Can a Doctor Perform Surgery on a Family Member

In the physician or surgeon, no quality takes rank with imperturbability. Sir William Osler (Aequanimitas)

You have developed an effective new surgical procedure to care for a heretofore last disease for which all previous therapies were perilous and ineffctive. The statistical data indicate that yous accept mastered the learning bend and tin can perform the functioning with low morbidity and consistently good outcomes. Colleagues are beginning to visit your institution to notice your conduct of the process, and you lot plan to present your results on a small-scale series of patients at an upcoming national coming together. Yous have for many years been recognized equally one of the nearly technically skilled surgeons working in your specialty. This week you've learned that your gramps has merely been diagnosed as suffering from an avant-garde land of the status for which you developed the new operation. What should y'all practise?

• A

  Legal and professional prohibitions prevent you from operating on a family member.

• B

  You must accept the established upstanding principle that a surgeon cannot operate on a family member under whatever circumstances.

• C

  Have a qualified colleague at another establishment exercise the procedure.

• D

  Accept a colleague exercise the procedure under your directly supervision.

• East

  If you and your grandfather agree, you should do the procedure.

Providing medical or surgical treatment to family, friends, and close colleagues has always touched fretfulness that lie undisturbed in caring for all other patients.

^one

• Moreno J.
• Lucente F.

Patients who are family unit members, friends, colleagues, family members of colleagues.

• Google Scholar

Every dr. has had relatives and shut friends ask for medical communication or care of 1 sort or some other. Well-nigh reply hands with a few suggestions or prescription of a routine noncontrolled medication when the ailment is easily identified, modest, and acute. Many fewer are willing to endeavor complex treatment of serious or long-term illnesses among people personally close to them. Surprisingly, one large, well-organized survey plant that 9% of qualified physicians had actually operated on family unit members.

¹

• Moreno J.
• Lucente F.

Patients who are family members, friends, colleagues, family members of colleagues.

• Google Scholar

Twenty-two percent of the study's respondents said they felt uncomfortable treating family. Another written report ranked physicians' condolement levels in treating different relatives.

Reagan et al

found that physicians were most comfy when providing therapy for their own children, and were least at ease when treating grandparents, which is why Grandpa was called for our case.

Emotional overlay markedly affects functioning by contributing all the strengths and weaknesses we refer to when we use the term "being human." Without these feelings we would be without the qualities of empathy, pity, business organization, and much respect for the reasons that there is a medical profession at all. Emotions filter the sensory data we receive and rank-guild its importance through personalization. They augment our thoughts, exaggerating or moderating responses; otherwise identical inputs, thus re-interpreted, may yield entirely different reactions dependent upon their emotional contextual interpretation.

Emotional organization of perceptual input also has a critical survival function that augments discriminative processes. When faced with the information that a saber toothed tiger was on the prowl, our hominid ancestors would have had an entirely different emotional response depending whether the tiger was in their immediate area, at the periphery of the tribe's campground, or across the river in the vicinity of another hostile tribe. Smashing impulsive heroic acts and devotional enhancements to family, nationality, ideals, and religion are stimulated past emotional linkages.

For all the richness emotions add to human life, emotions are generally considered in the earth's keen literature to exist at variance with reason. Considered with words denoting behaviors such every bit impulses, desires, and passions, the ancients, noted philosophers, and the Bible instruct that emotions should be controlled.

The ancient Greek philosophers considered emotional actions to exist of a lower animal nature, assuasive human to act opposite to reason.

As Sir William Osler recommended a century ago, surgeons require disengagement and imperturbability because the performance of major surgery is counterintuitive: in whatever other state of affairs, the slicing of another person with a abrupt instrument and invasion of the internal organs is the gravest manifestation of aggression and sick volition. Surgery harms before information technology heals, and the consequences of misadventure tin be terrible. A clear, disciplined, and decisive mind is critical in evaluating when and how to operate, manage contingencies, and control risks.

These kinds of important considerations aid us to empathise the cautionary view of the American Medical Association's (AMA) Council on Ethical and Judicial Affairs: "Physicians generally should not treat themselves or members of their immediate families."

The Council is concerned about whether the quality of intendance a doctor is able to provide will be adversely afflicted by strong emotional attachments to family members who become patients.

Operating on family unit members tin obscure objective judgments and affect the physician's power to go along with loftier-risk options, even when they are most necessary. The emotionally involved physician may misinterpret or deny data suggesting that a family member's diagnosis is more than serious than expected, or worsening despite treatment. The physician so-affected may depart from his proven routine to perform an "extraordinary" operation, sometimes euphemized as a "blue plate special," behaving badly and ill-advisedly to protect his emotional investment and maybe ultimately doing the patient more than impairment than skillful.

