Thorac Cardiovasc Surg 2017; 65(01): 005-008
DOI: 10.1055/s-0036-1597115
Reply by the Authors of the Original Article
Georg Thieme Verlag KG Stuttgart · New York

From Surgical Responsibility to Abstract Ideology

Brigitte Gansera
1   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Germany
,
Walter Benno Eichinger
1   Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Germany
,
Laura Sophie Gansera
2   Department of Cardiology, Klinikum Augsburg, Augsburg, Germany
› Author Affiliations
Further Information

Publication History

23 October 2016

25 October 2016

Publication Date:
28 December 2016 (online)

“Letter to the Editor”

As the authors of the manuscript, entitled “High-risk cardiac surgery in patients with intravenous drug abuse and/or active hepatitis C/HIV infection. An ethical discussion of 6 cases,”[1] we would like to thank the colleagues who made contributions and thoughtful comments, which are of clinical relevance as they report their own experiences. All comments are helpful for serious discussions and decision making in such borderline cases and they gave us inspiration for a general reply.

First, thanks to the authors of the U.S. American group G. Ziemer, M. Ferguson, and P. Angelos, Department of Surgery, University of Chicago[2] who gave us a sophisticated statement about their own perspectives, which are comparable to our own. In this context, the “U.S. solution” about the imperative to treat all patients seems to be well regulated and politically correct, in principle. However, individual practicalities, which occur in daily practice, are difficult to define.

We would like to add the current further course of patient 1 of our series. This 36-year-old recurrent intravenous drug abuser (positive for hepatitis C with a high virus load), was first operated upon in 2009 because of aortic valve endocarditis by one of the authors. As described, the patient was reoperated on by the same surgeon in 2013, because of prosthetic valve endocarditis, a huge abscess cavity, and tricuspid valve endocarditis. After 6 months (at this time the manuscript was still under review), the patient was readmitted, suffering from re-endocarditis of both prosthetic valves. Additionally, he suffered from new embolic strokes. It was verified that he continued intravenous drug abuse even during intensive care unit stay. Discussions about the risk, technical feasibility, and futility of a re-redo arose, and during 2 days of deliberation, the patient died due to acute sepsis and consecutive multiorgan failure.

One comparable case was reported recently by Hull and Jadbabaie.[3] The constellation was similar to the one described by us, but here the family ultimately decided to implement a do-not-resuscitate order, and the patient expired the following day. This highly interesting case report indicates that neither the United States nor Europe has specific recommendations about how many redoes are justified and reasonable. The most recent American College of Cardiology and American Heart Association guidelines only state: “surgery is not indicated if complications (severe embolic cerebral damage) or co-morbid conditions make the prospect of recovery remote.” In this context, we would like to emphasize the closing words in Hull's article: “If clearer guidelines were to be widely adopted, we might provide a better standard of care to these challenging patients.”

Additionally, we would like to thank Ziemer et al for inspiring us with another interesting surgical approach: tricuspid valve excision without replacement. We do not have any experience with this, but the results, as described,[4] are obviously promising.

Second, we would like to thank T. Carrel, University Hospital, Berne, Switzerland, for his comment.[5]

Carrel's experience[6] with this patient cohort confirms the deleterious 30-day mortality (20%) and the poor long-term outcome (1-year survival 50%). During this former period (until 1993), surgery in patients with persisting intravenous drug abuse was mostly not attempted and policy at this time was: one operation and not even a second one. Times have changed, as documented by Weymann et al[7] over a 20-year period (1993–2013): a perioperative mortality of 10% and a 5-year survival rate above 80%, in 20 patients. One must keep in mind that none of this cohort received a redo procedure. At least 11 (55%) patients experienced recurrent infective endocarditis during follow-up and were treated sufficiently with antibiotics. In our experience, most of prosthetic valve endocarditis had to be managed with redo surgery. We absolutely agree that ethics committees are not really helpful. This issue is discussed in detail in the following text.

Third, we would like to thank A. Laczkovics, Ruhr University, Bochum, Germany,[8] for his “clear-cut solution.” Although this commentary is intentionally devoid of ethical considerations, his statements are experience based and credible. “When the indication is given and technical feasibility is obvious, I do it always.” We agree, nevertheless, as nobody will blame us if we fail in such cases and we might be heroes when we succeed. Self-fulfilling prophecy should not be a part of our motivation. His is a really honorable attitude.

Fourth, we would like to thank N. W. Paul, Institute for the History, Philosophy and Ethics of Medicine & Clinical Ethics Committee, University Medical Center, Mainz, Germany, for his commentary.[9] This philosophic reflection presents not a dialogue, but rather a monologue sounding somehow abstract and detached from clinical relevance. This well-written comment seems to be not very helpful regarding our open questions.

