Ethics of palliative surgery in esophageal cancer.

BACKGROUND: Surgery is one of the important palliative methods for patients withesophageal cancer. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of them are related to patients and their illness, others to surgeons, their attitudes, skills and knowledge base.
METHODS: Pertinent moral challenges are addressed and analyzed with respect to prevailing perspectives in normative ethics (Ross style pluralism). Demandsregarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the beneficence, non-maleficence, justice, autonomy and proper patient information.
RESULTS: Moreover, variations in definition of palliative surgery as well as limited scientific evidence in efficacy, effectiveness and efficiency pose methodological and moral problems. We have shown that ethical principles (beneficence, non-maleficence, and justice) in all procedures and treatments in esophageal cancer, including psychological problems of the patients are effective in improving their quality of life.
CONCLUSION: Both surgical skills and moral sensibility are required to improve surgical palliative care in esophageal cancer, and should be taken into account not only in clinical practice but also in education and research.

Introduction

There are many distinctive ethical characteristics, dilemmas, and potential barriers for surgeons who are involved in esophageal surgery. Because of the inherent stresses for patients, families, and caregivers in treating cancer patients, many ethical concerns are magnified in this patient group. These concerns compound the potential ethical issues present in all clinical, operative and postoperative procedures.

In addition, when considering surgical interventions, the risk-benefit analyses are warranted in mid and lower esophagus and after neoadjuvant therapy patients should receive special attention for full recovery.

Ethical dilemmas and barriers might be similar to those noted for palliative care in general, but there are several distinctive characteristics that must also be considered.

On the other hand, progressions of the field of philosophy of ethics have enabled surgeons and other authorities with an ethical concept modelling beside other organizational aims and therefore providing a suitable operational model.

The inherent principle of palliative care is an integration of a solid support system with the primary focus to alleviate suffering and provide emotional and spiritual assistance. The ultimate goal is to establish a strong foundation of comprehension about the diagnosis and offer treatments that promote comfort and improve quality of life [1]. Today, supportive and palliative care has been recognized as an important component of quality of life care for patients, particularly those with advanced or incurable diseases such as cancer [2]. The objective of this review is to describe the associated ethical issues of palliative esophageal cancer care and its challenges.

Materials and Methods

Informed consent: Adequate informed consent can be particularly difficult to obtain from subjects at the end of life [3] and one cannot always assume that consent remains valid after patients deteriorate physically and mentally [4]. Although proxy consents for treatment are valid if the treatment is considered in the best interests of the adult patient, the use of a proxy decision maker to give consent for participation in a method of surgery is much more problematic. Ethical decision making in medical centers consists of both controllable and uncontrollable variables and the more uncontrollable the variable, the more difficult and complicated the decision making. If ethical decision making is ED, controllable variables c, and non-controllable variables nc, then the below equilibrium can be concluded: (F is a factor which is constant in each medical center).

The controllable variables are those variables that are easy to access and set such as the treatment time, dosage, and type of surgery. For example, in esophageal cancer, standard surgical operations and duration of hospitalization are considered controllable variables.

Uncontrollable variable is: a biological cancer from one case to other, ethical and psychological subjects.

The factor of (F) is related to level of the centers (medical training centers for students, interns and residents) or non-training centers (private or non- private).

F= 1 for all of medical training centers

F= 2 for non-training and non-private

F= 3 for private

ED = F (c + nc)

Considering the above mentioned remarks, using the seven ethical duties of “Ross” [5] among the decision making indices and incorporating them in the decision making algorithm, can lead to creation of a conclusive model of decision making for surgeons in medical centers.

For decision-making, it is essential that the questionnaires be prepared apart from the above- mentioned centers (training, private, non-private).

Six values in medical ethics

The foundation of medical ethics is supported by four pillars:

Autonomy - patient has the right to choose or refuse the treatment.

Beneficence - a doctor should act in the best interest of the patient.

Non-maleficence - first, do no harm.

Justice - it concerns the distribution of health resources equitably.

Added to the above four, are two more aspects which form the cornerstones of medical practice:

Dignity - the patient and the persons treating the patient have the right to dignity.

Truthfulness and honesty - the concept of informed consent and truth telling

All these together constitute the six values of medical ethics.

