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All in the family: How close is too close? The ethics of treating loved ones

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All in the family: How close is too close? The ethics of treating loved ones
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  Issues in Surgical Ethics All in the family: How close is tooclose? The ethics of treating loved ones  Jimmy Kerrigan, MD, a  Susan Rovelstad, MD, b Ira J. Kodner, MD, FACS, c  John La Puma, MD, FACP, d and   Jason D. Keune, MD, c St. Louis, MO; Philadelphia, PA; Santa Barbara, CA   From the Department of Internal Medicine  a  and Department of Surgery, c  Washington University School of  Medicine, St. Louis, MO; Department of Surgery, b  Albert Einstein Medical Center, Philadelphia, PA; Chef  Clinic   , d  Santa Barbara, CA  CME INFORMATION  Through joint sponsorship with the American College of Surgeons, thequarterly Ethics articles published by SURGERY will now offer thereader the option of earning 1 CME credit per article. These articles canbe used to earn credit for three years from the time of publication.To receive a CME certificate, participants must read the article and successfully complete a short post-test and evaluation form based onthe Ethics article. Additional information, the article in its entirety,the test/evaluation, and certificate are located on the AmericanCollege of Surgeons website:http://www.facs.org/education/SURGERYethicsarticles.html.The system requirements are as follows: Adobe  Reader 7.0 or aboveinstalled; Internet Explorer   6 and above; Firefox   1.0 and above or Safari   2.0 and above.  Accreditation Statement  This activity has been planned and implemented in accordance withthe Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and SURGERY. The AmericanCollege of Surgeons is accredited by the ACCME to providecontinuing medical education for physicians.  AMA PRA Category 1 Credits   The American College of Surgeons designates this educational activity for a maximum of 1  AMA PRA Category 1 Credit   . Physiciansshould only claim credit commensurate with the extent of their par-ticipation in the activity. Disclosure Information  In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider of this journal CME, mustensure that anyone in a position to control the content of theeducational activity has disclosed all relevant financial relationships with any commercial interest. Theeditor and author(s) of this article were required to complete disclosuresand any reported conflicts have beenmanaged to our satisfaction. How-ever, if you perceive a bias within thearticle, please advise us of the circum-stances on the evaluation form.The requirement for disclosure isnot intended to imply any impro-priety of such relationships, butsimply to identify such relation-ships through full disclosure, and to allow readers to form their own judgments regarding the material. Disclosure of Significant Relationships with Relevant CommercialCompanies/Organizations : Jimmy Kerrigan has no significant rela-tionships to disclose. Susan Rovelstad has no significant relationshipsto disclose. Ira J. Kodner has no significant relationships to disclose. John La Puma has no significant relationships to disclose. Jason D.Keune has a relationship with Emerson as the Emerson ClinicalScholar in Residence of the American College of Surgeons. Objective The learning objectives provided by this ethical challenge involving a cardiac surgeon who must confront doing urgent major heartsurgery on his own mother include the following: 1. Understand-ing the implications and appropriateness of operating on animmediate family member; 2. Determining if it is possible to besufficiently objective and to give first-rate care when closely related to the person on whom you are operating; 3. Understanding theethical challenges regarding the possibility of making the bestdecisions concerning postoperative management of the patient if you know that your choices may not only follow you to eventualdischarge from the hospital but also to family dinners and reunions.  