moralandethicalissuesingeriatric surgery · in real life, other issues figure prominently,...

Journal of medical ethics, I980, 6, 71-77

Moral and ethical issues in geriatric surgery

R Reiss 'Meir' Hospital, Kefar-Saba, Israel

Editor's note

After preliminary definitions, the ethical questionsarising particularly in the field of geriatricsurgery are examined. The author finds no ethicaljustification for bias against the elderly patient assuch in the allocation of scarce medical resources,nor for ignoring or overriding his wishes in respectof treatment; solutions must be based on thecircumstances of the individual case. Criteria forwithholding surgery in life-threatening situationsare discussed but not endorsed, though pointers todecision-making are given, notably the value of thesurgeon's sharing responsibility by interdisciplinaryconsultations with colleagues.

IntroductionModem medical technology has given the physicianawesome powers. His decisions not only affectlife and death of the individual, but also have greatinfluence over the rapidly increasing health expen-diture in most countries.In no area is the problem of such decisions as

difficult as in geriatric surgery. At this age thedramatic interference with the course of eventsaffects us daily as clinical surgeons.There is no doubt that the central issue in every

decision to operate or not, is a medical one: whatare the chances of success in a given case ? However,in real life, other issues figure prominently, con-sciously or sub-consciously, the most importantbeing:a) Quality of life, both before and after surgery.b) Capability of the patient to give informedconsent.c) Attitude of the surgeon and his willingness totake risks.d) Economic considerations, such as expenses andavailability of special services (intensive care unit).While each one of us often faces such problems andsolves them according to his beliefs, very littlehas been written on this subject, and no guidingcriteria have been elaborated.At this point we should attempt to discuss some

basic ideas concerning surgical decisions in thegeriatric group. I shall try to formulate somegeneral guide lines and focus on abdominal surgery,the area in which my own experience lies. I hope

that at least some of these ideas will be applicableto major procedures upon the elderly patient inother specialities.

Historical reviewThe ninetieth Psalm states: 'The days of our yearsare three scores and ten and if by reason of strengththey be four score'-figures that have hardly changedto this day. The Greeks were the first to postulatea cause of ageing. Hippocrates (460-377 BC) calledageing an irreversible and natural event that wascaused by a decrease in body 'heat'. Galen (I30-20I AD) further elaborated on this theory andstated that ageing was primarily caused by a changein the body's humors which produced increaseddryness and coldness. Maimonides (II35-I204) theJewish philosopher stated that life was predeter-mined and unalterable but that our lifespan couldbe prolonged by taking suitable precautions. Foralmost a millennium, the ideas of the Greeks andRomans prevailed. No serious research on theprocess of ageing was carried out beyond alchemicalsearch for the elixir of life.

In the last two decades much has been learnedabout old age in terms of statistical data and biology.Alexis Carrel (I873-I944) at the beginning of thecentury erroneously maintained that embryo-cells could be kept alive indefinitely in tissuecultures. Modern studies by Hayflick and othersshow that human diploid embryo fibroblasts have afinite lifespan in tissue culture of about 50 passages.Subsequent studies showed that animal cells hadtissue-culture lifespan that were precise and almostproportional to their in-vitro lifespans.The four most acceptable theories of ageing

available are:

a) The genetic theory - a failure in DNA repli-cation.b) The autoimmunity theory - loss of immuno-logical defence mechanism with age.c) Accumulations of free radicals that causedeleterious changes of biologic systems.d) A vertically transmitted ubiquitous slow virus,that may play a role in the ageing process.

Statistical dataBasic statistical data concerning old age have beenpresented by Comfort. These indicate, in essence,

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that if all known diseases could be cured, manymore people would live to be seventy or eighty,but very few would still be alive at the age ofninety. His theories have so far been confirmedin that, while the percentage of people alive afterseventy is much higher in western countriescompared with the Third World, the same very smallpercentage live to be ninety in both areas.

