AMA Journal of Ethics^®

Case

As 39-year-old Sam Ruffini sat confidently in the clinic chair, his hand tremor would have been noticeable only to a trained expert. The other signs of Parkinson disease, however, were unmistakable, such as the once-spry man’s shuffling gait. Mr. Ruffini had come to see Dr. Blue, a neurosurgeon renowned for treatment of functional nervous system disorders.

“I simply don’t want to suffer through years of trial and error with medications and their side effects. I’m a young, active guy. I can handle a surgery. If this can be improved with a one-time procedure, even if it’s brain surgery, I’d rather do that now and not wait until I’ve suffered through years of disability.”

Dr. Blue faced a dilemma. In previous years, he would have politely dismissed Mr. Ruffini and referred him back to the neurology department, since deep brain stimulation (DBS) surgery for Parkinson was still a measure of last resort for patients whose conditions had become refractory to best medical therapy. Mr. Ruffini had responded fairly well to levodopa and other standard medications for Parkinson, and he continued to function in his job as an investment banker. Although he complained about fatigue and other side effects of the medications, these did not seem to be disabling.

On the other hand, Dr. Blue had recently read about a clinical trial showing good results for patients who received DBS in the early stages of their disease, before their level of disability had progressed to the point of being “medically refractory.” He wondered if this foretold a new paradigm in thinking about proactive surgical interventions for neural disorders, including not only Parkinson but also essential tremor, depression, chronic pain, and others. In some cases, the stipulation that a patient’s condition be “medically refractory” prior to contemplation of surgery seemed to be a holdover from the era when that procedure was experimental and particularly risky. Dr. Blue’s rate of serious complications with DBS had become so low (less than 5 percent) that, depending on the patient’s preferences, he believed it could be a viable alternative to medical therapy even when the latter hadn’t failed.

When he met with the interdisciplinary DBS committee that week, Dr. Blue floated the idea of doing DBS for Mr. Ruffini. This idea was met with acrimonious objections from the neurologists and psychiatrists in the room. Based on the standard of care, they argued, Mr. Ruffini should be treated with medications, which were noninvasive and well understood, and must exhaust all reasonable nonsurgical therapies prior to being offered an invasive brain surgery.

Commentary 1

Proper selection of patients who will reliably benefit from treatment is critical to the successful outcome of deep brain stimulation (DBS). The ethical duties of the clinicians in this case involve careful balancing of a variety of interests of the patient, society, and their own practices. They need to create fair systems based on the best available research that allow individualized decisions for each patient and assess the likelihood of harm and benefit. In doing so, each clinician should be cognizant of whether decisional elements are merely a matter of tradition, rely on outmoded data, or are based on unwarranted assumptions.

In the current case, the surgeon needs to evaluate carefully which model of the patient-physician relationship is appropriate to apply, based on the facts’ relationship to the models. In particular, the surgeon must consider the role of informational vulnerability, paternalism, and an obligation to improve practice for all patients. This is no doubt a complex task because how various subjective values are balanced could lead to different conclusions. Acceptable solutions must be based on a clear ethical justification according to the values at stake.

The proper selection of a model for physician-patient relationship provides structure, security, and transparency to the relationship through designated roles and mutual obligations. A classic 1992 article by Ezekiel A. Emanuel and Linda L. Emanuel highlights four distinct models of relationships physicians may adopt, two of which, the interpretive and paternal models, are relevant here [1].

In the interpretive model, the physician aims to elucidate the patient’s values and assists him or her in choosing the available medical treatment that best preserves those values. By the surgeon’s account, Mr. Ruffini’s hand tremor is “mild,” his shuffling gait is becoming more pronounced—a marked change from his once-spry self—and he complains of fatigue and other side effects of medications that “did not seem to be disabling.” But the patient’s illness experience is also crucial. What may be described as a “mild” hand tremor by a physician may have a severe impact on a patient’s everyday life. Categorizing things like disability as mild, moderate, or severe may yield more disagreement and confusion than clarity; quality-of-life assessments are value-based and vary from patient to patient. A patient’s perception of disability is critical to evaluating whether his or her expectations about potential benefits correspond to realistic outcomes of the procedure.

The interpretive model anticipates that a patient’s values may not be known or fixed, and so the physician helps the patient articulate goals, aspirations, and commitments and provides clear guidance about which treatment plan best balances these values [1]. This model allows the patient to come to know more clearly his own identity and how various treatment options may bear upon that identity, a proposition particularly important when treating a neural disorder that, by its very nature, transforms and may largely dictate the lived experience of the body.

For example, Mr. Ruffini, valuing his active lifestyle, may be feeling anxious that his PD will slowly rob him of agency, and thus intervening before he has “suffer[ed] through years of trial-and-error with medications and their side effects” is reasonable. Additionally, Mr. Ruffini states, “If this can be improved with a one-time procedure, even if it’s brain surgery, I’d rather do it now and not wait until I’ve suffered through years of disability.”

