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2008 Annual Meeting Abstracts
A Survey of Ethically Challenging Issues in Urologic Practice
Aaron B Stike, Jacob E Boone*, Ashley B King*, Laurel J Lyckholm*, Luke Wolfe*, Harry P Koo, Adam P Klausner
Virginia Commonwealth University Health System, Richmond, VA
Introduction: The purpose of this study was to survey opinions regarding ethically challenging cases in urologic practice.
Methods: An ethics survey asked 3 demographic questions: type of practice (Q1: academic urologist, private practice urologist, medical student), age range (Q2: <45, 45-60, >60), and location of practice (Q3: urban, suburban, rural) and presented 10 ethical scenarios (Q4-13) (table 1). Email surveys were sent out to academic urologists (N= 249), private practice urologists (N= 258) and medical students (N= 360) selected at random from published lists. Answers were compared between demographic groups using Fischer’s Exact tests.
Results: Responses were received from 86 (35%) academic urologists, 62 (24%) private practice urologists, and 116 (32%) medical students. Lack of consistent opinion was common with <50% agreeing on a single answer choice for 4/10 ethical questions. Responses to Q5 differed based on type of practice and age (p<0.05). Responses to Q7 differed based on age and location of practice. Responses to Q13 differed based on type and location of practice (p<0.05).
Conclusions: This is the first study to survey opinions regarding ethically challenging questions in urologic practice. Responses were widely distributed and differed based on type of practice, age, and practice location. This study represents a first step toward the establishment of evidence-based consensus guidelines for ethically challenging issues in urologic practice.
Ethics SurveyQ4) An HIV-positive, unmarried male presents with erectile dysfunction that failed to respond to medical therapy. He requests placement of a penile prosthesis. The urologist should:
a. Not perform the surgery because it might lead to the spread of HIV
b. Only perform the surgery if the patient presents with a sexual partner that can be informed of the risks of HIV spread.
c. Only perform the surgery if the patient promises to inform all potential sexual partners of his HIV status and promises to use condoms during sex.
d. Perform the surgery without conditions as it is the patient’s own responsibility to inform potential partners. | Q5) A mentally incompetent 83 year-old male presents for results after a recent prostate biopsy. The pathology reveals prostate cancer. His daughter states that the family does not want him to know if it is cancer because he wouldn’t be able to handle that information. The urologist should:
a. Explain the obligation to fully disclose and inform the patient regarding his diagnosis.
b. Ask the patient how much he would like to know about his biopsy.
c. Comply with the daughter’s request, but ensure adequate follow-up. | Q6) A male patient is on renal dialysis for kidney failure. His son undergoes an evaluation to donate a kidney. Testing reveals that the father and son are not genetically related. The urologist should:
a. Tell them that they are not genetically related.
b. Tell them only that the kidney was not a match.
c. Attempt to discretely contact the patient’s wife as it is her decision to reveal this information. | Q7) A newborn child is declared “a boy.” A subsequent work-up a few days later reveals that the child is actually a genetic female. The child has congenital adrenal hyperplasia, a hormonal abnormality that causes swelling of the clitoris which can be mistaken as a penis. The urologist counsels the family that the child should be raised as a female and should undergo clitoral and vaginal reconstruction. The family refuses and states, “We will not raise our son to be a girl!” The urologist should:
a. Abide by the families wishes
b. Educate the family but ultimately abide by their wishes.
c. Obtain a court order to have the birth certificate changed to “female.” | Q8) A demented elderly male with multiple comorbidities presents with urinary incontinence. He is brought in by his daughter who is also his fulltime caregiver and legal guardian. Work-up reveals that the patient has an enlarged prostate which is causing his urinary problem. The daughter requests that the urologist perform a transurethral resection of the prostate to relieve his condition. The urologist should:
a. Not perform the operation because the patient does not appear bothered by the symptoms.
b. Not perform the operation as the patient lacks capacity to make a decision.
c. Perform the operation because it is medically indicated.
d. Perform the operation because it may ease the burden of care for the daughter. | Q9) A developmentally delayed 30-year-old male presents with incontinence. He is brought in by his caregiver who has power-of-attorney to make medical decisions for him. She mentions that the incontinence is interfering with their “sex life” and refers to the patient has her “fiancée.” The patient is in excellent health and appears well cared for. The urologist should:
a. Call social services because the patient is being sexually abused
b. Treat the patient’s incontinence and do not worry about the “sexual” relationship as the patient is obviously being well care for.
c. Treat the patient’s incontinence but counsel the caregiver regarding protective sexual practices.
d. Treat the patient’s incontinence but warn the caregiver to discontinue any sexual activity. | Q10) A male patient is in a chronic vegetative state after a motor vehicle accident. The wife requests placement of a penile prosthesis stating that she “has needs” and “it’s what he would have wanted.” The urologist should:
a. Not perform the operation as there is no medical necessity
b. Not perform the operation due to moral objection
c. Not perform the operation as the patient’s own wishes have not been clearly documented
d. Perform the operation | Q11) A patient presents with an incidentally-detected renal mass. The urologist notes that the mass was reported on a previous CT scan ordered by another physician. On the current CT scan, the mass has progressed in size and has become metastatic. The urologist should:
a. Inform the patient that the mass was reported previously but not addressed
b. Do not inform the patient of the past results and proceed with the evaluation
c. Ask the other physician to inform the patient of the previous results. | Q12) A patient is scheduled for placement of a penile prosthesis. On the way to the OR he mentions that he doesn’t want his wife to know about the procedure as it’s “really for my girlfriend.” After the procedure, the patient becomes unresponsive due to a myocardial infarction. The wife (next of kin) wants to know how “something like this could happen after a simple hernia operation.” The urologist should:
a. Inform the wife that her husband underwent placement of a penile prosthesis.
b. Inform the wife only that the patient “did not undergo a hernia operation.”
c. Not give the wife any medical information as this was clearly the patients wish. | Q13) A 16 year-old female presents to the urologist, accompanied by her father, with a urinary tract infection. Work-up reveals a sexually-transmitted disease. She asks you not to reveal the true diagnosis to her father. The urologist should:
a. Inform the father.
b. Not inform the father. |
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