•Seek the opinions of colleagues and patient family
members
•Do not perform the operation and refer the patient to
another physician
Option 1:
Perform the operation at the patient’s request
Respect for patient autonomy—an established ethical responsibility in medicine—honors the patient’s
right to make decisions that are consistent with his or
her personal goals and values. Autonomy in medicine
applies to both patients and physicians; that is to say,
patients may choose or decline specific treatments or
interventions, and physicians are free to act on their
best judgment, advising a course of treatment that will
yield the greatest medical benefit. 1 A distinction must
be made bet ween the concepts of autonomy and independence. Although patients have a right to and are
encouraged to make decisions about their treatment
plans, those choices should be based on clinical input
from their physicians and on the needs and concerns of
family and other caregivers. 2 In turn, the physician has
a responsibility to offer recommendations and ensure
that the patient can synthesize the information independently and arrive at an informed decision. Physicians
have an obligation to share their unique knowledge and
experiences to help their patients make truly informed
autonomous decisions, regardless of whether they are
in line with the physician’s recommendations.
In this case, several factors have contributed to the
patient’s desire to have the operation. Given that she is
aware of the significant risk of postoperative complica-
tions (including death) that could follow, the fact that
she repeatedly has asked for the operation provides
insight into her suffering. Her goal is clearly to achieve
an improved quality of life, but what if the operation
is unsuccessful? It can be challenging for patients to
grasp potential outcomes that they have not experi-
enced and to compare an unknown future to their
known present. 2 The possibility that her quality of life
might worsen following the surgery is likely difficult
for the patient to imagine. Therefore, the physician is
responsible for providing an accurate explanation of
the full range of perioperative risks so that the patient
can make an informed decision. 2
Patients also may have unrealistic expectations
about the potential outcomes of a procedure and
place unquestioning faith in their surgeons. 3, 4 When
this patient first presented, she was an otherwise
healthy young mother. Through her surgeon’s
thoughtful exam and workup, she was diagnosed
with cancer and underwent a treatment that dramatically changed her life. She lost her voice and,
over time, her ability to eat, but ultimately she was
cancer-free. Given these experiences, the patient
may have become more focused on the possibility
of success than the potential of the operation failing and worsening her condition.
The patient in this case has been informed of the
risks and benefits of surgery and is an adult who is
capable of making her own health care decisions. She
has engaged in a thorough discussion of those risks
and benefits with her surgeon, listened to the surgeon’s
recommendations, and has requested an operation to
restore her swallowing function. Since her initial presentation, the patient has actively participated in her
own care, following up regularly to receive treatment
for the esophageal stenosis and wound healing issues
that resulted as complications of her cancer treatment.
She went to great lengths for several years to preserve
her swallowing abilities and clearly demonstrated that
she was committed and willing to bear the treatments
necessary to regain the ability to swallow. The surgeon
engaged the patient in multiple discussions about the
risks involved and the potential consequences of the
operation. She nonetheless made the autonomous decision to proceed. Although he may disagree with this
course of action, a surgeon who views patient autonomy as a priority would support her decision.
Option 2:
Explain the reasons for not operating at this time
but continue to provide care for the patient
Commitment to beneficence and nonmaleficence
are key factors that guide physicians as they make
recommendations to their patients. Attempts to
determine the risk-benefit ratio of a particular treatment or intervention followed by discussion of the
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