This editorial can be found in the February 2024 issue of the American Journal of Bioethics.
Once anesthetized, patients are inherently “compliant” with surgical interventions because they can no longer intervene on their own behalf. In their target article, Minkoff et al. reasonably predict that the loss of a legal right to abortion will likely lead to patients’ loss of the right to refuse surgical interventions during pregnancy, including forced/coerced cesarean sections. Despite having no indication that they lack decision-making capacity (other than disagreeing with their medical team), women declining obstetric procedures have been threatened with reports to child protective services, had their decisional capacity questioned or ignored, and their objections overridden by physicians, hospital administrators, and courts. Most forced surgeries necessarily involve forced/coerced chemical restraint with anesthesia, lest patients be subjected to surgery without anesthesia. Such forced interventions are entirely counter to the principles of reproductive justice.
The authors state, “Once a decisionally-capable pregnant person has refused an obstetrical intervention, the provider’s role is to ensure that the decision is honored.” All people who work in operating rooms must develop a robust surgical conscience and protect patients from harm. Here, we specifically address the unique power of anesthesia professionals (anesthesiologists, nurse anesthetists, anesthesia assistants, and their respective trainees) to elevate patient autonomy and prevent forced surgical interventions if faced with a surgical team intent on providing forced surgical interventions. Our role in administering consciousness—, movement—, and sensation-altering medications places us in a unique position to prevent and mitigate obstetric violence.
What Is Forced Chemical Compliance?
Forced chemical compliance, or chemical restraint, entails administering medications “as a restriction to manage a person’s behavior or restrict freedom of movement”. Chemical restraint renders patients incapable of defending themselves against surgical assault on their persons. Marion Sims’ forced operations on unconsented and unanesthetized enslaved Black women are universally recognized as unethical. If the women Sims operated on had been anesthetized into easier compliance, the unconsented surgeries would not have been any more justified.
Anesthesia Makes Safe and Ethical Surgery Possible
The widespread availability of safe anesthesia revolutionized surgical care, including obstetric surgeries. Anesthesia makes surgery safer by controlling the patient’s level of interaction and consciousness, minimizing patient movement, and reducing the brutality and speed historically required for surgery without anesthesia. Surgical interventions without corresponding anesthesia management are considered unethical.
In the ethical practice of anesthesiology, patients (or their surrogates, parents, or guardians) must freely consent to care. Furthermore, anesthesia professionals are responsible for supporting patients’ right to self-determination. As anesthesiologists, we recognize that our power to temporize pain and consciousness with medications includes our ability to use the same medications as chemical restraints. In the case of forced interventions, chemical restraint both directly harms patients and facilitates surgical harm to patients. This practice is clearly in violation of our core responsibilities to respect patient self-determination and prevent harm.
To use anesthesia to force patients with capacity to undergo unwanted surgery is a reprehensible liberty violation. Corollaries to chemical restraint used against people with decisional capacity include 1) law enforcement’s direction of emergency service providers to use sedatives to subdue people in custody, leading to numerous deaths) and 2) drug-facilitated sexual assault (DFSA), including by anesthesia professionals. The negative impact of forced chemical compliance on unwilling people demonstrates the immense power possessed by those of us with ready access to highly effective drugs.
Anesthesiology professionals must demonstrate moral courage, elevate patients’ autonomy, and serve as protectors against forced surgeries rather than complicit participants. The refusal to induce general anesthesia in a patient will require the rare surgeon willing to operate on an awake, unwilling patient to rethink their position. The coercive use of neuraxial anesthesia in a patient with capacity, who provides an informed refusal, is equally unjustified.
Is Forced Chemical Compliance Ever Justified?
Chemical restraints are morally justified when they are part of a harm-reduction strategy. They are not justified as a mechanism to inflict harm. While some might argue being anesthetized for forced surgery is preferable to surgery without anesthesia, we argue that by denying access to forced anesthesia services, anesthesia professionals protect patients from the inflicted harm of the forced surgery itself.
In the practice of anesthesiology, there are specific situations where chemical restraint without direct patient consent or assent may be both medically and ethically indicated. These may include the anesthetic care of people who lack the capacity to make decisions for themselves, such as some intensive care patients, young children, and people with significant intellectual disabilities. In such cases, the risks, benefits, and alternatives to sedation are discussed with the person’s surrogate, parent, or guardian. Importantly, patients do not lack capacity simply because healthcare providers disagree with their decisions. In the case of forced/coerced operations, these ethical standards are not met.
Adding to the Trauma of Obstetric Violence
Up to 44% of all women report their birth experiences as traumatic. Forced chemical compliance with unconsented obstetric interventions adds additional trauma to patients, contributing to short- and long-term patient harm. Harms may include medical and obstetric PTSD, justified distrust of medical providers, and lack of willingness to obtain reputable obstetric care in the future. These issues are not trivial: mental health conditions are the number one cause of pregnancy-related deaths in the United States. In a post-Dobbs America, forced compliance will add additional injury to the forced continuation of many pregnancies. When anesthesia professionals are complicit in obstetric violence, they contribute to and augment patient harm. Forced chemical compliance in these circumstances is not the safe practice of anesthesia.
Anesthesia Professionals’ Obligation to Protect Patients from Harm
Anesthesia professionals are uniquely situated to protect patients from liberty violations via forced surgeries.
Anesthesia professionals often see ourselves as the last line of defense for patients against unsafe surgical conditions. This is because, under typical conditions, surgeons will not operate on unanesthetized patients. For surgeons and nurses who may themselves feel coerced into participating in the operation on an unwilling patient, the unwavering support of an anesthesia provider in protecting the patient may elevate the moral courage of the entire operating room.
In the case of forced surgery, anesthesia professionals protecting patients in compliance with their professional ethics should avoid allowing other anesthesia professionals to take over the assignment, if this reassignment is in order to comply with liberty violations. Of note, this is distinct from conscientious objection arguments which center on the healthcare provider, not the patient. In conscientious objection cases, healthcare providers remove themselves from providing treatment that is out of alignment with their own values. Such clinicians are usually expected to identify an alternative willing provider. In the case of forced surgery, stepping aside for a different anesthesiology professional to cause patient harm, is unjustified.
Anesthesia professionals must embrace our role in protecting patients from serious liberty violations, including the obstetric violence of forced surgery. If there is no willing anesthesia professional to chemically restrain a patient into compliance, this will inherently hinder the violence of forced surgeries.
Without a doubt, this will require moral fortitude and bravery on the part of anesthesia professionals. Understandably, providers will fear legal repercussions from failure to participate in a court-ordered intervention. While courts may authorize surgical interventions over a patient’s objection, orders rarely mention the provision of anesthesia. Anesthesiology professionals’ opinions regarding anesthetizing patients against their will are rarely requested or considered. No judge will come to the operating room to place an epidural or push a propofol syringe. The responsibility lies with us. We suggest documenting your discussions with the patient and medical team, as well as your ethical rationale for refusing to anesthetize the unwilling patient. Consult with legal representation as appropriate.
The abolition of obstetric violence from practice requires the moral fortitude of anesthesia professionals. As integral and necessary members of the surgical care team, we must ensure our significant power is not abused with the unethical use of forced chemical compliance.
The opinions expressed in this editorial are those of the writers and do not necessarily reflect the views or positions of any entities they represent.
Alyssa Burgart and Caitlin Sutton