American College of SurgeonsDivision of Education  Supported in part by Emerson (Emerson Clinical Scholar inResidence of the American College of Surgeons to J.D.K.). Accepted for publication January 17, 2011.Reprint requests: Ira J. Kodner, MD, FACS, Department of Surgery, Washington University School of Medicine, 26 PortlandDrive, St. Louis, MO 63131. E-mail: IJKodner@aol.com.Surgery 2011;149:433-7.0039-6060/$ - see front matter   2011 Mosby, Inc. All rights reserved.doi:10.1016/j.surg.2011.01.001 SURGERY 433   Y  OU ,  AS A HIGHLY EXPERIENCED CHIEF OF CARDIAC SURGERY  AT A SMALL TEACHING HOSPITAL , are asked to staff thecase of a 74-year-old diabetic woman presenting with acute, typical chest pain. Cardiac catheteriza-tion has been performed, showing that the patient has three-vessel coronary arterial disease, includinga nearly complete occlusion of the left maincoronary artery. When you enter the catheterization suite, youquickly realize both that the patient is your motherandthaturgentsurgicalrevascularizationisindicated. Your mother requests that you assume her care,as she trusts you and feels that you ‘‘know herbetter’’ than other surgeons and, as such, will take‘‘better care’’ of her. Another attending cardiacsurgeon, who is one year removed from fellowship,is on call and could be at the hospital within 30minutes. Timely transfer to a major tertiary carecenter is not possible. You have four options open to you: Option 1: Operate on your mother and plan to follow her postoperatively, as you are the most experi-enced cardiac surgeon at your hospital and shehas requested that you perform the operation.Option 2: Operate on your mother, but plan to relin-quish her care to another surgeon once the proce-dure is finished.Option 3: Ask the less experienced surgeon on call tooperate on your mother and continue her postop-erative care while you observe directly the sur-geon’s actions and offer ‘‘advice’’ along the way.Option 4: Ask the less experienced surgeon on call tooperate on your mother and resolve not to partic-ipate as a physician in her postoperative care inany formal way. ETHICAL DILEMMA  The dilemma presented here involves the deci-sion as to whether it is appropriate to operate onan immediate family member. Despite years of training that sculpt surgeons’ abilities to approachcases objectively, is it possible for any surgeon to besufficiently objective and give first-rate care whenclosely related to the person under the drape? Is it possible to make the best decisions concerningpostoperative management of the patient if youknow that your choices may not only follow you toeventual discharge but also to family dinners andreunions? DISCUSSION Option 1. Operate on your mother and plan tofollow her postoperatively, as you are the most experienced cardiac surgeon at your hospital,and she has requested that you perform theoperation. First, consideration will be given to  beneficence  ,the bioethical principle that dictates physiciansmust do what is right for their patients. 1 In thisinstance, you are clearly the most experienced car-diac surgeon in your institution. The most benefi-cent act would be to refer patients to the best surgeon available. In this scenario, that person is you. By deferring treatment to another, less experi-enced surgeon, the argument may be made that  you would be acting outside of the patient’s best interest.The second principle offered to guide ethicaldecision making is  nonmaleficence  , which is embod-ied by the Hippocratic dictum  Primum non nocere, literally ‘‘first, do no harm.’’ One way to evaluatethe nonmaleficence of an act is to determine whether the decision to be made exposes a patient to increased risk without evidence of anticipatedbenefit. It is not difficult to imagine that, whenoperating on someone with whom you are emo-tionally involved, like your mother, you may betempted to go to heroic lengths for a perceivedbenefit to the patient. There is a danger of putting your judgment in jeopardy due to your personalconflict of interest.Thorough informed consent is a central featureof the third ethical principle:  autonomy  . Appropri-ate emotional separation between surgeon andpatient allows both the presentation of all options without bias and the objective answering of allquestions in an attempt to help the patient decidethe best treatment for their particular condition.In this scenario, for example, you might find it en-ticing to neglect mentioning to your septuagenar-ian mother that she stands any risk of contractingthe human immunodeficiency virus from a bloodtransfusion, because you know she is a worrier. You also might be tempted to allay her fears withassurances that her procedure will be without complication, whereas this outcome cannot beguaranteed. Alternatively, any patients placed in such asituation may be hesitant to question theirphysician-relatives because of either a desire not to disappoint or an overinflated sense of theirdoctors’ abilities, leading them to consent to morerisky procedures than they would otherwise under-take. Consequently, because of a physician’s temp-tation to inform incompletely and a patient’sdesire to not