Consensus in Endoscopy

ETHICAL GUIDELINES FOR ENDOSCOPY Any discussion of medical ethics, including ethics and gastrointestinal endoscopy, must include four principles: autonomy, beneficence, nonmaleficence and justice. Autonomy is ‘self-ruling’. Beneficence means kindness, to be charitable and beneficial. This special medical obligation is implicit in the doctor-patient therapeutic relationship. Nonmaleficence from an ethical view may not mean to do no harm but rather to make sure the anticipated harm or risks of therapy are worthwhile relative to the good intended from the patient’s point of view. Justice requires fair treatment of patients and a respect for their rights. When reviewing the ethics of any aspect of endoscopy, it is worthwhile to keep the four principles in mind. Endoscopists must always consider the patient’s best interests, especially in today’s economic times when resource allocation and utilization are restricted. Knowing that their decisions will influence the health care budget at an aggregate or provincial level, the hospital budget at an intermediate level and the patient’s budget at a microlevel, endoscopists must attend to their patients’ needs and requirements, while doing no harm, all in the context of limited resources. Resources influence endoscopy. The cost per unit of endoscopy is calculable but these group goals may conflict with individual goals. Part of the financial equation is the professional’s remuneration. To be paid for services rendered is morally correct and endoscopists must convince the general public of this. Diagnostic and therapeutic safety is foremost. This implies formal training and maintenance of competence. Endoscopists must have good standards of care. Despite lack of funding and more physicians wanting to do endoscopy, training for technical and cognitive skills is mandatory. Endoscopy is not solely guiding the endoscope. After a formal training program, competence must be maintained. Short courses in endoscopy do not replace a recognized formal program. Their objectives should be clearly defined, patient safety considered and trainee competence ethically assessed. Endoscopic research protocols must be ethical. Patients must have informed consent. Studies must be supervised and results meticulously assessed. Publication may have an impact and should be free from errors and possible misrepresentation. Informed consent is most important not only in research but for all endoscopy procedures. Patient’s autonomy comes into play more in consent forms than any other aspect of endoscopy practice. Consents also must be legal; patients need to be aware of options, risk and benefits. Endoscopists should ask “What would a reasonable person do in the same circumstances?” Consents in offices are as important as those obtained in hospitals. It’s best to have the consent witnessed. All endoscopic procedures need periodic review and outcome analysis. Standards for endoscopists too need to be established. Guidelines need to apply to in-hospital as well as to free-standing endoscopy units.