Fundamental Ethical Issues in Unnecessary Surgical Procedures

Abstract

In clinical practice performing any surgical procedure is inconsistent because all surgical procedures carry definitely some degree of risk. Worldwide every year millions of patients go under knife, but many of them are enduring great pain and shelling out thousands and dollars for surgeries they don’t really need. This review work was planned with an intention to focus attention towards it with reporting cited evidences of unnecessary surgical operations and discuss ethical issues concern with it. In present review the references search included standard citations Google scholar, MEDLINE and PUBMED. We also used Google search engine for screening various news concern with highlighting this topic in community and online media. For articles we go through more than 60 articles from worldwide and 12 news media views from Google search in last one year. We used following quotes for their search-unnecessary surgeries, second opinion, ethical issues in unnecessary surgeries. Geographical variations were also kept in view. Our intension was highlighting ethical issues concern with unnecessary surgical operations. Henceforth we excluded such work that does not concern with ethical issues. Unnecessary surgery is that which is medically unjustifiable when the risks and costs are more than the likely therapeutic benefits or relief to the patient based on the patient’s lifestyle requirements. To avoid or minimize such interventions basic seeding of ethics in curriculum and strict laws will definitely helpful in clinical practice. In conclusion, our aim was to highlight this major issue and underline need of competency based medical bioethics education in Indian scenario.

Introduction

In clinical practice performing surgical procedure is inconsistent because all surgical procedures carry definitely some degree of risk [1]. Worldwide every year millions of patients go under knife, but many of them are enduring great pain and shelling out thousands and dollars for surgeries they don’t really need. The estimated figure for the unnecessary surgical operations all over the world varies from 30%-70% [2,3]. It is truly observed that majority of surgeries are performed simply because for profit or corporate target of these hospitals. It is surgeon’s moral responsibility to do best for his patient and think, is it appropriate or valid for a particular patient?

Now-a-days documentation of performing unnecessary surgeries is underlined by number of studies which directly indicate that for some highly controversial operations the fraction that are unwarranted could be as high as 30 percent [4].

Term “unnecessary surgery” is routinely used, however it is ill defined. For example, if a patient has an operation that fails to relieve from symptoms for which it was performed, that patient might well conclude that the operation was unnecessary, regardless of the medical evidence of the importance of the operation. No surgeon ethically wishes to perform an operation that will not help the patient, and certainly not one that may endanger the patient’s life. Physicians have a responsibility to ensure that treatment is appropriate, and most are concerned that their patients perceive them as doing so [4].

Herewith present review, we discussed the facts concern with fundamental ethical issues in unnecessary surgical procedures in India and worldwide scenario. The purpose of this review work is to assess the extent of unnecessary surgery from evidence recorded in the literature and to discuss ethical views concern with it.

Study Methodology

This review study work was planned with an intention to focus attention towards it with reporting cited evidences and discuss ethical issues concern with it.

Data Base Search Inclusion Criteria

In present review the references search included standard citations Google scholar, MEDLINE and PUBMED. We used Google search engine for screening various news concern with this topic to highlighting this topic in community and online media. For articles we go through more than 60 articles from worldwide and 12 news media views from Google search in last one year. We used following quotes for their search- unnecessary surgeries, second opinion, ethical issues in unnecessary surgeries. Geographical variations were also kept in view.

Exclusion Criteria

Our intension was highlighting ethical issues concern with unnecessary surgical operations. Henceforth we excluded such work that does not concern with ethical issues. Majority references were excluded concern with diagnostic approaches, medical fitness etc.

Practices of Unnecessary Surgical Procedures in India and Worldwide

Hysterectomy is performed about 3 times as often in the United States as in England and Wales, and prostatectomy 2.5 times as frequently [5]. Rates vary widely within other countries as well. Among 56 small rural areas in Manitoba, Roos and Roos reported a 2.7 overall variation in surgical rates, with a high of 4.2 times for cataract removal [6]. Wide variations in surgical utilization have been noted in the United Kingdom, Norway and Canada [7]. However, consistency of variations over time in one area and the findings from multiple studies that certain operations display wide variations in use wherever studied provide abundant evidence that most variations are real.

