|May 19, 2011|
Dan O’Connor discusses the pervasive problem of labeling some medical procedures ‘elective’ and others ‘necessary’
“Bionic hand for ‘elective amputation’ patient” - thus the BBC News headline to the recent story of ‘Milo’, a 26 year old European man who has chosen to have his non-functioning right hand amputated and replaced with a bionic prosthesis, controlled by nerve signals in his own arm. This is the second such operation performed by Viennese surgeon Oskar Aszmann, and it has stirred up some controversy over the question of elective amputation. In particular, it illustrates the pervasive problem of calling some medical procedures ‘elective’ and others ‘necessary’.
Milo lost the use of his hand in a motorcycle accident about a decade ago, but, crucially, the hand remained attached to his body. In order to take advantage of the extraordinary medical advance which the bionic prosthetic represents, he had to chose – or, as ethicists have it, ‘elect’ – to have his hand amputated.
It doesn’t seem like much of an ethical quandry: Milo made a choice about his body, a choice which had no obvious negative effects on anyone else. Case closed, right?
We need to bear in mind that, as it was, Milo’s hand represented no immediate or long-term physical danger to him. Unlike say, a leg which has been blown apart in a landmine explosion, it was not going to go gangrenous or sceptic and threaten the rest of his body. It was also, as far as we can tell, not causing him any physical pain. On one reading of medical ethics, there is no clear and present need for Milo to have his hand amputated. The case seems, on this reading, to fail the test of medical necessity, thus rendering it an issue of ‘choice’, of ‘elective amputation’.
But physical threat should not be the only thing that we consider when thinking about medical necessity. Sometimes we should consider patient’s other needs.
Milo’s hand did not function – and that’s a pretty crappy thing to have to live with for your entire life. Arguably, Milo needed a new hand to function in day to day life.
The question, then, becomes: is it OK to cut off your hand in order to get one which works properly? At this point, we should remember that, in most legal systems, surgery (cutting the body) is, without good medical cause, consideredprima facie a case of physical assault. You need a reason – a medical reason – to cut someone, to perform surgery on them. Thus the question becomes: is non-functioning a good enough medical reason to cut someone’s hand off in order to replace it?
To answer that question, we have to ask another: what do we mean by medical? Typically, ‘medical’ implies some form of healing, of restoration and so, in order to consider Milo’s surgery to be ethical, we would have to believe that it is a healing action, or at least part of a healing process. Milo lost the use of his hand, and his ‘elective’ surgery will allow him to replace that hand with a prosthetic which, in turn, will restore much of the functioning he had lost.
Even though there was no physical danger, no pain, to Milo from his hand, that does not mean that he could not be healed – and that the ‘elective’ surgery was perfectly ethical.
Milo’s case illuminates the limits of the idea of ‘elective’ as a useful way of describing surgeries or medical procedures which do not seek to address immediate physical harms to the patient. It is, in fact, exceptionally rare for a patient not to ‘elect’ to undergo surgery. That’s what a consent form is: the mechanism whereby a patient acknowledges that they are making a free decision to undergo surgery.
Now, of course, when the alternative to surgery is death or ongoing pain, then it’s not much of a choice, but it is still a choice. Clearly, chosing surgery in order not to die or to avoid horrible pain, is a different kind of choice than chosing surgery in order to have a hand which functions. The latter choice is far less constrained, far less final in its implications; but both still allow for some form of decision on the part of the patient.
If all surgery is, to a certain extent, elective, then why is it only some instances of surgery which seem to deserve the label ‘elective’ – along with all the negative associations of non-necessity (money wasting!) that go along with it? What does it benefit us to say that some surgeries are elective and some are not? Well, it serves two chief purposes: Firstly it is an aid to making decisons about the distribution of medical resources – economic triage – those procedures which are necessary are supposed to be first in line for public (or insured) funds, whilst those which are elective must find alternative, private sources. Secondly, the division serves as a way of legitimating certain medical practices and procedures over others: the more necessary the practice, the more legitimacy, ethical and professional, it can claim.
The pervasion of this matrix of triage and legitimacy results, unsurprisingly, in efforts by proponents of ‘elective’ procedures to describe them as necessary – in much the same way as I did with Milo’s hand amputation above. This is why cosmetic surgeons routinely describe themselves not as giving women the larger breasts that they have chose to have, but as enabling those women to overcome the severe psychological pain of feeling bad about their appearance. Just having bigger breasts is ‘elective’, but undergoing a procedure which will mean that you no longer suffer from psychological anguish, is arguably medically necessary. Thus it is that the myth of the elective/necessary division perpetuates the idea that cosmetic surgery is empowering and healing, rather than merely a technology for capitulating to arbitrary beauty standards.
It is the elective/necessary myth which underpins many of the arguments against Comparative Effectiveness Research (CER). CER effectively says that some procedures are, by dint of their expense and their success rate, elective rather than necessary, and thus less deserving of public funds. The ‘Death Panel’ scaremongerers are actually themselves scared of having any end-of-life procedure, no matter how expensive or useless, described as ‘elective’ rather than necessary. If we did away with the elective/necessary myth, and admitted that all medical procedures are in some way ‘elective’, then the debate about health costs would perhaps look considerably different.
So, back to Milo and his brilliant bionic hand. Of course it was an elective procedure: all medical procedures are. Instead of trying to fit every ethical case into the elective/necessary myth, we should focus instead on exploring how constrained people’s ‘elective’ choices are. Milo was constrained by the lack of functioning in his hand, and within those constraints he and his physician made a perfectly ethical decision.
Dan O’Connor – Research Scientist, Faculty, Johns Hopkins Berman Institute of Bioethics. Dan has two main research areas: the ethics of social media in healthcare and historicising the ethics of emerging diseases