The Right Choice?

Conflicts and the ethical practice of surgery


Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.

Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.

Dr. Peter Angelos
Dr. Peter Angelos
He was originally evaluated at a small community hospital where he was found to have a sigmoid colon cancer with a markedly dilated colon proximal to the narrowing. Unfortunately, he was also found to have significant undiagnosed and asymptomatic coronary artery disease that prompted the decision to transfer him to my medical center. When he got there, the patient was further worked up and found to have ischemic cardiomyopathy and the need for coronary artery revascularization prior to surgical intervention. His carcinoembryonic antigen was markedly elevated, suggesting the likelihood of metastatic disease even though the site had not yet been identified.

The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.

Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.

The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.

At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.

During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.

The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.

For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.

Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.

The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.

In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.

Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

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