by Craig Klugman, Ph.D.

Imagine if a patient went sky diving without a parachute and survived. You fixed up her body and explained to her the dangers of her activities. You refer her to a program that offers free parachutes and trains people on how to use them. Upon discharge, she does the same thing again and ends up back in your hospital? Do you perform the same surgeris again? What if she does this 3 times? Four times? Is there a point at which we “give up” on patients when they consistently return for the same problem from the same cause after ignoring all advice?

An article published in the Tampa Tribune raises just this dilemma. The reporter explains how heroin users who use dirty needles can acquire endocarditis that compromises their heart valves. The “fix” is a valve replacement that requires an 8-week hospital stay and costs about $500,000. The rub is that once they are healthy, many addicts leave, shoot up, and often are re-infected. Now doctors are saying “no” to working on these patients who come back more than once, sometimes twice.

In 2014, 447 people died in Florida with heroin in their bodies. This is a large increase from the 199 deaths in 2013. This trend is not just limited to the Sunshine State, nationally the number of deaths from heroin has increased 689% from 2001 to 2014 with a 28% increase from 2013 to 2014 alone. While these statistics are increases in deaths, the heart valve patients represent an increase in morbidity from heroin use—damage to one’s health.

This increase in heroin use is attributed to its low cost, easy availability and the closing of “pill mills.” Whereas people looking for a high may have had the option of getting opioid pills in the past, now they are using heroin instead. This is supported by data that shows that most people who use heroin started with other drugs first, most notably abusing prescription drugs.

Heroin use is relatively minor in the drug world with estimates of 681,000 U.S. users in 2013. This drug is highly addictive. The ethical dilemma is not from the use of heroin but from how it is ingested—by sharing of dirty needles. This is a major public health issue. Only 1 state (Alaska) allows the unfettered purchase of needles. Twenty-four states regulate the sale of syringes whether through requiring prescriptions, limiting quantities, limiting sales to pharmacies, or requiring information form the buyer. Sixteen states allow syringe exchanges but there may be additional local jurisdiction restrictions or have limits on exchanges (one clean needle for a dirty needle).

Therefore, an upstream approach to solving the ethical dilemma would be to make it easier for users to get clean syringes. That is second best to helping people “get clean.” However, the dilemma reported was about how to handle a downstream problem—when patients keep reinjuring themselves and needing the same expensive and resource intensive treatment. The Tampa Tribune reports that the Florida Society of Thoracic & Cardiovascular Surgeons states that patients get one valve procedure as a result of continued drug abuse. If they need a second, then they are on their own.

A 2008 discussion in the Annals of Thoracic Surgery offered commentary on a fictional case of an IV drug user who has an aortic valve replacement and then is re-admitted needing another valve replacement. The arguments against a second surgery include the high rates of lifetime morbidity and mortality for drug users, the risks to the team during repeated surgeries, the misallocation of resources, and surgeon autonomy—you get to pick your patients. The conclusion here is that you do the operation once.

On the other side—that a physician should operate again—are that drug addiction is a disease which may not have been well treated, that a physician has an obligation to treat patients when possible, and that physicians should not use contributory criteria (i.e. not treating diseases for which patient behavior was a causal factor such as smoking, obesity, alcoholism, sky diving without a parachute) on deciding on whom to operate. The conclusion is that physicians should provide help to patients in need.

Patients have the autonomy to make their own life decisions. And as has often been said, they have the right to make bad choices as well. The question though is whether society has to pay the price for poor decisions. A second question is how much can an individual claim to a communal resource (organs, hospital beds, healh dollars) When 8-year-old Aliyana Lucas received her third heart transplant there was critical discussion as to whether one person should receive this limited resource. Those three hearts mean that three people died for her to live, and at least two other people on the transplant lists did not get a transplant. Approximately 8,000 people on the transplant lists die each year without a chance to get even one organ.

In a world with limited medical resources we should (a) encourage upstream approaches (drug treatment programs, easy access to needles) and (b) ration these surgeries so that a person can have the first surgery but no surgery if they return needing the same procedure for the same reason. A second surgery could be permitted if the person had the same problem from a different cause. Instead, such people would be offered comfort measures only.

The idea of telling patients that we could help them but we will not help them goes against the grain of medical oaths and practice. Justice is the idea of what “is due” in terms of distribution of scarce resources and equity (treat likes alike). Justice says that there are limits to what can be done and in those cases, the community perspective may need to take precedence. For our reckless skydiver, this means she won’t have a third chance to jump.