Invited Commentary: From Moral Reflexes to Ethical Reflection: Ethical Commentary on the Refusal of Cardiac Surgery in Patients with Intravenous Drug Abuse, Active Hepatitis C, or HIV/AIDS

In the previous decades, medical indications for cardiovascular surgery underwent profound changes. With the development of novel surgical techniques, improved implantable materials, and refined procedures of anesthesia and narcosis, cardiovascular surgical interventions have been extended to patients who formerly would not have been eligible, such as patients with several comorbidities or old patients. At least in the system of German academic medicine, cardiovascular surgery has thus become not only a thriving clinical discipline but also a field in which questions of the medical adequateness and reasonability on one hand, and of futility and ethical justifiability on the other are gaining importance.

Not surprisingly, and disappointingly, the venture point for the discussion of the six cases in which refusal of cardiovascular surgery, due to intravenous drug abuse, or active hepatitis C or HIV/AIDS, is an intuition, a moral reflex. The main question emerging from this reflex is whether the underlying health conditions might be sufficiently acceptable reasons to refuse surgical revision or reoperations, even if the life of a patient is acutely endangered. Unfortunately, those health conditions are presented in a narrative way that lends itself to more or less scandalized cultural readings of addiction and infection instead of presenting clinical findings, data, and differential diagnosis as they would be required for a thorough analysis on the level of reconstructive clinical ethics.[1] The following commentary will therefore have to focus on some overarching themes of the article.

• References

• 1 Paul NW. Klinische Ethikberatung: Therapieziel, Patientenwille und Entscheidungsprobleme in der modernen Medizin. T. Juninger, A. Perneczky, C.-F. Vahl, C. Werner (Eds.), Grenzsituationen in der Intensivmedizin. 2008: 207-217
• 2 Carlsson J, Paul NW, Dann M, Neuzner J, Pfeiffer D. The deactivation of implantable cardioverterdefibrillators: medical, ethical, practical, and legal considerations. Dtsch Arztebl Int 2012; 109 (3334) 535-541
• 3 Polanco A, Itagaki S, Chiang Y, Chikwe J. Changing prevalence, profile, and outcomes of patients with HIV undergoing cardiac surgery in the United States. Am Heart J 2014; 167 (3) 363-368
• 4 Mirabel M, Sonneville R, Hajage D , et al; ENDOREA Study Group. Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis. Eur Heart J 2014; 35 (18) 1195-1204
• 5 Paul NW. A closer look at health and disease as prerequisites for diagnosis and prognosis. Medicine Studies 2010; 2: 95-100 . Doi:10.1007/s12376-010-0047-z