Another statistical fact not generally appreciatedis that the patient of seventy and above has a notinconsiderable life expectancy. Additional statis-tical data are relevant to the surgery of the old.The percentage of geriatric patients in the popu-lation of developed countries has increased fromabout 2 per cent at the beginning of the centuryto between 4 - 6 per cent now, and is certain toreach I0 per cent in certain countries by the end ofthe century. Furthermore, because of populationtrends in some cities, the percentage of old people inthe population might get close to I5 per cent or more.These numbers do not reflect the tremendous

impact of the elderly on the medical system, becauseof the. high incidence of degenerative metabolicand neoplastic disorders in this age group. Theirincidence among patients hospitalised in a generalhospital in our country is I5-2 per cent, specificallyin departments of general surgery (20 per cent)and urology (34 per cent). Obviously, they are veryheavily represented in certain types of surgicalprocedures, such as acute abdomenal surgery,amputations of gangrenous legs, prostatectomiesand hip nailing.

Because of the frequent need for lengthy andcostly rehabilitation it is not surprising that incountries with comprehensive health insurancesystems, an estimated 24 per cent of all healthexpenditures is related to the geriatric segment ofthe population. Obviously, as this percentage of thetotal expenditure increases, so might the pressureto limit by legislation the astronomical cost ofoptimal medical care for the old.One of the first issues we have to confront is:

What is the proper age to choose as a definitionof a geriatric patient? While the biological dataare often more important than the chronologicalage, for statistical purposes a cut-off point has to bedefined. No doubt this depends on the society welive in: forty-five may be old age in Nepal, seventymay be old age in Jerusalem and New York today,possibly eighty will be considered as the properage in the next two decades. It is very important tomake the distinction between functional age andformal age. It is the onset of biological deteriorationsufficient to interefere with the performance ofadult work tasks, which signals the onset of old agein those societies which accept functional age as astatus determinant. Formal age, in contrast, ispegged to some external event which is artibrarilyinvested with symbolic significance.

In most commercial and industrial enterprises a

worker is defined as 'old' at the age of sixty-five.Obviously, the correlation between functional ageand formal age is very poor, as we physicians knowfrom our practice. In our work we have used theage of seventy as a cut off point for data reportingand investigation.

Attitude of the surgeon'Because it is there' answered George LeighMallory when asked about his desire to climbMount Everest. This type of sentiment reflects theattitude of some surgeons. Many operations areperformed simply because of their feasibility. Asmore and more procedures become feasible andsafe in medicine, the problems of when to performthem become more complicated. Accusations in themedia concerning unnecessary surgery are per-sistent. This is true in modern medicine in general,particularly so in surgery - the most expensive andrisky segment of medicine.The aim of surgery in the elderly is to improve the

chances of the patient to achieve his life expectancy,or make his life more comfortable without unduerisk. Some of the considerations governing suchdecisions are primarily medical and concerncalculable matters such as mortality rate, successin relief of severe symptoms or the possibilityof alternative therapy. Other matters are muchmore complicated and cannot be strictly confinedto conventional medical thinking. Matters such asquality of life, dignity of death, expense to society,selection of patients when services are in shortsupply - such matters are often raised and are verydifficult to solve.

In principle, the decision to operate is no differentat the age of eighty from that at the age of fifty.In real life, however, such a decision is much moredifficult and many more factors have to be con-sidered. Probably nobody could argue that car-cinoma of the rectum or a gangrenous leg should notbe treated surgically in a reasonably well preservedpatient of eighty or even eighty-five. On the otherhand, when the surgeons approach an old patientwith various medical and social problems, thedecision becomes more difficult and clearly involvesethical and moral issues.

In the setting of the modern medical centre, moreoften than not the surgeon is strongly biased infavour of performing surgery. A few of the factorsaffecting this are:a) Enormous technical advances of surgery andresuscitation coupled with the somewhat naivebelief in the powers of medicine.b) Plentiful and sometimes unlimited funds madeavailable by health insurance systems.c) The moral and religious feelings of the patient'sfamily and physician emanating from the Biblicalinjunction 'Thou shalt not kill' as well as theHippocratic oath, are often interpreted as an


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Moral and ethical issues in geriatric surgery 73

absolute and uncompromising formula for thepreservation of life under any circumstances.

To these important reasons one might add some

less important but nevertheless operative in a

hospital setting such as:

a) Fear of malpractice by omission.b) The desire of young surgeon to operate.

c) The necessity to fill operating lists.d) The pride in successfully performing a difficultprocedure.

