A sixty-year-old man presented to an orthopaedic surgeon with a periprosthetic infection after total knee arthroplasty performed by another surgeon. He underwent removal of the components, placement of an antibiotic spacer, and antibiotic suppression therapy. Eight weeks later, a revision total knee arthroplasty was performed. The patient did well initially but returned four months after the revision with periprosthetic reinfection. The revision components were removed, another antibiotic spacer was placed, and antibiotic suppression therapy was again administered. During the operation, the entire extensor mechanism, including the quadriceps tendon, patella, and patellar tendon, was found to be necrotic and required radical débridement. Five months later, another operation was performed to remove the spacer, and a plastic surgeon was consulted to assist in the wound closure because of the presence of extensive scar tissue. Intraoperative cultures were negative during these two most recent procedures.
The orthopaedic surgeon presented the patient with four treatment options: arthrodesis, resection arthroplasty, amputation, or revision total knee arthroplasty with extensor mechanism allograft and a possible flap closure (rotational or free flap). The patient refused a knee arthrodesis and voiced a strong preference for amputation over arthrodesis. The patient's first choice, however, was to save the knee and to have a second radical revision performed. The surgeon then discussed in detail the risks that would be involved with reconstruction, including the high risk of reinfection and other wound complications. An infection, he explained, could lead to amputation, sepsis, and death. The surgeon also informed the patient that the procedure was not commonly performed, had no proven success rate, and could be fraught with complications. The patient remained steadfast in his choice and elected to undergo radical reconstruction of the knee.
1Department of Orthopaedic Surgery, Winthrop University Hospital, 222 North Station Road, Mineola, NY 11501. E-mail address: email@example.com
2Department of Bioethics Education, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029
3Department of Orthopaedics, Mount Sinai Medical Center, Manhattan Orthopedic and Sports Medicine Group, 1065 Park Avenue, New York, NY 10128
This case raises a number of difficult ethical issues, including informed consent, patient education, autonomy, decisional capacity, paternalism, and physician responsibilities. We would like to address two of these issues. The first issue is the need to balance patient education and informed consent. Can patients be swayed into choosing possibly harmful treatment options because of the type of information that is presented by the physician and the way in which that information is proposed? The second issue is the need to balance patient autonomy and patient welfare. Is the treating physician obligated to comply with the treatment option chosen by the patient?
Informed Consent and Fiduciary Responsibility
When informing a patient of treatment options, should a physician offer every possible option to a patient? Or, instead, should a physician screen the options and only present a limited set? Subsequently, if any possibilities are omitted from the list of offered treatments, should the patient be told that some options are not being offered? Most importantly, in a discussion with the patient, when multiple treatment options are proffered, should they be offered as equivalent options?
In this case, although revision total knee arthroplasty with extensor mechanism reconstruction was a theoretical option, it seemed to have no realistic chance of success, and the high likelihood of reinfection made it downright dangerous. Physicians have a fiduciary responsibility to their patients; that is, they are trusted to consider the interests of their patients and to concern themselves with providing benefits and avoiding harm. The term fiduciary, often associated with financial matters, literally refers to a relationship in which one individual is entrusted to act on behalf of another. Although a great deal of what counts as benefit or harm may be subjective, substantial risks of disability or death and interventions that involve considerable burdens with minimal benefits should be universally recognized by physicians as harms.
When a patient comes to a doctor for help, the patient legitimately expects to receive good advice. In other words, a patient relies on the doctor to offer only options that are reasonable and to steer him or her away from options that would be ruled out in a risk-to-benefit analysis. Patients do not have the training to be able to understand and assess treatment options, and they do not have the experience to be able to evaluate whether or not the risks associated with an intervention are acceptable or unreasonable. It is, therefore, part of the physician's professional responsibility to consider those factors and to offer only recommendations that are informed by that consideration.
In that sense, the physician's fiduciary responsibility necessitates that the offered options be restricted to those that would be offered by a consensus of admirable experts. Because esteemed colleagues are likely to agree that a complex total knee arthroplasty revision with an extensor mechanism allograft in the context of recurrent infection would subject the patient to unreasonable risks, the option should be not offered as a realistic treatment choice. In the interest of fully informing the patient, the orthopaedic surgeon should mention that, technically, the procedure could be attempted, but that no competent surgeon would offer it as a treatment option because the inherent risk of reinfection and the high likelihood of failure make it unacceptable. Providing the information in this way would inform the patient and, at the same time, explain the reasons why the procedure is not an option in his case. This would allow a patient who was considering the possibility of another total knee arthroplasty revision to understand why it was not being offered again, and it would, hopefully, discourage him or her from seeking out the anomalous surgeon who might be willing to try the procedure one more time.
What if, however, the situation were somewhat different? Perhaps a treatment that might be deemed unreasonable when performed by most surgeons could be accomplished with a reasonable chance for a successful outcome by a super-specialist with an extraordinary technique, skill, or proficiency or by a surgeon who had access to special equipment. If these circumstances were well known, it would be incumbent on the initial surgeon to offer the patient a referral to the expert.
