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Ethics in Cardiothoracic Surgery

Ethical Obligation of Surgeons to Noncompliant Patients: Can a Surgeon Refuse to Operate on an Intravenous Drug-Abusing Patient With Recurrent Aortic Valve Prosthesis Infection?

^a Cardiothoracic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
^b Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
^e Division Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
^c Miami-Dade County Attorney's Office, Miami, Florida
^d Kaplan University, School of Criminal Justice Online Program at Kaplan, Miami, Florida
^f Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina

^_* Address correspondence to Dr Sade, Medical University of South Carolina, 96 Jonathan Lucas St, Ste 409, MSC 612, Charleston, SC 29425-2270 (Email: sader@musc.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.

The first 300 words of the full text of this article appear below.

	Introduction

 
Robert M. Sade, MD
One of the most frustrating situations confronting a physician is a noncompliant patient. When a patient receives clear instructions, acknowledges those instructions, fails to follow them, and then slips into even worse difficulty than he had before, we sometimes want to throw up our hands and retreat. Surgeons have a special difficulty in this area when, for example, a patient with peripheral vascular disease in need of a bypass operation finds himself unable to stop smoking and therefore unlikely to gain durable benefit from the operation.

Cardiothoracic surgeons are in a parallel situation when a patient who abuses drugs has an operation and then will not or cannot stop using drugs. Personal lifestyles are very difficult to change, whether or not a patient's addiction is involved. Intravenous drug abusers find it particularly difficult to stop using, but resources are available to help those who wish to break an unwanted habit. Particularly nettlesome is the problem of the patient who abuses drugs intravenously, develops endocarditis, has a valve replacement, and then, after a drug-free period, reverts to drug use. Two experienced surgeons who have opposing views of what should be done in such a situation consider the following case.

	The Case of James Smith

 
James Smith is 29 years old and married with 2 children who are 2 and 4 years old. He is frequently absent from home for extended periods and works odd jobs to support himself. He used marijuana when a teenager, and by his early 20s was regularly using cocaine, including intravenously. He is seen in the emergency department with a febrile illness, and is found to have severe aortic insufficiency due to an aortic valve infection.

The chief of cardiothoracic surgery, Dr William Jones, replaces the aortic valve with a St. Jude Medical prosthesis. Mr Smith does well postoperatively and is discharged . . . [Full Text of this Article]