The study involved more than 350,000 malpractice claims, of which 29% involved a delayed diagnosis. Such errors may account for the permanent injury or death of up to 160,000 patients each year, the study found, with researchers noting that “it is probably a lot higher than that.” Case in point, when all medical errors, not just diagnosis errors, are taken into account, the rate of medical harm occurring in the US is estimated to be over 40,000 harmful and/or lethal errors each and every day [8].

In 1987 more than 230,000 Americans had coronary bypass operations, twice as many as in 1980, but only few are life-and-death affairs performed on patients who have just had heart attacks. It has been estimated that 44% of bypass operations are inappropriate. Life expectancy is improved only if the left main artery was diseased and if there was damage to the left ventricular muscle. Glue ear involves a painless accumulation of mucus-like fluid in the ear and can cause partial deafness. Some 100,000 operations are conducted each year in England and Wales. A controlled trial involving 149 children found that about one-third of the operations were inappropriate, as surgery was effective only for those with a severe form of the disease [9]. The Harvard University School of Public Health estimates that as many as 1.3 million Americans suffer disabling injuries in hospitals yearly, and 198,000 of those may result in death; 7 out of 10 of which were preventable (48% from faulty surgery), and 1/3 from negligence [10].

Practices of unnecessary surgical procedures in Indian scenario are over top peek in both urban as well as rural setup [11]. A large study known as “Delhi Delivery Care” sponsored by the Indian Council of Medical Research (ICMR) recently explore that number of women patients in private hospitals are directly or indirectly forced to undergo significantly higher number of ultrasounds and caesarean deliveries [12]. The caesarean rate is as high as 53.8% in private hospitals and 41.4% in nursing homes. Even in rural set up in Pravara Rural Hospital the percentage of caesarian deliveries for the last three years is 20.4%, 24.2% and 27.4% for 2012, 2013, 2014 respectively [13]. This is much above 10 to 15 per cent limit suggested by the World Health Organisation (WHO). Thousands of women in rural as well as urban India are forced to have hysterectomy, taking advantage of the women are covered under government insurance schemes [14].

Such cases are exposed many times and brought notice to media, higher authorities, etc. Other than this there is seen list numbers of surgeries performed today without any special cause or may with any special interest.

This issue is not only concern with India but worldwide such practices are problem for system. Such practices affect population health as well as economy. In USA, due to insurance scheme based system, the cost as well as number of unnecessary surgeries is more. Medicare, Medicaid and their private insurance counterparts spend billions of dollars on such operations that shouldn’t be done [15].

For example, about 10% of spinal fusions procedures paid for by Medicare in 2011 were unnecessary, either because these cases were not on the stand of medical background or as suggestive history or because clinicians did not follow standards of care by exploring non-surgical treatments, according to USA TODAY analysis report of data from Medicare program concern audits [16].

That utilized to $157 million in payments, just for spinal surgical procedures in one year. Only the most egregious claims of unnecessary surgery make headlines [17]. The Maryland cardiologist sentenced in 2011 on criminal charges that he put cardiac stents in more than 100 patients who didn’t actually required for them; or the lawsuit filed this year by nearly 100 patients alleging that a Cincinnati doctor did needless spinal surgeries to implant bone-grafting devices [18].

Surgeon’s Responsibilities and Code of Ethics [19]:

• Every country has been stated Surgeon’s responsibilities and code of ethics by their regulatory authorities in their respective countries.

• Looking for patient welfare and behavior of the clinician are a part of the heritage of medicine originating with the Code of Hammurabi, a code of ethics dating from 2000 B.C.

• Although the concepts may remain similar throughout history, guidelines for ethical issues must address the demands of contemporary surgery practices in worldwide.

• As Fellows of the American College of Surgeons, code of professional conduct, that surgeon treasure the trust that his patients on him, because trust is integral part to the practice of surgery.

In every step of management like pre-, intra-, and post-operative care, he should truly accept responsibilities concern with his patients. In exercise of the powers conferred under the section 20A read with section 33(m), of the Indian Medical Council Act, 1956 (102 of 1956), the Medical Council of India, makes the regulations relating to the Professional Conduct, Etiquette and Ethics for registered medical practitioners [20].

Ethically Every Surgeon Should [21]

• Serve as effective advocates of his patients’ need and urge.

• Disclose therapeutic options, including their proper risks and benefits for patient himself rather than any interest.

• Disclose any kind of conflict of interest that might influence decisions.