While the surgeon is often biased in favour ofsurgery, under some circumstances he might beprejudiced in the opposite direction and resent theidea of operating on a very old patient. Cohen in a

recent psychiatric study devoted to the geriatricpatient, discusses the reasons that may prevent thephysician from providing the most effective treat-ment in geriatric cases. Among the most importantfactors he lists the following:

a) The aged stimulate the practitioner's fearsabout his own age.

b) Elderly patients arouse the practitioner's con-

flicts about his relationships with parental figures.c) The practitioner thinks he has nothing tooffer old people because he believes that theycannot change their behaviour or that their prob-lems are all due to untreatable organic brain disease.d) The practitioner believes that his skills will bewasted with the aged because they are near deathand not really deserving of attention.e) The patient might die while in treatment, whichcould challenge the practitioner's sense of import-ance.

While the decision to perform or not to performa surgical procedure on an old and deterioratedpatient may be ethically and morally debatable,there is no such controversy as far as post-operativecare is concerned. Once surgery is performed,there is a binding moral contract between thepatient and the surgeon to use every availabletechnique that can benefit the patient. There isabsolutely no moral or ethical justification towithhold from the old patient techniques such as

intravenous alimentation, intensive care, haemo-dialysis - if medically indicated - for economic or

other reasons. If the number of beds in an IntensiveCare Unit is limited, there is no moral justificationto discriminate against the elderly, as occasionallyhappens. The appropriate allocation of beds shouldbe made on the basis of medical need and chances ofsuccessful treatment in the unit.

Attitude and legal rights of the patient andhis familyAn important role in the decision-making processcan be played by the patient if he is lucid andcapable of informed consent. Fortunately, such is

the case with most elderly patients and the operativedecision is reached after a thorough discussionbetween the surgeon and the patient, just as it isin the younger age group. Is the right of the patientto refuse surgery after proper explanation to belimited? If the surgeon feels that a given operationis absolutely necessary may he try to influence thepatient to have it? Some authors such as Ramsey,seem to imply as much by claiming that the patient'srefusal to undergo surgery should be restricted andreasonable. Ramsey explains that even the com-petent patient should be protected against a morallywrong decision - he should not be allowed toreject life and choose death. In clinical practice wefeel that there is no way to restrict the free choice ofthe patient because of his age. The fact that themedical team recommends surgery and the familysupport the idea does not diminish the moral rightof the patient to refuse treatment. If a patientrefuses to have his gangrenous leg removed, acolostomy constructed or indeed if he refuses anysurgery, one should abide by his wishes and use thebest alternative means of therapy available.A much more complicated problem is that of the

incompetent or not fully competent elderly patient.The decision to be reached in such cases is verydifficult and no unequivocal answers exist. Onetheory maintains that under such circumstances thedecision should be made by the surgeon and heshould be guided by what in his opinion mostcompetent patients would elect to do under similarconditions. Others, such as Zachary or Veatch haveused much more restrictive criteria recommendingsurgery only if meaningful survival could resultfrom the contemplated procedure. The termpassive euthanasia has been used under suchcircumstances - but in our view it hardly applies tonot performing surgery.

Is the law capable of giving us solid guide-linesconcerning so-called passive euthanasia? It doesnot seem so. Louisell, in a lengthy review ofeuthanasia, refuses to lend support to the legali-sation. He states: 'Our era is one that seeks, andoften for good reason, a constant expansion ofjuridical order in human affairs. But not everyhuman relationship stands to profit from completejuridicalisation. The refusal so far of legislatures tointrude into the mercy-death area has been prudent'.The dilemma may be described as follows: shouldsurgery be performed in very old, bed-riddenpatients, with advanced degenerative disorders ofthecentral nervous system, or very advanced carcino-matosis ? If an acute surgical complication, such asbleeding or a peritonitis occurs in such a patient,is one justified under some circumstances not torecommend surgery ? Are there any circumstancesjustifying withholding a surgical procedure in lifethreatening situations and if so, what are the cir-cumstances ? Two types of criteria have beenrecommended and considered:


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a) Ordinary versus extra-ordinary care. Manymoralists and theologians maintain that the dyingor terminal patients should receive only what isdescribed as ordinary or standard treatment. Thereis no obligation, moral or ethical, to use unusualand extraordinary means to prolong artificiallythe life of such a patient. In practice this is not avery useful criterion for a surgeon as it raises morequestions than it answers. Determining whether apatient is terminal or not is practically difficultand often impossible in surgical emergencies.It is even more difficult if not impossible to defineordinary as against extra-ordinary care under suchcircumstances.

