Medical ethics and dermatology

Ethical questions arise in all fields of medicine, and dermatology is no different. One of the more remarkable cases that I encountered during training was that of a woman who became pregnant while taking a medication known to cause birth defects. Despite explicit and severe warnings, she insisted that she be allowed to keep taking the medicine throughout her pregnancy. When her dermatologist refused to prescribe the medicine, the patient convinced the hospital’s ethics board to recommend that her obstetrician continue prescribing the medication during pregnancy. The woman received her prescriptions at the board’s recommendation, and the baby was tragically but not unpredictably born with birth defects.

Although I wholeheartedly disagree with the ethics board’s recommendation, I can see how ethical principles are sometimes difficult to apply in practice. The four guiding principles of medical ethics are often taught to be “autonomy, beneficence, non-maleficence, and justice.” Loosely translated, these principles mean: respect someone’s right to choose; do good; do no harm, and act in a fair or equitable way.

The above example is extreme. The ethics board made a mistake and prioritized “autonomy” above all other considerations (including “do no harm”). But many less dramatic ethical considerations occur almost every day in practice. When treating patients, I find that the common sense strategies of putting the patient first and asking what I would want for a family member go a long way towards making sound ethical decisions.

In Mohs surgery, a tissue removal technique for curing skin cancers, shades of grey are often encountered. Cancer is not always black and white. Sometimes, invasive cancer has been eliminated, but the edges have “in situ” cancer – cancer confined to the top layers of the skin, or the edges exhibit “actinic keratoses,” best understood as “pre-cancers.” Severely sun-damaged individuals sometimes have cheeks or scalps that are covered with precancers and “in situ” cancers. Continuing to cut in such cases is sometimes not in the patient’s best interest. Instead, once the invasive cancer is removed, I frequently discuss switching strategies with my patients. We often treat the area around an invasive cancer with an anti-cancer cream post-operatively instead of dogmatically continuing to cut and missing the forest for the trees.

Personalized medicine is often medicine at its best. One recent patient presented to me for a second opinion regarding a melanoma on his eyelid. The first surgeon the patient saw recommended complete removal of the lower eyelid and a 3 month reconstruction process during which the patient would not be able to see from that eye. The patient and I discussed that the large margin the first surgeon recommended is the standard of care. However, the patient stated that at his age he did not want to undergo an extensive surgery. He understood the risks and chose a smaller margin. He understands that the “middle ground” option that he wanted is not in line with the official guidelines for treating cancers like his, but the smaller surgery that he chose is the option that is right for him. The standard of care is a guideline. The patient comes first.

As interesting as philosophical principles like autonomy and nonmaleficence are, I have found that the most useful principles are variations of the Golden Rule. Treat patients like you would want your family or loved ones treated. And put the patient first.

If you or a loved one has a skin cancer or other skin care needs, please consider Premier Dermatology and Mohs Surgery of Atlanta. It is our privilege to take care of you.