• Be sensitive and respectful for patients, understanding their vulnerability.

• Fully disclose adverse events and medical errors without any hesitation and consider that first.

• Acknowledge patients’ psychological, personal, social, cultural, spiritual, financial needs.

• Special attention and needs of terminally ill patients.

• Acknowledge and support the needs of patients’ families in emergency situations.

• Respect the knowledge and dignity of other clinicians working along with you in community.

As a surgeon it is responsibilities [22]

• Provide the trustworthy highest quality surgical care.

• Abide by the values of honesty, confidentiality, and altruism.

• Participate in lifelong learning –Continue Medical Education (CMEs), workshop, conferences, online reading, etc.

• Maintain competence throughout lifetime while serving to your patients.

• Maintain your own standard of practice in community with goodwill.

• Provision of top ranked care for community.

• Proper communication with government authorities.

• Efficient distribution of healthcare resources.

• Provision of surgical care without any regard to gender, race, disability, religion, social status, or ability to pay.

• Regular participate in educational programs addressing professionalism.

Possible Aetiology for Unnecessary Surgical Procedures [23]

• Lack of competence to know when a surgery is not necessary.

• Corporate target.

• Market competition.

• Skillful practical teaching (Human guinea pigs) exercise.

• Wrong insisting of patients?

• Bitter truth: Health industry is driven by market economies, this one important reason for unnecessary surgeries in India and worldwide scenario.

• Wrong information – Not provide correct information regarding its indications.

• Consent is obtained with inadequate information.

Solution for Curbing the Menace of Unnecessary Surgical Procedures:

1. Second opinion [24,25]:

Second opinions are very important and urge, especially for people who are just diagnosed with complex or serious health conditions, because medicine is an art as much as a science. Even experienced doctors can disagree on a diagnosis or treatment plan. That disagreement can result in significantly different diagnoses, treatments and, most importantly, outcomes.

2. Finding the right physician/surgeon:

3. Biomedical ethics education and awareness – CMEs & workshops

4. Strict lawful conduct

The autonomy is the right provided to the patient, simultaneously doctors has to obey principles of Beneficence and non-maleficence that means he has to provide best treatment to his patient and see his patient should not suffer any harm during the treatment. The base of medical ethics stands on this conclusion which extends with provision of justice. Patient justice is the first duty of any doctor. Whatever the doctor interact with patient either from first visit, he should always think for patient betterment and always gives priority to the best of his knowledge.

Ethics is not the only discipline that deals with these issues: the law and theology also prescribe certain behaviors. Law is concerned with rules and regulations and that have effect within geographical boundaries. In one of the definition of Best surgeon is the person who knows when not to touch the knife. Actually the demarcation line between necessary and unnecessary surgical procedure is blurred. Tom Beauchamp and James Childress framed their model of medical bioethics on this concept and proposed these four parameters as basic fundamental principles of medical bioethics. Medical confidentiality is an important extended principle of medical bioethics along with informed consent [25–27].

Many countries along with India have made this a legal provision in their laws. Modern healthcare system and technology integration is one the challenges in its implementation [28–30]. It is surgeon’s moral responsibility to do best for patient and think, is it appropriate for a particular patient? Medical justification, desire of patient and qualification of surgeon for that operative are important ethical issues respectively dealing with beneficence, patient autonomy and non-maleficence, the basic traditional values of medical bioethics. It is not justifiable to do unnecessary surgical operations only for the sake of benefits to surgeon himself and or hospitals [29–31].

According to fundamental code of ethics, always consider first the well-being of the patient. The patient being treated at the time must be the physician’s primary concern. Informed consent includes adequate information about the details of procedure, associated risks, benefits, and alternatives before any surgery. Performing unnecessary surgery violates rules of fundamental code of ethics. It may be a basis for malpractice in routine practices. However, it may be difficult to prove which cases are unnecessary [32].

Conclusion

Unnecessary surgery is that which is medically unjustifiable when the risks and costs are more than the likely therapeutic benefits or relief to the patient based on the patient’s lifestyle requirements. To avoid or minimize such interventions basic seeding of ethics in curriculum and strict laws will definitely helpful in clinical practice. In conclusion, our aim was to highlighting this major issue and underlines need of competency based medical bioethics education in Indian scenario.

Financial or Other Competing Interests

None.