JUST SAY NO Ethical Considerations of Patient Care in the Gray Zone AAOS ETHICS COMMITTEE Nancy M. Cummings, MD 1

“ The ethical dimension of medicine is typically noticed only when a physician finds him or herself in a dilemma in which it is not obvious which of which of two treasured principles of professional ethics should be upheld and which should be sacrificed.” 1 2

Objectives Explore the ethical challenges of disagreeing with a patient about his/her course of treatment Define the obligation/role of the physician Understand how gray areas can become black and white 3

Introduction In today’s practice environment of shared decision making and information availability, patients present to the orthopaedist with their own expectations of what their work up or treatment course should include. Gone are the paternalistic days when Marcus Welby, MD, could come into the room and put his hand on the patient’s shoulder and tell the patient what should be done. 4

There is a line that the physician needs to draw when the patient insists on an alternative course of treatment. 5

Case Barbara Gail (BG) Decker is a 15-year-old soccer player who comes to your office midseason. She has sustained a twisting injury to her knee in the preseason. iStockphoto/Thinkstock 6

Your exam indicates a torn ACL. Her parents insist that BG finish out the season in a brace and want no iStockphoto/Thinkstock further testing. 7

What do you do now? Are you comfortable returning her to play? Do you want more information? 8

You convince BG’s parents to obtain an MRI which shows no meniscal or articular cartilage injury. You get BG fitted for a brace, and she returns to play. iStockphoto/Thinkstock 9

After the soccer season is over, BG and her parents return to your office and request allograft reconstruction of BG’s ACL so that she can play the second half of the basketball season. iStockphoto/Thinkstock 10

You tell Mr. and Mrs. Decker and BG that you would prefer to use an autograft rather than an allograft. Either way she would not be able to play basketball this year. 11

What do you do now? 12

The MOON study data does not support the use of an allograft in this athlete. 2 13

BJ’s father says that they obtained a second opinion at Superstar Orthopaedics, Inc., across the street. The doctor said that if BG had an allograft reconstruction, she would not iStockphoto/Thinkstock miss the basketball season. 14

Your office manager has brought to your attention that your productivity has dropped as of late. Erik Snyder/Lifesize/Thinkstock 15

Mr. and Mrs. Decker want you to operate on their daughter because they know you are the Best! p.s. And they want you to use an allograft. iStockphoto/Thinkstock 16

What do you do now? What do you tell them about your colleagues across the street? 17

Or… Do you change your treatment plan and operate on her using an allograft? 18

The Devil is in the details…… Stockbyte /Thinkstock 19

Summary The key to resolving this dilemma is to initiate and participate in a shared decision-making process. Avoid a paternalistic (Marcus Welby) approach and if that doesn’t work….. 20

Do the right thing. 21

References 1 Capozzi J, Bronson W, Rhodes R: Moral Complexity. J Bone Joint Surg Am, 2011 Aug 03;93(15):e doi: /JBJS.K Spindler K, Parker R, Andrish J, et al, MOON Group: Prognosis and predictors of ACL reconstructions using the MOON cohort: A model for comparative effectiveness studies. J Orthop Res, Vol 31, Issue 1, pages 2-9, January Owens DK, Qaseem A, Chou R, Shekelle P: High- value, cost-conscious health care: Concepts for clinicians to evaluate the benefits, harms and costs for medical interventions. Ann Intern Med 2011;154(3):

Elwyn G, Edwards A, Kinnersley P, Grol R: Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract, 2000, 50, Rolita L, Spegman A, Tang X, Cronstein B: Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. J Am Geriatr Soc, 2013 Mar;61(3): American Academy of Orthopaedic Surgeons: Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, I.A., I.F. Adopted 1988, revised

American Academy of Orthopaedic Surgeons: Shared Physician-Patient Responsibilities, Position Statement Adopted American Academy of Orthopaedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Services to Patients, Mandatory Standard 1. Adopted April 18, 2005, amended April 24,