Economics vs. Empathy
Editor's Note: This op-ed previously ran in the Inquirer on March 16, 2014.
During my wife's recent elective, minimally invasive hysterectomy at Harvard Medical School's Brigham & Women's Hospital, she was subject to a routine - but avoidable - practice known as morcellation. In this gynecological procedure, the uterus is ground up into smaller pieces and pulled out through tiny incisions in the patient's body.
After my wife's surgery, it came to light that by spreading contained early malignancies of the uterus, morcellation has been a significant cause of disseminated stage 4 cancers in women for well over a decade. In fact, Brigham and the Society of Gynecologic Oncology conceded that one in 400 to 1,000 women were in danger and that those at risk could not be identified with certainty before their operation.
My wife was one of those unidentifiable women at risk. Her hidden, or "occult," uterine cancer, known as a leiomyosarcoma, was spread throughout her belly cavity, seriously endangering her life.
Since December, this issue has received attention in the Wall Street Journal, the Boston Globe, the New York Times, and The Inquirer, among other newspapers. Despite this publicity and the severe danger to some women, the procedure is continuing to be accepted, endorsed, and practiced by gynecological surgeons everywhere. The Food and Drug Administration and Congress have yet to restrain, or formally comment on, this danger to women's health.
In a Feb. 26 Wall Street Journal article by Jennifer Levitz, a spokesman for Brigham & Women's Hospital said, "Abandoning this procedure would be a major step back for hundreds of thousands of women for whom this procedure is a completely appropriate option." Of course, the issue is not with the minimally invasive surgery, but with morcellation. If these cannot be reconciled safely within the field of gynecology, perhaps doctors should stop performing both.
Brigham's argument is, of course, a classic utilitarian one: The good or desires of the majority override the good of a minority - in this case, the one woman in 400 to 1,000 with "occult" uterine cancer. This argument might work in political elections, but it certainly does not guarantee a just society or a correct ethical decision.
In the case of morcellation, the utilitarian position would be that spreading deadly cancers inside the abdominal cavities of some women is justified because "hundreds of thousands of women" benefit from small incisions and same-day surgery. Not to mention the economic benefit in reduced liability and the enhanced profit margin when the length of stay in the hospital is reduced.
It is terrifying to know that an entire American establishment is arguing for the notion that sacrificing the lives of unsuspecting women is acceptable. This is a chilling admission on the part of my profession.
Why would the gynecological community make such a case? I think it is ultimately linked to our underdeveloped ability, as a health-care system, to practice true empathy for our patients' suffering.
As a surgeon, I have seen an overt emphasis on marketing and enhancement of the volume of practice and, thus, revenue flow. But the cost of this emphasis on the business of medicine seems to be an inability to empathetically, carefully, and self-critically look at the devastating complications we cause. When empathy is gone, the self-criticism that comes along with it is also history. Given that reality, it is easy to see how purely utilitarian arguments can take hold of an establishment's ethical reasoning.
I now have the bad fortune of understanding, from personal experience, that this is a significant flaw in my professional culture. This flaw has prevented some very powerful medical institutions and professionals from acting courageously to protect women by abandoning the practice of morcellation.
Harvard philosopher and ethicist John Rawls, a major force in the evolution of American ethics and justice, said inequalities in outcome could be considered "just" only as long as the worst-off members of society also benefitted from the unequal distribution of chances. Accepting the spread of a deadly cancer by the practice of morcellation is a severe violation of these rules of justice and the American respect for individual liberty.
That our medical ethics have fallen to this state is a tragedy that must be recognized and corrected.
Hooman Noorchashm and Amy Reed, husband-and-wife physicians, have campaigned to ban electric morcellators since December 2013, soon after Reed's unsuspected uterine cancer was spread by the device during a routine hysterectomy.
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