To Treat or Not To Treat: An Ethical Dilemma
Looking at the CT scan with observant and attentive eyes, the doctors and healthcare providers involved in the case were shocked to find a mass on the patient’s left ventricle, in addition to an expected kidney stone. Sometimes, as mentioned in this case example, unrelated medical conditions are found incidentally, when working a patient up for what they are currently complaining about. In this case, a 32 year old healthy male came in complaining of flank pain. A CT was ordered to evaluate for kidney stones and came back with results of a kidney stone and a mass on the heart. The providers were unexpectedly left with the question of whether to intervene with the mass on the heart or not, as the patient was asymptomatic in regards to that issue.
Standard treatment for symptomatic heart masses is surgical resection. However, asymptomatic masses are generally not found until an autopsy is done. When an asymptomatic mass is found incidentally, it proves to be a major ethical dilemma between issues of non-maleficence and beneficence. On the one hand, the majority of the time these masses are benign myxomas or lipomas and will not progress or cause symptoms. However, it is always possible that the mass is malignant, can rapidly spread, and can cause symptoms leaving it unresectable later on.
When looking at the core values of PA practice through the lens of this case, we must look at beneficence and nonmaleficence specifically. If we only focused on beneficence, the answer would be clearly to remove the mass, as in the long run it would prevent any possibility of progression of the mass to anything more harmful than it currently is. As stated in the case above, if the mass grew around the coronary vessels it would no longer be able to be resected and would also cause symptoms. Next, looking only at nonmaleficence, it would still leave the conflict of whether to resect or not. This is because doing no harm would be impossible in either case. If resection is chosen, it places the patient at risk for surgical complications, whereas not resecting puts the patient at risk for developing symptoms of the mass. Finally, we can combine both beneficence and nonmaleficence and realize that both point in favor of resection while only nonmaleficence guides us to choose not to resect.
This decision of course can only be made after the diagnosis is confirmed via multiple modes of imaging, as the above case has shown to have done. Additionally, the choice must be confirmed by the patient after giving informed consent, in order to comply with the core value of autonomy.
Some people may read this case and completely disagree, while saying that the risk of surgery provides such a great risk that it overrides the other logical explanations of how resection complies with beneficence and nonmaleficence. They may also argue that most asymptomatic cardiac masses are found after death during autopsy, and just because this one was found during the patient’s lifetime does not mean that doctors must intervene. These people may argue that most cardiac masses are benign and will not cause symptoms, which provides a great enough reason to leave it alone until further notice. However, in my opinion the mere idea that it may become symptomatic and grow to be unresectable is reason enough to resect when it is found. If we would choose to wait, resection may end up being more complicated later on and place the patient at greater risk of surgical complications. We cannot comfortably turn a blind eye on this issue once it is found because our job as PAs is to treat and keep patients healthy. Therefore, despite most masses being found post-mortem we cannot ethically ignore a mass that we find during a patient’s lifetime because of the miniscule chance that it may become something bigger.
Ethical decisions like these are not easy to make and require thought, weighing all of the applicable core values of PAs and how they all fit into the case. After measuring how beneficence and nonmaleficence fit into the above case, I have decided to proceed with resection of the asymptomatic mass found incidentally on the patient’s left ventricle. This decision was carefully made after acknowledging that at this point resection is possible, with the least possible risk of complications. Resection at this point will prevent any future complications which includes, but is not limited to, symptoms of a cardiac mass and growth into an unresectable state.
Sources:
Barrera, L. A., & Mondal, S. (2022). Ethical and clinical dilemma from an incidental cardiac lipoma in a young and healthy patient. Annals of cardiac anaesthesia, 25(3), 353–355. https://doi.org/10.4103/aca.ACA_65_21
