Ethical strategies for managing challenging plastic surgeon–patient relationships

Plastic surgeons sometimes face challenging relationships with patients, especially those with underlying psychiatric issues. An ethical framework for managing untenable surgeon-patient relationships is presented in a special Plastic Surgery Focus article in the February issue of Plastic and Reconstructive Surgery.

“Particularly when psychiatric conditions are present, plastic surgeons may be tempted to end the surgeon-patient relationship—at the risk of ethical challenges related to patient abandonment,” comments ASPS Member Surgeon Christian J. Vercler, MD, of University of Michigan. “We outline some strategies for managing these difficult relationships, including specific steps toward achieving the best possible patient-centered clinical outcomes.”

Psychiatric issues contribute to ethical dilemmas in plastic surgery

Once an operation has been performed, surgeons have an ethical obligation to care for the patient until treatment is completed.

“Nevertheless, there are circumstances that can challenge this patient-surgeon relationship and even justify termination,” the researchers write. Their article was prompted by the difficult case of a patient with a psychiatric diagnosis who underwent plastic surgery to reconstruct a self-inflicted wound, followed by repeated episodes of self-mutilation.

Informed by a review of the literature and application of ethical principles, Dr. Vercler and colleagues describe three pathways to managing patients with complex psychiatric conditions:

Maintain the relationship and continue surgical treatment. Demanding or hostile patient behaviors may stem from a fear of abandonment. Reinforcing the surgeon’s commitment to providing the best possible care may help to mitigate these fears—and may enable resolution of the patient’s psychiatric issues. If so, and if realistic expectations can be established, it may be possible to proceed with surgical treatment.

Maintain the relationship without further surgery. Some patients may reject recommended treatment yet continue to seek care, often related to underlying depression and anxiety. Providing supportive nonsurgical care may help to address the barriers to following recommended treatment—if there is a “reasonable expectation” that the barriers to care are reversible.

Terminate the relationship. In severe cases, terminating the patient-surgeon relationship may be the best option, particularly if the surgeon’s involvement seems to contribute to worsening of the patient’s psychiatric condition. In such situations, a “therapeutic discharge”—following established ethical principles and legal requirements to transfer responsibility to another qualified physician—may ensure that the patient receives needed care while breaking a “maladaptive treatment cycle.”

“In writing this article, our main objective was to restate surgeons’ ethical obligation to not abandon their patients postoperatively, even when patient behavior makes this incredibly challenging to do so,” Dr. Vercler comments.

“While the described case illustrates the rare exception in which therapeutic discharge is required, we hope our paper will provide tools to help surgeons fulfill their ethical responsibility, enabling them to stay involved in the patients’ care in an ethical and effective way.”