At first: Why should futility and ethical justifiability gain an “increasing” importance? Do ethics change with modern surgical techniques, in particular concerning ethics in cardiac surgery?

Ethical considerations per se were existent during the period of our cardiac pioneers. Catchword: Should a patient be transplanted or not? This tone might be understandable in terms of increasing numbers, for example of transcatheter aortic valve implantation (TAVI) in patients with dementia. If this fact, a problem that certainly needs discussion, was the motivation, this should be formulated precisely. Certainly, medical and technical advances raise new questions, but the severity of ethical and moral discussions is and was always alive. Robert Spaemann, my philosophy teacher, wrote[10] [rough translation]: “The breathtaking progress in bio-sciences as well as that of medical technology led to at least partial shattering of the medical professional ethos. Professional ethos is a question of normality. Its integrity becomes manifest in so far and in particular, as there is no need to talk about it, or only when its deviation must be dismissed.” We remember Spaemann's lectures about antique ethics and one of his citations from Plato's goodness-lesson (Politea 488c, basic translation): “when somebody, who never has built or never has navigated a ship, thinks he has to take the rudder...it will be the downfall of the state. Writing principles on the pin board without being versed in the virtuosity of navigation, if this is the ruling concept, makes it foreseeable that nobody will be capable of safe navigation in the future.”

Prof. Paul's remarks suggest in a self-evident manner that abstract reflections on definitions are able to occupy a superior and commanding position. This can, however, be regarded as a fundamental error.

Second: yes, presentation of the cases is arbitrary as they occur in daily practice, and discussion is narrative. The only way to illustrate this topic is based on experience, and explicitly not on schematic definitions. We can talk about statistics, epidemiology, but how to argue with a nurse when her colleague was hurt by a needle of a human immunodeficiency virus (HIV)–positive patient? Is this risk really comparable with: “to get wet when it is raining”[9]? The valueless character of a theoretical calculus of probabilities with “low impact” and “asymmetric risk” might be described with an extreme but appropriate example: Fukushima was assured to be safe, epistemologically at least to nearly 100%, and destroyed the environment of thousands of people. Was this risk calculable? One should ask the people concerned. Our paper tried to open an ethical discourse and strictly intended not to deal with abstract risk stratifications. The manuscript describes practical experiences in a high-risk cohort, in which no guidelines exists. It does not deal with theoretical ideas; therefore it needs little abstract philosophical argument. After carefully reading the comment, one should recognize the intent on the basis of the complexity of questions. As Dr. Weiland yet mentioned within his comment[11]: “probably, epistemologically well founded statistic risks are one thing, daily experience is another.” “Well-founded thoughts” are strongly linked to concrete events. Our medical review was part of the discourse between surgeons and nurses, whether one has the right to say no or not—a discourse, or the attempt of a balancing act, with respect to ethical and live-practical aspects, and therefore just not “a moral reflex.”

Statistics are always the results of events that have occurred and are not predictive precursors of experience. Retrospective mathematical determinations of frequencies in medicine are no reliable prophecies of incidents; at best they are estimations of probabilities. Life does not always depend on statistics. In this context, “scandalized cultural readings of addiction and infection” sounds like ignorance of the real issue. After all, the six exemplary cases were presented against a background of more than 25 years of surgical experience. These six selected patients, operated on during a short-time frame, provoked a discussion of the persistent dilemma. Nevertheless, the authors would like to thank Prof. Paul for his thorough and meditative reflection, albeit his recommendations seem to be of limited relevance for daily surgical practice .

Fifth, we would like to thank four authors, who submitted contributions after publication:

Kathleen N. Fenton, Novick Cardiac Alliance, Memphis, Tennessee, for her thoughtful surgical comments[12] Dr. Hans-Christian Weiland, Munich, Germany,[11] who gave us some insights from his experience with drug addicts from a psychological point of view; Dr. Domanin et al, Milano, Italy,[14] on their comment from the vascular surgery point of view; and Dr. Hermann J. Sons, Ahlbeck, Germany,[15] for his letter to the editor.

Some remarks concerning Dr. Fenton's thoughts: For us, the most important aspect was Dr. Fenton's differentiation between: “what should be done?” and the personal question: “what should I do?”

Some weeks ago we had to operate on a 84-year-old woman with three-vessel disease, severe left main stem stenosis, associated with severe asymptomatic carotid stenosis. After discussion of pros and cons of a simultaneous procedure, the patient asked: “What would you recommend if I were your mother.” A really difficult question. We performed coronary artery bypass grafting (CABG) without carotid endarterectomy, and the old woman went to intermediate care in a fine condition after 8 hours.

This patient was autonomous in her decisions, although she left them to us surgeons.

