Ethical Framework of Certified Registered Nurse Anesthetists (CRNAs)
CRNAs operate within an ethical framework fundamentally grounded in respect for patient autonomy, beneficence (doing good), and patient safety, with the primary obligation being to obtain valid informed consent and serve as the patient's advocate throughout anesthesia care. 1, 2
Core Ethical Principles
Patient Autonomy and Informed Consent
The cornerstone of CRNA ethical practice is respecting patients' autonomy—their right to be involved in decisions affecting their care. 1 This manifests through several key requirements:
Valid consent requires three elements: adequate information disclosure, patient capacity to understand and decide, and voluntary decision-making free from coercion. 1, 3
Information disclosure must include: the nature and purpose of anesthesia, significant foreseeable risks and benefits, available alternatives, and the option of no treatment with its consequences. 3
The disclosure standard has shifted from what a "reasonable physician" would disclose to what a "reasonable patient" would want to know—meaning CRNAs must provide all "material risks" that this particular patient would regard as relevant. 1, 3
Patients retain the right to refuse information, though CRNAs must explain the consequences of this choice, document the discussion, and give patients opportunity to change their minds. 1, 3
Beneficence and Patient Safety
CRNAs must work with the consciousness to benefit patients and make them as safe as possible throughout the perioperative period. 2
Beneficent practice involves: communicating with compassion, being considerate of patient needs, maintaining professional knowledge and standard operations, ensuring team communication, and maintaining constant awareness of patient safety. 2
The principle of beneficence sometimes conflicts with autonomy—for example, when patients with capacity decline life-saving treatment, their decision must be respected. 1
CRNAs serve as patient advocates even when patients are anesthetized, attending to basic needs and representing patients who cannot speak for themselves. 4
Capacity Assessment
Adults must be presumed to have capacity to consent unless there are reasonable grounds to conclude otherwise, which must be documented. 1, 3
Pain, illness, and premedication do not necessarily render patients incapable of consenting. 1, 3
Capacity is decision-specific—patients may retain ability to make simpler decisions while lacking capacity for more complex ones. 3
When patients lack capacity, CRNAs must make efforts to reverse or minimize temporary incapacity to enable patients to make their own decisions, and when not possible, treat patients in their best interests. 1
Ongoing Consent Process
Consent is an ongoing process, not a single event, requiring repeated discussion and documentation at every stage. 1
For courses of treatment (e.g., chronic pain management), consent must be confirmed and documented before each individual component, with any changes to risks, benefits, or alternatives discussed fully. 1
Patients may change their minds and withdraw consent at any time, so long as they retain capacity. 1, 3
Common Ethical Challenges CRNAs Face
Interprofessional Conflicts
The most frequently occurring ethical issue CRNAs encounter is conflict in the nurse-physician relationship. 5
CRNAs experience moral distress when: pressured to give anesthesia to unoptimized patients, differences of opinion regarding anesthetic plans occur, dealing with end-of-life issues, working with incompetent providers, and during interprofessional struggles between CRNAs and anesthesiologists. 6
Working with incompetent or impaired colleagues is the most disturbing ethical issue CRNAs report. 5
Moral Distress
CRNAs experience moderate levels of moral distress when they believe they know the morally correct course of action but are unable to follow through with these behaviors. 7
Moral distress manifests as: anger, guilt, sadness, and has been identified as a contributing factor to burnout and turnover. 7
CRNAs in medically supervised practice report higher moral distress (lower Ethics Stress Scale scores of 176.8) compared to independent practice CRNAs (187.8). 6
Conflicts Between Production and Caring
CRNAs experience ethical tension between production pressures and caring obligations, particularly when institutional demands conflict with patient-centered care. 4
Professional Identity and Nursing in Anesthesia
CRNAs view anesthesia nursing as an integration of technical tasks and caring, where the relationship with the patient and serving as the patient's representative are central. 4
CRNAs are highly aware of their professional identities as nurses, even though there are overlapping tasks and skills between CRNAs and anesthesiologists. 4
A major aspect of nursing is performed while the patient is anesthetized, with CRNAs attending to patients' basic needs and maintaining vigilance for patient safety. 4
Practical Implications for Reducing Ethical Conflicts
To reduce moral distress and ethical conflicts, CRNAs require: increased administrative support, increased communication and reciprocated collegial respect between anesthesiologists and CRNAs, and CRNA representation on ethics committees. 6
Unresolved ethical conflicts negatively influence morale, leading to avoidance of issues and contributing to burnout. 5
Ethics education programs should address the specific issues encountered in CRNA practice, including interprofessional conflicts, capacity assessment, and informed consent challenges. 5