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Ann Thorac Surg 2004;77:760
© 2004 The Society of Thoracic Surgeons
Surgeons rarely refer patients to other surgeons, so we should not be surprised that Dr. Click did not refer Mrs. Barefoot, even though other surgeons have more experience and better results with the operation that the patient initially preferred. Should Dr. Click have referred this patient to another surgeon?
As requested, our discussants have given us two different responses to this question. Nicholas Kouchoukos answered, "Yes" and found several ethical transgressions in Dr. Click's handling of the referral. He points to the paramount obligation of physicians to do what is best for the patient rather than to do what is in one's own self interest. On these grounds Dr. Click should have referred Mrs. Barefoot, if only for a second opinion with the possibility that another surgeon could offer the patient a better result.
Lawrence Cohn takes the contrary view that Dr. Click was justified in not referring Mrs. Barefoot, because the standard for whether a surgeon should do a particular operation is not whether he has the largest experience or the best results, but whether he is competent to do it. The originator of a new procedure or an early disciple would nearly always have the largest experience, would be further along the learning curve, and therefore, would usually have better results than most of the surgeons who follow. Thus, says Cohn, if only the surgeons with the best results and largest experience did a particular operation, most patients would not have access to relatively new procedures because few surgeons would be doing it. It is competence, not extraordinary expertise, that a surgeon must offer his patients.
Case histories provide a useful basis for consideration of controversial issues, because they put a human face on and bring to life what otherwise may be a dry theoretical discussion. However, such brief case reports have a serious limitation; the information available is necessarily sketchy, and much of the missing information is germane to the topic. For example, Mrs. Barefoot arrives in Dr. Click's office with a treatment preference based on publicly available information, but her views will be further developed and refined by what the surgeon tells her. How much information has Dr. Click given her? How much has he told her about surgical options other than the two he finally offered? What was her response to that information? How much has her view of anticoagulation and commitment to a Ross operation shifted? How forthcoming was he with outcome data of his own practice and of others? We don't know the answer to any of these questions.
There is also much we do not know about Dr. Click. He believes that "the Ross operation is better for pregnant women," but does he believe the Ross operation to be substantially better or only slightly better than the alternatives? His motivation in not referring Mrs. Barefoot is critically important in judging his actions. What is his practice environment? In his academic department, are the collections he generates only marginally related to his salary? Is his practice fiercely competitive with the more experienced surgeon in town or do they have a collegial relationship?
The answers to these and other contextual questions may very well shift our view of Dr. Click's ethical behavior. This is why principles of ethics play an essential role in medical ethics. They provide the framework upon which concrete details of a particular case can be arranged to help make correct judgments. The principles applicable to this case have been cited by Kouchoukos and Cohn: The surgeon's first priority is the patient's best interest; sufficient factual information must be disclosed to patients to allow them to make informed decisions based on their own values; and surgeons should maintain competence through critical self analysis and provide competent services.
Kouchoukos and Cohn applied these principles but came to different conclusions about Dr. Click's ethical position, in part because they made different assumptions about the content of the surgeon-patient conversation regarding surgical options and outcome probabilities. However, both of these surgeons agree that there are situations in which the ethical course for the surgeon is to refer the patient to a more experienced surgeon. Exactly how a surgeon should be able to recognize these situations is not obvious. One thing is clear: honest and uncompromising appraisal of our own capabilities is the critical requirement for making correct judgments about our own competence, both in general and for particular procedures. For surgeons, this may be the most difficult task of all.
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