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Changes in the Ethics Environment

Wednesday, October 16, 2002

As members of our cardiothoracic surgical specialty are subjected to an increasing frequency and variety of stresses, ethical considerations are assuming a more prominent role in everyday practice. Frustrated by the ever-changing procedural and financial restrictions of Medicare and managed care; by the complexities of business arrangements with partners, competitors, referring physicians and hospitals; by the inducements to utilize new drugs, devices and protocols; by the unrelenting pressure to lower morbidity and expected/ observed mortality rates; by shortening hospital lengths of stays and constraining hospital costs, today's surgeons are experiencing difficulties in avoiding conflicts of interest or obligation. Consequently, there is added responsibility to function as moral fiduciaries and patient advocates, protecting and promoting the patients' best interests.

Just as the ethics environment in clinical practice is changing, the STS Standards and Ethics Committee is experiencing a shift in the focus of its activities. Previously, the major efforts of the Committee were directed towards performing peer reviews of cardiothoracic surgeons or surgical programs that were outliers for mortality results. The peer review process involves sending a team of Committee members to an involved hospital to review the basic data, the facilities, and the personnel and then to prepare a comprehensive report, including specific recommendations for improving surgical outcomes.

More recently, the Committee has become increasingly involved in ethical considerations related to everyday practice. The Committee has formulated specific requirements for reporting conflicts of interest for publications, presentations at scientific sessions and for volunteer leadership; these requirements are now in effect. Ethical issues involved in Medicare's failure to fund Lung Volume Reduction Surgery and its effect on the National Emphysema Therapy Trial were extensively studied.

The Committee has evaluated "exclusive privileging," a technique whereby some hospitals have required such stringent volume and performance standards that certain surgeons, especially younger and recently-trained surgeons, are excluded from consideration for open heart surgery credentialing.

The vexing problem of cardiac surgeons being employed by large groups of cardiologists occasioned an in-depth evaluation by our committee which resulted in a "white paper," which appeared in the STS Newsletter. We later presented our ethical and legal concerns about this practice to the Ethics Committee of the American College of Cardiology. These concerns were later published in editorials in the Journal of the American College of Cardiology, as well as in The Annals of Thoracic Surgery - both in July 2001.

The Committee proposed a policy for physician advertising and publicity, which was approved by the STS Council, and now appears on the STS website and in the 2002 Annual Meeting program book, page 288. Further, the Committee has spent considerable time evaluating two separate examples of possible false, deceptive, and misleading advertising. In one instance, the Committee recommended expulsion from the Society and in the other instance, censure of the involved surgeon.

In the course of these evaluations, hospital websites were found to be a significant area of concern. Although cardiothoracic surgeons usually are personally involved in preparing print media advertising, similar attention may not be paid to website advertising. In efforts to gain competitive advantage for hospitals or physician organizations, lay publicists provide information for public website viewing that is often marginally educational and deceptively persuasive. Physicians are held responsible for the website content in which their services are being promoted, but often do not participate in its preparation nor verify its veracity. Examples of this type of questionable advertising include unwarranted claims of success of operative procedures employing new technologies; inappropriate denigration of "gold standard" procedures previously validated in peer-reviewed journals; undocumented claims of shorter hospital lengths-of-stays and lower costs; atypical patient testimonials; and exaggerations of a surgeon's operative experience and credentials. Many medical institutions have policies requiring that information appearing on their websites have signed approval by the physicians whose services are involved. The Standards and Ethics Committee supports these policies and further recommends that STS members frequently monitor their websites to ensure that they do not contain false, deceptive and misleading advertising.

The Ethics Forum, a subcommittee that includes representatives from the 4 major thoracic societies, has been very active in providing a series of ethics sessions at national and regional meetings. At the 2001 American Association for Thoracic Surgery meeting, the topic was, "Is it ethical to advertise surgical results to increase referrals?" The 2001 Western Thoracic Surgical Association featured a point-counterpoint session entitled, "Products, profits and professionalism: Surgeons should not benefit from development of new technologies." At the 2001 Southern Thoracic Surgical Association meeting, the subject was "Cardiothoracic surgeons should make decisions to operate solely on medical grounds." At the 2002 Society of Thoracic Surgeons meeting, the Alley Honorary Lecture featured a panel entitled, "Current ethical issues in thoracic surgery."

From the discussion above, it is readily apparent that the ethics "climate" is undergoing significant changes in clinical practice as well as in the recent activities of the Standards and Ethics Committee. The covenant of trust between vulnerable patients and the thoracic surgical profession needs to be maintained by placing the interests of patients above the quest for fees, fame or market dominance, whether pursued by surgeons or others on their behalf.

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