J Thorac Cardiovasc Surg 2001;122:1049-1050
© 2001 The American Association for Thoracic Surgery
Reply
Martin F. McKneally, MD, PhD
Department of Surgery and Joint Centre for Bioethics
University of Toronto
Toronto General Hospital
University Health Network
Toronto, Ontario M5G 2C4, Canada
Reply to the Editor:
I appreciate Walker's thoughtful response to my editorial "We don't do that here."
1 We are in agreement that variation between institutions and countries precludes generalizing to a universal guideline about the operative treatment of type A aortic dissections in elderly patients. His claim that "well-trained, compassionate, and honest physicians have no difficulty . . . avoiding overtreatment" in this group is a generalization from the particular experience of a respected senior surgeon at a major center, the Texas Heart Institute. During the week I received Walker's letter, I asked a talented young surgeon, who had just completed a weekend on call at an institution I was visiting, for his opinion; he had repaired three type A dissections that eventful weekend. He told me that families appreciated knowing the consensus of senior surgeons when they are faced with a decision about operations of this magnitude in their loved ones, and he said that he would appreciate a richer description than generally appears in our texts and journals about the principles and values that guide mature judgment in areas of this complexity. I submit that cookbooks are good, and those by master chefs make an especially valuable contribution. Similarly, well thought out policies about the appropriate limits of complex surgical interventions in elderly patients can improve on and strengthen decision making for surgeons and families, without replacing individual judgment. I still favor policy over anecdote, and I encourage surgeons like Walker to help in its development.
The participation of the public in policy decisions that limit care is a larger issue. I raised it to warn against decisions by professionals behind closed doors, because the resources involved are usually public resources. As physicians and surgeons find themselves required to make decisions about the allocation of scarce health care resources, I believe we should follow the advice of the distinguished lawyer-ethicist Haavi Morreim. 2 She maintains that the operating room, the intensive care unit, and the personnel who staff them are not exclusively ours to give or withhold. When we exclude the broader community in which our practice is embedded from health policy decisions, we risk legal and public reprisal. 2,3
I agree with a refinement that Walker introduced in his comments about public participation in health policy. Well-informed laymen, even medically sophisticated, experienced patients, should not participate counterproductively in the medical analysis of resource allocation problems. Their appropriate role is vetting and ratifying institutional policies that guide decision making about the allocation of these resources. I hope other readers will join Walker in commenting on this and other ethical issues raised in our Journal.
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References
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McKneally MF. "We don't do that here": reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians. J Thorac Cardiovasc Surg. 2001;121:202-3.
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Morreim EH. Balancing act: the new medical ethics of medicine's new economics. Washington: Georgetown University Press; 1995. p. 47-51, 85-88.
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Aaron HJ, Schwartz WB. Rationing hospital care: lessons from Britain. N Engl J Med. 1984;330:52-6.
