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Concluding RemarksRobert M. Sade, MD

Surgeons rarely refer patients to other surgeons, so weshould not be surprised that Dr. Click did not refer

Mrs. Barefoot, even though other surgeons have moreexperience and better results with the operation that thepatient initially preferred. Should Dr. Click have referredthis patient to another surgeon?

As requested, our discussants have given us two dif-ferent responses to this question. Nicholas Kouchoukosanswered, “Yes” and found several ethical transgressionsin Dr. Click’s handling of the referral. He points to theparamount obligation of physicians to do what is best forthe patient rather than to do what is in one’s own selfinterest. On these grounds Dr. Click should have referredMrs. Barefoot, if only for a second opinion with thepossibility that another surgeon could offer the patient abetter result.

Lawrence Cohn takes the contrary view that Dr. Clickwas justified in not referring Mrs. Barefoot, because thestandard for whether a surgeon should do a particularoperation is not whether he has the largest experience orthe best results, but whether he is competent to do it. Theoriginator of a new procedure or an early disciple wouldnearly always have the largest experience, would befurther along the learning curve, and therefore, wouldusually have better results than most of the surgeons whofollow. Thus, says Cohn, if only the surgeons with thebest results and largest experience did a particular oper-ation, most patients would not have access to relativelynew procedures because few surgeons would be doing it.It is competence, not extraordinary expertise, that asurgeon must offer his patients.

Case histories provide a useful basis for considerationof controversial issues, because they put a human face onand bring to life what otherwise may be a dry theoreticaldiscussion. However, such brief case reports have aserious limitation; the information available is necessar-ily sketchy, and much of the missing information isgermane to the topic. For example, Mrs. Barefoot arrivesin Dr. Click’s office with a treatment preference based onpublicly available information, but her views will befurther developed and refined by what the surgeon tellsher. How much information has Dr. Click given her?How much has he told her about surgical options otherthan the two he finally offered? What was her response tothat information? How much has her view of anticoagu-

lation and commitment to a Ross operation shifted? Howforthcoming was he with outcome data of his own prac-tice and of others? We don’t know the answer to any ofthese questions.

There is also much we do not know about Dr. Click. Hebelieves that “the Ross operation is better for pregnantwomen,” but does he believe the Ross operation to besubstantially better or only slightly better than the alter-natives? His motivation in not referring Mrs. Barefoot iscritically important in judging his actions. What is hispractice environment? In his academic department, arethe collections he generates only marginally related to hissalary? Is his practice fiercely competitive with the moreexperienced surgeon in town or do they have a collegialrelationship?

The answers to these and other contextual questionsmay very well shift our view of Dr. Click’s ethical behav-ior. This is why principles of ethics play an essential rolein medical ethics. They provide the framework uponwhich concrete details of a particular case can be ar-ranged to help make correct judgments. The principlesapplicable to this case have been cited by Kouchoukosand Cohn: The surgeon’s first priority is the patient’s bestinterest; sufficient factual information must be disclosedto patients to allow them to make informed decisionsbased on their own values; and surgeons should main-tain competence through critical self analysis and pro-vide competent services.

Kouchoukos and Cohn applied these principles butcame to different conclusions about Dr. Click’s ethicalposition, in part because they made different assump-tions about the content of the surgeon-patient conversa-tion regarding surgical options and outcome probabili-ties. However, both of these surgeons agree that there aresituations in which the ethical course for the surgeon is torefer the patient to a more experienced surgeon. Exactlyhow a surgeon should be able to recognize these situa-tions is not obvious. One thing is clear: honest anduncompromising appraisal of our own capabilities is thecritical requirement for making correct judgments aboutour own competence, both in general and for particularprocedures. For surgeons, this may be the most difficulttask of all.

760 ETHICS IN CARDIOTHORACIC SURGERY KOUCHOUKOS ET AL Ann Thorac SurgSURGEONS REFERRING TO SURGEONS 2004;77:757–60