disappoint by choosing anythingother than what they believe their physician would Surgery March 2011 434  Kerrigan et al    want, true informed consent, free of coercion, canalmost never be guaranteed in these situations.One of the most basic ways to evaluate fairnessor justice when deciding the treatment of a singlepatient is to determine whether that patient isbeing treated the same as any other patient wouldbe in a similar situation. This fourth principlestates that one should not use more or fewerresources on a person because of any factors otherthan their medical problem, such as religious faithor ability to pay.In your mother’s case, perhaps the usualpostoperative course is to sign the patient overto a board-certified surgical intensivist, with yoursurgical fellow following the patient’s courseand alerting you to any potential problems. Yet, would it not be difficult to avoid spending an ex-cessive amount of time poring over your mother’sdaily laboratory results and radiographs, takingtime and attention away from the other patientsunder your charge? Might you initiate extensivediagnostic tests that you might not otherwiseuse and, by doing so, prevent their use for otherpatients for whom they are more immediately indicated? Option 2. Operate on your mother, but plan to relin-quish her care to another surgeon once the proce-dure is finished. This option is perhaps the least defensible usingthe ethical principles explained above. Would themost beneficent act really be to turn your patient over to another surgeon in the postoperativeperiod, a time when that surgeon would be lessfamiliar with her case and perhaps less experi-enced in managing the complications of the pro-cedure that you performed? Ownership of patientsis ingrained in surgeons from medical schoolonward, and transferring care permanently toanother attending surgeon is difficult and not indicated. Option 3. Ask the less experienced surgeon on call tooperate on your mother and complete her postop-erative care while you observe directly his actionsand offer ‘‘advice’’ along the way. This path may be the one that most surgeons would take in this situation, despite its beingfraught with challenges. During the procedureitself, a single surgeon must always be in chargeof the case. Direct participation in the operation inan assistive role may alleviate your ethical concerns while allowing you to lend your expertise to thecase. Following this course of action, however,may engender a false sense of security.Despite assigning yourself an advisory role, any suggestions you make will likely be accepted im-mediately by the less experienced surgeon. This younger surgeon would not want to jeopardizetheir standing in the hospital and their remainingin your good graces by disagreeing with you, evenif he or she thinks that your suggestion increasesrisk to the patient. Alternatively, do you limit your-self to making broad suggestions and delegate day-to-day management to the less experienced sur-geon, leaving your mother open to potential mis-management when you told her preoperatively that you would be helping with her care?In both situations, the balance of beneficenceand nonmaleficence may be skewed by your pres-ence, because your ‘‘advice’’ influences the thera-peutic strategies of an otherwise capable surgeon.It also has the potential to create a coerciverelationship with the other surgeon. Your presencein the room may confer a false sense of security if  your mother over- or underestimates your involve-ment in her care. Truly obtaining informed con-sent from your mother under such circumstancesbecomes difficult. Finally, if something goes wrongand she suffers an adverse outcome, on whom will you and your family place blame --- yourself or theless experienced surgeon who is attending yourmother with your assistance? Option 4. Ask the less experienced surgeon on call tooperate on your mother and resolve not to partici-pate as a physician in her postoperative care inany formal way. This option is most likely the least ethically tenuous of all the options presented here, but it may be the most difficult choice for a surgeon. You will find it necessary to separate yourself from thesituation while trusting your colleague to manage your mother appropriately. This approach allows you to step away from the decision making process.There are no issues concerning beneficence, be-cause you believe that the less experienced surgeonis going to provide the correct treatment for yourmother’s condition. Even though your motherrequested that you care for her, you have theopportunity before surgery to explain your con-cerns to her; after this conversation, most likely, she would allow another surgeon to take her case, at  which time she may provide true informed consent,more fully exercising her autonomy.The possible pitfalls that must be addressed inthis situation regard nonmaleficence. With a lessexperienced surgeon,a patient is probably exposedto some increased risk during complex operativeprocedures. 