Patient autonomy in times of shortage

Being self-aware sometimes to the point of turning self-critical — I, as a constituent of an anesthesiologist’s society, am writing this freestanding letter to bring forth our ethical questions and concerns regarding a shortage of not only medications but also skills, funds and time.

Scenario 1: Patient requests for spinal anesthesia for cesarean section, but a shortage of hyperbaric spinal anesthetics warrants epidural anesthesia as its replacement. What must be done? Is it sufficient to inform the patient, consent the patient for epidural anesthesia and move on?

Scenario 2: Patient requests for ultrasound-guided transversus abdominis plane block but a shortage of traditional team’s skill in regards to the “new kid on the block” discourages its use in the patient. What must be done? Is it sufficient to acknowledge team’s deficiency, give the option to choose an alternative method or an alternative team, and move on?

Scenario 3: Patient requests for labor epidural analgesia but a shortage of Medicaid funds warrants the hesitant team to explain alternative options for labor analgesia. What must be done? Is it sufficient to inform the patient about procedural costs, consent the patient for bearing costs and move on?

Scenario 4: Patient requests for preoperative placement of an epidural catheter for postoperative analgesia, but the shortage of time is discouraging it due to the patient arriving very close to scheduled surgical time despite being the first case of the day. What must be done? Is it sufficient to inform the patient, choose first-case-start-delay versus intraoperative/postoperative placement of the epidural catheter and move on?

All the aforementioned scenarios (case vignettes) boil down to the question: What constitutes patient autonomy? Is it an ethical responsibility or a legal obligation? For understanding, the providers will have to put themselves in their patients’ shoes and realize that the patients may want to know why their providers choose what they choose to present to them as their options. Will the patients’ consent change when they are able to comprehensively explore the available options and why they are available? Or will they be overwhelmed with the exhaustive information about what, why and how? Will they realize that their autonomy may never be absolute, but only relative to its inter-dependence on so many factors which may include, though not limited to, the availability of medications, skills, funds and time?

Being an anesthesiologist, the potential scenarios (case vignettes) presented here are only limited to the practice of anesthesiology. However, the responsibility lies with the providers of all clinical specialties, medical or surgical, procedural or non-procedural to acknowledge it to their consenting patients if their specialties are facing the challenging shortage of medications, skills, funds and time.

It may be interesting to let the patients know about why the specialties are facing the challenging shortage of medications, skills, funds and time. However, providers’ personal interpretations about ongoing shortages may only confuse independently interpreting patients instead of helping them to choose alternative options, including alternative teams.

Alternatively, if proactive patients want to enforce their relative-to-almost-absolute “right” to choose, it may become interesting when they collaborate with their providers in ongoing activism against societal and political challenges which may be leading to a shortage of medications, skills, funds and time. Essentially, it is all about being aware and making aware of challenges while balancing too many possible choices with too little available choices.

Deepak Gupta is an anesthesiologist.

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