December 2015

Ethics Corner

Kamal Ibrahim, MD, FRCS(C), MA
Ethics and Professionalism Committee Chair

The Ethics and Professionalism committee decided to republish the following article below because of its value in the current healthcare environment. It was written by James Roach, MD when he chaired the committee and published in the newsletter of March 2014. The committee believes this article is important to present to the membership as a part of its educational responsibilities. 

The committee would like to get feedback from the entire membership about the ethical issues which they see as important to discuss, therefore the committee will formulate a survey which will be sent to all members in the near future.

James W. Roach, MD
Ethics and Professionalism Committee Past Chair

In past, SRS E-Newsletters the Ethics Committee has considered several cases involving the principles of moral reasoning.  As a review, these principles include the following:

1.  The principle of non-maleficence – this requires the surgeon to avoid harming the patient. 

2.  The principle of justice – the treatment rendered must be fair to the patient and or society from the stand point of benefits, risks and costs.

3.  The principle of respect for autonomy – this necessitates that the physician respect the patient as an individual, who, when given adequate information, can provide make informed choices regarding treatment. 

4.  The principle of beneficence – when possible the surgeon has a responsibility to help the patient. 

Today we explore the ethics of practicing spine care in the current cost-conscience medical environment.  We explore the principal of justice in this environment by posing the following questions:

  1. What do we ethically owe our patients and what do we ethically owe to society as a whole?  Do these responsibilities conflict? 
  2. Is consideration of cost in the delivery of spine care ethical or do we "owe" all patients all things regardless of the burden on society? 

Physicians typically believe they have the moral requirement to advocate helpful treatments for their patients.  However, this requirement assumes the advocated treatment is believed to be more likely to help rather than hurt the patient.  To be confident that the possible benefit outweighs potential harm, the probability of both outcomes must be known to every reasonable extent.  At the same time society increasingly believes physicians have an obligation to provide cost effective medicine, if possible recommending treatments that accomplish equal outcomes at the lowest cost.  In many instances the obligation to the patient and to society are not in opposition but occasionally they can be, especially when the treatment is expensive and not fully established as beneficial, or perhaps for an individual patient when the potential harm may outweigh the benefit. 

However creating such a list of useful medical interventions is very difficult.  Over 20 years ago, Oregon instituted the Oregon Health Services Commission (OHSC) and charged them with developing a ranking of medical services to fund as many high priority treatments as possible.  The ranking attempted to weigh quality of well-being after treatment and cost-effectiveness.  Over the years the list has required multiple revisions and has struggled to be just and equally applicable and in spite of the best efforts, the plan has not produced an economic benefit as it has experienced multiple budget shortfalls.

Inevitably physicians will be challenged when patients demand a new but expensive and relatively unproven treatment or if the patient requests a workup which includes unnecessary advanced testing.  If the physician declines to provide the treatment or testing, the patient will likely conclude it was only because of the cost.  This necessitates that the surgeon spends sufficient time explaining that outcomes of less expensive treatments can be equivalent or even better than more expensive treatments.  Many spine surgeons would consider the following as examples of the above: the use of general pool blood rather than autologous blood donation, the use of a traditional TLSO brace instead of a brace that costs two or three times more, and limiting advanced image testing in low back pain cases when it is unlikely to further refine the diagnosis.  In addition to the above, spine surgeons can easily find themselves opposed to a family who is seeking a spinal fusion for a severely involved neuromuscular patient who does not have a favorable risk to benefit ratio.    

Thus while physicians do have increasing pressure from society to practice cost effective medicine, unfortunately much of the definition regarding “effective” remains elusive. We must work to continue to provide what we feel is the best for our patients while resisting expensive treatments when an equally beneficial alternative exists.  We must continue providing prudent and appropriately indicated diagnostic workups for our patients and to recommend spinal fusions for the severely involved neuromuscular patients only when we believe the benefit to the individual outweighs the risk of harm and not just because the family demands it.  In addition, individual spine surgeons have an obligation probably to society and certainly to their patients to better elucidate the expected outcomes for the treatment of spinal conditions.  Perhaps establishing spinal surgery registries that can store outcomes data would assist in assessing the risks and benefits of various interventions as well as their cost.  In conclusion, we are directed by the moral principle of justice to ensure the treatment rendered is fair to the patient and society from the stand point of benefits, risks and costs.

Chair: Kamal N. Ibrahim, MD, FRCS(C), MA  Committee: Brian G. Smith, MD; Oheneba Boachie-Adjei, MD; Paulo J.S. Ramos, MD; M. Wade Shrader, MD; John P. Lubicky, MD; Hilali Noordeen, FRCS; Timothy S. Oswald, MD; James M. Eule, MD; Timothy A. Garvey, MD; H. Robert Tuten, MD