Or, what if the surgeon considered herself or himself to be one of those extraordinarily skilled practitioners who could offer the patient a reasonable chance of a good outcome with the otherwise unreasonably risky intervention? Although this belief may constitute an accurate assessment of his or her skills, there is always the danger of personal judgment being distorted by hubris. Consultation with colleagues and a focus on commitment to the patient's good are the only safeguards against overreaching.
Offering a patient treatment options with unacceptably high risks and little chance of a successful outcome is unprofessional and not in accordance with the best interest of the patient. It is important, therefore, that the treating surgeon be aware that the manner in which the treatment choices are presented is just as important as the choices themselves. Physicians have a tremendous influence over the decisions made by their patients. Patients look to us as highly trained professionals who have special knowledge and expertise that most people do not possess. They rely on us to guide them in making a good treatment choice and to help them avoid making choices that would not serve their interests. In the presentation of options, a surgeon can easily slant the discussion and influence the patient to choose the option that the physician prefers. It is therefore critical for a physician to check his or her preference against a standard of professional judgment so that any influence that is exerted is directed at the patient's benefit and no other goal.
In our case scenario, the options of resection arthroplasty, fusion, or amputation all seem to be the more reasonable treatment choices, with a much higher likelihood of success than repeat revision surgery. If, however, all of the options are presented as equivalent alternatives or in a manner suggesting a similar chance of success with comparable risks, the patient would likely be led to choose the limb or function-sparing procedure. When the choices are explained as, “We can try to put in a new knee and get your leg working again, or we can fuse the knee so it never moves, or we can remove the leg,” the patient reasonably concludes that revision is his best option. What patient who heard such a presentation of options would not opt to give the revision one more attempt? The options presented that way would not convey an accurate picture of the risks, or a fair assessment of the expected success of each alternative, or a sense of the professional standard.
Some surgeons may see the situation in totally different terms. They might argue that the duty to respect patient autonomy—that is, the right to determine one's own health-care decisions—obliges the doctor to provide the treatment that the patient chooses. This raises our second ethical issue; namely, once a patient chooses a specific treatment plan, is the treating physician obligated to comply with that treatment choice? As we see it, the view that physicians must comply with their patient's treatment choice misses the point of both respect for autonomy and the special duties of the medical profession.
We should respect the choices of others when their choices flow from autonomy. Respect for autonomy requires moral respect only for those who actually possess the ability to act as a good ruler over themselves, are able to take responsibility for their actions, and can actually understand and appreciate the relevant facts of the situation. When it comes to medical decisions, patients typically lack the ability to fully understand and appreciate the risks involved. Without that ability, and in ignorance of the significance or implications of their preferences, they cannot be held accountable for their choices. That is precisely the reason why doctors are, and can be, sued for malpractice when they go along with a patient's unreasonable refusal of treatment or unreasonable treatment choices. In other words, patients are, at least sometimes, not able to fully judge the risks and likely success of an intervention, and therefore they cannot assess whether or not a particular treatment is a medically reasonable option. That means that they lack autonomy for making a determination with regard to that particular issue; therefore, their judgment on that specific point cannot be autonomous.
If the surgeon were to conclude that a total knee arthroplasty revision in this case would be unreasonably risky, should he or she perform the procedure if the patient is adamant in wanting to try it one more time? We hold that the physician is actually duty-bound to refuse to perform the procedure and to once again explain to the patient that no competent doctor should pursue revision total knee arthroplasty under the circumstances. Of course, the patient would be free to leave the doctor's care and try to find another surgeon. But unless there is some compelling factor that the original surgeon overlooked, it is our hope that no orthopaedic surgeon would offer total knee arthroplasty, as doing so would violate the ethical standard of care.
A treating physician is therefore not obligated to provide a treatment regimen that he or she feels is inappropriate for a particular patient just because that patient desires that particular intervention. In fact, the surgeon would be remiss in providing care that was unreasonable simply because it was the patient's choice. The treating physician should make a sincere attempt to convince the patient to choose a more suitable treatment option. This may require a complete re-explanation of the nature of the problem and the appreciable risks and benefits of each treatment option.
In conclusion, doctors have a responsibility to present their patients with treatment choices that have a reasonable chance of succeeding without causing undo harm. Offering far-fetched therapeutic interventions as acceptable treatment options when they have little chance of success or have unacceptably high complication rates is unethical and not in accordance with acting for the good of the patient. Similarly, presenting all possible treatment options as if they have equivalent chances of being associated with success, failure, or complications is misleading and fails to provide patients with the information that they need for the formulation of an informed decision about treatment. Lastly, if a patient chooses a treatment option that, in the physician's opinion, is inappropriate and a violation of professional standards, the physician should not feel obligated to provide it. Acting for the good of the patient may mean refusing to provide a specific treatment when there is a strong likelihood that the treatment will cause more harm than good.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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