Is a surgical procedure of any type extraordinaryor standard ? Are some procedures, such as openingofan abscess or amputation ordinaryand others, suchas radical surgery for cancer extraordinary? Obvi-ously, this distinction is not of great practical use.

b) A second criterion often proposed but equallydifficult to use is the criterion of anticipated qualityof life. It is based on the belief that below a certainstandard of quality and function, life is not worthliving.

According to this argument, if one cannot expectto restore by surgery a minimal standard of qualityof life, no surgery should be proposed. Rhoadsargues very strongly for this approach: 'Themortality of life is IOO per cent. Death is inevitable.There is no special virtue in staving it offindefinitely.But living must be made as comfortable as possible.The general message must be that medicine nowshould be more orientated to the fact that it ismore concerned with the comfort of individualsthan with the prevention of death, which has beenits prime concern for centuries'. While the standardof quality of life is something that cannot be ignored,and will probably be invoked in the future withincreasing frequency at present one should use itwith very great caution.There are great dangers for a surgeon to use the

argument of quality of life, as a justification for notrecommending surgery in cases of acute abdomenor, massive bleeding. In our experience such casesare exceedingly rare. Indeed, if the surgeon feelsthat the likelihood of a successful outcome is highhe will insist on operating, especially under emer-gency circumstances - except under most unusualconditions. If such unusual circumstances dooccur the issue and the reasons for not operatingshould be thoroughly discussed with the patientand the family if at all feasible.A case offering a glimpse of the difficult issues

involved concerning the incompetent patient wasthat of Joseph Saikewicz. While the case dealt withchemotherapy it is also relevant in deciding whetherto operate on an incompetent patient. Late in I977the Massachusetts Supreme Court issued a written

opinion explaining why it had intervened to orderphysicians to stop treating Joseph Saikewicz.Saikewicz was a 67-year-old man suffering fromacute myeloblastic monocytic leukaemia. Whatmade his case unique was that he was profoundlyretarded (IQ of io). He had been institutionalisedsince I923 and was unable to understand the burden-some treatment proposed for him or the choices thatwould have to be made about chemotherapy, whichwould offer at most a temporary remission. Oneshould briefly review the arguments of both sides inthe Saikewicz case, for they are very relevant to thedilemma of operating on old and legally incom-petent patients.

IN FAVOUR OF TREATMENT

a) The life of the patient may be extended.b) The majority of people in a like situationwould probably accept treatment.c) There is no way to determine whether theexpected quality of life should be so low that treat-ment should be refused.

AGAINST TREATMENT

a) Poor chances for long survival.b) Suffering and anguish related to intensivetherapy such as pain, transfusion, tubes dressing,as opposed to relatively painless death in somecircumstances.c) Competent adults in the same situation wouldhave the option to refuse therapy and some, nodoubt, would do so.The decision of the court re-emphasises the

absolute right of the lucid patient to refuse lifeprolonging treatment. However, it does not suffi-ciently clarify the respective role of the surgeon andthe family in border line cases. By placing the finalauthority in difficult cases with the courts, itproposed a solution that is applicable to very fewelective cases and practically no emergencies.Another of the court rulings that is worth mention-ing is a statement concerning the mentally incom-petent patient 'To the extent that this formulationequates the value of life with any measure of thequality of life, we reject it'. This statement of thecourt seemingly rejects completely the considerationof quality of life as a basis of not performing surgeryin life threatening conditions.

In conclusion, the two sets of arguments seemwell balanced and the decisions in concrete caseswill have to depend on the best interest of thepatient. It seems to us that the experienced phy-sician is in a much better position to make suchjudgment than either the family or a court of law.In border-line cases, we have found the followingthree measures to be of great value:a) Consideration of the functional and neuro-logical status of the patient, prior to the onset of theacute problem.


