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Ann Thorac Surg 2004;77:757
© 2004 The Society of Thoracic Surgeons
a Cardiac, Thoracic and Vascular Surgery, Inc, St. Louis, Missouri, USA
b Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
c Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina, USA
At the Annual Meeting of The Society of Thoracic Surgeons in January 2003, The Ethics Forum sponsored a debate on a topic of great interest to cardiothoracic surgeons. When patients who need an operation are referred to us, we feel obligated for a variety of reasons to provide surgical care to the patient. There may be times when we ought to refer a patient to a more experienced surgeon for the good of the patient, yet we rarely make such a referral.
A case was presented to provide focus for the discussion. Two of our colleagues who have long been among the leaders of cardiothoracic surgery were assigned to either the positive or negative side of the question: Are surgeons ethically obligated to refer patients to other surgeons who achieve better results? The case, the two opposing positions, and a concluding comment follow.
Case
A 23-year-old woman was recently found to have severe aortic stenosis with a small aortic root and is in need of an operation. Mrs. Barefoot was married a year ago, comes from a large family, and plans to have a large family of her own. She is a voracious reader and Internet user, and her search for information has led her to the conclusion that the best treatment for her aortic stenosis is a Ross operation. She realizes that the long-term results of that operation are unclear, but wants to avoid anticoagulation in her childbearing years.
Her cardiologist refers her to Dr. Click, a cardiothoracic surgeon at University Hospital. He examines the patient, reviews her data, and agrees that she needs an operation. He has done 13 Ross procedures with 2 deaths, a mortality rate of 15%, which compares with 2% to 3% at the heart centers with larger volumes, including Crosstown Memorial Hospital, the competing center in the same city. The aortic valve operation he does best is mechanical valve replacement with root enlargement if necessary, which he believes to be a suitable procedure for her valve problem.
Dr. Click believes that the Ross operation is better for pregnant women, although the long-term results are uncertain, and he thinks briefly about referring her elsewhere. Instead, however, he decides not to refer her, but to offer her the choice of a mechanical valve replacement, which can be managed safely during pregnancy, or a Ross procedure.
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