Food for thought: “Ethics in Urology”

25 November 2011

Decisions about medical treatment always involve ethical issues since they must take into consideration the issues of the patient’s age, medical history and his or her psycho-social background. The EAU guidelines provide clinical guidance for the 16,000 EAU members and countless urologists in virtually every corner of the earth. Clinical decision-taking is based on data derived from trials which are most often based on natural scientific principles.

Unfortunately, the guidelines don’t provide guidance on how to handle ethical issues which, in daily practice, often arise in connection with the extremes of age. Medicine is not only a natural science and cannot be reduced to numbers and statistics alone.

Evolutionary medical aspects, genetic variability, as well as psychological and social context factors can have major and unexpected effects on the course of a treatment, making medicine to a large extent a science of experience. Since the time of Rene Descartes and his book Traité de l’homme (1632), we like to think about the human body as a machine. Broken parts are fixed and the system will work again.

But it is not as simple as that. Taking into account the aforementioned, we also need recommendations that are complementary to the guidelines, which advise us when to act, what to do, how to do it as these factors will influence the extent of our treatment in an individual patient’s case. These recommendations about what ought to be done or what should

NOT be done are ethical issues

The Strategy Planning Office of the EAU feels that a discussion about ethical conduct in urology is needed. Constant challenges, arising from the numerous ongoing developments in medicine, in health politics and across society, require ethical evaluation not only from medical professionals in general but also within each subspecialty. Ethics are valid independently from cultural values and even personal beliefs of what is wrong or right. What is actually done in a certain situation could be in conflict with ethical standards, yet be acceptable within the respective social environment.

Ethics of self-promotion and advertising
The World Medical Association began to develop ethical principles regarding medical research as early as in 1964. The Declaration of Helsinki has since then been subject to a number of changes and modifications. Its current version stems from the 59th WMA General Assembly in 2008. But ethical issues arise not only in situations connected to research. During the past 30 years, economy and economists have taken the lead in health care.

Medicine and thus, in many countries, Urology has made the transformation into a business, forcing physicians to think more and more in economic terms, with the result that an ever increasing number of physicians add the MBA to their MD’s. With the advent of the internet, the patients for their part have become customers.

As a result, for the first time in history the implementation of a new technique (the Da Vinci robot) became market-driven and not on the basis of evidence-based medicine alone. Hospitals and physicians nowadays advertise their treatments and expertise on the internet, via Facebook and in Twitter. Flashy homepages lure patients with the promise of a cure. Like bees around a honey-pot, patients are highly attracted by lasers, protons and everything that looks like the latest development from the Star Trek crew.

Physicians have the ethical obligation to provide honest information. Unrealistic claims about treatment outcomes, advertising false numbers of procedures or omitting crucial information in order to attract patients, are not acceptable. Economic investments in expensive equipment clearly imply a conflict of interest particularly when the personal income of the doctor is dependent upon executing a certain number of procedures. In this scenario, the doctor may be tempted to recommend this treatment more often.

An additional ethical issue can arise if a surgeon can only perform one technique when alternatives, perhaps superior procedures exist: in this situation the patient may not be referred to another centre as “business” would be lost. As well as the conflicts of interest that exist when a surgeon is paid per item of service, be it in private practice or by the hospital or government, the relationships between the medical profession and industry, and the ethical aspects involved, have attracted a lot of worldwide interest lately from health authorities and the press.

Ethics of elderly patients and at the end of life
In our ageing Western societies new ethical challenges arise. A discussion is needed about ethical conduct when managing elderly patients, and about preserving and enhancing dignity in death. New diagnostic possibilities require to be dealt with sensibly. In the elderly, quality of life is a most important aspect. The patient has to be given full information about the options, taking into account his/her age and probable life expectancy. Of importance are comorbidities and the family history. If the parents lived to their 90’s, chances are pretty high that the patient will reach this age as well.

The patient must have the opportunity and the right to refuse treatment, especially when the expected outcome is likely to be of questionable value. Therefore, the information has to be presented as objectively as possible because ethics should be seen from the perspective of the patient. We need a discussion about dignity in death, not only within the urologic community, but also in public. Patients and their relatives can be very demanding when it comes to decision-making at the end of life, something which can make patient management quite difficult. Doctors can thus be pressured into decisions of questionable ethical value. The reasons for this behaviour are often based on conflicts of interest in the family of the patient. While the relatives don’t want to lose a loved one, the patient himself can feel guilt towards his relatives in refusing further treatment.

Over- and undertreatment
Over- or even undertreatment is a challenging topic, not only when it comes to the senior patient. Screening for prostate cancer in asymptomatic octogenarians would be a typical example of overdiagnosis in this cohort which may easily lead to overtreatment. In pediatric urology, parents might push their child towards a certain procedure that may not be necessary, or even withhold treatment that is important for the child. To get informed consent from the child can be an additional ethical challenge. Adolescent urology is a field of urology that is largely unknown to many urologists. In the transition from childhood to adulthood, patients can get lost to follow-up, thus not getting the treatment and above all psychological support they need in this difficult period of life.

Does the EAU need a committee for ethical standards?
The European Association of Urology is not only the second largest urological association, but also one of the most influential medical societies worldwide. It therefore seems important that the EAU considers its leadership role in ethical issues. For this reason, the Strategy Planning Office can see a need, and potential value of an EAU ethical standards committee and inclusion of such standards into the EAU guidelines. So far, neither the European Association of Urology, nor the European Board of Urology has taken on this issue. This committee could be integrated into one of the already existing EAU offices or alternatively become an office of its own. We propose that it not only consists of urologists, but also of representatives from other professions with ethical expertise, and patients. The purpose of such a committee will not be to re-invent the ethical wheel but to provide guidance in challenging situations which occur every day in urological practice. The American Board of Urology (ABU) has recognised this need and issued a paper on ethical practice of urology on their homepage. According to this statement, practical assessment of professionalism and ethical urological practice is done through “peer review, examination of billing records, and queries to state licensing boards at periodic intervals.”

The full version of this article and references are published in the October/November 2011 issue of EUT.

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