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.)

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.”