When healthcare loses the caring
“[R]ecognition of the inherent dignity… of all members of the human family is the foundation of freedom, justice and peace in the world.” — Universal Declaration of Human Rights, United Nations. December 10, 1948.
Another simply heart wrenching story appeared in the Australian news today of a man needlessly suffering years of incapacitating pain from osteoarthritis that has left him totally disabled. Doctors are refusing him knee replacement surgery because he’s fat and they say his weight risks higher complications. But they have offered to perform bariatric surgery on him.
As the Geelong Advisor reports:
Raymond Harris needs two knee replacements but Geelong Hospital will not operate at his current weight of 159.7kg... Mr Harris said his surgeon at Geelong Hospital had told him he needs to drop to 140kg before they will put him on a waiting list for surgery, but despite years of trying, Mr Harris can't shed enough weight... Barwon Health said Mr Harris was required by his surgeon to reduce his weight to avoid complications...
Mr. Harris said he had been overweight since he was a child. "My whole family is fat. My older brother weighs about 170kg, while my brother, who is in his 30s, weighs about the same as me. My mother is also very big." He said despite what many people might think, his weight is not a result of gluttony... Mr Harris has acute osteoarthritis in both knees and can barely walk for the pain. He has been unable to work for the past 20 years.
"It is ruining my life completely," the former power station operator said. "I get up in the morning and for the first half hour I can hardly move at all. I take a handful of tablets and they start to work after about half an hour...
He said doctors had offered him gastric reduction surgery but he was against the idea...
Last fall, Australian Bishop Gow, a man who’d devoted his life to charitable work caring for others, was denied knee surgery because was told he was too fat. Some of the cruelest cases in medicine are patients left to suffer excruciating pain and complete disability, and are denied pain relief and the chance to return to functioning, quality lives, simply because they are fat. Regardless of whatever self-righteous justification healthcare professionals may attempt to use, this is blatant prejudice.
Examinations of the medical literature shows** that “obese” patients can do just as well after joint replacement surgeries as thinner people, so denying them the relief and benefits of a proven medical procedure has no sound argument. And especially not from a rationing of healthcare resources standpoint.
Even if one were to accept the hospital’s argument that knee surgery is a higher risk procedure for him than a thinner person, by that line of reasoning then no medical procedure would ever be done on those most in need of them. No woman, for instance, would ever be eligible for a coronary artery bypass — because they have nearly double the rates of infections, longer hospital stays, and are more likely to die after the procedure than men, according to some research. Rather than hospitals and medical professionals working towards bettering treatments to improve outcomes for all patients, have we come to the point of rationalizing to deny care for those who cost more or take more of our effort and resources?
While knee surgery is claimed to be too risky and bariatric surgery supposedly isn’t — that is not what any reasoned risk-benefit analysis would conclude. The most reliable and credible medical evidence consistently and overwhelmingly shows that bariatrics would raise his chances of dying by at least seven-fold just in the first year, with the risks even higher for a man and a person of his size. The duty of healthcare professionals is to understand sound science and apply medicine to do right by patients and advocate for care that benefits them. Beneficence is the fundamental ethical code of professional conduct and clinical decision making.
Respect for persons and human dignity is another of the principles enunciated in the 1979 Belmont Report, created to ensure there would never be repeats of abuses of discriminated persons as suffered under the hands of Nazi doctors. “The preservation of human dignity and the prevention of indignity are obligations built into the ends of medicine,” wrote Dr. Edmund D. Pellegrino, M.D. “The ends of medicine are focused on the good of the patient as a human person.”
Dr. Pellegrino’s essay, “The Lived Experience of Human Dignity,” was published this March in Human Dignity and Bioethics: Essays Commissioned by the President's Council on Bioethics. This passage seems an especially important reminder that this poor man is a person deserving of compassion and human dignity and of the moral imperative of healthcare professionals to advocate for those in their care:
Physicians cannot ignore those many assaults on human dignity, intrinsic as well as attributed, that are taken for granted in the bureaucratic, commercialized, and impersonal places that hospitals have, all too often, become. Some of this is indeed unavoidable, given the complex nature of contemporary medical care. But physicians, administrators, and policy-makers must always ask, “What is the impact of our organization or ‘system’ on the care of the persons they were designed to help?” A more collective sense of shared responsibility for the “dehumanization,” the “depersonalization,” or the “alienation” that the sick feel in today’s health and medical care institutions must fall on the physician. Physicians can exert enormous moral influence if they take their advocacy role seriously as part of their common professional ethic.
If our goals as healthcare professionals are to help improve the lives of patients, then all patients deserve that — not just the ones whose bodies it's popular to see as more fitting.
