Burger Ingrid, Schill Kathryn, Goodman Steven
Phoebe R. Berman Bioethics Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
Ann Surg. 2007 Apr;245(4):507-13. doi: 10.1097/01.sla.0000242713.82125.d1.
The purpose of the paper is to examine the ethical arguments for and against disclosing surgeon-specific performance rates to patients during informed consent, and to examine the challenges that generating and using performance rates entail.
Ethical, legal, and statistical theory is explored to approach the question of whether, when, and how surgeons should disclosure their personal performance rates to patients. The main ethical question addressed is what type of information surgeons owe their patients during informed consent. This question comprises 3 related, ethically relevant considerations that are explored in detail: 1) Does surgeon-specific performance information enhance patient decision-making? 2) Do patients want this type of information? 3) How do the potential benefits of disclosure balance against the risks?
Calculating individual performance measures requires tradeoffs and involves inherent uncertainty. There is a lack of evidence regarding whether patients want this information, whether it facilitates their decision-making for surgery, and how it is best communicated to them. Disclosure of personal performance rates during informed consent has the potential benefits of enhancing patient autonomy, improving patient decision-making, and improving quality of care. The major risks of disclosure include inaccurate and misleading performance rates, avoidance of high-risk cases, unjust damage to surgeon's reputations, and jeopardized patient trust.
At this time, we think that, for most conditions, surgical procedures, and outcomes, the accuracy of surgeon- and patient-specific performance rates is illusory, obviating the ethical obligation to communicate them as part of the informed consent process. Nonetheless, the surgical profession has the duty to develop information systems that allow for performance to be evaluated to a high degree of accuracy. In the meantime, patients should be informed of the quantity of procedures their surgeons have performed, providing an idea of the surgeon's experience and qualitative idea of potential risk.
本文旨在探讨在知情同意过程中支持和反对向患者披露外科医生具体手术成功率的伦理观点，并研究生成和使用手术成功率所带来的挑战。
通过探究伦理、法律和统计理论来探讨外科医生是否、何时以及如何应向患者披露其个人手术成功率的问题。所探讨的主要伦理问题是在知情同意过程中外科医生对患者负有何种类型的信息披露义务。这个问题包含3个相关且在伦理上具有相关性的考量因素，并将对其进行详细探究：1）外科医生的具体手术成功率信息是否能增强患者的决策能力？2）患者是否想要这类信息？3）披露信息的潜在益处如何与风险相权衡？
计算个人手术成功率需要进行权衡，且存在内在的不确定性。目前缺乏证据表明患者是否想要这类信息、它是否有助于患者做出手术决策以及如何以最佳方式向他们传达这类信息。在知情同意过程中披露个人手术成功率具有增强患者自主性、改善患者决策能力以及提高医疗质量等潜在益处。披露信息的主要风险包括不准确和误导性的手术成功率、对高风险病例的规避、对外科医生声誉的不当损害以及破坏患者信任。
目前，我们认为，对于大多数病情、手术程序和手术结果而言，外科医生和患者的具体手术成功率的准确性是虚幻的，从而消除了在知情同意过程中作为一部分进行传达的伦理义务。尽管如此，外科行业有责任开发能够高度准确评估手术成功率的信息系统。与此同时，应告知患者其外科医生所实施手术的数量，以使患者了解外科医生的经验以及对潜在风险有定性的认识。
