**4. Ethics case analyses: a need for comprehensive just care and patient illness narratives**

multidisciplinary medical team about the patient in a brief, accessible case presentation. The features of these cases serve as valuable starting points for understanding the complexity of medical decision-making, unifying repeat heart valve replacement, post-operative care, and

A 24-year-old homeless, female patient is brought into the emergency department by a family member and presents for sepsis related to IVDA. The patient has a 10-year history of drug use with previous endocarditis, requiring cardiac surgery and debridement of an infected tricuspid valve approximately 14 months prior to the current admission. She has a history of untreated depression. The patient is admitted for complaints of joint pain, swelling, and general malaise. She reports injecting heroin and crack cocaine in her extremities (feet, arms, and hands) daily. The patient was drug-free for a short period of time with the assistance of residential treatment and hospitalization at a nursing facility where she received IV antibiotics for the endocarditis. However, the patient missed a dose of Suboxone (buprenorphine and naloxone) due to lack of transportation, did not seek support from health care professionals, and was unsuccessfully attempting to stop her persistent drug use on her own. Her continued drug use and failure of medical management have resulted in the need for preoperative cardiac surgery for large vegetation in the tricuspid valve. The patient is willing to pursue addiction treatment following surgery and post-operative care and has had a history of taking Suboxone as an effort to stay clean and sober. An ethics consult is called to provide a recommendation on whether it is ethically permissible to re-operate in this patient with infective endocarditis from persistent IVDU. The ethics committee further weighed in on recommendations for achieving a unified care model in which the immediate medical needs namely, heart valve replacement, antibiotic therapy, and acute peri-operative pain management. Critical in the discussion was also providing a pathway that includes comprehensive

A 29-year-old married male with a history of depression, multiple suicide attempts, polysubstance intravenous drug use (heroin and methamphetamines), and a history of endocarditis was brought to the emergency department by EMS following a suspected overdose. The patient was unresponsive until EMS delivered multiple doses of naloxone in route to the emergency department. Upon arrival, the patient was alert but had difficulty speaking. The patient's wife, who is a recovering addict, alerted EMS to her husband's overdose. Upon questioning the patient's current drug use, he admits to using methamphetamine cut with Fentanyl over the past week. The patient was drug-free for approximately 1.5 months after a prior hospital admission for septic mitral valve endocarditis due to IVDA, as well as renal failure, which was resolved following treatment. He received a bioprosthetic mitral valve and antibiotic therapy. Aside from his brief period drug-free, he has never been in treatment specifically for his chemical dependency and currently feels like he doesn't need such treatment. The patient suffers from multiple cerebral septic emboli with hemorrhagic

mental health treatment, and the need for ongoing recognition of the patient's story.

mental health care for the patient's depression and addiction.

**3.2. Case 2: resistance to IVDU treatment**

**3.1. Case 1: a unified care model**

138 Advanced Concepts in Endocarditis

The above cases are representative of several medical, social, and ethical issues presented when patients are suffering from IE secondary to IVDU and who may require a repeat heart valve surgery and extensive mental health care for addiction and other related mental disorders (e.g., depression). In situations where patients have IE secondary to IVDU and need a new heart valve—their first surgical intervention—surgeons and others are more likely to treat the typical young patient with a probable successful surgical outcome without a need to seek ethical counsel. In our experiences, while most patients receive minimal chemical dependency treatment post-surgery, relapse (as discussed above) is likely, and a comprehensive mental health care program with monitoring, social support, and a recognition of the social determinants that contribute to the relapse are often not sufficiently addressed.

Thus, these patients return with IE and in need of a second, third, or more heart valve replacement surgeries. Surgeons and other healthcare professionals, particularly those working in community hospitals with limited financial resources, may question their duties to this patient population while considering their obligations to their medical community and society at large. Heart valve replacement surgeries, post-operative care, and addiction treatment are costly, and the financial burdens to patients, healthcare institutions, and the general community may deter surgeons from moving forward despite the patient's need. We can add the statistic about how the cost is increasing using the data from NC either here or in the paragraph with all the other statistics. Furthermore, the social stigma and biases against drugaddicted patients impact medical decisions, particularly when combined with the potential risk to health outcome measures, which can affect individual health care professional evaluations, work satisfaction, and trust among the general patient population.

