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June 2021

Ethics Corner

Joseph F. Baker, MD
Ethics & Professionalism Committee Member

Resource Constraint and Provision of Spine Care

In New Zealand healthcare is delivered largely by a universal healthcare system with only a very small proportion of patients holding private health insurance. The public hospital system is comprised of regional ‘District Health Boards’ that are funded by the tax payer and provide health care for their local population.

Care for acute pathology - such as infection or trauma, cancer or, pathology which, if left alone could have disastrous consequences, for example spinal cord compression, is guaranteed. However, the provision of elective surgical services is not. This arises from the mismatch between demand/need for surgical intervention and the available resource, that is, the availability of medical staff, nursing staff, operating room capacity and ancillary services such as physiotherapy and rehabilitation services.

As surgeons we have a duty to provide the best possible care to our patients. This involves taking the time to educate our patients about their disease, the natural history of the disease and treatment options including both operative and non-operative1. Surgical practice is under pinned by adherence to core ethical principles - most relevant to routine day to day practice are the four pillars: justice, beneficence, non-maleficence and autonomy2,3. Like much of clinical practice there are no absolutes and these pillars serve only as a guide for us to deliver the best possible care for our patients.

Operative treatment of spinal disorders may range from the most basic single level decompressive procedure to the extremely complex involving major deformity correction with multiple approaches, multiple surgeons (perhaps from different subspecialties), and sometimes in a staged fashion. The amount of resource required to successfully carry out the treatment plan for different procedures can therefore vary dramatically but the aims are often similar – to alleviate pain and restore function.

As surgeons, we also have a duty to use the resources we have available to us wisely. Access to the operating theatre is one of the scarcest resources – in the time it takes to perform a major deformity correction, it may be possible to complete two, three or even more less complex cases and improve the lives of a greater number of  individuals (and their families or dependents) rather than just one. This is an increasing dilemma for those faced with resource constraint and the need to justly allocate them.

Fortunately, in our sphere of practice we have some guidance available. All elective surgery in New Zealand is ‘prioritised’ by a central mechanism created by the Ministry of Health whereby the following factors for each patient needing surgery are considered:

  • Impact of disease on life
  • Severity of pain
  • Likelihood of disease progression
  • Consequences of disease progression
  • Likely outcome of surgical intervention
  • Risk of complications

Although a surgeon may consider that a procedure is appropriate, and the patient accepting of the risks and wanting to proceed, they may fall under the ‘threshold’ and therefore not make the waitlist in the public hospital. The reasons for this may be multiple according to the list above: perhaps they have poor cardiac function and are considered higher risk which may then require additional resource either pre- or post-surgery; perhaps their condition is unlikely to deteriorate rapidly and therefore are prioritised below an individual who has a condition that predictably deteriorates at a faster rate.

There is a ‘bypass’ mechanism to this process: at the surgeon’s discretion patients may be automatically waitlisted if undue delay could have catastrophic consequences. For example, a patient with cervical myelopathy and obvious spinal cord compression or a patient with progressive neurologic deficit does not need to go through the prioritisation system and risk missing a place on the operating list. Currently there is no prioritisation system established for paediatric patients and so a child or adolescent may be treated optimally without fear of missing out based on the demand on the system.

Although we are guided by an official prioritisation system, patients in need do miss out on receiving the optimal care for their condition. This results in prolonged suffering, potential significant reduction in quality of life or perhaps more time of work and financial consequence. The core principle of non-maleficence is key – working within this system we must be sure that no significant harm comes from the delay when a patient does not meet the required threshold to make the surgical waitlist.

The system perhaps undermines surgeon altruism and patient autonomy as the ‘contract’ formed between surgeon and patient may not necessarily be fulfilled if the patient does not meet the required threshold for the waitlist. The justness of the system can be challenged. While it appears just to provide surgical treatment to those in greatest need, an elderly patient who has paid taxes for many years and contributed to society in many other immeasurable ways may feel otherwise if they do not make the waitlist while a younger patient, perhaps one who has never paid tax nor ever will, may make the waitlist. 

However, the system aims to maximise the number of patients receiving care that is truly needed and will improve lives so it aims to provide maximum benefit while accepting that the healthcare system cannot provide treatment to every individual who may have treatable pathology.

The ability to automatically waitlist patients with conditions that, if left alone or treatment deferred, could have a catastrophic outcome (e.g. paralysis) or the ‘salvage’ procedure would be significantly more complex or costly than the proposed index, means that non-maleficence is adhered to as much as possible. The system accepts that some patients will be denied ideal treatment and continue to suffer.

As surgeons whose practice includes management of spinal deformity this system of prioritisation can negatively impact on case numbers. As more complex cases score negatively due to their higher risk profile they are less likely to meet threshold and proceed to operative intervention. The system allows a small (<10%) of cases to be allocated as teaching cases (particularly important when one hosts a Fellow or teaches Residents) and therefore bypass the prioritisation but this requires the surgical waitlist to be manageable and such is the demand on the access to surgery this is not so common in reality. Where proficiency is driven by performing a procedure on a regular basis this potential reduction in case volume is a natural concern.

Practising evidence-based medicine is also prudent to justly allocate resources. While a more complex procedure may confer sound biomechanical advantages over a more traditional approach to addressing pathology, for example when considering whether or not to use an interbody device in the treatment of degenerative spondylolisthesis, more cost-effective treatment options may lower cost, reduce theatre time and ultimately allow the finite resource to be accessible to more. On this basis continued research should be encouraged to help guide clinicians how best to use their time in the operating room.

No healthcare system is perfect. The model in the New Zealand public hospital system facilitates delivery of surgical care to those deemed most in need. Core ethical principles cannot be totally adhered to for each individual case – the overarching societal needs must be considered overt hose of the individual. Perhaps now, as we face the consequences of a pandemic and accept the need rationalise resource allocation even further, we are best placed to appreciate how ethical principles can guide use through these dilemmas that we face on a daily basis. 

 

  1. Todd NV, Birch NC. Informed consent in spinal surgery. Bone Joint J 2019;101-B:355-60.
  2. McCullough LB, Jones JW. Unravelling ethical challenges in surgery. Lancet 2009;374:1058-9.
  3. Paredes AZ, Aquina CT, Selby LV, DiFilippo S, Pawlik TM. Increasing Importance of Ethics in Surgical Decision Making. Adv Surg 2020;54:251-63.

 

Chair: B. Stephens Richards III Committee: Anthony M. Petrizzo; Jochen P. Son-Hing; Gary Fleischer (C); Stuart H. Hershman (C); Christopher J. Kleck (C); Robert F. Murphy (C); Mark Oppenlander (C); Paulo Jose Silva Ramos (C); Anuj Singla (C); William F. Young Jr. (C); Jacob M. Buchowski; David A. Hanscom; Steven D. Glassman, Chair Elect; Sherif M. El Ghamry; Hee-Kit Wong; S. Samuel Bederman; John P. Lubicky