Responding to patients requests: Balancing professional obligation and conscientious objections Perspectives from plasti

1. Responding to patients requests: Balancing professional obligation and conscientious objectionsPerspectives from plastic surgery GME Grand Rounds October 21, 2008 Mary H. McGrath MD MPH UCSF Plastic Surgery

2. Patient self determination

3. The evolution of patient autonomy into the dominant principle in medical ethics • Patients should be accurately informed • Patients should participate in decision making • Patients are entitled to dictate their therapy

4. Obligations of all occupations

5. The obligation of beneficence • What is good for the patient • What will benefit the patient

6. The duty of beneficence – professional obligation • Benefit the patient • Self-imposed altruism • Supererogatory

7. “In the last 25 years, patient autonomy has displaced physician beneficence as a dominant principle in medical ethics. This has enhanced the moral right of patients to refuse unwanted treatment and to participate in clinical decisions. But now, in some cases, patient autonomy is being absolutized. The right to refuse is becoming a right to demand treatment. The result is danger to the moral and professional integrity of physicians. A reassessment of the mutual moral obligations of physicians and patients to respect each other’s autonomy is in order.”Edmund Pelligrino. Patient autonomy and the physician’s ethics. Ann R Coll Physicians Surg Can 1994; 27:171-173.

8. Teaching principle in plastic surgery training • One of the most significant decisions the plastic surgeon makes is whether to perform the requested surgical procedure. • The surgeon is guided to make sound decisions about whether to do a requested surgery by learning criteria that define suitable candidates • Learn the questions to ask • Pay attention to psychological motivations • Use observation and develop an intuitive sense • Make sure a correctible deformity exists • Develop good judgment through experience

9. Contraindications to plastic surgeryWhen to say “no” • Imperceptible or minimal deformity • Patient who is / has • Uncertainty about what he’d like to change • Untreated psychiatric illness • Body image disturbance, i.e. anorexia • Unstable personality disorder • Body dysmorphic disorder : “imagined ugliness” • Under emotional stress • Unrealistic expectations • Unable to consider an imperfect result • Seeking revision of prior surgery that is reasonable • Identifies surgery with a particular goal (job promotion)

10. Finally, who decides when a patient’s request is not consistent with cultural or societal norms?

11. Respect autonomy of both parties • Analyze extremism or deviation from cultural conformity: consider the individual’s motivationand judgment • Apply the obligation of beneficence: • form an opinion of what is in the patient’s best interest • Exercise of physician autonomy based on values, judgment and experience • communicate thoughtfully • help with other resources

12. Thank you