However, it is vital to be aware that the procedures of implanting and stimulating the electrodes are brain-invasive and entail significant risks. Although the paternalistic model has fallen out of favor as a default standard model, there are instances where elements of it should still be employed. This model calls for the physician to act in the patient’s best interest based on what he or she knows of the patient. In particular, when clinicians encounter a patient with significant vulnerabilities, they incur a greater obligation to protect that patient’s interest. Besides a patient’s usual medical vulnerability, Mr. Ruffini’s lack of understanding of DBS constitutes an informational vulnerability [2]. First, Mr. Ruffini believes that DBS is a one-time procedure. However, once implanted, the system may become infected, parts may wear through the skin, and the lead or lead/extension connector may move [3]. Additionally, systems require battery changes throughout the life of the technologies and need ongoing monitoring and programming. A DBS procedure is not like a traditional ablative procedure in which a lesion is made and then the intervention is complete.

Informed consent in this case involves more than understanding the expected good and bad short-term outcomes; it involves understanding the ongoing burdens of the technology. Mr. Ruffini’s informational vulnerability results not only from a lack of specialized knowledge but also from misinformation. Patients often come to DBS with an informational vulnerability, having received misleading information or skewed portrayals of outcomes from the media and other forms of public discourse that occur outside the clinical encounter. Studies have pointed to overwhelmingly positive reporting of neuromodulation, heralding the arrival of the future and prominently featuring “miracle stories” [4]. Reports tend to showcase only the spectacular while obscuring the spectrum of all possible outcomes. Patients’ susceptibility to this type of informational vulnerability may justify or, perhaps, obligate the team to respond more paternalistically and protectively. Physicians seeking to protect patients must do their best to overcome patient misunderstandings caused by inaccurate or sensationalized accounts from the media or other discourses and must be careful to address assumptions that may not be correct—particularly that “less invasive” always means “less harm.”

In this particular case, though, the team members’ attempt to prioritize protection over self-determination may not be ethically justified, because the criterion they are relying on to determine harm may not make sense. The traditional proposition that the least invasive intervention is always preferable can serve the purpose of limiting harm associated with overambitious goals. However, this obvious-sounding proposition is dubious in this instance. The faulty premise here is equating “more invasive than medications” with “more dangerous in the long term than medications.” Medications to treat PD are associated with not only fatigue but also a variety of neuropsychiatric symptoms, including depression, apathy, anxiety, obsessive behaviors, impulse-control disorders, hallucinations, and delusions that are difficult to treat, cause great disability, and can distress both patient and family [5]. Social and physical harms associated with uncontrolled side effects of medications that will ultimately fail to manage PD symptoms create a new dynamic.

While the long-term efficacy and safety of DBS implemented early in the course of the disease is uncertain [6], DBS can result in significant improvement in many of the motor symptoms while also decreasing the need for PD medications and improving overall quality of life [3]. An emphasis on long-term benefit might indeed lead to a preference for DBS in this case.

Ultimately, it is the patient’s assessment of risks and benefits that should guide deliberation. A recent article evaluating EARLYSTIM has argued that the appropriate time for surgery is when the needs and expected benefits outweigh the risks for a patient who has received objective and comprehensive information about individualized risks and benefits of the DBS [7]. In the current case, the goals that Mr. Ruffini wants to accomplish are not disclosed, but the metric still needs to be about the likelihood of achieving those goals with DBS. Whether using a paternalistic or interpretive model, the calculus should not be about a simplistic change in physical symptoms, but rather the functional impact the changes may make for the patient.

Despite cognizable risks, patients may remain steadfast in their desire to move forward with treatment. Even when patients aggressively advocate for procedures, there are limits on patient-centered care, including internal and professional limits, such as the institution’s standard of care provision. While these limits are important safeguards, their appropriateness should be reassessed if there is proof of advances in treatment. The interdisciplinary DBS committee needs to give clear reasons why this specific patient should not receive DBS at this time. If the patient’s centrally important goals could be reached and due diligence has been undertaken to offset vulnerability and collaborate on proper consent, there is ample justification for this team to offer DBS—provided it carefully monitors and collects information in a systematic manner for this patient.

Offering DBS to Mr. Ruffini could be undertaken based on several different models, all of which should reinforce that the surgeon’s obligations to provide high-quality care to all his patients remain the same. If the team decides to pursue DBS for Mr. Ruffini, there are two main options for offering it. First, the patient could be offered the procedure as “off-label” use. In this instance, Dr. Blue still has an obligation to collect information to ensure best outcomes for this patient and for his future practice. Dr. Blue could either review the case series in the future or contribute to a national registry. However, the amount of data would be modest, and many people could be put at risk before an unknown negative consequence became apparent.

The other option is to offer DBS only as part of a well-controlled research study. Although this option increases burdens for the patient and the clinicians, it is least likely to cause harm to future patients and protects this patient through the careful oversight afforded research participants. Offering this procedure as part of a research protocol would be the ideal, but many practicalities of our current medical system pose barriers to doing so [8]. Moreover, by the time a research study was funded and approved by the regulatory bodies, Mr. Ruffini’s condition could have already advanced to a severity level that he is attempting to avoid through early DBS, which, worse yet, could make him a “standard” DBS candidate and preclude his inclusion in the study. Too little information is provided in the current case to give a definitive opinion as to whether it is obligatory to offer DBS, but the option of offering the procedure to Mr. Ruffini is ethically supportable if proper safeguards are put into place and robust outcomes information is collected.