Invited Commentary

Thank you for inviting me to comment on this interesting article. It is a very moving challenge, because it involves medicine and morals. But I hesitate to judge on moral issues in that they exceed my medical responsibility.

Also, there may be too many questions raised and the answers required may be too complex, and the response may exceed the length of the commentary and the patience of the reader. Therefore, I would like to state my principles briefly before commenting on some details.

I became a surgeon because I wanted to help people generally; and my manual dexterity is better that my intellectual ability, so I became a surgeon!

I think the key concept for every surgeon must be the indication. (A famous German surgeon quoted: “For every individual something must be sacrosanct; for a surgeon it must be the indication”). And after considering the indication, of course, feasibility is the next decisive issue. So if you can help somebody with an operation, you have to do it. Or, if the indication is correct and you are not competent enough, another surgeon should do it. This principle is documented best in the treatment of congenital heart disease, where only specialized centers or surgeons operate on these patients.

The indication should not be influenced by the behavior of the patient before or after the first (second or third . . .) operation. Also, a drug-addicted person has to be treated like every patient after a bypass operation, or one who continues to eat and drink and is overweight, or a patient with peripheral vascular disease who continues to smoke. The surgeon has to follow these patients, but must not change the indication and obligation for an operation with a fair chance of success if technically possible. (I have performed cardiac transplantation in a middle-aged man because of severe coronary heart disease, and he reduced his smoking habits from 120 cigarettes per day before to “only” 60 after the procedure; he consequently developed coronary heart disease again in the transplanted heart. He successfully received a triple coronary artery bypass graft and recovered.)

There will always be discussions concerning the risk of an operation. No rules can be established because the risk assessment differs, understandably, from center to center and surgeon to surgeon.

In these circumstances, a surgeon wishing to enhance his or her reputation could be seen to be in a win-win situation: if the operation is successful, the surgeon will be praised, if not, nobody will blame the surgeon as he or she tried heroically to save the patient.

In my humble opinion, in certain circumstances an operation can be rejected with good reasons, except in emergencies. Every layperson can be prosecuted if he fails to render assistance in, for example, a car accident that he or she came on by chance. Therefore, every hospital has to give first (and final?) aid in emergencies.

But if a surgeon develops an animosity due to the behavior of a patient, he or she can, but should not, refuse to operate on the patient for understandable reasons. But it would be wise not to ask moral questions, if only the correct indication should be proven. Then the surgeon avoids taking action against the patient, especially if he or she answers with the truth.

It is good practice that an institution undertaking the first operation feels competent to operate a second or third time. However, due to financial considerations or an adverse prognosis, there is a tendency to reject risky patients with inadequate excuses such as no spare capacity or no space in the intensive care unit. This is difficult to prove; however, if a particular institution repeats this behavior, a referral to the medical council (Ärztekammer) would be advised.