Ethical Dilemmas at the Bedside: How Do We Decide?

Editor's Commentary

First, let me begin by thanking you for your publication of the paper by Gansera and colleagues[1] and thus introducing to us this new and innovative format: an article that ends with questions, open for the readers to write the discussion and conclusion section! It is an interesting way to sort out bioethical problems in general, and I hope this will be the first of many papers published in this style.

I read with interest the paper and its accompanying commentaries, and hope to add a little to the discussion from my own perspective.

The authors present six cases that raise distinct medical and ethical issues. As Paul[2] mentioned in his commentary, the clinical details provided are too incomplete to permit a detailed analysis of each case, which would at any rate be beyond the scope of my letter. However, we can take advantage of the issues raised to address the general ethical approach that can be used by surgeons faced with similar cases in the future.

In the first place, we may divide the issues raised by the authors into those that are pertinent to ethical analysis and those that are not. Perhaps, the most important question, the one with which we must always begin as surgeons faced with a patient, is that addressed in some way by all of the commentators but most directly by Laczkovics[3] and Paul[2]: what is the indication for surgery, and what is the likely outcome? The ethical question of “should” surgery be offered must begin precisely with this medical analysis. This risk/benefit analysis for the patient corresponds to applying the ethical principals of beneficence and nonmaleficence. Other relevant issues include the risk to the health care team and the (financial) cost to society. Factors brought up by Gansera that are, in my opinion, not ethically relevant include whether or not the patient is a foreigner, whether or not another hospital or surgeon refused to treat him, and whether or not the patient's condition is somehow the result of immoral or risky behavior. These issues are all related to the ethical principal of justice: it would be unjust to discriminate against the patient because of his national origin or behavior, and it would be unjust to disregard excessive risk to the team or cost to society.

As surgeons confronted with difficult ethical problems such as these, each of us must rephrase the question from that commonly asked: “what should be done?” to the more personal question: “what should I do?” Surgeons have, in a sense, two areas of responsibility: one to the patient and one to society as a whole. Those two responsibilities can and should be considered separately. When I establish a relationship with a patient, I accept a certain fiduciary responsibility to advocate for that patient's best interest. For this reason, I strongly agree with Ziemer and colleagues[4] that cost-related decisions must not be made at the bedside. When caring for an individual patient, my primary responsibility is to offer that patient the best care possible under the concrete circumstances at hand. As a member of society, though, I also have a (separate) responsibility to advocate for prudent use of resources; this advocacy necessarily implies a study of the likely outcomes of the intervention questioned, and comparison to other types of surgery,[5] without making moral judgments about the patients.[3]

So what should I do when confronted with patient issues as discussed by Gansera? Each patient must be assessed according to the likely short- and long-term results with and without operation. Operation should be offered if it seems to be in the patient's best interest. Drug use or drug addiction, per se, is not a contraindication to operation,[4] but it must be taken into consideration in terms of its likely effects on long-term outcome. Active infection or multiple prior operations similarly should be considered only in terms of their prognostic significance[2]; difficult cases can (and should) be transferred to a more experienced center if it is in the patient's best interest.[5] The risk to the team should be minimized by use of universal precautions and by limiting participation to only those necessary (i.e., excluding trainees). The issue of whether or not providers should be able to “opt out” of caring for infectious patients is a complex one; in my opinion it should be handled in a manner analogous to conscience objections: the refusal should be documented in advance (at the time of hire or affiliation with the hospital, NOT when confronted with an emergency case) and permitted if it can be handled with no effect on patient care and minimal disruption to staffing. Exemptions from caring for patients should never be granted in a manner that permits discrimination of any type. No patient should be denied care by the surgeon at the bedside based on financial considerations; cost issues must be decided at the level of society, and enforced by the hospital administration, so that the surgeon remains always the patient's advocate.

Finally, it is important to consider the one key principle of medical ethics that seems to have not been mentioned yet: that of autonomy. It is never more important than in high-risk, complicated cases to have a detailed conversation with the patient or surrogate regarding the relative risks and benefits of surgery. The information must be presented to the patient in a manner that is direct but that he can understand; this should include a nonjudgmental but frank discussion of the effects of his lifestyle on his short- and long-term outcome. Recruiting the patient to be an active partner in making decisions regarding his health care as it relates to the lifestyle he chooses for himself has the potential to be much more effective than having the patient strike a “bargain” with the surgeon by signing a contract. It may be that in many cases such a direct conversation leads the patient himself to conclude that an operation may not be in his best interest.

• References

• 1 Gansera LS, Eszlari E, Deutsch O, Eichinger WB, Gansera B. High-risk cardiac surgery in patients with intravenous drug abuse and/or active hepatitis C or HIV infection: an ethical discussion of six cases. Thorac Cardiovasc Surg 2015; ; Epub ahead of print
• 2 Paul NW. 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/AID. Thorac Cardiovasc Surg 2015; ; Epub ahead of print
• 3 Laczkovics A. Invited commentary. Thorac Cardiovasc Surg 2015; ; Epub ahead of print
• 4 Ziemer G, Ferguson MK, Angelos P. Surgery in patients with intravenous drug abuse and/or active hepatitis C or HIV infection: an ethical discussion of six cases. Thorac Cardiovasc Surg 2015; ; Epub ahead of print
• 5 Carrel T. High risk cardiac surgery in intravenous drug-addicted patients: are there any limits for repetitive surgical treatment?. Thorac Cardiovasc Surg 2015; ; Epub ahead of print