Tough Situations: Residents discuss ethics-fraught cases

The options: Follow the patient’s wishes and use the most expensive one; use one the hospital recommends; use the intermediate one; recommend that the patient have the surgery done by another surgeon.

The principles: Autonomy; beneficence; nonmaleficence; equitable distribution of health resources (justice).

Questions to consider: How well does the patient understand the merits of each device? What is the hospital’s motive for recommending the less expensive implant? Can the physician handle the case impartially, given her financial involvement?

Authors’ guidance: “Because no surgeon is completely free of conflicts of interest, we suggest that the initial surgeon determine the implant and course of management for the patient with reference to her own training and the scientific literature. Only under rare circumstances should the decision be transferred to another surgeon. The surgeon with financial conflicts of interest should disclose fully her relationship to the implant and her financial interest in it. If the patient feels comfortable with the plan, then he may choose to proceed with care or should be free to seek a second opinion.”

 

Medical Tourism

The situation: A 45-year-old underinsured, morbidly obese man sees a surgeon about a bariatric procedure. The surgeon recommends gastric banding, but the insurance company repeatedly denies coverage. The insurer suggests it might be covered if the patient has it done overseas. The patient is directed to a website, which promises first-rate care at cut-rate prices. The patient asks the surgeon whether he should go to Bangkok for the procedure. (Surgery. 2010;148:597-601.)

The options: Tell the man, “No, medical tourism is bad for you”; “No, medical tourism is bad for Thailand’s health system”; “Yes, and I’ll resume care when you get back”; or “Yes, and I’ll resume your care if you sign a release form.”

The principles: Nonmaleficence; justice); beneficence; autonomy.

Questions to consider: If medical tourism redirects medical resources away from Thailand’s poorer residents, how should that factor into the surgeon’s response? Does the physician’s obligations to the patient trump other concerns? Has the patient been fully informed about the risks and legal recourse involved in medical procedures performed abroad? What steps should the physician take to protect himself?

Authors’ guidance: “We first always should be our patient’s advocate, but we also must be willing to consider the implications of our actions. This point is especially potent when considering our views and actions regarding medical tourism.”