The emotional impact of providing surgical care with the likelihood the patient will be back again for repeat heart valves due to IVDU can prompt moral distress, cynicism, and resentment of this patient population regardless of the moral obligations to treat when medically necessary, or beneficial. All of these considerations for repeat heart valve replacement surgeries should not be dismissed. They are essential for building a case for comprehensive just care, which is guided by core ethical principles of beneficence, non-maleficence, and justice, as well as a recognition of the individual patient's story through narrative medicine. Narrative medicine prompts healthcare professionals to absorb, interpret, and co-author the dynamic story-telling in patient care. By co-authoring the illness narratives of patients, providers are able to acquire deeper insight into each patient's understanding of their illness, their goals for recovery, and the triggers that act as obstacles to recovery. Furthermore, through these illness narratives, providers will bear witness to the individuality of medical cases and recognize that some patients really can be helped even with the likelihood of relapse and future harm, which can reduce moral distress and clinical cynicism (e.g., "why try to help if these patients will end up abusing drugs again") [20–22]. However, the illness narratives need to be sustained; patients' stories do not end once they complete their post-operative care (e.g., antibiotic therapy).

The use of IV drugs to combat feelings of depression and despair are not uncommon among untreated patients. Reasons for why she did not seek medical attention for her depression are unknown, but given the difficulties of navigating the health care system, federal insurance programs, and community programs that can aid a patient in accessing mental health care, it is not surprising that her depression went untreated. A person already addicted to IV drugs may have even more difficulty accessing mental health care due to the cognitive effects of the drugs, the stigma of drug use, and the lack of social support in seeking help. This patient tried to stop her drug use, but could not stop without the necessary social support and addiction therapy. Because she was previously successful at recovery, is a good surgical candidate for a medically indicated tricuspid valve replacement, and has a strong commitment to seeking post-operative care and addiction treatment, the surgical intervention should be granted. An ethics committee convened with this case and further recommended that it is critical for a team-based approach to be utilized for patients with IVDU who are seeking valve

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 141

A range of medical specialists and addiction experts, along with the surgical team, are essential for developing and implementing a treatment plan. It is also recommended that these patients sign a behavioral agreement in addition to the standard surgical consent form that details the patient's level of understanding about the risks and benefits of the surgery, addiction interventions, and any other medical and psychosocial care that promotes a good clinical outcome. Clinical outcomes are often determined by the success of the surgeries and post-operative care. However, we need to begin to look more critically at the long-term success of recovery, factors contributing to relapse, and how a team-based approach can aid the patient in quickly getting back into recovery. Recovery is a life-long process and a good clinical outcome may take years to fully measure and understand despite the more immediate surgical successes.

In the end, this patient did receive re-operative tricuspid and aortic tissue valve replacement. However, the behavioral contract, a non-legally binding contract, was not used. This contract prompts the patient to understand the need to get comprehensive treatment beyond a valve replacement, as well as empower the patient to take charge of her life, and maintain physical and mental health through ongoing counseling, therapy, and pharmaceutical interventions to treat her depression and addiction. The value of the contract is that it is a way to understand the patient's illness narrative and her commitment to recovery; although not used for this particular patient, it is a useful tool that can be beneficial for other patients. Of course, basic human needs (home, food, social support) are also needed, yet securing these resources for patients can be a challenge without having social work, nursing, and community support. There are limitations to what a surgeon can do beyond immediate surgical care, so it is critical for a wider health care community to recognize their ethical obligations to this patient population.

In regard to the second case, this young male patient is struggling with mental health issues particularly untreated depression and addiction—and is married to a recovering addict, who either can be a positive or negative influence in his recovery depending on their willingness

**4.2. Case 2 analysis: a deeper understanding of medical need**

replacements.

It is our general position that repeat heart valves for patients with IE secondary to IVDU ought to be given if they are medically beneficial and if the patient is willing to commit to addiction recovery and ongoing, comprehensive mental health treatment that aims to address the social triggers, existing mental health disorders, and other factors that influence the chemical dependency. This is not the responsibility of the surgeon alone, but a medical team that has access to hospital and community resources, appropriate skills, knowledge to address the whole patient and their medical and psychosocial needs, and the ability to combat social stigma by treating the patient as a person with a very specific narrative. When repeat heart valves are not medically necessary or ethically beneficial, may cause undue suffering, and/ or the patient is unwilling to commit to a comprehensive treatment program after thorough guidance by the health care team, then it is ethically justifiable to refuse surgery. However, each case is unique, and there may arise unique considerations that have not yet been previously addressed or ethically analyzed. Thus, it is essential that a narrative ethical approach that calls attention to the nuances of the case, i.e., the elements of the patient's story, is automatically part of the medical assessment and a sustainable chronic care plan.

