SURGICAL ETHICS CHALLENGESJames W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor

We are pleased that this month’s article in the Surgical Ethical Challenges series has been contributed by a journal reader.The editors encourage the readership to submit articles on matters of surgical ethics for publishing consideration.Submissions should be of a length and format similar to papers typically appearing in Surgical Ethical Challenges over thelast several years. Those considered by the editors to be of sufficient interest and good quality will be published in TheJournal of Vascular Surgery.

The ethics of postoperative responsibility:Where does it end?

Leah B. Rosenberg, BA, New York, NY

The definition of a specialist as one who “knows more aboutless and less” is good and true. Its truth makes it essentialthat the specialist, to do efficient work, must have someassociation with others who, taken altogether, represent thewhole of which the specialty is only a part.Charles H. Mayo 1938

You performed an urgent aortobifemoral bypassprocedure on a 51-year-old daycare worker who pre-sented to a local emergency department with acutelower extremity pain from thrombosis of the distalaorta. The patient has a history of poorly controlleddiabetes, hypertension, and schizoaffective disorder.She has not seen a physician in years. Postoperatively,you discuss the importance of better managing herdiabetes and monitoring her general health status byinvolving other professionals, such as an endocrinolo-gist, psychiatrist, and a general internist to providefurther care coordination. Although the patient ap-pears relieved to have averted her recent health crisis,she expresses anxiety about the future. You are con-cerned that she will not receive the follow-up carethat she needs. How should you proceed? More thanone answer may be appropriate.

A. Provide her with the numbers of the appointmentlines of an endocrinologist, psychiatrist, and a gen-eral internist.

From the Mount Sinai School of Medicine.Competition of interest: none.Correspondence: Leah B. Rosenberg, 50 E 98th St, New York, NY 10029

(e-mail: Leah.Rosenberg@mssm.edu).J Vasc Surg 2006;44:1369-710741-5214/$32.00Copyright © 2006 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2006.08.051

B. Have an office staff member make appointments for thepatient with the three specialist physicians mentionedabove within the next 2 weeks.

C. Contact the three physicians before and after the pa-tient’s appointments to apprise them of her case and toverify that she arrived to the appointments.

D. Manage her diabetes yourself and monitor her vascularstatus over the long-term through continuing visits toyour office.

E. Contact the hospital’s Department of Social Work.

The profession of medicine, with its unique obligationsand responsibilities, stands apart from other occupations.Whether these obligations expand according to the partic-ular needs of a patient is a matter of debate. Although thelegal system requires a minimal standard of physician fidel-ity, ethical clinical practice for patients with extensive psy-chosocial issues may demand additional patient supportand administrative services.

Vascular surgeons are accustomed to attending patientswho are referred by a primary care physician who has apre-existing relationship with the patient. When a patientsuch as the one in the example arrives at an emergencydepartment without a primary care physician, the vascularsurgeon who provides the emergency surgical care findshimself or herself in a complex professional situation. With-out further care coordination among the three expert phy-sicians, the patient will almost certainly fail to receive thecorrect treatment and may require another emergent vas-cular procedure in the future.

The ethical analysis of this case turns on whether thispatient scenario is an example of noncompliance, healthcare system failure for marginalized populations (eg, thementally ill), or a combination of both. What does it meanto attend a noncompliant patient? How might the profes-

sional duties of a surgeon be different for a patient at risk

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for receiving suboptimal care because of psychosocialdifficulties?

Patients who have diseases complicated with psychoso-cial issues often need a level of follow-up and attention thatmay exceed the usual standard of care. Although a vascularsurgeon acting as a referral specialist may not be the desig-nated “attending physician,” the requirements of surgicalprofessionalism entail a higher level of attending to thepatient’s specific needs. This is especially true in the emer-gent phase when the patient is most vulnerable.

Certain diseases, especially those with a primary surgi-cal treatment, have the effect of casting referral specialistsinto the unfamiliar and unanticipated role of temporarycare coordinator for patients who do not have long-standing physician relationships. In this scenario, thesurgeon is, for better or worse, the only physician cur-rently involved in the care of an underserved or otherwisemarginalized patient.

