How to Manage a Teenaged Patient Seeking Medically Unnecessary Rhinoplasty

What is the ethical course of action?

—Richard Holt, MD, MPH, University of Texas Health Sciences Center, San Antonio.

Discussion

As with many ethical dilemmas, several fundamental principles of bioethics are in play here. In fact, to some degree, all four of the principles have some impact on your dilemma—autonomy, beneficence, nonmaleficence, and justice. These principles, as well as the duties of a physician to a patient, will all play a role in your decision-making. You must first consider the patient’s autonomy, her freedom to make healthcare decisions. Unless she is an “emancipated minor,” her parents will have to give ultimate consent for surgical intervention. That is not to say that the patient’s wishes and opinions are not to be considered. She is approaching the age of majority and appears to be an intelligent and competent person for her age, and her assent for the procedure is a significant part of the decision-making process. It is very important that all parties in the discussion consider her best interests.

The dyadic set of principles—beneficence and nonmaleficence—has been guiding a physician’s responsibility to patients for thousands of years. Acting to benefit the patient and avoiding harm are foundational to a proper professional practice. The evolution of these dyadic principles now includes weighing benefit versus risk so that the physician can make appropriate recommendations for a particular patient and the patient can decide the ratio of benefit to risk with which he or she is comfortable. Because most patients have a limited knowledge of the medical and surgical information needed to consider the ratio, it is ultimately the physician’s responsibility to inform the patient—and in this case the parents—of the evidence-based risks and benefits so that an informed decision is possible.

Woven throughout most medical encounters and ethical considerations is the principle of justice, wherein the patient is evaluated, informed, and cared for like other patients with the same or a similar condition, applying the resources of the healthcare system and the physician’s expertise in an equitable manner. This can be a challenge to the physician’s ethical decision-making, owing to the desire to treat each person as a unique individual and the recognized phenomenon that some patients and their stories are more compelling than others.

At this time, our society considers autonomy to be the most important aspect of patient care—American medicine now aims to be “patient-centered,” which is a good thing, and anything that interferes negatively with a patient’s autonomy is seen as a bad thing. A patient’s ability to make an autonomous decision—in this case the choice to have surgery or not—depends heavily upon freedom from outside interference. Given the fact that this young woman has apparently made up her mind to have the surgery, even before your consultation, what could negatively interfere with the autonomy of her decision? There are several ways in which a physician can “bias” the patient’s decision:

1. Skewing the information for a benefit/risk assessment in favor of benefit;
2. Facilitating her decision by reporting false or inaccurate information to the insurance company so that the surgical procedure will be covered in good part; and
3. Overly enhancing computer-assisted images of what improvement is likely to be gained.

If the physician reports the medical history and physical findings in a manner that could result in the insurance company pre-authorizing the procedure, then the physician is guilty of “gaming” the system, even if the motive is beneficent. Also, any discussion of “enhancing” medical information for the purpose of obtaining an approval for a procedure needs to be examined in light of whether the physician stands to benefit from the procedure, primarily in the form of financial remuneration. While we can hold that most physicians have beneficence as their guiding motive, some have an underlying financial motive for such behavior. This must not be condoned, because it violates the purity of the patient-physician relationship and the deontological responsibility of the physician for honesty and veracity.