#### **4.1. Case I analysis: establishing standards of care**

In this first case, there are a number of social factors that are contributing to the patient's current medical state. First, this is a young, homeless patient who does not have the means to acquire sustainable basic human needs. Regardless of whether her drug use led to the homelessness or vice versa, she is surviving in an unhealthy, unsupportive, and harmful environment, which is an obstacle to addiction recovery and overall health. When living in a residential treatment facility, she was able to have security, shelter, food, warmth, and community support, in addition to, medical treatment, all of which are essential for a recovering addict who, unfortunately, did not have these resources prior to her first valve surgery. However, these resources are limited; they are only available for the duration of her medical treatment for the endocarditis, and not for the ongoing recovery for her addiction. Her lack of essential resources, social instability, and homelessness are likely to have played a role in her subsequent relapse while on Suboxone; this demonstrates the necessity for holistic and comprehensive care in order to fully rehabilitate a patient with a chronic condition. Furthermore, this patient has a history of untreated depression—another significant factor that could have led to her current medical state.

The use of IV drugs to combat feelings of depression and despair are not uncommon among untreated patients. Reasons for why she did not seek medical attention for her depression are unknown, but given the difficulties of navigating the health care system, federal insurance programs, and community programs that can aid a patient in accessing mental health care, it is not surprising that her depression went untreated. A person already addicted to IV drugs may have even more difficulty accessing mental health care due to the cognitive effects of the drugs, the stigma of drug use, and the lack of social support in seeking help. This patient tried to stop her drug use, but could not stop without the necessary social support and addiction therapy. Because she was previously successful at recovery, is a good surgical candidate for a medically indicated tricuspid valve replacement, and has a strong commitment to seeking post-operative care and addiction treatment, the surgical intervention should be granted. An ethics committee convened with this case and further recommended that it is critical for a team-based approach to be utilized for patients with IVDU who are seeking valve replacements.

medicine prompts healthcare professionals to absorb, interpret, and co-author the dynamic story-telling in patient care. By co-authoring the illness narratives of patients, providers are able to acquire deeper insight into each patient's understanding of their illness, their goals for recovery, and the triggers that act as obstacles to recovery. Furthermore, through these illness narratives, providers will bear witness to the individuality of medical cases and recognize that some patients really can be helped even with the likelihood of relapse and future harm, which can reduce moral distress and clinical cynicism (e.g., "why try to help if these patients will end up abusing drugs again") [20–22]. However, the illness narratives need to be sustained; patients' stories do not end once they complete their post-operative care (e.g.,

It is our general position that repeat heart valves for patients with IE secondary to IVDU ought to be given if they are medically beneficial and if the patient is willing to commit to addiction recovery and ongoing, comprehensive mental health treatment that aims to address the social triggers, existing mental health disorders, and other factors that influence the chemical dependency. This is not the responsibility of the surgeon alone, but a medical team that has access to hospital and community resources, appropriate skills, knowledge to address the whole patient and their medical and psychosocial needs, and the ability to combat social stigma by treating the patient as a person with a very specific narrative. When repeat heart valves are not medically necessary or ethically beneficial, may cause undue suffering, and/ or the patient is unwilling to commit to a comprehensive treatment program after thorough guidance by the health care team, then it is ethically justifiable to refuse surgery. However, each case is unique, and there may arise unique considerations that have not yet been previously addressed or ethically analyzed. Thus, it is essential that a narrative ethical approach that calls attention to the nuances of the case, i.e., the elements of the patient's story, is auto-

matically part of the medical assessment and a sustainable chronic care plan.

In this first case, there are a number of social factors that are contributing to the patient's current medical state. First, this is a young, homeless patient who does not have the means to acquire sustainable basic human needs. Regardless of whether her drug use led to the homelessness or vice versa, she is surviving in an unhealthy, unsupportive, and harmful environment, which is an obstacle to addiction recovery and overall health. When living in a residential treatment facility, she was able to have security, shelter, food, warmth, and community support, in addition to, medical treatment, all of which are essential for a recovering addict who, unfortunately, did not have these resources prior to her first valve surgery. However, these resources are limited; they are only available for the duration of her medical treatment for the endocarditis, and not for the ongoing recovery for her addiction. Her lack of essential resources, social instability, and homelessness are likely to have played a role in her subsequent relapse while on Suboxone; this demonstrates the necessity for holistic and comprehensive care in order to fully rehabilitate a patient with a chronic condition. Furthermore, this patient has a history of untreated depression—another significant factor that could have

**4.1. Case I analysis: establishing standards of care**

led to her current medical state.

antibiotic therapy).

