Offering High-Risk Surgeries for Complications of Intravenous Drug Use

Benjamin Richter, BA; David Oxman, MD, FACP

CASE STUDY
A 51-year-old man with intravenous opioid addiction presented to the hospital with a spinal abscess requiring drainage, spinal fusion, and prolonged intravenous antibiotics. His history of addiction made him difficult to manage longitudinally. Despite prior efforts to control pain with both opioid and nonopioid therapies, he left the hospital and skilled nursing facility twice against medical advice (AMA). Additionally, he was found to be using intravenous drugs in his hospital room. He has had three operations in the past year and is now in the hospital receiving an extended course of parenteral antibiotics. He is currently threatening to leave AMA again before completion of his antibiotic treatment. The orthopedics team is concerned that, without completion of his antibiotic treatment, his spinal infection will recur and require more surgery. Furthermore, they feel frustrated that, given his ongoing use of intravenous drugs, he will invariably develop a new spinal infection and will want to know what their “obligation” is to take him back to the operating room for another surgery, one that would be more complex, costly, and dangerous than the previous surgeries. Are they compelled to re-operate on him no matter the circumstances? Or is it ethical, in the setting of the patient’s ongoing intravenous drug use, to refuse to offer repeat surgery?

ETHICS ANALYSIS
Managing patients who are nonadherent with medical care is a common source of frustration for physicians. It can be particularly challenging in patients with medical problems related to recreational drug use, where self-destructive behaviors associated with addiction are the proximate cause of illness. While there is little controversy about providing routine care for illness due to recreational drug use, when intravenous drug users (IVDUs) require complex and costly surgical interventions such as heart valve replacement for recurrent endocarditis or surgery for complicated spinal infections, the moral and ethical considerations can become complex.

Does Personal Responsibility for Disease Matter?
Fundamental to the ethos of medicine is the duty to provide medical care to patients in need without consideration of factors such as personal responsibility for illness. But should there be limits to this approach? Are providers allowed to deny interventions, even lifesaving ones, because we feel the procedure is doomed to fail, too costly, or that a patient’s behavior simply makes them undeserving of a second chance?

Whether patient responsibility for disease should be factored into treatment decisions is a debate that is not new to the current opioid crisis. The issue is written about extensively in relation to smokingrelated disease, with some authors going so far to argue that active smokers should not receive cardiac surgery for tobacco-related disease.1 Similarly, some cardiac surgeons argue, Why replace a heart valve a second time for infectious endocarditis when a patient will inevitably incur reinfection due to ongoing drug use? Proponents of limiting these surgeries for active IVDUs argue that denying complex surgical treatment is fair in these circumstances because the surgery does not fix the underlying problem of the addiction, and therefore performing these costly procedures is both futile and a poor use of limited resources.2,3 Furthermore, we risk introducing moral hazard (a situation where there is a lack of incentive to guard against risk when one is protected from its consequences) by repeatedly rescuing addicts from the life-threatening consequences of their behavior.4

However, this stance raises the question, How far do we take this reasoning? Should the patient who was nonadherent with her blood pressure medications be denied dialysis for avoidable end-stage renal disease? What of the motorcyclist requiring neurosurgery for head injuries that could have been avoided by wearing a helmet? The mainstream bioethical consensus is that calibrating judgements about personal and moral responsibility for disease is an inherently subjective, value-laden, and dangerous game that practitioners should generally avoid.5 There is also a growing recognition that many unhealthy behaviors, including drug addiction, are not chosen freely but rather are, at least in part, determined by factors out of patient control, such as genetics, family dynamics, and structural societal barriers such as lack of access to preventive care or healthy nutrition for the economically disadvantaged.

Stewardship of Resources or Moral Judgment?
Some writers see arguments of resource stewardship or futility in cases of complicated IVDU-associated illness as cover for a more judgmental approach—one that reflects the medical community’s enduring biases against patients with opioid addiction and still castigates their behavior as a moral failing rather than a chemically driven disorder.6 After all, would these providers deny repeat coronary bypass to the inveterate fast food eater—someone whose similar unrepentant behavior may also doom surgery to long-term failure?

This is not to say that providers cannot place limits or conditions before proceeding with complex costly surgical treatments. In transplantation medicine, patients are routinely excluded from transplant for histories of medical nonadherence or because of unfavorable psychosocial circumstances. Ultimately, successful medical outcomes require a partnership between providers and patients in which both parties share responsibility for care. To facilitate this partnership in cases of complicated IVDU-associated disease, some authors have recommended formal evaluation of patients’ likelihood to engage in outpatient addiction treatment programs or the use of abstinence contracts. Additionally, professional societies and hospitals have been called on to develop guidelines to avoid arbitrary decision-making by providers.7

Resolution
For this patient, the consult team recommended continued multimodal pain control under the guidance of the pain management and psychiatry teams to facilitate patient adherence. Additionally, open discussion with the patient about the treatment plan and his own responsibility were encouraged. In the event that he left the hospital prematurely and re-presented with a recurrent spinal infection in the setting of medical nonadherence, the ethics team’s advice reflected the plurality of what they felt were ethically defensible positions—from performing repeat surgery, to limiting a surgical intervention in some manner, to (after careful consideration and discussion with hospital administration) not repeating surgery and limiting treatment to antibiotics alone.

References

  1. Underwood MJ, Bailey JS. Coronary bypass surgery should not be offered to smokers. BMJ. 1993 Apr 17;306(6884):1047-1048.
  2. DiMaio JM, Salerno TA, Bernstein R, Araujo K, Ricci M, Sade RM. Ethical obligation of surgeons to noncompliant patients: can a surgeon refuse to operate on an intravenous drug-abusing patient with recurrent aortic valve prosthesis infection? Ann Thorac Surg, 2009 July;88(1):1-8.
  3. Hull SC, Jadbabaie F.When is enough enough? The dilemma of valve replacement in a recidivist intravenous drug user. Ann Thorac Surg. 2014 May;97(5):1486-1487.
  4. Doleac JL, Mukherjee A. The moral hazard of lifesaving innovations: naloxone access, opioid abuse, and crime. SSRN. 2018 Mar 6.
  5. AMA Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics’ Opinions on Allocating Medical Resources. Opinion 2.03: Allocation of limited medical resources. Virtual Mentor. 2011;13(3):228-229.
  6. Mendiola CK, Galetto G, Fingerhood M. An exploration of emergency physicians’ attitudes toward patients with substance use disorder. J Addict Med. 2018 Mar/Apr;12(2):132-135.
  7. Libertin CR, Camsari UM, Hellinger WC, Schneekloth TD, Rummans TA. The cost of a recalcitrant intravenous drug user with serial cases of endocarditis: need for guidelines to improve the continuum of care. IDCases. 2017 Feb 7;8:3-5.