The patient’s risk for failing to receive necessary caremay arise from an inability to access the care because ofpsychologic disease. This reason for care underuse presentsa different kind of ethical scenario than the case of a patientwho knows the risks and autonomously chooses not tocomplete the therapy. The frequently paranoid symptomsof schizoaffective disorder undermine the patient’s abilityfor full autonomous choice but do not completely derailher competence for self-determination.

As Jones et al1 have observed, an “all-or-nothing”approach to compliance may do such patients a disservicebecause their psychosocial limitations allow them a cur-tailed, but present, clinical benefit from the services thatthey do access. Although the physician has numerous re-sponsibilities to the patient, there are also reciprocal obli-gations for the patient to do his or her part in makingprovision of the care possible.

In 2002, the American College of Surgeons publisheda Code of Professional Conduct that was subsequently en-dorsed by its Board of Regents.2 The Code is phrased interms of accepting responsibility for eight items related topatient care and 11 society-level issues. However, no clearreference is made to a responsibility for ensuring a givenpostsurgical patient’s receipt of optimal multispecialtycare. The Code provides an account of a surgeon’s re-sponsibilities bounded by event and temporality. Underthe heading “Scope of Surgical Care,” the followingactivities are included:

. . .preoperative diagnosis and care; educating the patientabout the risks and benefits of [the] operation and obtain-ing informed consent; selection and performance of theoperation; and postoperative surgical care.3

Another statement is unequivocal: “the surgeon’s re-sponsibility extends throughout the surgical illness. Whenthis period has ended, it is appropriate for the surgeon torelinquish the responsibility for management of the pa-tient.”3 As peripheral vascular disease can be said to be asurgical illness insofar as it is a pathologic process that may

be treated with surgery, this statement suggests a clear

marker for termination of the surgeon-patient professionalrelationship—that point at which postoperative care of thesurgical site has reached its resolution. On the other hand,one could argue that the treatment is palliative and will failwith time, requiring periodic follow-up visits. The bottomline remains that one should not attempt to treat diseasesthat go beyond one’s expertise, and this patient has comor-bidities that requires expertise of specialists in addition tothe vascular surgeon.

In light of these concerns, the options after the casemay now be analyzed. Option D represents the most ex-pansive professional role and likely appears to most sur-geons to be an inappropriate incursion into the domain ofother specialties. The diversity of modern medical disci-plines4 allows for individuals to acquire a level of expertknowledge that could not have been possible in past gen-erations and emphasizes the necessity to avoid exceedingone’s competency. Gruen et al5 observes that “superspe-cialization has been necessary to cope with burgeoningknowledge and highly refined procedures.” However, onerepercussion of this type of specialization can be frag-mented patient care borne of poor interprofessional com-munication and, at times, outright “buck-passing” be-tween clinical services.

Most patients with complex diseases that require surgi-cal and nonsurgical treatments as part of a comprehensivecare plan benefit greatly from one physician who acts as a“base of operations” to ensure that the overall course oftreatment remains coherent and appropriate. However,acting as a base of operations or a fully-fledged primary careprovider requires a clinical skill set that vascular surgeons, asreferral specialists, do not normally have. The ACS Codereflects a justified response of “this is not my obligation” tothe excessively wide-ranging demands of Option D. Thetimely referral to the general internist is of paramountimportance to the patient’s clinical course.

In contrast to the extensive professional duties of Op-tion D, Option A presents a far more circumscribed ac-count of the surgeon’s role. In this model, the professionaldomain concerns the pathology of the surgical site inrelative isolation from the manifestations of the systemicdisease and assurance of subsequent treatment. Once thepathology is removed, under the law the surgeon owes thepatient only a recommendation for further completion ofher overall treatment. For a highly organized patient withsufficient resources, the provision of referral phone num-bers may be an adequate next step. For many patients,however, regardless of psychosocial complexities, the “ex-treme experience” of surgery and the worrisome exacerba-tion of a chronic condition may result in a need for extraguidance in decision-making.5

Although Option A is currently the postoperative stan-dard of care for many surgeons, the risk of patients failing toreceive adequate treatment seems too great to accept thisdiscontinuity between the surgical and nonsurgical treat-ment of comorbidities. When surgeons care for patientswith extensive psychosocial needs, however, particularly

those that may include paranoid symptoms, mere satisfac-

JOURNAL OF VASCULAR SURGERYVolume 44, Number 6 Rosenberg 1371

tion of the legal requirement for referral is insufficient forconnecting a patient with the necessary follow-up care.Thus, Option A is ethically unacceptable and should berejected.