© 2008 Sandy Szwarc
** How do the “obese” fare after joint replacement surgeries as compared to “nonobese?” [Reprinted from Calling a Spade a Spade.]
A 2002 study of 180 total knee replacement (TKA) procedures in the Journal of Arthroplasty looked at how body weight affected one-year outcomes and reported that “body weight did not influence adversely the outcome of TKA.”
A longer-term study following patients for an average of seven years was conducted by researchers at the Department of Orthopaedics, Johns Hopkins University School of Medicine in Baltimore, Maryland, reported: “There were no significant differences in the combined percentage of good and excellent results between the two groups. On the basis of the results of this study, it is believed that weight as a factor by itself should not compromise the... results of total knee arthroplasty.”
Here in the U.S., the Agency for Healthcare Research and Quality (AHRQ) under its Evidence-based Practice Program recently examined the evidence on TKA procedures, the most common orthopaedic procedure performed. They noted that it had previously been established that the evidence supports these surgeries because they improve functional status, relieve pain and result in relatively low perioperative morbidity. For this NIH report, the AHRQ was especially interested in determining who is most likely to benefit and in what patients the procedure may be contraindicated. Their conclusion: “Age, obesity, or gender do not seem to be significantly correlated with TKA outcomes.”
Do things other than clinical data influence who gets these surgeries or in treatment delays? The AHRQ report found “lower rates of TKAs among blacks despite a higher prevalence of osteoarthritis in this group.” They found “the evidence regarding non-white groups is quite consistent. Non-whites receive TKAs about half as often as whites.” And a Canadian study looking at the equitable nature of waiting lists reported that while there were no biases in waiting times for joint replacement surgeries with respect to age, gender, education or work status; there were in other respects. Waiting time was determined by the patient’s body mass index and the primary language they spoke, as well as marital status.
While it is believed that the surgeries won’t last as long and need more revisions in the obese, this isn’t necessarily the case. Researchers at the University of Utah, Salt Lake City, published their study of 840 hip and 911 knee joint replacement surgery patients, aged 55 to 74 years, in a recent issue of the American Journal of Preventive Medicine. They also found “no statistically significant association was found between obesity and the risk for hip or knee revision procedures.”
And a ten-year follow-up study of TKAs performed on 22 obese patients and 34 nonobese patients at the Complete Knee Center of Arkansas, Van Buren, found that while stair climbing was more difficult among obese post-op patients, overall, “10-year Hospital for Special Surgery scores and Knee Society scores for patients who were obese were comparable with scores for patients who were nonobese and given lower preoperative Hospital for Special Surgery scores, improvement in knee score was greater. Revision rates in patients who were obese were not higher than in patients who were nonobese at 10 years follow-up.”
Addressing the specific question as to if obesity is contraindicated because of surgical complications, researchers at the University of Arizona, College of Medicine in Tucson examined 405 primary bilateral TKAs done under one anesthetic for incidences of wound infections and systemic complications. They found: “Preoperative and postoperative knee scores were not significantly different for any patient group. Local wound complication rates did not differ between any of the study groups... there was no significant difference in complication rates between patients with obesity who underwent unilateral or simultaneous bilateral total knee arthroplasties. Based on these findings, obesity does not seem to be a contraindication to bilateral total knee arthroplasties under one anesthetic.”
A retrospective examination of complications for the two years following joint replacements in 130 obese and 51 nonobese patients at Lutheran General Hospital in Park Ridge, Illinois, concluded: “The hospitalization time, number of days with a fever, number of transfusions, preoperative and postoperative hemoglobin levels, and days requiring intramuscular narcotics were very similar between the two groups. There were 0.29 minor complications per nonobese patient, but only 0.22 per obese patient. Major complications were encountered 0.22 times per nonobese patient and 0.10 times per obese patient. The patient is not necessarily at a higher risk for perioperative complications in total joint arthroplasty.”
As the AHRQ noted, function and quality of life can greatly improve after a joint is replaced. This benefit is shared equally among fat and thin. A study of TKAs performed from 1989 and 1994 by University Orthopedic Specialists in Tucson, Arizona, reported: “Knee prosthesis and functional scores improved statistically after TKA.” Among the patients who had limited functional capacity, the most common cause was “progression of their arthritis at other sites, especially lumbar spine and hips, and cardiopulmonary problems....[but] Patient weight, body mass index (BMI), and age at surgery showed no correlation with postoperative functional scores.”
A study published in Obesity Research examined one-year outcomes among 592 primary total hip arthroplasty patients and 1011 primary TKA patients. It concluded: “Obese patients enjoy as much improvement and satisfaction as other patients from total joint arthroplasty.”
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