The ‘I’s have it: Ethics and the vascular community

Who in their right mind would organize the main event of a surgeons’ convention around the topic of unnecessary procedures? Surely this would almost certainly guarantee an empty auditorium. But Dr. Peter F. Lawrence, President of the Society for Vascular Surgery, had the wisdom and courage to do just that when he organized the Stanley Crawford Symposium at the recent Vascular Annual Meeting. Amazingly, he was rewarded not with approbation but rather with a standing-room turnout and congratulatory remarks. For Dr. Lawrence had the foresight to realize that vascular surgeons acknowledge that it is not only physicians from other specialties who are guilty of performing unnecessary procedures but also some of our own. Further, he had the insight that the attendees would share his desire to discuss what, in prior years, may have been a taboo subject.

When he first approached me to present at that symposium on the ethics of unnecessary procedures I thought I would produce a talk that would point out how the SVS could help its members reach an ethical high ground. But I soon realized that the SVS cannot be responsible for its members’ ethics. Ethics is, after all, an individual matter. Yes, I am certain that the vast majority of our members are indeed ethical and place their patients’ interests ahead of their own.

However, as in any large group, there will be individuals who value "I" in the word "Individual" as being more important than the "i" in the word "Ethics." "I" becomes "Me" and, unfortunately, "Me" becomes the defining factor in the equation that describes the doctor and patient relationship.

In preparing the talk I was struck that the word Individual provides clues to unethical behavior. The word contains three I’s, and three words that begin with the letter I are primarily responsible for unethical and unnecessary procedures. They are Indifference, Ignorance, and Incompetence. Perhaps the most unethical is the physician who is Indifferent: Indifferent to data, indifferent to results, indifferent to complaints, indifferent to patient suffering. This physician has no moral compass and will do whatever he or she pleases.

However, let’s start with Ignorance. I don’t want to come across as biased against other specialties, but I will not step away from a position I have frequently stated: Some of our colleagues in other specialties are not sufficiently educated in vascular diseases to be able to recognize that they do not have the judgment or skills to offer appropriate treatment. Nor do they recognize when they should refer to a vascular surgeon rather than attempt a procedure they should not be doing. How else can we explain the full metal jacket superficial femoral artery in a patient who was not even complaining of anything but was found to have a stenotic artery on routine testing?

Well, I’ll give the physician the benefit of the doubt. Perhaps the physician is uneducated about the natural history of peripheral arterial disease and believes that he or she was preventing an amputation. However, with some physicians I believe ignorance is not only a choice but an excuse!

Similarly, Incompetence is an individual problem. It seems it is a little-appreciated fact that surgery and endovascular procedures are not generic. Just as not every golfer can play scratch golf and join the professional circuit, not every surgeon or interventionalist is proficient. Rather, some will have bad results and bad results cause more procedures.

By coincidence, there are other factors that begin with the letter I that may promote unnecessary procedures and that are not necessarily related to individual mischief. Perhaps the most important I word is Insensitivity. It is the inability to recognize that one actually is ignorant, incompetent, or lacking in strength of character to the point of being indifferent to the effects of unethical behavior; that one is indifferent to the suffering of others or the moral responsibility of being an ethical physician.

But it’s not only self-driven issues that promote unethical procedures. It’s those other I’s, and first amongst all must be Income, or rather, lack of it. As long as our government does not adequately reimburse us for our work, some physicians will see volume as the only method to rectify the disparity. I believe that there were fewer inappropriate procedures when there were not as many surgeons, cardiologists, and radiologists and when they were all paid more appropriately. Related to Income is the I of Insurance reimbursement, which also drives procedures. We have only to see what happened to atherectomy after it was finally reimbursed. I am not necessarily implying that the tremendous increase in volume is inappropriate but surely it can be explained only by the fact that we are now being paid for a procedure that previously was not being compensated.