Proposed Surgery During an International Pandemic

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Editor’s Note:

This column presents a problematic medical-surgical case that may pose a medical-ethical dilemma for patients, families, and healthcare professionals. As these cases are based on real medical situations, identifying features and facts have been altered to preserve anonymity and to conform to professional medical standards. In this case, a family must weigh the benefits and burdens of a proposed surgical procedure.

Question:

Is it ever appropriate to perform a surgical procedure if it is not medically necessary?

Story

Nathaniel is presently an active 21-month-old infant. Overall, he has done exceedingly well since birth and has required no hospitalizations or surgeries. After the first several months of life, he began to develop increasing difficulty with nasal symptoms and sleeping difficulties, and ultimately developed perforated eardrums after having had several episodes of otitis media and treatment with appropriate antibiotics. There seemed, however, to be no problem with the infant’s hearing. Nathaniel’s father also had problems with his ears as a child, and ultimately required a tympanostomy tube placement.

Nathaniel’s mother dutifully took him for several visits to the otolaryngologist, with the ultimate recommendation of the placement of myringotomy tubes. The operative procedure date was established. However, shortly thereafter, the procedure was postponed because of the onset of coronavirus (COVID-19), wherein all elective surgical procedures in the state were appropriately curtailed for the foreseeable future.

Nathaniel and his family did well (as well as any family with four young children could do) under a ‘stay-to-home’ statewide mandate. Interestingly, he showed no evidence of ear symptoms during that time (he had not been in daycare for nearly two months during the quarantine).

As the individual states’ medical systems began to reopen for non-urgent procedures, Nathaniel’s surgery was rescheduled. The otolaryngologist informed the mother that he had quite a backlog of cases and wanted to offer the earliest operating time to infants and young children. In preparation for the surgery, Nathaniel was seen by the otolaryngologist several days prior to the re-established surgical date. The doctor noted that the exam revealed no evidence of an ear infection and there was no perforation of the eardrums or ear drainage. Even though the COVID-19 situation seemed to be more quiescent at that time, there was no guarantee, should the surgery be declined, that Nathaniel would be awarded another block of operating room time in the foreseeable future.

The family has planned to relocate to another state due to a job-related move for the father. Unfortunately, the new job has sub-standard health insurance coverage that will not cover a pre-existing medical condition, and any surgical costs would have to be paid by the family.  In addition, the parents have no recommendations for surgical subspecialty care at the new location.

Nathaniel’s mother, a highly-qualified BSN, asks her father, a medical ethicist, whether or not she should go forward with Nathaniel’s proposed surgery to place the myringotomy tubes.

Discussion

This situation involving elective surgery for the patient has two clear-cut options: to allow the surgical procedure or to decline the procedure.

In performing the surgical procedure, Nathaniel’s family would enjoy the certainty of the myringotomy tube placement being done under a controlled and non-urgent situation. Knowing that this surgery has minimal operative time and risk of anesthesia, being done in the face of minimal persistent effusion certainly adds to the ease and success of the procedure. Additionally, the family would enjoy the peace of mind knowing that their current healthcare coverage would relieve any (or at least provide minimal) financial responsibility for the parents.

Also, knowing that the surgical procedure would be accomplished before the upcoming move, the parents would also be able to enjoy the comfort of knowing the benefits of this completed surgery. There should (barring unforeseen events) be minimal urgent need for the identification of a necessary medical-surgical procedure during the early time of the relocation to the new community

In declining the elective surgical procedure at this time, Nathaniel and his family need to recognize an entirely different set of potential consequences. If the mother were to change her mind (after having declined the procedure), and then request that the surgical procedure be done prior to relocating, this option may no longer be possible. The doctor may not have any residual operating room time as he is attempting to catchup on his backlog of postponed surgeries. Furthermore, should there be a recurrence of COVID-19 [an additional wave of infections], elective surgical procedure may—once again—be postponed. Also, in not doing the surgery at this time, the issue of potentially unnecessary surgery is no longer germane, and the patient would have no risk of the operative procedure or any subsequent medical care related to the placement of myringotomy tubes.

Without the myringotomy tube placement, there is the possibility of persistent unrecognized ear problems. This, however, seems highly unlikely in the face of the medical knowledge in the patient’s family and the recognized intention of appropriate well-child care in the new location. Nonetheless, declining the procedure does raise the possibility of future surgery under less-than-optimal conditions, primarily because the family will have minimal immediate information about medical care in the new community. Again, the specter of sub-optimal insurance coverage is also unavoidable.

It appears to be the case (as in many other infants and young children) that there is increased frequency and problem with ear infections when the child is in a daycare setting. With the upcoming relocation, the family’s older three children will be in the school where their father will be teaching. This provides a situation under which Nathaniel may have the luxury of remaining at home for a defined period and during which a daycare setting will not be necessary. This period should grant Nathaniel some time to mature and, perhaps, have less exposure to illness. Nathaniel’s mother would be able to daily access her son’s hearing, speech, development, and gait (all of which may be impacted by unrecognized persistent ear infections).

Recommendations

There are two approaches that are permissible in this situation:

• It is permissible to reasonably take the approach of declining the surgical procedure;
• It is permissible to reasonably take the approach of allowing the surgical procedure;

Denouement

The mother elected to decline the surgical procedure as she was unable to justify the potential risks for her son under the present clinical setting. Nathaniel has done exceedingly well in the interval of ‘shelter-in-place’ during the COVID-19 pandemic. In part this was likely due to healthy siblings and minimal exposure to other sick children. The child has had no evidence of any other ear symptoms. The child’s speech and hearing, including his gait and balance, have all developed along standard developmental guidelines. The move is proceeding according to schedule, and the family will be in the new location shortly.

Column Editor:

Ferdinand D. Yates, Jr is an Active Associate Pediatrician at Children’s Healthcare of Atlanta and is in private pediatric practice in the Atlanta area.

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