patient feels that she wants additional treatment and would
like to find another surgeon who would be willing to proceed with an operation, it would be acceptable for the
surgeon to refer the patient to another specialist and turn
over the case to that individual.
Surgery has the potential to improve a patient’s quality
of life and to rid a patient of cancer; it also can take away
a patient’s ability to eat or speak and change the patient’s
physical appearance forever. Each time a patient undergoes an operation, all of the possible outcomes must be
considered and weighed against other treatment options.
It is impossible to predict the outcome of every operation,
so recommendations must be grounded in data and experience. Physicians use data and other objective measures
to justify their advice, but for each individual patient, the
only outcome that matters is the one he or she experiences.
The patient in this case poses an ethical challenge to the
surgeon because every course of action has the potential
to result in harm. If the surgeon chooses to operate as the
patient requests, she may suffer more than she already has
and her family will suffer if she dies or has a painful and
protracted postoperative course. However, if the surgeon
refuses to operate or offer another intervention, the patient
will face a lifetime of severe dysphagia and discomfort,
which may ultimately cause her more harm psychologically and place an enormous burden on her family. The
surgeon’s argument against operating is based on the medical facts of the case. His professional experience, as well as
the patient’s history of poor wound healing and a previous
pharyngocutaneous fistula, inform his recommendation
not to operate. He is upholding his professional responsibility to provide a complete overview of the possible
outcomes of surgery and the estimated likelihood of success given his past experience and the patient’s history. 10
However, the decision to continue conservative management or pursue aggressive treatment ultimately belongs
to the patient. ♦
1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics:
A Practical Approach to Ethical Decisions in Clinical
Medicine. 7th ed. New York: McGraw-Hill; 2010.
2. Elwyn G, Frosch D, Thomson R, et al. Shared decision
making: A model for clinical practice. J Gen Intern Med.
2012; 27( 10):1361-1367.
3. Nabonzny MJ, Kruser JM, Stefens NM, et al. Patient-reported limitations to surgical buy-in: A qualitative
study of patients facing high-risk surgery. Ann Surg.
January 2016 [e-pub ahead of print].
4. Torjuul K, Nordam A, Sorlie V. Action ethical
dilemmas in surgery: An interview study of practicing
surgeons. BMC Med Ethics. 2005;6:E7.
5. Gavriel H, Chowdhury AT, Duong C, Spillane J,
Sizeland A. Poor functional performance following
bidirectional dilatation of severe post radiation
oesophageal stricture. Acta Otolaryngol. 2015;135( 6):
6. Torjuul K, Nordam A, Sorlie V. Ethical challenges in
surgery as narrated by practicing surgeons. BMC Med
7. Pillay B, Wootten AC, Crowe H, et al. The impact
of multidisciplinary team meetings on patient
assessment, management and outcomes in oncology
settings: A systematic review of the literature. Cancer
Treat Rev. 2015; 42( 1): 56-72.
8. Wheless SA, McKinney KA, Zanation AM. A
prospective study of the clinical impact of a
multidisciplinary head and neck tumor board.
Otolaryngol Head Neck Surg. 2010;143( 5):650-654.
9. Schwarze ML, Bradley CT, Brasel KJ. Surgical “
buy-in”: The contractual relationship bet ween surgeons
and patients that influences decisions regarding life-supporting therapy. Crit Care Med. 2010; 38( 3):843-848.
10. Quill TE, Brody H. Physician recommendations
and patient autonomy: Finding a balance between
physician power and patient choice. Ann Intern Med.