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Ethical Issues in the Management of Renal Cell Carcinoma.

Year: 2015
Type: article
Abstract: Kidney cancer is a common and lethal cancer; in 2014 it will account for an estimated 63,920 new diagnoses and 13,860 deaths in the United States alone1. The clinical care of affected patients, as well as participation in clinical research involving kidney cancer, poses many potential ethical challenges for the clinician and investigator. The issues discussed in this review, while commonly encountered in this setting, are not exclusive to kidney cancer and will be relevant to many facets of medical care and clinical research. Informed Consent, Disclosure of Surgeon Experience, and Outcomes Surgical therapy is the mainstay of treatment for renal cell carcinoma2 and, therefore, issues of informed consent prior to surgical intervention are paramount. The concept of informed consent developed in the early 20th century as advances in surgical and anesthetic techniques made elective surgery possible3. Today, informed consent is well-accepted as a central aspect of the surgeon-patient relationship. Traditional informed consent has required the surgeon to disclose certain procedure-specific factors: potential surgical complications and risks, benefits of the proposed surgery, available alternatives and likely outcomes of the treatment. The American Urological Association goes even further in its Code of Ethics, requiring the surgeon to provide the patient with “all of the information necessary to consent and to make his own choice of treatment, regardless of my own advice or judgment. The information provided must include known risks and benefits, costs, reasonable expectations and possible complications, available alternative treatments and their cost, as well as the identification of other medical personnel who will be participating directly in the care delivery”4. The need to disclose physician-specific factors (experience, previous outcomes, training), however, is more controversial. Studies have correlated surgeon volume5 and objective ratings of surgeon skill6 with patient outcomes; these findings suggest that disclosure of these surgeon-specific factors may be relevant to patients' informed decision making. A survey of patients supported this, as a majority of respondents found information on surgeon volume and outcomes essential7. Legal opinion on this matter, however, is conflicted. Many states have adopted a “reasonable person” standard for determining the content of an informed consent discussion3,8 and two State Supreme Courts have addressed the specific issue of surgeon experience9. In 1996, the Wisconsin State Supreme Court held that physician experience and outcomes as compared to other physicians’ is a meaningful part of the “alternative treatment options” that need to be discussed during the process of informed consent9. In 2001, however, the Pennsylvania State Supreme Court defined informed consent as including procedure-specific factors only and categorized information about the physician as outside of the scope of informed consent9. The ethical principle of autonomy is central to this debate. If knowledge of surgeon experience is necessary for patient decision making, its disclosure enhances patient autonomy and therefore is appropriate. While the Wisconsin Supreme Court categorized this information as an important aspect of “surgical alternatives”, Clarke and Oakley10 argue that surgeon ability is an important risk factor, and therefore an essential component of any informed consent discussion. While accepting the importance of patient autonomy, Burger reasons that disclosure of surgeon-specific performance information is only imperative if it is accurate enough to affect patient decision-making9. She contends that physician-specific outcomes data is often tied to arbitrary end-points, can be manipulated by patient selection, and is unfairly biased against younger surgeons9. The issue of disclosure of surgeon experience is very relevant to the surgical management of renal cancer. Laparoscopic and robotic-assisted partial nephrectomy have become popular and widely utilized interventions for small renal masses11. Several studies have demonstrated a learning curve with the use of these surgical modalities and surgeon experience has been shown to independently predict patient outcomes12. Whether currently available individual surgeon-level data is of high enough quality to impact patient decision-making is unclear. Nevertheless, most authors agree that providing this information when asked by the patient is imperative to maintain an open and honest physician-patient relationship8. With patients’ increasing use of internet data sources, the proliferation of physician rating systems, and a widespread interest in healthcare quality improvement, the question of individual physician-level outcomes data is likely to be an area of discussion for the foreseeable future.
Source: PubMed
Language: English
Field: Medicine
Open Access status: green
OpenAlex ID: W2413030099
FWCI:
Cites: 46
Cited by: 4
Related to: 10