Ethical Considerations in the Treatment of Head and Neck Cancer

David P. Schenck, PhD

Disclosures

Cancer Control. 2002;9(5) 

In This Article

Abstract and Introduction

Background: The second half of the 20th century saw not only important developments in medical science and technology, but also a rapid growth in the application of biomedical ethics in medical decision making. Withdrawal of treatment, allowing to die, informed consent, and patient autonomy are concerns that now comprise a part of the overall medical treatment, particularly in patients with head and neck cancers.
Methods: The author discusses ethical issues relating to disfigurement/dysfunction in head and neck cancer patients and examines the aspects of "principlism" -- autonomy, nonmaleficence, beneficence, and justice. Two case reports are presented to illustrate the ethical challenges that may confront physicians who treat head and neck cancer patients.
Results: Head and neck oncology generates unique problems relating to disfigurement and dysfunction. An algorithm that considers the patient's medical good and greater good, as well as the goods of others, can assist in arriving at appropriate ethical decisions.
Conclusions: Bioethical decision making requires the integration of virtues with principles, followed by the application of these standards to each patient.

"Ethics [. . .] begins with the character of the physician." -- John Conley, MD

Ethical considerations in the treatment of head and neck cancer comprise a relatively unexplored area within the context of overall cancer care. Intensive study has focused on nonmedical aspects of cancer care,and many of the ethical issues involved in head and neck cancer are arguably no different than those in cancers of other parts of the body. However,head and neck oncology is associated with unique sequelae, often involving changes to the patient's personal identity.

In cases where disfigurement, dysfunction, and the threat to personal identity are possible consequences of disease management, decisions about treatment planning can become even more complicated than they would otherwise be in treating life-threatening disease. When death is certain or possible,weighing quality of life, treatment morbidities, and length of life against one another is already problematic. In cases where threats to the identity or "intactness" of the person are possible, another issue in cancer care is added. Pneumonectomy, mastectomy, prostatectomy, and bowel resection are life-altering interventions, and decisions to consent to these procedures do not come lightly. The results of these treatments are not necessarily visible to others and do not inevitably change physical appearance or alter social functioning to the degree that laryngectomy, mandibulectomy, and orbital exenteration can. Although an isolated patient may have no more hesitation in submitting to composite resection than to gastric resection, that is not to say that there is no difference in what the patient may be confronted with in giving consent to these interventions. In cases of head and neck cancers, the question of what treatment approach is appropriate, or whether treatment should be considered at all, is accompanied by additional unique questions,such as whether a fundamental change in personal identity can be tolerated, or even whether disfigurement/dysfunction is seen as identity altering at all. Patients with head and neck cancers may be more vulnerable, with their values far more at stake, than patients with other serious diseases.

Thus, it is not surprising that studies to date on the ethical aspects of head and neck cancer have tended to focus on quality-of-life issues as well as more theoretically oriented issues such as moral principles.[1] Quality- of-life studies have included such aspects as psychosocial issues of the head and neck patient -- self -image, coping abilities, social relationships, performance and functional abilities, and scales for measuring patient perceptions of disfigurement/dysfunction and quality of life.[2,3,4,5,6,7,8,9,10,11,12] Meanwhile,the more theoretically oriented ethical issues have addressed patient autonomy, the character of the physician in the healing relationship, the meaning of life-threatening disease for the patient, informed consent in a highly vulnerable patient, and the line between physician persuasion and coercion.[13,14,15,16,17] Pellegrino[18] offers the most thorough assessment of this and was the first to offer a systematically related set of clear moral principles combined with virtues in an approach to ethical decision making. The present article is an attempt to pursue the importance of character and virtue ethics in head and neck cancer a bit further.

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