The 2014 Research Colloquium Presentations Abstracts
Supporting information for: 2014 CBSSM Research Colloquium and Bishop Lecture (Myra Christopher)
Andrew G. Shuman, MD, Assistant Professor, Department of Otolaryngology, University of Michigan
"When Not to Operate: The Dilemma of Surgical Unresectability"
One of the most anguishing choices a surgeon can make is deciding not to embark upon an operation because a tumor is deemed unresectable. Despite the widespread acceptance of patient autonomy and transparency in medical practice, there remains an unstated paternalism “behind the mask,” within the confines of the operating room. The concept of surgical unresectability derives from a complex combination of tumor factors, patient factors, and surgeon factors. In many cases, these decisions are intensely personal and subjective, with disagreements even among surgeons in the same field. There is a risk that the voice of the patient may be lost in making these decisions, as surgeons weigh these intangible variables in ways that may be incommunicable. However, the consequences of proceeding with an operation unlikely to achieve its intended outcome may be similarly terrifying. In this presentation, a cancer surgeon and reconstructive surgeon will discuss these dilemmas from multiple perspectives using real-life case examples from their practice. We will collectively try to tease out the inherent biases informing such decisions from the standpoint of doctors, patients, and clinical ethicists. The theoretical underpinnings of the authority of surgical judgment will be explored, noting that pursuing goods internal to the practice of surgery requires such decisions, and asking whether Polanyi’s concept of tacit knowledge explains (or even permits) a degree of paternalism.
Anomalies of the kidney and urinary tract are the most common prenatally diagnosed fetal structural abnormalities, and are a major cause of end-stage kidney disease in children. Severe, prenatally diagnosed cases present a number of unique ethical issues with respect to the care of the pregnant woman, fetus, and neonate. We will use a case-based approach to explore these issues in the context of prenatal counseling, and in the neonatal period. On a case-by-case basis, efforts are made antenatally to coordinate counseling from appropriate consultants such as maternal-fetal medicine, neonatology, and pediatric urology and nephrology. We argue, however, that significant differences exist both between individual physicians and between subspecialties more broadly with regard to beliefs about prognosis, therapeutic interventions available, and appropriate utilization of palliative versus life-prolonging options. Unlike for other high-risk perinatal conditions such as extreme prematurity, no guidelines or standardized interprofessional processes exist for the provision of coordinated, timely, and non-directive care to these patients. This has implications for choices made regarding prenatal care, resuscitation efforts at birth, and utilization of palliative and life-prolonging care options, and we argue that the implicit biases and differences in both counseling and practice must be explicitly addressed and considered in order to facilitate more effective counseling for families facing these diagnoses. We will discuss the prenatal use of the term “lethal pulmonary hypoplasia,” a term that implies an unequivocal outcome but is a tissue-based diagnosis that can only be made after birth, not on the basis of obstetric ultrasound. We will also discuss the strikingly different rates of utilization of and attitudes towards dialysis initiated in the neonatal period, both between individual care providers and between institutions.