Ethical Considerations in the Treatment of Head and Neck Cancer

David P. Schenck, PhD

Disclosures

Cancer Control. 2002;9(5) 

In This Article

Case 2

A 70-year-old man presented with a history of squamous cell carcinoma of the larynx first diagnosed by a privately practicing otolaryngologist 11/2 years earlier. He underwent primary radiation therapy at an outside facility, but that failed and he underwent salvage laryngectomy 3 months later. Six months postoperatively,he presented to a major cancer research and treatment center for evaluation for a tracheal esophageal puncture. At that time, the head and neck surgeon noticed a lesion in the posterior tracheal wall. A biopsy showed the lesion to be consistent with recurrent squamous cell carcinoma. The patient underwent a resection of the stomal recurrence with mediastinal tracheostomy, pectoralis flap reconstruction, total thyroidectomy, and partial parathyroidectomy. A 3.5-cm mass was removed at surgery, which showed high-risk features of perineural invasion and extracapsular spread.

Considerable debate over appropriate treatment developed between the attending head and neck surgeon and the radiation oncologist. The patient did not qualify for any of the protocols active at this center at the time. The radiation oncologist argued that there were no data available to suggest a likely positive outcome from re-irradiation in diseases of this type, and that he also would be concerned about comorbidities. Additionally, he expressed concern for a slippery slope, fearing that treatment off-protocol, as was being suggested, included a risk of damaging the research integrity of the institution. He also noted that the chance of cure in this patient was small.

The surgeon countered that while these observations were true, patients often came to the cancer center as a last hope when treatment elsewhere had not been successful. He agreed that the cure rate was approximately 5%, but he also believed that patients who want to continue to fight their disease should be offered whatever treatment the center reasonably could provide. As for the dangers of re-irradiation, he believed that if the risks were not absolutely contraindicated, then taking the risks should not summarily be ruled out since many standard medical therapies have resulted from calculated attempts to go beyond established norms. How can this be resolved?

The medical facts of the case are clear to the oncology team responsible for this patient's care. Inasmuch as this man has been in their care for the past several months, they have also become familiar with his family, especially his wife and niece who have always accompanied him. The family understands that the disease is serious and that his life is in jeopardy, but they and the patient look hopefully to the physicians to give him every chance at extended life. The patient's outlook remains positive, supported by a strong religious faith. He has said that he is eager to try anything.

The patient's medical good at this point is realistically limited to forestalling rapid progression of the disease and to palliation. His greater good now would be to come to terms with his approaching death. This means envisioning the remainder of his life in a way that is most fulfilling in terms of his values and past life, one that provides a satisfying and logical conclusion to his life narrative in some holistic sense. Any consideration of the goods of others is most appropriately centered on his family, and here their good is ideally to be an effective and meaningful part of the composition of this final chapter of his life.

This is a case in which the autonomy of the patient is not at issue, but certainly the other three principles need to be examined. Beneficence is the goal of the surgeon who would offer the patient additional radiation and possibly chemotherapy, for three reasons: to slow the progress of the disease, to palliate, and to offer the patient a tool that may be useful to him in crafting the end of his narrative. Despite the expectation that additional treatment may have no long-term effect, it is a symbolic tool in the patient's struggle, of his response to the events of his life, and it may figure prominently in the patient's effort to author that final chapter. The surgeon is also concerned with nonmaleficence, though to a lesser extent than beneficence. He hopes to prevent unnecessary harm to his patient -- in this case, unnecessary suffering that can be alleviated by radiation.

The radiation oncologist in this case also has concerns for beneficence and nonmaleficence, though he views them differently. He believes the amount of good that can realistically be achieved is minimal, and he is genuinely concerned that re-irradiation may well bring more harm than is warranted for any good that may be accomplished. He is also legitimately concerned with the harm that may come to the institute if they begin to stray from its research mission, departing essentially from standard therapy outside of active protocols.

The major issue in this case could be viewed as a debate over justice. The surgeon has argued that the cancer center offers treatment to patients with little hope of cure in an effort to "stay with them" and provide every last measure of effort available. Against this microview by the physician of this specific patient, the radiation oncologist has taken the macroview in favor of many potential patients. If the center's research program is followed carefully, avoiding off-protocol use of therapies not clearly indicated or of doubtful efficacy, the promise of doing more good for more patients in the long term is protected. His view is not one of unconcern for this patient but rather the espousal of the classical utilitarian approach of "doing the greatest good for the greatest number," which he considers as part of a research center's mission.

The problem could be solved by referring the patient to a privately practicing radiation oncologist who would not be faced with such a dilemma. While this is pragmatic, and the patient would receive the attending physician's recommended treatment, it circumvents an ethical issue that should leave us still feeling uncomfortable.

In this particular case, the virtue of fidelity to trust is significant. The patient has sought the help of the head and neck surgeon who has, in first accepting him as a patient, promised to use his knowledge and expertise to the best of his ability for the good of the patient. He has also promised tacitly to accompany him though his care. Although there is an appropriate way to refer this patient out, this physician would be abandoning his obligation to his patient in terms of fidelity to trust. The surgeon feels that if this virtue is not maintained, the physician-patient relation would be needlessly and thus wrongly broken. He views his current concern as his duty to this patient. This is not to discount the research mission of the center or the value to large numbers of persons if protocols are strictly followed, respecting the spirit and purpose for which they were funded. He nevertheless views his first priority,by careful practice of the virtue of prudence, to be that upon which the philosophy of medicine is founded, or the duty to effect a right and good healing action.[28] The healing in this case will clearly not be cure of the disease, but rather a faithful, compassionate response to the patient's having chosen the resources of this center in anticipation of care that will be responsive to his view of his situation at this time. The surgeon sees that as the greater good for this patient, given the patient's stance before the disease and the support of loved ones in terms of some meaningful struggle for all of them. In his mind, not to follow through with his own response to these needs, where he reasonably can, would be to fail in fulfilling his obligation to his patient.

Here again, including the virtues with a careful balancing of appropriate principles serves to maintain the intimate nature of the physician-patient relation in terms of the classic philosophy of medicine. However, this is not to declare the surgeon "right" and the radiation oncologist "wrong." Both physicians are equally committed to patient good. Nevertheless, following the algorithm above ensures a more detailed, systematic view of the problems encountered in medical care and helps us become aware of the ethical foundations on which our ethical decisions can be based. If the purpose of medicine and its obligation to patients is to heal, there is no less an obligation to know how and why the decisions intended to do that are formed, regardless of what is meant by healing in a particular context.

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