Option E, or the referral to the hospital’s Departmentof Social Work, may be warranted if the patient claims aninability to attend future appointments because of financialor family role barriers. In many cases involving patients withserious psychosocial issues, social workers are an invaluableresource and a professional partner. However, the inclusionof social work may be inappropriate for other patients whoare able to coordinate certain aspects of their lives withadditional help from the clinical staff. A successful transferof care for such a patient may include the enhancedfollow-up of Options B and C.

The office-assisted referrals of Options B and C bothsatisfy the ethical claim of increased attention for a patientwith psychosocial issues. Even after the appointments aremade, the patient retains the option of autonomouslychoosing to go to the appointment, consulting anotherphysician, or declining further treatment. A refusal of care isnot the same as underuse of necessary therapies as a result ofstructural barriers. Bickell et al6 have suggested that carecoordination techniques such as designating an office staffmember who makes the necessary appointment phone callsmay provide the patient with a better chance of connectingwith the appropriate referral physicians. In this case, asuccessful transfer of care from the vascular surgeon to ageneral internist, who then provides a seamless transition tofurther coordination and primary care oversight. Option Cmay be appropriate for patients who are in the most tenu-ous psychological, social, or financial situations.

For most patients with psychosocial problems, such asthe example, the office-based referral of Option B wouldassist the patient without appearing unduly paternalistic.Moreover, the patient may obtain better care if the sur-geon’s office staff makes the appointment, as the call will

probably be timelier and underscore the urgency of the

referral for both patient and referred physician. This seam-less approach helps the patient better understand the mul-tispecialty care as a necessary step in a complete course oftreatment and thus may enhance her compliance withrecommended care.

The preceding scenario characterizes the differencebetween what the law requires of a referral and what ethicalmedical practice demands. Miles Little7 speaks of a unique“duty of presence” that surgeons must cultivate in theirclinical relationships. Little writes, “presence is at best areal, physical, cognitive, and engaged presence; at least adelegated presence. . . .”7 The surgeon who chooses Op-tion B considers the transfer of care as part of the overalltreatment of the patient; an extension of the surgical pres-ence that is at once intense and deeply necessary. In thisway, it is possible for vascular surgeons to fully attend totheir patients by planning care around specific psychosocialneeds, without abdicating responsibility for guidance inreferral or personally providing primary care as the attend-ing physician. Although the law provides base-level guide-lines for referral practices, the claims of professional ethicsoften call for interpretation and extension.

REFERENCES

1. Jones JW, McCullough LB, Richman BW. The surgeon’s obligations tothe noncompliant patient. J Vasc Surg 2003;38:626-7.

2. ACS Task Force on Professionalism. Code of professional conduct. J AmColl Surg 2003;197:603-4.

3. American College of Surgeons Board of Regents. Statements on princi-ples, 2004. Available at http://www.facs.org/fellows_info/statements/stonprin.html. Accessed June 21, 2006.

4. Jones JW. Turf wars: the ethics of professional territorialism. J Vasc Surg2005;42:587-9.

5. Gruen RL, Arya J, Cosgrove EM, Cruess RL, Cruess SR, Eastman AB,et al. Professionalism in surgery. J Am Coll Surg 2003;197:605-8.

6. Bickell NA, Mendez J, Guth AA. The quality of early-stage breast cancertreatment: what can we do to improve? Surg Oncol Clin N Am 2005;14:103-17.

7. Little M. Invited commentary: is there a distinctively surgical ethics?

Surgery 2001;129:668-71.