One major point of Dr. Fenton's remarks seems to be autonomy. Autonomy presupposes the capability to decide. Addiction per se is defined as anancasm, which is the opposite of autonomy. Perhaps it is rather about “recognition” or “acceptance.” Acceptance of human beings, for example in handicapped persons, will allow us to decide together with our patients about the best solutions. However, addicts are not autonomous but dependent on drugs, which dominate their lives and decisions. This phenomenon and the specific psychological dynamics of drug addicts are well described in Dr. Weiland's thoughts.[11]

It is not a free decision of drug addicts to give themselves another “shot” or not, it but depends on their anancasm. The intention of our paper was not at all to discriminate against the behavior of addicted patients; this really “would be unjust,” but to face the dilemma of those who are involved in their treatment and thus carry responsibilities. In this context, Dr. Weiland's remarks about the “helplessness to help” underpin our experience, although the position of a psychotherapist is hardly comparable to that of a surgeon. Moreover, it never was our intention to blame foreign patients. We just added this information to complete personal data.

Our ethical dilemma was not predominantly about whether to operate on foreign patients or not, but to ask about morals and ethics of the foreign university hospital when putting this sick patient on the airplane without consulting us. In our opinion, when talking about responsibilities or ethics, we cannot ignore such realities. Another reality is a not so unusual refusal practice of some departments not to perform such; let us say “ unthankful,” risky, and unprofitable operations but to send the patients (even as emergencies!) to municipal hospitals (such as ours) that have the obligation to treat every patient. After nearly 30 years of experience, we are convinced that this policy is not a matter of lack of experience/infrastructure or lacking capacities, but simply a matter of economic calculations. When talking about responsibility and ethics: how can we exclude reality or such strategies? In this context the statement: “whether or not another hospital or surgeon refused to treat a patient is not ethically relevant”[12] is definitively wrong.

Certainly, such policies should be discussed in a political and not a medical forum.

Another aspect in this context, which fortunately, is not yet practice in Germany: culture of transparency. Since 2014 the U.K. National Health Service (NHS) publishes the individual mortality rates for consultant surgeons on the publicly available Web site “MY NHS,” which was supposed to represent a milestone in transparency. The United Kingdom was the first in the world to ever release such data.

Before this background, Sarah Knapton recently published an article in The Telegraph entitled “One in three heart surgeons refuse difficult operations to avoid poor mortality ratings, survey shows.”[16] Source of this article was the new book of Dr. Samer Nashef, Cambridge, The Naked Surgeon, in which he anonymously polled heart surgeons, asking them whether they had ever boosted their ratings by refusing to operate on patients who they feared might die in the theater. Just under one-third of the specialists who responded said that they had recommended a different treatment path to avoid another death to their score and 84 percent said that they were aware of other surgeons doing the same. Dr. Nashef wrote: “I conducted this survey to find out how much impact transparency has on surgeons' decision-making and tragically it is quite a big influence. About 30 percent of them said that they had turned patients down for surgery even when they knew full well that surgery was in their best interest. So for the high risk patients and sometimes those that could benefit most for an operation, there is evidence that suggest they are not being offered surgery because of concerns about figures and outcomes.”

Thank goodness, the German health system currently kept us surgeons untroubled by such assessments, hopefully keeping in mind that the better surgeons are also often asked to do the most helpless cases, which means they are likely to be penalized under such systems.

Nevertheless, one can speculate about the results of such an anonymous survey when German surgeons would answer it honestly. Thanks to Dr. Domanin and colleagues. We appreciate to receive their comment as it describes their experiences concerning the main topic of the original paper from another point of view: from vascular surgery. This piece is an interesting contribution. It echoes or own experience, in particular concerning the statement that under “impelling conditions or evident emergency no “ifs and/or buts” exist—in such cases our duty is to save lives and give almost a chance to everyone.” However, Dr. Son's remarks: “Our attitude was as simple as wise: what else would/could we do except of surgery” are heroic (we did it the same way!), but they are not referring to the major point of the discussion, notably not to the dilemma about how often we should perform redoes in addicted patients without curable prospects.

In summary, all four invited colleagues purported to be “masters of the situation” do not want to get engaged with uncertainties. Essentially only the editor admitted that such cases sometimes may result in unsolvable conflicts or situations without clear solution strategies, which are worthy of discussion with others. His citation of Mencken puts it to the point[13]: “To think that there is a solution for every human problem is plausible, but wrong.”

Therefore, at last, many thanks to the Editor-in-Chief, who created a new forum in the journal and gave us the opportunity to initiate it. As he seems to be fond of apt quotations, we will finish with the words of Crosby, Stills Nash, and Young:

Teach your children well, their father's hell did slowly go by and feed them on your dreams -the one they picked, the one you'll know by.

Don't you ever ask them why, if they told you, you would cry....[17]

 
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