Review of an ethical dilemma: Case history: A 68 year old male is admitted to the surgical ward with a six month history of pain in the right calf. The pain is described as a crampy pain, occuring after minimal activity and is relieved by rest. The pain has increased in severity over the six months. There is no rest pain. PMH: o 2001 – below knee amputation of left leg due to peripheral vascular diasease. o Hypertension o Heart failure SOC H: o Lives alone. o Has home help 3 times a week. o Ex-smoker of 7 years. Used to smoke 20 cigarettes a day. o Occasional alcohol. O/E: o Slight cyanosis of toes. No ulceration or necrosis. o Foot cold. o Femoral pulses normal. Distal pulses not palpable. The patient is investigated by the vascular surgery and the anaestetic teams and is informed that, due to his heart failure, the risk of surgery will be too high, and he will not be offered any surgical treatment. The patient is very upset, fearing this will eventually lead to an amputation of his right leg, and requests surgery even if the risk is high. Ethical dilemma: This patient is demanding an intervetion that the surgeon believes is inappropriate bacause of the high risk to the patient. The surgeon unilaterally declares that he or she will not perform the operation, leaving the patient with little choice. The patient on the other hand, believes that he has the right to choose what intervention would be appropriate, and that the surgeon has an oblegation to use his or her skills to treat him according to his wishes. Thus, the major problem lies in determining who defines appropriateness and too high a risk, the surgeon or the patient? What do the medical facts say? Peripheral vascular disease is a common disorder with a steep age-related incidence that affects 5-10% of the over 55-year age group. (1) Plaques develop causing narrowing of the arteries leading to muscle ischaemia and pain. When such ischaemic pain affects the calfs it is called intermittent claudiaction. Although troublesome and disabeling, the natural history of intermittent claudication often runs a benign cause, with only 1%-3% of claudicants ever requiring major amputation over a 5 year period. (2) Further more, patients with peripheral vascular disease suffer increased cardiovascular morbidity, related mainly to coronary artery disease. This coexisting coronary artery disease poses an increased risk of perioperative myocardial infarction and cardiovascular death. (3) Therefore, the clinical management of intermittent claudication centers around symptom relief and prevention of secondary vascular complications. However, if it can be offered with low risk, selected patients may require endovascular or surgical intervention. Endovascular procedures, most often percutaneous balloon angioplasty with or without stenting, are recommended for short segment stenotic lesions in the aortoiliac and infrainguinal arterial segmants, while operative revascularisation is recommended for patients with long segment and multi-segment disease, especially if obstruction is present. (4) The selection of patients for such interventions is guided principally by the severity of symptoms and is typically limited to those patients where medical therapy has failed, or where critical limb ischaemia puts the patient at high risk of amputation. However, as for any other surgery, the patient’s general health, and likelyhood of surviving the anaestetic and the operation also determines who is offered this intervention. (4) What personell are involved? At least three parties are involved in determining the management of this patient. The surgen and the patient are both involved, as mentioned above. Furthermore, the referring physician plays a major role. As is true for the surgeon, the refering physician evaluates the appropriateness of a particular intervention for a given patient, and on the basis of his or hers personal treshold for risk and responsibility for the overall outcome for the patient, decides wether or not to refer the patient for further intervention. An ethical analysis of this case, requires an understanding of the perspectives on defining surgical appropriateness of the three parties involved. The Surgeon’s Perspective: The definitions of poor surgical risk and medical appropriateness are context dependent and are based on the values and goals of the person defining the term. An analysis of the surgeon’s role in determining what is inappropriate treatment, however, must examine the surgical definition of too poor risk, and the ethical bases for this definintion. Even among the health profession, there is no clear agreement as to the definition of medically or surgically futile or inappropriate treatment. During the 1990s there was an intensive debate about the meaning and usefulness of the expression “medical futility”. (5) Several books have been written on the subject, and a medline search, searching the database from 1966 to 1998, using the words “futility” AND “medical” revealed 752 articles on the subject. Only a few of these articles (43) expressed the opinion of the authors regarding who is to decide about futility, and out of these 43 articles, 35 articles stated that they tought of the physicians as decision makers, in only three cases together with the patients and in one case together with relatives. Only two articles stated that the use of medical futility may jepordise the patients’ autonomy and that the patient or family were to be the major decision makers. (5) However, even though most authors maintain that the physician’s opinion ought to rule when it comes to decide about what treatment is medically futile or inappropriate, there is still no agreement as to the definition of medical futility. In the litterature, four different conceptions have been proposed (6,7): Physiological futility (there is no obligation to provide treatment that is physiologically futile), imminent demise futility (there is no obligation to provide treatment if the patient is unlikely to survive til discharge), lethal condition futility (there is no obligation to provide treatment if the patient may survive for a short while, but the underlying condition will result in death in not too distant future) and qualitative futility (there is no obligation to provide treatment when the resultant quality of life is so poor that a reasonable person would not choose treatment). Therefore, the definition of futile treatment under one concept, may not be covered by another definition of futility, making it problematic for the surgeon to justify his or hers decision on the basis of these definitions. The principle of beneficence, to do god, or in other words to act in such a way that the patient experiences net benefit, (8) becomes relevant here. The surgeon has an obligation to do what he or she thinks will benefit the patient the most over all. Furthermore, the obligation to cause no harm to the patient (non-malificence), (8) can support the surgeons decision not to operate. Therefore, if the surgeon considers the intervation requested by the patient to be potentially harmful to the patient without any compensating benefits, the surgeon has, according to these princilples, not