Surgery News - March 2008 - (Page 22) 22 ETHICS THE RIGHT CHOICE SURGERY NEWS • M A R C H 2 0 0 8 Declarations of Intraoperative Complications D) Immediately tell the wife that the operation involved unforeseen complications, but was successful. E) Tell the family and patient only that there were unforeseen complications, but uring an urgent colon resection for that the operation was successful. No surgeon wants to be sued, lose padiverticular bleeding in an 86-yearold man, a medical student, C. Atlas, tients’ confidence, or admit errors. But the spirit of informed consent has holding a retractor, applied too ethically and legally replaced much pressure, creating a 4-cm paternalism in surgery. Mutual tear in the area of the splenic decision making by the physihilum. The repair was comcian and patient (or family) plex but completed satisfactoabout treatment is grounded rily, and the spleen was salin respect for the patient’s right vaged. to autonomy. The patient’s wife is very upKantian ethics demand that set by her husband’s illness. one may neither lie nor deTheir grown children, an atceive, but one may select to torney and a pediatrician, are BY JAMES W. JONES, whom the whole truth, due to arrive soon. What M.D., PH.D., FACS through full disclosure, is told. should be done? A) Do not disclose the tear because This exception, however, cannot apply in there are likely to be no permanent con- the physician-patient relationship. The physician must share with the patient what sequences. B) Provide a detailed description of the is planned preoperatively and how the treatment is proceeding. The extent of distear to the wife immediately. C) Wait until the children arrive before closure is determined by what information giving the wife a detailed description of the physician believes the patient needs in order to participate in treatment decithe error. Editor’s note: The following is condensed from an article published in the Journal of Vascular Surgery ( Jones, J.W.; McCullough, L.B., 2002;132:531-2). D sions. The character of such information should satisfy what is known in law and ethics as the reasonable person standard (Faden, R., Beauchamp, T. A History and Theory of Informed Consent; New York: Oxford University Press, 1986; Informed Consent: Autonomous Decision Making of the Surgical Patient; in McCollough, L., Jones, J., Brody, B., Eds.; Surgical Ethics; New York: Oxford University Press, 1998). The physician is not expected to discuss every aspect of iatrogenic splenic tears, but should explain the risks of complications and the expected treatment outcome. Patients should also be told if and how trainees will participate in their treatment. A 4-cm tear of the spleen, even when repaired successfully, may cause clinically significant complications, The surgeon’s postoperative care will include additional evaluation and response to any other potential complications, which should be shared with the patient or family. Assuming that the patient had agreed to his wife’s involvement in the decisionmaking process, she should be informed about the complication, its management, and its clinical implications, but the surgeon may wait until her children arrive. When the patient can again make decisions, he should be told about the complications, including how the tear occurred. Option B would be ethically acceptable only if the family would not soon be there to support the wife. Options D and E risk lack of disclosure because details of the complications, and their potential effect on the postoperative course, are not explained. Too little information may increase anxiety, causing the patient and his family to fear that the complications are worse than they really are. Option A involves nondisclosure and is ethically unacceptable. The reasonable person standard as the benchmark of informed consent emerged in response to a particularly notorious case of physicians electing not to disclose unpleasant information that patients needed when selecting therapy: the severe complications of cobalt radiation therapy in treating breast cancer (Natanson v. Kline, 186 Kan. 393, 404, 350 P.2d 1093, 1104 [1960]). ■ DR. JONES is a visiting professor at the Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, and an ACS Fellow (jwjones@bcm.tmc.edu). 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