Ethical Considerations in the Treatment of Head and Neck Cancer

David P. Schenck, PhD

Disclosures

Cancer Control. 2002;9(5) 

In This Article

Case 1

A 44-year-old single woman presented to a private otolaryngologist with a sore throat, left otalgia, dysphagia, and a weight loss of 20 pounds over the previous 6 months. She smoked approximately 400 packs of cigarettes annually and used alcohol moderately throughout her adult life. A panendoscopy revealed an extensive tumor in the left hypopharyngeal lateral wall. A biopsy was positive for squamous cell carcinoma, which was staged as T3 N0 M0. She was given a tracheostomy and a PEG tube. She began a course of chemotherapy and radiotherapy that was completed 2 months later. Her tracheostomy and PEG tube were removed 3 months after that. Six months later, she represented with a lesion in the left hypopharynx just above the pyriform sinus, and she was referred to a major cancer center. The biopsy of this new lesion was consistent with squamous cell carcinoma.

Communications with this patient were difficult. She had a significant history of paranoid schizophrenia that required hospitalization at 20 years of age. She also had a history of epilepsy and had suffered two grand mal seizures during her hospitalization 1 year ago when her medications were stopped. The epilepsy was brought under control when medications were resumed. The patient also seemed to have limited mental capacity. She was competent to make her own decisions and had a pleasant demeanor, but she had trouble following a line of thought. She was usually accompanied by her 65-year-old mother, with whom she lived. The mother would defer to her daughter's decision about her own health care, but she was of no assistance in helping her daughter think through the issues. It appeared the mother also had limited capacity to process information provided by the physician.

When given the recommendation for a total laryngectomy with pectoralis major flap reconstruction, the patient at first appeared to accept that, saying,"Well, I guess we better do the operation then, right?" The surgeon responded that indeed he thought that the wisest course of action, but in wanting to ensure that she understood what that meant, he said, "Do you realize that we will remove your voice box in order to try to stop this cancer? We have ways of helping you communicate after the surgery, but you will not have your own voice box." She then quickly responded that she did not want to lose her voice box. The surgeon explained that she could make that choice if she wished but that she would then certainly die of this cancer, would no doubt suffer more in the long term, and would be back on the feeding tube before long. "Oh, then I guess we'll have to do the operation," she replied. This circular conversation was repeated several times with the surgeon asking her to think about what they had discussed and return for another visit in a week. At this follow-up visit, the same pattern repeated itself. The surgeon determined that she was unable to make a rational decision.

In this case, the woman was competent in the eyes of the law and society to make her own life choices, ill-advised as they might be. However, inasmuch as she could not follow a rational argument, she was incapable of giving truly informed consent, or even refusing treatment, with an understanding of the consequences. Should the physician try to arrange for a more capable surrogate? First in line would be her mother, but she appeared no more capable than her daughter, and in any case, the patient would never be declared legally incompetent to make healthcare decisions for herself.

The medical facts and the psychosocial issues seem to be clear. Because we must assume that she is competent, albeit irrational and incapable of processing information effectively, it would appear that the only ethical approach is to defer to her right to make her own decision, to respect her autonomy. She cannot have beneficence forced on her. However, the bow to autonomy is too easy an answer in this case. Moreover, it neglects the physician-patient relationship while granting trump status to autonomy in a difficult situation.

If the virtues are made part of the calculus,we do not have to end up just declaring autonomy the winner out of some sort of default, and we can ensure a genuine caring for this patient. Guided by prudent choices, and practicing the virtues of compassion and fidelity to the patient,we are led in a slightly different direction. Compassion guarantees that the physician share the patient's suffering no matter what treatment she chooses, and fidelity ensures that he remains caring of her, does not "abandon" her, and keeps her greater good in mind, not solely her medical good. In focusing on the virtues as guides to the proper balancing of principles and focusing on character in relationship to this patient, we are led more in the direction of nonmaleficence than anything else. We cannot force her into a laryngectomy. It also appears that no amount of beneficent persuasion is likely to secure her consent and that whatever decision she makes will not be informed. However, if we fall back onto autonomy out of frustration, little more than abandonment results. In this case, nonmaleficence, the principle of doing the least harm, is the principle most in tune with virtuous professionals who maintain their commitment to their patients in a healing relationship. If we cannot do much good, we should at least do as little harm as possible. That means following this patient's wishes regardless of the harm that may come to her as a result, for to do otherwise would be to bring even greater harm on her despite the good that was intended. One of the fears the surgeon had, as his conversation with this patient developed,was that she might eventually consent to surgery, allow it to take place, and in another reversal regret the loss of her larynx after the operation. He was justified in fearing that this could well destabilize her and precipitate a serious crisis. This might then do her even more serious harm than if she were left with her disease unresected, and it would certainly destroy the physician-patient relationship, a sine qua non for healing of any kind to occur.

In the end, we must ask if there is any real difference in outcome if we yield to autonomy due to our inability to communicate effectively with this patient, or if we lean in the direction of nonmaleficence. We must answer that there is, for in the first instance, we have merely come down on the side of the abstract principle that seems to bear the greater weight, while in the second,we have focused on the character of the healer, that which is largely responsible for the relationship between physician and patient. This patient left the clinic and was lost to follow up, but the context in which she did so was significant. Instead of disconnecting or backing off and letting her have her autonomy out of frustration or because of impasse, the physician maintained the physician-patient relationship through his exercise of the virtues. There was no indication that further attempts to bring her to some functional level of understanding would be successful, but in going through the decision-making process that he does, prudence ensures that he maintain his obligation to her in terms of fidelity. At the same time, the character of the physician is reinforced.

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