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you in the past and is likely to believe that you will be equallycapable of treating any surgical situation. Although you havedone your best to fully explain all elements of the current sit-uation to him, his judgment may be adversely affected by theanxiety and duress of acute illness. Most patients cannotappreciate the subtleties of treating a complex conditionenough to make an informed distinction between variouslycapable surgeons. Recommending, rather than simply offer-ing, transfer is a more appropriate approach to the manage-ment of this problem.

Evaluation of one’s limitations, Choice D, should notbe performed at the expense of patients requiring urgentcare. When outcomes cannot be reasonably predicted, theindependent surgeon’s efforts to expand his armamentar-ium can be rightly considered reckless experimentation.2Furthermore, the emergent nature of the patient’s condi-tion does not permit the quiet reflection on alternativestypically available before elective operations.

Choice E, recommending referral, obtaining thepatient’s consent, and arranging transfer to a surgeon withthe current skills and knowledge to treat the condition,meets the ethical and clinical needs of this situation. When adangerous condition requiring special skills presents, and abetter qualified surgeon is readily available, a referral shouldbe strongly urged if transfer will not increase the patient’srisk. This reflects the physician’s obligation in the process ofinformed consent: when evidence supports one alternative asclearly superior, it should be recommended.3 In 1996, theWisconsin Supreme Court (in Johnson v. Kokemoor) ruledthat information about the informed consent processincludes disclosure to patients of information about theavailability of other physicians with better outcomes.4

The transfer of care must be surgeon to surgeon toensure that the exchange of pertinent information is com-plete, the specialized care required is available, and anothersurgeon accepts responsibility for the patient.

REFERENCES

1. McKneally MF, Martin DK. An entrustment model of consent for sur-gical treatment of life-threatening illness: perspective of patientsrequiring esophagectomy. J Thorac Cardiovasc Surg 2000;120:264-9.

2. Jones JW. Ethics of rapid surgical technological advancement [editor-ial]. Ann Thorac Surg 2000;69:676-7.

3. McCullough LB, Jones JW, Brody BA. Informed consent: autonomousdecision making of the surgical patient. In: McCullough LB, Jones JW,Brody BA, editors. Surgical ethics. New York: Oxford University Press;1998. p. 15-37.

4. Icenogle DL. Update on informed consent law: the Johnson V.Kokemoor decision. Wis Med J 1997;96:58-61.

You are a busy vascular surgeon located in a large com-munity hospital 2 miles from a world-renowned cardio-vascular center specializing in complex aortic surgery. Apatient whom you have previously treated just presentedin your emergency department with a tender but hemo-dynamically stable 10-cm thoracoabdominal aorticaneurysm. A computed tomography scan showsextravascular blood. The patient and his family trust youand insist that they want the patient to remain underyour care. You are an excellent technical surgeon, but youhaven’t repaired a thoracoabdominal aneurysm since res-idency. What is the most ethical course of action?

A. Send the patient directly to the specialty center.B. If you believe that the outcome will be satisfactory,

take the patient to the operating room.C. Explain the situation to the patient, and let him

choose where he wishes to have his surgery.D. You must understand your limits, and you base your

decision accordingly.E. Recommend that a more qualified surgeon perform

the operation and, with the patient’s consent, arrangetransfer to the specialty center.

The best answer is E. The least appropriate responseis C.

Choice A, immediate direct transfer, would not beappropriate without careful clinical evaluation to ensurethat transportation to another center would not aggravatethe patient’s condition. The patient’s consent to transfermust be sought and obtained, and the referring surgeonshould personally ensure that a duly qualified surgeon isavailable and willing to treat the emergent conditionbefore the patient leaves your center.

Choice B places the patient at undue risk when thesurgeon is not current in the skills required to perform ahighly difficult operation.

Choice C places an unfair burden upon the patient.Clinical studies have shown that patients are excessivelytrusting of the surgeon’s skills, particularly in life-threaten-ing situations.1 This patient has been treated successfully by

From the Department of Surgery, University of Missouri, and the Centerfor Medical Ethics and Health Policy, Baylor College of Medicine.

Reprint requests: James W. Jones, MD, PhD, University of Missouri,Department of Surgery (M580), One Hospital Dr, Columbia, MO65212.

J Vasc Surg 2002;35:192.0741-5214/2002/$35.00 + 0 24/9/121640doi:10.1067/mva.2002.121640

SURGICAL ETHICS CHALLENGES

When to refer to another surgeonJames W. Jones, MD, PhD, and Laurence B. McCullough, PhD