Relatives may themselves sense the awkwardness of a profound disruption of long-accepted family unit roles and find the adaptation difficult when a spouse, child, or sibling of a sudden becomes their administrative doctor. It is not unlikely that relatives may be deeply uncomfortable reporting intimate, peradventure embarrassing, personal information to a treating doc who is likewise a family member, and they may in fact non do so, providing an inaccurate history that ultimately confounds correct diagnosis.

In almost ordinary circumstances, patients empathize that they must adopt a dispassionate posture toward their doctor during the course of treatment, much like the dr.'due south approach to them, then that therapy tin can go on smoothly and rationally. The overlay of normal familial affections (or disaffections) upon the doctor-patient human relationship risks the addition of a mortiferous contaminant to this critical dispassion. Problems of control, authority, and boundaries influence all medico-patient relationships, and are prominent factors in the effectiveness of care; they naturally intensify, and can take unexpected and uncontrollable turns, when dr. and patient have a long-established history in an entirely different context.

^{half dozen}

• Street Jr, R.
• Krupat R.
• Bell R.A.
• Kravitz R.L.
• Haidet P.

Behavior virtually control in the physician-patient relationship effect on communication in medical encounters.

• Crossref
• PubMed
• Scopus (159)
• Google Scholar

The patient who is too your grandfather may be reluctant to accept crucial instructions for post-operative intendance from his grandson, and you may exist unable to invoke the phonation of physicianly dominance necessary to ensure that your grandfather/patient volition act in his own all-time interest.

Your obligation to patient confidentiality volition get complicated as other family members begin to impose their own expectations and emotional demands upon yous. As the treating physician, yous will surely learn things about your granddad and his medical status that would normally be far out of bounds to his grandson, and might fifty-fifty pique your nonprofessional involvement. You volition have to be prepared to compartmentalize that data and wall information technology off from your time to come affectionate relationship with him.

Information technology will be ethically and clinically vital that you do not permit fantasies of heroism to intrude upon your decisions; your grandfather should receive exactly the same preoperative evaluation that y'all would give any other patient, and you should proceed to operate only after establishing reasonable certainty that his avant-garde condition volition be susceptible to your surgical intervention. Amidst the additional, and profound, considerations in treating a relative, especially surgically, will exist the potential damage that a bad issue might have upon your own emotional well-beingness and your future interpersonal family relationships.

⁷

Council on Ethical and Judicial Diplomacy
American Medical Association. Opinion viii:19: Cocky-treatment of treatment of firsthand family.

• Google Scholar

In our fictitious scenario, the application of a novel procedure that has been neither extensively tested nor peer reviewed is heavily laden with risk despite early successes. The ethical principles involved in implementing a new surgical technology need a sound scientific basis, careful development and refinement, and close preparation and supervision of newly minted surgical adherents.

The surgical learning curve is real. Even relatively minor procedural changes in a center renowned for its surgeons' technical skills required a period of accommodation and refinement among experienced thoracic surgeons who began to apply bilateral rather than single internal thoracic artery grafts for coronary bypass.

^nine

• Lytle B.W.
• Cosgrove D.One thousand.
• Loop F.D.
• Borsh J.
• Goormastic M.
• Taylor P.C.

Perioperative take a chance of bilateral internal mammary artery grafting analysis of 500 cases from 1971 to 1984.

• PubMed
• Google Scholar

The pattern is consistently replicated with every technical or technologic innovation in surgery.

^,

Despite published opinions urging special caution, including this one, there are in fact no legal or professional prohibitions confronting operating on family members, eliminating Option A every bit a reason for rejecting the concept. The AMA's position specifies exceptions: "It would not always exist inappropriate to undertake self-treatment or treatment of immediate family members. In emergencies or isolated settings where there is no other qualified dr. bachelor, physicians should not hesitate to treat themselves or family members until another md becomes available."

⁷

Council on Ethical and Judicial Affairs
American Medical Association. Stance 8:19: Self-treatment of handling of immediate family.

• Google Scholar

These considerations reject the absolutist posture of Option B as well. Refusing to provide essential intendance to a person in demand solely on the basis of relativity places an arguable intellectual principle before relief of astute human suffering, and cannot be defended. Option C must be dismissed because there is as yet no surgeon qualified to perform the necessary procedure bachelor at another establishment.

Pick D at first appears to be ethically acceptable. Having a colleague under your direct supervision at the operating tabular array would allow your expertise to benefit your grandfather and would buffer the emotional constraints. Most surgical expertise is transferred to inexperienced surgeons in only such a manner during surgical residencies and fellowships. However, even a very skilled and adept colleague will still exist low on the learning curve, with an added increment of risk to the patient. The possibility that you might have to step in and take over the functioning and manage such risk cannot be ruled out.

