Cataract surgery: Multiple options become ethical issue
Negotiation is best strategy
Options for a cataract patient might include a monofocal lens that will require the use of glasses, or a multifocal intraocular lens that might not, but carries the risk of side effects such as glares and halos.
Patients with cataracts may hear about premium intraocular lenses from their friends, and tell the ophthalmologist, "That's what I want. I don't ever want to wear glasses again."
"But premium intraocular lenses may not be appropriate," says John Banja, PhD, a medical ethicist at Emory University's Center for Ethics in Atlanta. "This is a scenario that ophthalmologists confront fairly often." According to the American Society of Cataract and Refractive Surgery, there were an estimated 3.3 million cataract surgeries completed in the United States in 2011.
"Ophthalmologists are a group of physicians who you don't think of all that often in terms of ethical dilemmas," says Banja. "They don't deal with front-burner, headline-grabbing ethical issues. But this is an interesting problem that they confront frequently."
Negotiate with patient
Rosa Braga-Mele, MD, MEd, FRCSC, an associate professor in the Department of Ophthalmology at the University of Toronto in Canada, says cataract patients are much more aware of their options than in the past. "Particularly with the baby boomer population aging and access to the Internet, patients want to be part of the decision-making process," she says. "It is a team effort."
Braga-Mele says she informs cataract patients of their options, then indicates what she thinks is a good choice for them. "Ultimately, they make the final decision, unless I think it would be detrimental to their eye health to either proceed or not proceed," she says.
Some ophthalmologists offer just one option to the patient, while others offer multiple options and go with what the patient wants, even if the ophthalmologist has second thoughts about whether the patient's choice is truly appropriate, says Banja. "But the overwhelming number will negotiate with the patient, in the hope of identifying a choice both can live with," he says.
In addition to the patient's eye anatomy, the patient's personality may come into play. "For example, ophthalmologists are very reluctant to put a premium lens into a person who is an arch perfectionist," he says. "If there are side effects like night glares and halos, the perfectionist patient is likely to find them very disconcerting."
If ophthalmologists feel strongly that the patient won't be happy with a premium intraocular lens, they might present only the monofocal option. "This removes the choice completely from the patient," says Banja. "Of course, if the patient is unhappy with the physician's refusal to accommodate their wishes, the ophthalmologist can refer him or her to another doctor."
Patient may demand
Some patients may demand a multifocal or premium intraocular lens regardless of the physician's recommendation against it. "Suppose the patient says, 'I'm the one who is paying for this, you do what I tell you to do,'" says Banja. "A small group of physicians might give it a try."
The physician may have seen tens of thousands of patients go through the surgery and have vast prognostic experience, but he or she could still be wrong that a premium intraocular lens won't work for a particular patient. "There is always a fallibility dimension," says Banja. "The physician may have thought a certain patient would do horribly, and the patient ends up just loving it."
It's an ethical dilemma if patients demand a certain technology or procedure, such as an intraocular lens, even though it's not in their best interest, says Braga-Mele.
"The doctor needs to learn to steer the patient in the correct direction," she says. "If they feel uncomfortable, they need to let the patient know. They may need to refer them elsewhere for care."
Options for a cataract patient might include a monofocal lens that will require the use of glasses, or a multifocal intraocular lens that might not, but carries the risk of side effects such as glares and halos.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content