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Ann Thorac Surg 2004;77:757-758
© 2004 The Society of Thoracic Surgeons
Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
My charge in this debate is to defend the position in the scenario described that the surgeon is obligated on ethical grounds to refer the patient who desires a Ross operation to another surgeon who has achieved better results with this procedure. My remarks relate only to the specific conditions put forth in the clinical summary. As with many ethical issues in medicine, there is no clear-cut answer to this dilemma. However, I will offer an argument in support of the supposition that the surgeon has acted unethically in this situation by offering to do the procedure himself. Let us first examine the background information.
What does the patient believe and know?
The patient believes, based up information she has gathered herself, that the Ross procedure is her best option. She knows that she does not want to take oral anticoagulants during her childbearing years. She appears to know the limitations of the procedure, including the possibility of a second operation.
What does the surgeon believe and know?
He believes that the Ross operation is preferable to a mechanical valve replacement for a woman who wishes to become pregnant. He knows that his experience with this procedure is limited and that his operative mortality is higher than that of his colleagues in his own area and elsewhere. He knows that he can perform a mechanical valve replacement with a low operative risk.
What does the surgeon do?
He offers the patient the options, with himself as the operating surgeon, of either the Ross procedure or a mechanical valve replacement.
Is the surgeon acting unethically by offering the patient two options, believing that one is inferior to the other, and by not referring the patient to a more experienced surgeon?
I would answer yes. Ethical is defined in the Random House Dictionary of the English Language as (1) pertaining to or dealing with morals or the principles of morality; pertaining to right and wrong conduct; (2) in accordance with the rules or standards for right conduct or practice, especially the standards of the profession.
Why is the surgeon acting unethically?
I believe he is acting unethically for several reasons: (1) He is offering the patient the option of a procedure (mechanical valve replacement), which he believes is inferior to the alternative procedure (pulmonary autograft) in her particular circumstance; (2) He is not fully abiding by the wishes of the patient to avoid oral anticoagulation. Although her decision to avoid anticoagulation could be questioned, it is nevertheless a valid one, because satisfactory alternatives to replacement of the aortic valve with a mechanical valve exist that do not require permanent anticoagulation; (3) He is not offering the patient the option to discuss the Ross operation with a more experienced surgeon (across town or elsewhere); (4) He is putting his self-interest (ie, doing another operation to increase his numbers, collecting a fee, preserving his referral base, and so forth) above the best interests and welfare of the patient. Therefore, I believe that he has violated the standards of our profession (as described in definition #2 above).
What should the surgeon do to demonstrate ethical behavior?
I believe that he should thoroughly discuss the pros and cons of both the Ross operation and the mechanical prosthesis with the patient and also acquaint her with the other alternatives that would avoid oral anticoagulation (ie, aortic allograft, porcine, or pericardial bioprosthesis) to be certain that she is fully aware of all the available options. He should fully describe the relative risks of the two therapeutic options that he is proposing. He should candidly discuss his personal experience and outcomes with the two procedures. He should most certainly offer the patient the option to discuss the Ross procedure with a more experienced surgeon. Most of all, he should consider the welfare of the patient as more important than his own personal interests.
There are no clearly established rules that pertain to what is right or wrong in this particular clinical situation. The surgeon must make the decision to act ethically based upon his own moral compass, a clear understanding of the implications of all therapeutic options, a critical assessment of his own abilities and limitations, and the general ethical principles of the medical profession, which include the doctrine of primum non nocere.
Footnotes
The debaters were assigned a position to take and were asked to articulate a strong argument in support of the assigned position. The statements contained in their essays should not be construed as representing the authors' personal opinions or beliefs.
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