Menu-based Surgery: When are Surgeons Just Technicians?

Abstract: After a decade of training, a subspecialty surgeon develops the skills necessary to evaluate a patient and determine the operation necessary to treat the illness. Collaboratively, the goals of care are elicited, and the treatment plan is developed. For most elective operations, the goals congruent: to cure the problem – the patient then consents to surgery. What happens when the goals are aligned, but the means to reach those goals are not? What ought a surgeon do when the patient disagrees with the operation proposed contrary to the surgeons expertise?

Consider the case where the operation most likely to cure a locally metastatic thyroid cancer is a total thyroidectomy with modified radical lymph node dissection. If the patient does want a cure, but insists the surgeon only remove half the thyroid, effectively choosing select parts from the ”menu” of surgeon capabilities.

Such conundra are arising more frequently in surgical practice, as information about patient options is ubiquitous on the internet, and the response of surgeons is varied. In this debate, questions of autonomy and paternalism will be discussed. The panel of surgeons will discuss if autonomy reigns and the surgeon should always support a menu-based approach to foster the surgeon-patient relationship; the surgeon should compromise if the patient understands the risks; the surgeon should maintain a practice where they do not offer operations that are not medically indicated; lastly beyond medical indications – only offer best medical practice for success. Just because a surgeon can, does it mean they should?