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b) The great value of multidisciplinary consul-tations in a difficult decision, sharing the respon-sibility with a gerontologist, a psychiatrist and agastro-enterologist or other relevant specialist.c) The attitude of the family while not legallybinding is of paramount importance in directingour therapeutic approach to the incompetentpatient. We tend to abide by the family decisionin such matters - in all but the most exceptionalcases.

While its opinion is clearly not legally binding,while it cannot substitute its will for the will of thepatient - in incompetent, senile or comatosepatients - the will of the family must be considered.It is worth while, therefore, to discuss brieflypossible attitudes of the family toward the geriatricpatient.

Firstly the present day public, educated by thecommunication media, is weU aware of the impactof surgical procedures and the use of life-prolongingtechniques. The public is aware of the questionsthat have been raised concerning the capabilitiesof medicine to alter the quality of human life andmay be highly critical of some types of activitiesthat seem natural to us as doctors. One also has torealise that while most families are devoted to theelderly patient under their care, others may beconsciously or sub-consciously strongly biasedagainst the patient for emotional and economicreasons. We would like to conclude that our primaryethical and moral obligation is to the patient andnot to the patient's family, and we should notabdicate too easily the right to make the properdecision medically whilst making every attemptto gain the family's consent and willing cooperation.Such a course will help in the patient's recovery andrehabilitation and it will also diminish the risk oflitigation and malpractice suits.

Economic considerations

The last issue that has to be considered is the eco-nomic one. We live in an era of exploding healthexpenditure and desparate attempts by society tocontain costs.A hospital cost containment bill is at present

being considered by the US Congress. One targetof administrators, and even some surgeons eagerto contain costs, may be the geriatric patient whois practically always not productive, often poorand occasionally severely handicapped.A recent editorial in the New English Journal of

Medicine states in this respect: 'We have been toldthat various economic dislocations make it neces-sary for this country to reconsider its priorities,to husband its dwindling resources and to cut backexpenditure on items that are not of vital nationalimport'. Such considerations are not purelytheoretical - and may very well be used to interfere

with optimal care of geriatric patients. It is ourview that decisions concerning the allocation of aproportion of the nation's resources to medicinein general and to its various subspecialities arepolitical decisions and possible cuts in some areasare necessary for the public good. On the otherhand, the individual surgeon caring for the indi-vidual patients cannot afford to have such con-siderations in mind. Every means of medicaltherapy should be used, provided it is available andbelieved by the surgeon to be beneficial to hispatient. In our view it would be un-ethical, immoraland discriminating to refuse, certain types of carein geriatric patients on the basis of financial con-siderations - while the same therapy is routinelycarried out in younger patients.

Factors infuencing surgical mortality ingeriatric patientsSurgical mortality in the strict sense does notbelong to the moral and ethical issues, yet, if oldage combines with terminal illness or severedebility, the contra-indications may well be greatlyincreased over other patients, and correspondinggreater regard would have to be given to the riskfactor. In other words, whilst a forty:sixty chanceof success may well justify an operation in youngerpatients, such a risk might be unacceptable ingeriatric cases where the expectancy of life is alreadycompromised by factors other than mere old age.The tremendous advances in anaesthesia, intensivecare and surgery have dramatically reduced themortality of major abdominal procedures in theelderly. To comment on this tremendous change inrespect to surgical mortality we would briefly like toreport on our study concerning 325 laparotomiesin patients above seventy. This entire group wasoperated upon after I969 and advanced anaesthesiatechniques (Neurolept analgesia) were combinedwith careful operative and post-operative monitor-ing. The surgical policy was based on the premisethat early surgery is the best solution to abdominalemergencies involving sepsis or blood loss in theelderly patient.The number of laparotomies in elderly patients

has increased by more than ioo per cent over thelast decade. This reflects a new and more optimisticattitude to surgery in such patients. The mortalityin the entire series was remarkably low -6 4 percent. The analysis of different groups shows a lowmortality in elective procedure for benign disease,and for curative cancer procedure. Moderateincrease is noted for emergency procedures inbenign situations. The only group that carries ahigh mortality of30 per cent are palliative proceduresfor patients with advanced intra-abdominal malig-nancy.These figures are a strong argument for trying to

