Tough Situations: Residents discuss ethics-fraught cases

Residents in the general surgery program at Washington University in St. Louis, Mo., participate in monthly “pizza grand rounds,” in which they discuss ethics-fraught situations they encounter. Some of the situations are the subjects of papers published in Surgery. Here are summaries of a few of those published situations. The papers intentionally do not mention the actions ultimately taken, so that the attention remains on the principles and questions involved.

 

Newborn in Critical Condition

The situation: An infant girl is born to a 17-year-old mother at 25 weeks by C-section. An echocardiogram finds patent ductus arteriosus, a condition in which the two major arteries connected to the heart remain connected to each other after birth, leading to abnormal blood flow. A head ultrasonogram finds severe hemorrhaging in the brain. The NICU team has multiple discussions with the parents about the infant’s strong likelihood of severe physical and mental developmental delay and the possibility that she might die. The parents say they want everything possible done to keep the infant alive. (Surgery. 2009;146:122-125.)

The options: Withhold treatment to prevent further harm to the infant; follow the parents’ wishes and proceed with aggressive treatment; use medical therapy only; or consult the hospital’s ethics committee.

The principles: Doctor’s obligation not to inflict harm (nonmaleficence); patient’s right to make their own healthcare decision (autonomy); doctor’s obligation to contribute to patient’s welfare (beneficence)

Questions to consider: How well do the parents understand the critical nature of the situation? How do you define ‘futility’ in health care?

Authors’ guidance: “In this case, further operative treatments would cause harm (violating nonmaleficence) without ensuring benefit to the patient (questionable beneficence). In other words, operative treatment would be futile. As such, the surgeons are ethically and medically justified to refuse to operate.”

 

Conflict of Interest

The situation: A 66-year-old man sees an orthopedic surgeon about osteoarthritis of the knees that he “can no longer live with.” The surgeon decides that total knee arthroplasty is indicated. The patient wants an implant he’s seen on television. It’s the most expensive one on the market. The hospital has asked surgeons to use another kind of implant it says is “cheaper and equally effective.” The surgeon wants to use a third implant, intermediate in cost, because she helped develop it, is most comfortable with it and almost always uses it. She has stock in the company that makes the third implant. (Surgery. 2010;147:738-741.)