only the right to, but an obligation to refuse treatment. Two other principles which must be explored are integrity and justice. Personal and professional integrity requires the surgeon to master and maintain the knowledge base and clinical skills required for the profession. He or she must use these skills to provide a service for the patient and the profession, but must be aware of his/her limitations. (9) The surgeon is the person ultimately responsible for the outcome of a particular intevention and has a right not to be forced to perform any intervation against his or her will, a view supprted by the british medical councel in “guidelines on good medical practice”. (10) Furthermore, the surgeon has a responsibility to the institution and peers not to preform unnecessary and inappropriate surgeries, which can support such a refusal to treat. In an era of limitied budgeds and increasing limited resources, justice has become an important, though sometimes controversal, principle. (11) Inappropriate or futile surgery on one patient, may result in delay or denial of a needed intervention for another patient. The surgeon has a responsibility to provide the best, and most appropriate treatment for all patients, which does also involve distributing resources appropriately and fairly. If the surgeon feels that performing an operation one one patient, will deprive other patients of resources without any compensating benefit to the patient undergoing the operation, he or she has a right and a responsibility to refuse performing the operation. The referring physician’s perspective: The referring physician will evaluate the appropriateness of a particular intervention from the same ethical principles as the surgeon. Being the first medical contact, he or she has a key role in the management of the patient, functioning as a gatekeeper deciding what options to make available to the patient. The key difference between the surgeon and the referring physician, however, lies in the difference in the two cultures. When the referring physician feels that the likely outcome without surgical treatment is death, he or she may be inclined to refer to surgery as a last desperate hope. Furthermore, in medecine more than in surgery, the culture has been to do anything possible that the patient desires, even if it is considered to be futile or inappropriate. Although the same principles of professional integrity and the right to refuse to treat are upheld by the medical profession, there have been cases where the courts have ordered attempts at resusitation over the objections of medical personel, reinforcing the view that the patient autonomy dominates over these other ethical principles. (12) The patient’s perspective: The patient posesses none of the medical knowledge or skills of a medical professional, and is therefore not equipped to make decisions on medical grounds. He or she cannot determine the likely mortality rate, or the incidence of the various complications. However, the patient himself is the only person who can truly identify what would be in his best interest, and what can be considered too poor a risk. Only the patient can determine if, to him, a high risk of perioperative mortaility and a not insignificant risk of worsening quality of life is worth risking in return for the possibility of some benefit. Patient autonomy, the right to make informed decisions about own treatment, is a concept that has become increasingly important in the last few years. The British medical council states that “you must respect the right of patients to be fully involved in decisions about their care” and “you must respect patient’s autonomy and their right to decide wether or not to undergo any medical intervention. (10) Conclusion: At the moment there is a major division between those who believe that it is always the patient’s right to determine what is, in their own situation, medically appropriate, and those who believe that this responsibility should lie entirely with the physician. The group who is opposed to any physician role in the determination of medical appropriateness argue that nothing in medicine is absolute, and that a surgeon can not determine with one houndred percent certainty that an intervention will not have the desired outcome, and that it therefore will be indefencable to limit the patient’s right to choose for him or her self. Defenders of the physicians role in the determination of what is futile and what is inapproperiate treatment counter that other important principles such as integrity, social justice and the surgeons autonomy and right to refuse, should be valued on the same level as patient autonomy. While the courts are usually relied on for guidance in resolving such conflicts, there seem to be considerable uncertainty regarding the subject, and cases that have so far gone to court have been ruled in the favour of both parties on different occasions. (12, 13) Given the current medical and legal confusion it is important that the physicians discuss openly with other members of the health care team and with the patient, and try to reach an agreement. In the rare case that the disagreement is not resolved at this point, the surgeon must turn to the relevant institutional policies to resolve the dispute. A growing number of hospitals and institutions have developed policies to deal with demands for futile or inappropriate treatments, a trend likely to be reinforced by developments in the field. References: 1. Halperin JL,. Evaluation of patients with peripheral vascular disease. Thromb Res 2002 Jun 1; 106(6):V303- 11 2. Dormandy J, Heeck L, Vig S. The natural history of claudication: risk to life and limb. Semin Vasc Surg 199 Jun;12(2):123-37 3. Garasic JM, Creager MA. Percutaneous interventions for lower-extremity peripheral atherosclerotic disease. Rev Cardiovasc Med 2001 Summer; 2(3):120-5 4. Comerota AJ. Endovascular and surgical revascularization for patients with intermittent claudication. AM J Cardiol 2001 Jun 28;87(12A):34D-43D 5. Lofmark R, Nilstun T. Conditions and consequences of medical futility – from a litterature review to a clinical model. Journal of Medical Ethics 2002 Apr; 28(2) 6. Brody BA, Halevy A. Is Futility a Futile concept? Journal of Medicine and Philosophy 1995 (20): 123-144. 7. Schneiderman LJ, Jecker NS, Jonsen AR. Medical Futility: Its Meaning and Ethical Implications. Annals of Internal Medicine 1990 (112): 949.954. 8. McCollough LB, Ashton CM. A Methology for Teaching Ethics in the Clinical Setting: A Clinical Handbook for Medical Ethics. Theoretical Medicine 1994 (15): 39-52. 9. McCollough LB. Preventive Ethics, Professional Integrity, and Boundary Setting: The Clinical Management of Moral Uncertainty. Journal of Medical Ethics and Philosophy 1995 (20): 1-11. 10. GMC, Guidelines on Good Medical Practice. 3rd Edition. Gmc-uk.org 11. Ubel PA, Arnold RM. The Unbearable Rightness of Bedside Rationing. Archives of Internal Medicine 1995 (155): 1837-1842. 12. In The Matter of Baby K, 16 F. 3d 590 (4th cir. 1994) 13. Gina Kolata. Withholding Care From Patients: Boston Case Asks, Who decides? New York Times April 3, 1995.
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