Results

We have shown the obtained results and the ethical dilemmas during the treatment of esophageal cancer in different medical centers. The economic factor is one of the main ethical challenges in esophageal cancer. Unfortunately, ethical issues are rather ignored in private treatment centers due to economic problems of the patients and this ultimately results in patients' dissatisfaction with the treatment process. These dilemmas were lower in non-academic and academic centers.

In the following some of the ethical dilemmas are discussed in esophageal cancer.

Ethical dilemmas particular to surgical palliative surgery for esophageal cancer

There are several ethical dilemmas that are particular to surgical cancer. First and foremost, the invasiveness of a surgical procedure and the potential morbidity and mortality directly related to these procedures can make decision making especially difficult. Magnitude of operations is quite different to other therapies, such as chemotherapy and radiation therapy, and necessitates special consideration.

Second difference related to surgery is the loss of decision-making control during and sometimes for prolonged postoperative periods. While a majority of physicians in both developed and developing countries tell the truth more often today than in the past, the assumption that truth-telling is always beneficial to patients can be questioned. The issue of truth-telling is still approached differently in different countries and cultures and there is a need for an increased awareness of cultural differences to truth- telling among patients from ethnic minorities [6]. Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. Variables having major influence on surgeons in choosing palliative treatment for patients with advanced, solid malignancies are: truth-telling, hope, social culture, level of education, religious beliefs and several variables such as economic level are very important.

Discussion

The main objective of palliative treatment in patients with operable esophageal cancer is to achieve an improvement of dysphagia and quality of life.

The longer survival observed in patients with resection of the primary tumor may partly be explained by patient selection. Elderly patients (≥ 80 years) had a similar survival, irrespective of resection of the primary tumor. Careful consideration of the individual patient, extent of disease and treatment-related factors are important in decision- taking for palliative treatment for patients with advanced RC [7].

Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies to focus on patient outcomes [8].

The ethical challenge is to find a delicate balance. On the one hand, avoiding ageism and providing a therapy to older patients that offer the only meaningful chance for improved survival, especially in early-stage disease, and avoiding overzealous therapy with significant morbidity and mortality to older persons who are already at greater risk for functional loss and death [9].

The mortality rate and the daily cost, based on daily bed charge were significantly higher in the older cancer patients. Experience shows that older people had a more difficult recovery in ICU than the younger people and we should focus on providing care and treatment for those with acute critical illness, and not be so much concerned with those illnesses related to terminal pathology. A problem exists in educating physicians about which patients will derive no benefit from the ICU. This will determine whether it is best to decrease or avoid the use of the ICU and its accompanying expense in situations where it does not significantly increase survival and the quality of life of patients [10]. The understanding that ethics in palliative care is most effective when incorporated early in oncology care, integrate palliative along with anticancer therapy from the time of diagnosis. The American Society of Clinical Oncology has described responsibilities for oncologists to care for their patients in a continuum that extends from the moment of diagnosis throughout the course of the illness. In addition to appropriate anti-cancer treatment, this includes symptom control and psychosocial support during all phases of care, including those during the last phase of life [2]. One should note that "every life is beautiful" and cannot be denied of the patient. Therefore, different methods should be tried to increase the quality of life of the patients. There are several methods for palliative therapy in esophageal cancer; one of which is esophageal stent insertion.

Esophageal stent insertion is widely available and enables the patient to be treated locally. Most papers report success and complication rates of this method [11, 12]. The ethics of palliative surgery and management care should continue to focus on the relief and improvement of the quality of life of patients with esophageal cancer.

Ethical dilemmas occurred at the time of diagnosis, in connection with telling the truth, in providing information, in the treatment of pain, and in decision- making situations concerning active treatment. Dilemmas of active treatment concerned chemotherapy, intravenous infusions, blood transfusions and antibiotics [13].

Finally, we found that ethical communication is applied theoretically in all surgery centers. It is hoped that future studies help to resolve ethical dilemmas in this field.

Conclusion

To provide better care for these patients, additional surgical skills of medical ethics must be observed. This is necessary not only for patients but also for all cancer researches. Medical ethics should be considered as early as the admission time and should continue till the end of treatment.