Limning the Limits

Shortly after I submitted my last post “Limning Autonomy in Surgery” I was contacted by the blog editor letting me know that I had made a typo in my title and that he would go ahead and correct it for me. The problem is that I really do mean to use the word “limn.” When I was at Wheaton College a couple of my professors edited a book entitled Limning the Psyche, so I figured the verb “to limn,” which means to draw, delineate, or describe, was in common parlance. These entries are not an attempt to “limit” autonomy, but rather to draw out what it looks like in the surgical encounter. Indeed, it is as we reach the limits of autonomy in certain situations that we understand its outlines and contours.

The practice of surgery is inherently parentalistic. (Historically paternalistic is the term used, but my wife is also a surgeon. . .  ) For many reasons (which I plan to unpack in subsequent posts) the surgeon’s decision-making takes precedence to the patient’s. I am not arguing that it ought to take precedence; I am merely reporting that it does (c.f. Hume’s fork.) The prime example is the decision that someone is “not a surgical candidate.” This could be due to a tumor being “unresectable” or to the physiologically deconditioned state of the patient, or the narrow margin of improvement a patient could make with an operation. The point is that this is a function of the praxis of the surgeon, which hopefully has been developed in the crucible of residency and through years of experience. Charles Bosk, in his classic text Forgive & Remember: Managing Medical Failure, notes that it is this development of sound surgical judgment that is the most important part of a surgical residency. Surgeons are intimately linked with the outcomes of their patients, and every day is the Catch-22 of cutting someone (for their own good) and the Hippocratic dictum primum non nocere. So we are cautious and, in making a decision who will benefit from an intervention, parentalistic.

But society has rejected paternalism and the abuses that went along with it. Parentalistic actions must be expunged from practice, so all decisions made by the surgeon are open to question. Barron Lerner explored and contrasted the paternalistic / non-paternalistic approach in his recent book The Good Doctor.  One of the results of this is the necessity to define certain interventions as “futile.” Then the hospital can have a futility policy that states that physicians do not have to perform futile procedures. For example, let’s say a family demands that an aortic root replacement be performed on their grandmother who has been deemed “not a surgical candidate” by the cardiac surgeon. The contemporary “way out” of a situation like this is to state the procedure itself is futile, and then invoke the futility policy. The problem that I have with this is that it reifies the idea of a “futile treatment” and pretends to be more objective than it is. There is a tremendous amount of subjectivity involved in decisions like these. The uncertainties surrounding the many variables in play belie precise objective quantification.

A particular surgeon operates on a specific patient on any given day and that event is a performance. We predict outcomes by conglomerating large numbers of these performances and statistically analyzing these data, but I contend that the decision of whether or not a patient “is a surgical candidate” is one that relies on the kind of tacit knowledge that Polanyi described. I am not trying to disparage endeavors to minimize variations in performance nor attempts to capture these statistics in a way to hopefully better understand what exactly our surgical interventions do, I am merely saying that there is much more to it than that.  No matter how well-informed  about an operation a patient is, there is something incommunicable that the surgeon knows that requires him or her to make definitive judgments on behalf of the patient. This is where autonomy hits the wall.