2,3  Any adverse outcome may leave you Surgery Volume 149, Number 3 Kerrigan et al   435   wondering if the situation could have been avoidedhad you assumed your mother’s care or at least advised the less experienced surgeon. ETHICAL  Although the question of treating family mem-bers may come up rarely in modern surgical prac-tice, the occurrence was common in the past. Thefirst discussion of treatment of family members inthe Western canon came in Thomas Percival’s 1794 Medical Ethics  , the text of which was used in formu-lating the American Medical Association’s (AMA)initial ‘‘Code of Medical Ethics’’ in 1847. 4 Specifi-cally addressing the treatment of family members,this AMA code stated that, ‘‘The natural anxiety and solicitude which he experiences at the sicknessof a wife, child, or anyone who by the ties of consan-guinity is rendered particularly dear to him, tend toobscure his judgment and produce timidity andirresolution in his practice.’’ 5  After several revisions, the most recent iterationof the AMA guidelines on the treatment of family members now reads, in part, ‘‘  .  physiciansgenerally should not treat themselves or membersof their immediate families  .  [except] in emer-gency settings or isolated settings where there is noqualified physician available.’’ 6 Outside of the AMA, many professional organi-zations have said little about the matter. The American College of Surgeons remains mute onthe topic, while Donna Blaszcyk, a representativeof the Joint Commission stated, ‘‘There are no Joint Commission standards which speak to theethics of physicians treating their family members.The organization follow[s] organizational policy and procedure in accordance with state law andregulations. Organizations are also required todefine what constitutes a   conflict of interest   ’’(Personal communication, April 4, 2010). We looked to our state and hospital guidelinesfor further guidance on this topic. The only men-tion on this topic in Missouri law is in the MissouriRevised Statutes 195§070, which prohibits prescrib-ing narcotics for oneself ‘‘except in a medicalemergency.’’ 7 There is no mention of this practice when treating family and no discussion of othertreatments(ie,surgery)codifiedinlaw.InMissouri,the decision is left to the institution or, failing that,the practitioner.For example, Barnes-Jewish Hospital, the insti-tution with which 3 of us are associated, has statedin its  Medical Staff Rules and Regulations   that, ‘‘A Medical Staff member may not render direct pa-tient care to a member of his/her immediate fam-ily without express written permission from his/her Department Chief. In this publication, ‘‘imme-diate family’’ includes a ‘‘spouse, parent, child, orsibling.’’ 8 If there are no institutional guidelinesto follow, physicians are left to independently con-sider whether treating family is something with which they are comfortable.Physicians are still asked to treat family membersmore frequently than one might presume, as dem-onstrated in 2 studies 9,10 published in the early 1990s. The earlier study, published by La Pumaet al, 9 prompted the AMA and the American Col-lege of Physicians to reconsider and modify theirmemberpoliciesinlightofthestudy’sresults,whichrevealed that 99% of surveyed physicians had pro- vided medical advice, diagnosis, or treatment tofamily members, whereas 9% had performedsurgical procedures on relatives.The later study published by Reagan et al 10 ex-plored the demographics of this phenomenon, 1. Am I trained to meet my relative’s needs? 2. Am I too close to probe my relative’s intimate history and physical being and to cope with bearing bad news if need be? 3. Can I be objective enough to not give too much, too little, or inappropriate care?4. Is medical involvement likely to provoke or intensify intrafamilial conflicts? 5. Will my relatives comply more readily with medical care delivered by an unrelated physician? 6. Will I allow the physician to whom I refer my relative to attend him or her? 7. Am I willing to be accountable to my peers and to the public for this care? From La Puma, J, Priest, ER. “Is there a Doctor in the House?: An Analysis of the Practice of Physicians’ Treating Their Own Families.” JAMA .April 1992; 267(13): 1810-1812 Fig.  