Should Considerations in Patient Dignity Affect Our Surgical Decisions?
The patient was a 32-year-old man. Two years ago, he had abdominal perineal resection and sigmoid colostomy for rectal cancer in another hospital, as well as physician-recommended adjuvant chemotherapy. One year after surgery, a prominent lesion appeared at the stoma. When he came to our hospital in April 2016, the tumor had already invaded most of the lower abdomen wall, which had an ulcerated and infected surface, and the colostomy bag could not be fitted properly. It was suspected that the patient had metastatic lesions in the lungs as well, but this could not be confirmed. The patient was otherwise in good physical condition and strongly requested surgery. The patient explained that the lesion had prevented him from contact with people, even his family, which made him feel that he had no dignity, and this caused him immense pain (Figure 1). However, based on principles of oncological surgery, extensive local resection is not beneficial to the patient if there are suspicions of distant metastases. It was the patient’s last words that helped me make my decision: “I can’t even hug my daughter. What’s the point of living? Doctor, only you can restore my dignity!” I had repeated communication with the patient and his family, clearly explaining to them the indications, complications, and risks of the surgery. There were also differing opinions in the discussions within our department. In the end, I decided to proceed with the surgery for the sake of his dignity. The surgery was a success, and the patient recovered well (Fig. 1). The patient returned home 2 weeks after surgery. He hugged his 4-year-old daughter, who had, until then, refused to be affectionate with him. However, liver metastases appeared 4 months after the surgery and he received additional treatment. This was the first time in the 30 years since I became a surgeon that I performed surgery for the dignity of the patient, even if it meant going against the current clinical guidelines.
Cancers at stoma sites are rare, and only 20 cases have been reported in the literature to date. Even among these 20 reports, most are only case reports.2,3 Primarily, from the perspective of surgical technology, there is no problem with tumor resection in this case. It is also possible to complete reconstructive surgery. Our surgery would have a huge physical impact on the patient, not to mention the suspected distant metastases. Given these reasons, should this surgery be performed. This is a new issue that surgeons may encounter: It is incontrovertible for a surgeon to base the decision of surgery on the surgical principles and clinical guidelines. However, what should the surgeon do when faced with nonbiomedical factors, involving medical ethics, patient dignity, and social factors?
First, from an ethical and humanistic perspective, the patient in this case felt, through his relationship with his family and especially his daughter, that the disease debased his dignity as a human being. In particular, it was difficult for him to fulfill his role as a father, because he was unable to express his love for his daughter. A hug from a daughter was a very precious thing for this father at the current stage in his life.