Background:
A gynecologist examines a 63-year-old 5-foot, 315-pound patient named Marie with a diagnosis of stress incontinence in Canada. After performing an ultrasound, the gynecologist discovers an ovarian cyst and elects to perform a surgical hysterectomy and remove both her ovaries. The surgery injures her colon leading to post-operative complications. A surgeon confirms that leakage from her colon could kill her unless he conducts a second reparative surgery. Marie appears to be cognizant of her situation, but denies surgical treatment. When the doctor chooses to comply with her wishes, her son threatens legal action against the doctor unless he operates, claiming his mother is acting incompetent.
Dilemma:
The immediate dilemma is whether or not the surgeon should operate using surrogate consent under the principle of non-maleficence or respect Marie’s autonomy. However, from a medical standpoint an additional dilemma surrounds Marie’s initial surgery. For a diagnosis of ovarian cyst and stress incontinence, was invasive surgery the best treatment? Did Marie give truly informed consent if the surgeon did not educate her on other treatments? Without the initial surgery, the current dilemma between Marie’s surgeon and her family would not exist.
Analysis:
When reading Marie’s case, it is easy to skim over her listed age, stature, and weight, but they are crucial to her medical diagnosis and avoidance of the dilemma described above. Marie is only 5 feet tall, but weighs 315 pounds. Marie’s calculated BMI of 61.5 (“Adult BMI Calculator: English”) categorizes her as morbidly obese. Obesity serves an additional risk factor for gynecologic surgeries. According to a report released by The American College of Obstetricians and Gynecologists, “As BMI increases for women undergoing abdominal hysterectomy, so does the risk of surgical site infections and wound complication” (Committee Opinion 275) and “Obese patients commonly have comorbid conditions…that can complicate intraoperative and postoperative care” (Committee Opinion 277).
Marie is 63 years old, classifying her as a post-menopausal woman (According to the Canadian Women’s Health Network, the average age for menopause in Canada is 52). Ovarian cysts are common in women of reproductive age and often serve a functional purpose in ovulation, but they are a concern in menopausal-age women. Along with other symptoms of urinary urgency and frequency as in Marie’s case, cysts may indicate the presence of ovarian cancer (Le and Giede 669).
However, the case report made no mention of testing the cyst for malignancy—as is the standard recommendation in Canadian gynecology (Le and Giede 670)—beyond its discovery during the ultrasound. While we don’t have all the details of Marie’s pre-surgery health, it seems logical that the case report would have mentioned cancer had it been the operation’s cause. Instead, it suggests that the operation was to alleviate her incontinence caused by uterine pressure from the cyst. Surgery is the most invasive of available treatments for stress incontinence (less invasive options include vaginal cones and electrical stimulation) and the official recommendations of The Society of Obstetricians and Gynaecologists of Canada suggest, “As part of the management of stress incontinence, women should be encouraged to try non-surgical options, including weight loss (in obese women)” (Reid et al. 3). In terms of cases that do require surgery, the society agrees that a hysterectomy may be performed when removing a woman’s ovaries, but it acknowledges “whether there are any benefits of concomitant hysterectomy at the time of bilateral oophorectomy for conditions other than ovarian cancer…remains unknown” (Lefebvre et al. 4).
Discussion:
What I’m asking is why her surgeon chose the most invasive treatment for a woman whose circumstances make surgery highly risky. Since this case revolves around autonomy, I’d like to focus on this principle in relation to Marie’s first surgery. The case report states that the “gynaecologist elected to perform a hysterectomy and bilateral oophorectomy” (Waluchow and Gedge 71). Notice it doesn’t say that Marie elected for surgery, which makes me wonder if the doctor educated her on other available treatments. Clearly, Marie voluntarily consented to the surgery, but was her consent informed? Beauchamp and Childress list disclosure, recommendation, and understanding as three necessary elements within the information component of informed consent (124). They also state that “Diagnoses, prognoses, the nature and purpose of intervention, alternatives, risks and benefits, and recommendations typically are essential” (132) parts of a disclosure.