establish the diagnosis by non-invasive techniques


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and trying to avoid surgery in geriatric patientswith advanced malignancy. An important factorinfluencing mortality is the involvement of lifesupport systems. Marked increase in mortalityis present when more than one system is involved.Differences in age within the group and durationof surgery did not play an important role as far asmortality was concerned. One year follow-up in thisgroup demonstrates the excellent result as far asquality of life is concerned. Once patients withincurable malignancy were deducted, more than3/4 of the group were alive and in good functionalstatus one year after surgery.

ConclusionsIn every scientific study we try to draw clear-cutconclusions. This is obviously not possible in thisinstance. We would like, however, to attempt toformulate some rules that may be of help in reachingdecisions in borderline cases. All difficult decisionsin geriatric patients can be established only onan individual basis and based on thorough know-ledge of the individual patient, his mode of life andhis family. Solutions should be found, based on thecircumstances of each case rather than by meansof a dogmatic formula approach. At the edge oflife the decisions have to be based on science buttempered by compassion and humanity.The most important attribute for the surgeon

is to have the correct philosophy in relation to thegeriatric patient. Such a philosophy is guided byclinical experience and judgment and foundedon sound biological principles. The competentand lucid patient has to be treated as a full andwell informed partner in the operating decisionand informed of the risks and alternative modes oftherapy. On the rare occasions when the patientdoes not accept our recommendation and refusessurgery we have to abide by his choice uncon-ditionally. On the freedom of choice of the com-petent patient Judge Schroeder of the KanasSupreme Court in I960 declared: 'A doctor mightwell believe that an operation is desirable ornecessary but the law does not permit him tosubstitute his own judgment for that of the patientby any means'. Legally, the family does not seemto have a definite role in the decisions to be made;in practical terms however, the function of thefamily is of great importance. The family's consentand goodwill, will help in the patient's recovery andrehabilitation and diminish the risk of malpracticesuits.Most of the ethical decisions concerning geriatrics

can only be taken by experts, because they alonehave the expert knowledge. There are, of course,a few ethical decisions which can be painted inblack and white, but most ethical decisions involvea choice between different tones of grey. Hereexpert knowledge is tremendously important. Multi-

disciplinary consultations with experts in fieldsof psychiatry, geriatrics and rehabilitation are ofgreat value to the surgeon and permit sharing ofresponsibility in difficult cases. The distinctionbetween ordinary means of therapy, which areobligatory, and extra-ordinary ones, which areoptional, has very little meaning for the surgeonand cannot usefully be considered while makingdifficult decisions. The notion of expected qualityof life is of course valid and significant but becauseof its subjective and unpredictable nature, it canonly be considered within a spectrum of otherconsiderations.Economic reasons obviously play a determining

part in the availability and delivery of surgicalcare in various parts of the world and even invarious parts of the same country. While this is true,in the case of individual surgeons treating anindividual patient it would be unethical and immoralnot to recommend, for financial reasons, specifictherapeutic methods that can be of benefit to thepatient. It is the duty of the surgeon to use advancedmethods such as haemodialysis, intensive care units,intravenous alimentation for the old patient, justas he would for the young, provided he feels theyare medically indicated and available in his hos-pital. The great complexity of caring for the oldrequiring major surgery, raises the possibilitythat some might attempt the creation of a newsub-speciality: geriatric surgery. In our view suchdevelopment would be useless and might even beharmful to the old surgical patient by separatinghim from the younger group and possibly relegatinghim to second grade care.On the other hand, because of the fact that the

general surgeon as well as many surgical specialistshave to deal with the old with ever increasingfrequency - much more emphasis should be put ongeronto-surgery in medical education and surgicalresidency training. More intensive exposure togeriatric problems will permit the surgeon to makethe individual and social decisions necessary in thecare of the aged with wisdom and authority.

Bibliography

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Cohen, G D (I977). Approach to the geriatric patients.Medical clinics of North America, 6i, 855.

Comfort, A (I956). The biology of senescence, HoltRinehart Wilson.

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