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Thorac Cardiovasc Surg 2016; 64(01): 007-008
DOI: 10.1055/s-0035-1551677
Invited Commentary
Georg Thieme Verlag KG Stuttgart · New York

Invited Commentary

Contributor(s):
Gerhard Ziemer
1   Department of Surgery, University of Chicago Medicine, Chicago, Illinois, United States of America
,
Mark K. Ferguson
1   Department of Surgery, University of Chicago Medicine, Chicago, Illinois, United States of America
,
Peter Angelos
1   Department of Surgery, University of Chicago Medicine, Chicago, Illinois, United States of America
› Author Affiliations
Further Information

Publication History

20 September 2014

28 February 2015

Publication Date:
02 June 2015 (online)

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High-Risk Cardiac Surgery in Patients with Intravenous Drug Abuse and/or Active Hepatitis C or HIV Infection: An Ethical Discussion of Six CasesThorac Cardiovasc Surg 2016; 64(01): 002-005
DOI: 10.1055/s-0035-1551682

We are happy to accept the Editor-in-Chief's invitation to give an Anglo-American perspective on the article by Gansera et al in this issue of The Thoracic and Cardiovascular Surgeon.

We start by congratulating the authors and their clinical surgery group as a whole for just doing the right thing in providing lifesaving treatment for a high-risk group of patients. Nevertheless, it is important to acknowledge the risks involved for caregivers in providing such surgical treatment, and we therefore strongly suggest that only experienced teams of surgeons, anesthesiologists, nurses, and other paramedical personnel should be involved in caring for such patients. Within any group of caregivers, however, the risks should be shared among the experienced personnel available.

We support the decision to operate in all patients reported in the series, although we believe that the decision was questionable in one case (no. 3). The possible argument not to operate in case 3, however, would have been based on the devastating clinical state of the patient rather than on the presence of HIV/AIDS/hepatitis C.

To avoid unnecessary reoperations in patients with infective valve disease, a preferential use of homografts at least for aortic and pulmonary valve replacement may be considered. In the tricuspid valve position, the technique of tricuspid valve excision without replacement is effective for several years (or forever) and is definitely a reasonable option for many patients.

We believe that there are no valid reasons not to operate and reoperate, even numerous times, on patients with these critical infections. Their accompanying addictions (which actually qualify as separate diseases) do not comprise a rationale for nonoperative treatment. Reasons not to operate should only include the short-term futility of the procedure just as the presence of any devastating clinical condition might be an argument against surgery. An estimated 80% mortality in 5 years in and of itself is hardly a contraindication for a surgical procedure because many patients treated for end-stage cardiovascular disease or cancer face similar poor long-term results.

Certainly, cases such as those described in this series raise economic concerns. Our Western health systems are costly and guidelines for limiting treatment should be agreed upon by physicians and the general public. The individual decision to save money by denying potentially lifesaving treatment to a patient should not be left to the physician on duty in these emergency situations.

Howard Markel, in documenting the U.S. AIDS epidemic in the 1980s and 1990s, stated: “The history of epidemics teaches us, again and again, that blame is a central component of these events, whether it is cast upon socially ostracized groups of people, water supplies, politics, or religious beliefs.”[1] (p. 1025) (The problem with blaming the victims of epidemics is that the practice often leads to the inappropriate withholding of medical care from patients.)

In the British Medical Journal in 1987, Raanan Gillon directly refuted the argument that doctors should have the right to decline to treat AIDS patients.[2] He noted that some surgeons have argued that the risks of transmission of AIDS to other patients, to the medical staff, to the doctors themselves, and to their families justify the withholding of surgery from AIDS patients. However, the medical evidence does not support this assertion because the risks are actually not significant. Gillon also astutely noted that it is unacceptable to withhold treatment for conditions that the surgeon may believe have resulted from the “voluntary sexual perversion or mainline drug abuse” of many HIV-positive patients. As he stated: “The norms for withholding medical treatment simply do not include moral disapproval by the doctor of his patient's lifestyle or actions.”[2] (p. 1333)

Although physician attitudes differed with regards to their risk exposure in the early days of the AIDS epidemic, societal expectations were clear. The British General Medical Council stated in 1985, “In pursuance of its primary duty to protect the public the Council may institute disciplinary proceedings when a doctor appears seriously to have disregarded or neglected his professional duties, for example by failing to visit or to provide or arrange treatment for a patient when necessary.”[3] (p 10)

Although there is no national legislation to enforce individual treatment of patients by physicians in the United States, discriminating against any group on the basis of disability is illegal. In one case, the U.S. Department of Health and Human Services concluded that a surgeon violated Section 504 of the Rehabilitation Act of 1973, which prohibits disability discrimination by health care providers who receive federal funds, when he did not perform a much-needed back surgery on an HIV-positive patient. The surgeon's refusal to provide the necessary surgery resulted in termination of Medicaid funding for this provider.[4]

Hospitals in the United States that receive federal funds are prohibited from restricting or denying any patient treatment based on sexual orientation or gender identity. Health provider organizations, including the American Medical Association and American Counseling Association, have made clear that providers and institutions that offer services to the public cannot deny those services to patients based on sexual orientation, gender identity, HIV status, or any discriminatory ground.[5] However, there is currently no punitive action for noncompliance other than withdrawal of state or federal funds.

With more recent but rare cases of Ebola infections in industrialized nations, a change in health care providers' attitude to diseases that may significantly threaten harm to health professionals may be evolving.[6] [7] In October 2014, the Rhode Island Department of Health clarified for its jurisdiction that failure to treat and/or care for patients with Ebola is a potential breech of the licensing law for health care professionals.[8] Basic care is mandated for these patients, but whether surgical procedures that put health care workers at substantial additional risk are mandated remains an unanswered question.

Since the Antonine Plague (also known as the Plague of Galen) in 165 to 180 ad, the risks of health providers in treating infectious diseases have been recognized.[9] Whether now, 2000 years later, we can draw a line between what is and what is not an acceptable risk for health professionals to take in their daily work is unknown. Such a clear delineation should be decided upon jointly by the medical profession and society. Decisions such as these are complex and difficult, but may be increasingly important for the future of the ethical practice of medicine and surgery.