In my opinion, Marie’s doctor did not rightly balance the principles of autonomy and beneficence. By not reviewing all treatments and corresponding risks (perhaps he viewed surgery as the best option), he violated Marie’s right to informed consent. I believe doing so would have resulted in Marie consenting to a different treatment. However, let us say that the case description’s language didn’t adequately describe Marie’s consent process and that she, herself, elected for surgery from the list of well-explained treatments. In this case I would advise the doctor to push her towards a less risky treatment as an act of beneficence, weighting beneficence higher than autonomy. This would avoid the complex colon surgery dilemma where one must make a judgment of Marie’s competence while she is in an impaired state.
Works Cited
“Adult BMI Calculator: English.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 21 Oct. 2014. Web. 06 Feb. 2015.
Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2009. 115-25. Print.
Committee Opinion: Gynecologic Surgery in the Obese Woman. Publication no. 619. The American College of Obstetricians and Gynecologists, Jan. 2015. Web. 7 Feb. 2015.
Le, Tien, and Christopher Giede. “Joint SOGC/GOC/SCC Clinical Practice Guideline: Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses.” Journal of Obstetrics and Gynaecology Canada (2009): 668-73. Web.
Lefebvre, Guylaine, Catherine Allaire, John Jeffrey, and George Vilos. “SOGC Clinical Practice Guidelines: Hysterectomy.” Journal of Obstetrics and Gynaecology Canada (2002): 1-12. Society of Obstetricians and Gynaecologists of Canada. Web.
“Menopause.” Menopause. Canadian Women’s Health Network, 2006. Web. 07 Feb. 2015.
Reid, Robert, Beth L. Abramson, Jennifer Blake, Sophie Desindes, Sylvie Dodin, Shawna Johnston, Timothy Rowe, Namrita Sodhi, Penny Wilks, and Wendy Wolfman. “Managing Menopause.” Journal of Obstetrics and Gynaecology Canada 36.9 (2014): 1-74. Web. 6 Feb. 2015.
Waluchow, Wilfrid J., and Elisabeth Gedge. “Case 1.1 When Physicians and Family Disagree.” Well and Good: A Case Study Approach to Health Care Ethics. By John Thomas. 4th ed. Peterborough, Ontario: Broadview, 2014. 71-76. Print.
I think that you bring up a good point about the informed (or uninformed) nature of Marie’s consent. The informed part of consent implies that a certain level of understanding needs to be achieved in order for the consent to be informed. However, we don’t have a clear definition of what that level of understanding is. You bring up a lot of great evidence about the strange decision to even have the original surgery and I agree that it really does bring into question whether Marie (or even the doctor) was informed about the risks of performing that surgery.
I am also wondering about the difference between being informed versus understanding. For example, a patient can be told the facts ( a necessary part of being informed), but that doesn’t necessarily mean he or she understands. In fact, from the perspective of the doctor, it may seem like that a patient who understands would agree with his or her advice. However, this cannot be the case. Physicians can’t force patients to follow their advice just because they “think” that the patient doesn’t understand. As a result, we are left with the dilemma: “how do we gauge understanding?”.
Hey, Carolyn. Thank you for your post, for I enjoyed reading about your analysis of the original surgery. Although I appreciate the evidence for the questionable decision-making for the first operation, the current ethical dilemma poses greater importance. To begin with, the patient’s son articulates that his mother is not acting “normally” with her refusal of a life-saving procedure. Thus, the son claims that the mother cannot adequately consent. One must consider the reasons for the patient’s refusal of treatment when analyzing the validity of the son’s statement. For example, the patient distrusts the medical team because of the mistake in the first surgery. In addition, the medical team fails to answer her questions. Furthermore, as you explained, the decision to perform an oopherectomy questions the physicians’ judgement. Thus, perhaps the patient refuses treatment due to fear of dying from another surgery with the same medical team. Therefore, the mother’s lack of consent does not reflect her desire to die, as the son claims. Instead, she refuses treatment, because she does not want to die. As a result, the mother is not acting out of character, and she should have the autonomy to make the medical decisions.
I find it very interesting how you analyzed the primary surgery with great detail. There are definitely some unanswered questions about the physician’s treatment call. However, for argument’s sake, let’s say that the first surgery was the best treatment option. The bigger issue now is whether or not the patient should be allowed to refuse treatment. While the son states that he believes his mother is acting incompetently, I’m not sure that is the case. She gave the physician permission to perform the first surgery because she wanted to fight for her life. However, I feel that the complication made the patient wary to trust the physicians again. So maybe she is electing not to have the surgery out of fear of another complication rather than incompetence?