Selection E is ethically acceptable, provided that you frankly acknowledge and prospectively manage the sort of personal and professional conflicts we have just described. The reward of accepting Option E is, of course, that y'all are the only surgeon qualified to perform this performance. You tin can assistance to minimize the disadvantages by fully adopting your physicianly personae during the course of treatment. Think of and refer to your granddaddy in clinical reflection and discussion with colleagues as "the patient" and non equally "my grandfather." The words you lot use volition help to frame and subject area your judgment and beliefs. You would exist well brash to thoroughly review the patient's case with an experienced colleague, take the dispassionate authorization of his recommendations, and enquire him to bring together the example as second surgeon.

You should clinch the patient that he tin can speak freely most his health and other concerns, and describe to him how the usual rules for managing confidential information will be rigorously followed: only information that he specifically authorizes will be disclosed to family unit. Y'all should not abridge the consent process or otherwise allow an temper of familiarity to alter your standard patient procedures. Fully explain both the benefits and risks of the proposed operation, neither shielding the patient from such information nor protecting yourself by hanging crepe. You must conceptualize, and discuss with a thoughtful and disciplined colleague, the possibility that the patient could feel major, potentially unmanageable complications. Finally, you should have a frank and detailed conversation with the patient nigh end-of-life care in the event that the performance leaves him ventilator-dependent in the surgical intensive intendance unit or otherwise dysfunctional.

You should present Options D and selection East to the patient, as well as information well-nigh their benefits and risks. You should brand information technology clear to your grandfather that you will implement the alternative that he prefers. Your grandfather has probably lived long enough to have encountered complicated emotions and contending imperatives before, and may even be able to lend y'all some of his own wisdom to untangle the trouble.

References

1. • Moreno J.
   • Lucente F.

   Patients who are family members, friends, colleagues, family members of colleagues.

   in: McCullough L.B. Jones J.W. Brody B. Surgical ideals. Oxford University Press, New York 1998
2. • La Puma J.
   • Stocking C.B.
   • La Voie D.
   • Darling C.A.

   When physicians treat members of their own families. Practices in a community infirmary.

   N Engl J Med. 1991; 325 : 1290-1294
3. • Reagan B.
   • Reagan P.
   • Sinclair A.

   'Mutual sense and a thick hide'. Physicians providing care to their own family unit members.

   Arch Fam Med. 1994; 3 : 599-604

4. Editorial Staff of the Smashing Books. Emotion.

   in: Adled Grand. The great ideas a syntopicon. Encyclopedia Britannica, Inc, Chicago 1952
5. Council on Ethical and Judicial Affairs, Code of Medical Ethics. AMA Press, Chicago 1996
6. • Street Jr, R.
   • Krupat R.
   • Bell R.A.
   • Kravitz R.L.
   • Haidet P.

   Beliefs about command in the physician-patient relationship.

   J Gen Int Med. 2003; xviii : 609-622
7. • Quango on Ethical and Judicial Affairs

   American Medical Association. Stance 8:xix: Self-treatment of treatment of immediate family.

   Code of Medical Ethics. AMA Press, Chicago 2002
8. • Jones J.W.

   Ideals of rapid surgical technological advocacy.

   Ann Thorac Surg. 2000; 69 : 676-677
9. • Lytle B.W.
   • Cosgrove D.M.
   • Loop F.D.
   • Borsh J.
   • Goormastic M.
   • Taylor P.C.

   Perioperative run a risk of bilateral internal mammary artery grafting.

   Circulation. 1986; 74 : III37-III41
10. • Dagash H.
    • Chowdhury One thousand.
    • Pierro A.

    When tin I be proficient in laparoscopic surgery? A systematic review of the evidence.

    J Pediatr Surg. 2003; 38 : 720-724
11. • Gates E.A.

    New surgical procedures.

    Am J Obstet Gynecol. 1997; 176 : 1293-1298

Article Info

Footnotes

James W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor

Identification

DOI: https://doi.org/10.1016/j.jvs.2005.07.018

Copyright

© 2005 The Society for Vascular Surgery. Published by Elsevier Inc.

User License

Elsevier user license |

How you can reuse

Permitted

For not-commercial purposes:

• Read, print & download
• Text & data mine
• Translate the article

Non Permitted

• Reuse portions or extracts from the article in other works
• Redistribute or republish the final article
• Sell or re-utilise for commercial purposes

Elsevier'southward open access license policy

ScienceDirect

Admission this article on ScienceDirect

• View Big Paradigm
• Download Hi-res image
• Download .PPT

Related Articles

florescoulin.blogspot.com

Source: https://www.jvascsurg.org/article/S0741-5214(05)01158-4/fulltext

Share this post