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Commentary on “The Skilled Specialist’s Ethical Duty to Treat”

With the initial reading, Frederick A. Paola and Israel Freeman’s “The Skilled Specialist’s Ethical Duty to Treat” would seem to present an open-and-shut case of failure to recognize an ethical duty to provide specialized care. The attending physicians’ assessment of what the patient needed--urgent coronary artery bypass grafting surgery--makes almost any denial of surgical therapy an inadequate response. The authors’ evaluation of the surgeons’ response, which includes a detailed comparison to the criteria identified by Beauchamp and Childress of what comprises a general obligation of beneficence, only formalizes their disappointment. There is a real sense that the internists responsible for this patient’s care felt that illegitimate political and professional (and perhaps economic) concerns were allowed to hold sway. As presented in the article, this most certainly did occur. In fact, a refusal to perform surgery because of concern for mortality statistics would horrify even those who publish such statistics. Many cardiovascular specialists (and other specialists) incorporate such concerns into their day-to-day decisions about the treatment of patients. There are several gaps in the authors’ clinical and ethical discussion, however, that are worthy of commentary. First, the decision to discharge a patient with a tightly blocked major coronary artery who had sustained a non-Q wave (incomplete) infarction would raise a few eyebrows. Patients in such a precarious condition may benefit from low-level exercise testing prior to discharge, precisely because of a known propensity to clinical instability and recurrent infarctions. Although this decision to release the patient led quickly to an awkward and frightening predicament (two days later, the patient was brought back to the hospital in cardiac arrest and acute pulmonary edema), it does not lessen the questions raised regarding a refusal to operate. Second, it is unclear whether the patient agreed to medical therapy or if