she is still intubated when her 2 adult children arrive at bedside. They refuse to give consent for excision and grafting, and request that she be removed from the ventilator and allowed to die naturally. The state that their mother is an “old hippie” who spurns modern technology, who is fiercely independent, and is extremely vain. They state that she would never want to live with this amount of scarring and she always valued her independence more than anything; they say she had always told them that she never wanted to be “kept alive on machines.”

The intern on the service believes that the patient’s wishes should be respected and wants to extubate the patient and put her on a morphine drip until she dies. The chief resident is adamantly opposed to this idea and he has asked social work to come and evaluate the situation and is considering reporting the case to adult protective services. He says the patient has a high chance of full recovery and that comfort measures only is tantamount to murder.