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
further testing.
iStockphoto/Thinkstock
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
miss the basketball season.
iStockphoto/Thinkstock
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
1Capozzi
J, Bronson W, Rhodes R: Moral Complexity.
J Bone Joint Surg Am, 2011 Aug 03;93(15):e88 1-3.
doi: 10.2106/JBJS.K.00084.
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 2013.
Owens DK, Qaseem A, Chou R, Shekelle P: Highvalue, cost-conscious health care: Concepts for
clinicians to evaluate the benefits, harms and costs
for medical interventions. Ann Intern Med
2011;154(3):174-180.
22
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, 892-897.
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):335-40.
American Academy of Orthopaedic Surgeons: Code
of Medical Ethics and Professionalism for
Orthopaedic Surgeons, I.A., I.F. Adopted 1988,
revised 2011.
http://www/aaos.org/about/papers/ethics/code.asp
23
American Academy of Orthopaedic Surgeons:
Shared Physician-Patient Responsibilities, Position
Statement 1182. Adopted 2011.
http://www.aaos.org/about/papers/position/1182.asp
American Academy of Orthopaedic Surgeons:
Standards of Professionalism on Providing
Musculoskeletal Services to Patients, Mandatory
Standard 1. Adopted April 18, 2005, amended April
24, 2008.
http://www3.aaos.org/member/profcomp/provmuscserv.pdf
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