The 7 questions posed by La Puma and Priest.* Surgery March 2011 436  Kerrigan et al   noting that older physicians and general practi-tioners were, not surprisingly, more likely to havetreated family members. Many of the practitionersinbothofthesestudieswerenotedtohavebeenun-easywithtreatingfamilymembers,citing‘‘perceivedlack of objectivity,’’ ‘‘inadequate assessment,’’ ‘‘diffi-culty refus[ing],’’ 10 and inadequate medical train-ing 9 as sources of anxiety when treating relatives. Why should family members be treated any differentlythanotherpatients?Forsomephysicians,emotional ties may be stronger with friends andcolleaguesthanwithsiblingsorgrandparents.Medi-care only lists spouses, parents, children, siblings,stepparents, stepchildren, stepbrothers, stepsisters,children-in-law,siblings-in-law,grandparents,grand-children, and spouses of grandparents and grand-children as those for whom treatment expenses willnot be reimbursed to the practitioner due to theirstatus as ‘‘immediate relatives.’’ 11 No similar consideration is given to colleagues,friends, lovers, or other associates, some of whommay hold a special place in the hearts of thephysicians asked to treat them. Physicians shouldgive special consideration to the propriety of initiating a doctor-patient relationship wheneverthey are asked to see patients with whom they areacquainted outside of the office or hospital setting.There is no question that, in emergencies, aphysician should treat any patient in need, whetheritisafamilymemberornot;however,forethoughtisrequired in deciding what one should do in anelective situation. In 1991, La Puma and Priest  12 provided 7 questions that should be answered be-fore electively treating family members; however,these may be considered when treating any patient  with whom one is associated closely (Fig).Althoughno simple algorithm will make the decision for aphysicianofwhetherornottotreataparticularindi- vidual, perhaps these questions can serve as a guidein determining to what extent treatment is an op-tionandwhenoneshouldreferapatientfor furthercare from another physician.Thisissueis fraughtwithseveralethicalconcernsand is becoming more complicated with increasedregulation in medical practice. It is likely that Medicare and Medicaid, as well as state medicalboards, will consider this topic in more detail as therules of reimbursement become more detailed.The ethical issues will remain and will requireserious thought from practitioners before treatingfamily members, whether it be suturing a superfi-cial laceration or bypassing an occluded coronary artery. REFERENCES 1. Beauchamp T, Childress JF. Principles of biomedical ethics.6th ed. New York: Oxford University Press; 2008.2. Eltabbakh GH. Effect of surgeon’s experience on the surgi-cal outcome of laparoscopic surgery for women with endo-metrial cancer. Gynecol Oncol 2000;78:58-61.3. Vickers AJ, Bianco FJ, Serio AM, et al. The surgical learningcurve for prostate cancer control after radical prostatec-tomy. J Natl Cancer Inst 2007;99:1171-7.4. Krall EJ. Doctors who doctor self, family, and colleagues. WMJ 2008;107:279-84.5. American Medical Association. Of the duties of physiciansto each other, and to the profession at large: of the dutiesof physicians in reward to professional services to eachother. In: Code of Medical Ethics. Chicago: American Medi-cal Association; 1847. chap 2, article II.6. AMA Code of Ethics. Opinion 8.19-Self-treatment or treat-ment of immediate family members. American Medical Association Web site. www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion819.shtml. June 1993. Accessed November 15, 2010.7. Who may prescribe. Missouri Revised Statutes. Section195.070 RSMo. Revised 2009.8. Barnes-Jewish Hospital medical staff rules and regulations.Barnes-Jewish Hospital 2008;December I(A):1(a).9. La Puma J, Stocking CB, La Voie D, et al. When physicianstreat members of their own families. Practices in a commu-nity hospital. N Engl J Med 1991;325:1290-4.10. Reagan B, Reagan P, Sinclair A.   Common sense and a thickhide.   Physicians providing care to their own family mem-bers. Arch Fam Med 1994;3:599-604.11. 42 CFR 411.12-Charges imposed by an immediate relativeor member of the beneficiary’s household. Code of FederalRegulations - Title 42: Public Health. cfr.vlex.com/vid/411-imposed-immediate-member-beneficiary-19806017. Decem-ber 2005. Accessed May 25, 2009.12. La Puma J, Priest ER. ‘‘Is there a doctor in the house? Ananalysis of the practice of physicians’’ treating their ownfamilies. JAMA April 1992;267:1810-2. Surgery Volume 149, Number 3 Kerrigan et al   437
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