140 Advanced Concepts in Endocarditis

A range of medical specialists and addiction experts, along with the surgical team, are essential for developing and implementing a treatment plan. It is also recommended that these patients sign a behavioral agreement in addition to the standard surgical consent form that details the patient's level of understanding about the risks and benefits of the surgery, addiction interventions, and any other medical and psychosocial care that promotes a good clinical outcome. Clinical outcomes are often determined by the success of the surgeries and post-operative care. However, we need to begin to look more critically at the long-term success of recovery, factors contributing to relapse, and how a team-based approach can aid the patient in quickly getting back into recovery. Recovery is a life-long process and a good clinical outcome may take years to fully measure and understand despite the more immediate surgical successes.

In the end, this patient did receive re-operative tricuspid and aortic tissue valve replacement. However, the behavioral contract, a non-legally binding contract, was not used. This contract prompts the patient to understand the need to get comprehensive treatment beyond a valve replacement, as well as empower the patient to take charge of her life, and maintain physical and mental health through ongoing counseling, therapy, and pharmaceutical interventions to treat her depression and addiction. The value of the contract is that it is a way to understand the patient's illness narrative and her commitment to recovery; although not used for this particular patient, it is a useful tool that can be beneficial for other patients. Of course, basic human needs (home, food, social support) are also needed, yet securing these resources for patients can be a challenge without having social work, nursing, and community support. There are limitations to what a surgeon can do beyond immediate surgical care, so it is critical for a wider health care community to recognize their ethical obligations to this patient population.

#### **4.2. Case 2 analysis: a deeper understanding of medical need**

In regard to the second case, this young male patient is struggling with mental health issues particularly untreated depression and addiction—and is married to a recovering addict, who either can be a positive or negative influence in his recovery depending on their willingness to work together toward mutual recovery. Without mental health treatment, his depression, suicidal ideations, and addiction will continue. One of the primary problems with this case is the patient's reluctance (which might be confounded by potential neurologic dysfunction due to his embolic strokes) to mental health treatment, feeling as though he does not need it despite the magnitude of health complications arising from his pervasive drug use. Specifically, the IVDU has led to multiple hospitalizations, a mitral valve replacement, and multiple, serious co-morbidities that have left him with ongoing physical pain and cognitive impairment. Prior to testing for valve functionality, this patient, too, was presented to an ethics committee, which prompted discussion regarding whether valve re-operation would be beneficial to this patient with serious comorbidities that may increase his surgical risk and lead to a poorer quality of life.

he completed extended care, he then should seek aggressive inpatient chemical dependency treatment to limit the risk of relapse and recurrence. However, the medical team may be at an impasse given the patient's current resistance and lack of commitment to addiction recovery.

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 143

While it is recommended the medical team should have ongoing dialog with the patient to understand his reluctance at undergoing mental health treatment, and continuing to identify providers, care facilities, etc., that could aid in his recovery, additional steps may be needed before proceeding with any future medical interventions (e.g., valve replacement). If medical therapy alone fails e.g. progression of disease, worsening valve functioning, or recurrent emboli that lead to further complications, treatment options will need to be re-evaluated. Depending on his medical state, the patient may not be a future candidate for a replacement valve, and thus other medical resources and personnel, such as palliative care, may be

In our first case, it is recommended the patient sign a behavioral contract to strengthen her existing commitment toward recovery, which further illustrates she does not have to go through recovery alone, i.e., the medical team will not give up on her if she maintains her commitment. In this second case, however, a behavioral contract may not be enough, since such non-legally binding contracts are symbolic gestures of the medical team's medical/ social/legal relationship to a patient the shared responsibilities of both parties. When a patient is not willing to share responsibilities in the relationship and is resistant to addressing serious

**4.3. Addressing the ethical and social problems of repeat valve replacements and** 

Valve replacements in IVDU must be administered regardless of the negative connotations associated with addiction or illicit drug use, with the patient's health, surgical success, and access to comprehensive addiction treatment being the goals of treatment. Both conscious and unconscious biases can affect clinical judgments that lead to unjust decision-making and

Similar to the health disparities we see in organ transplantation cases, where racial and ethnic biases have affected the length of time on a transplant waiting list, or lifestyle behaviors (e.g., alcohol addiction) have affected judgments about probability of success for organ replacement surgeries, medical judgments are not immune to bias when determinations about medical outcomes are being made. That is, it is all too easy for a surgeon to determine that her patient does not qualify for a valve replacement because of the high surgical risk, which may be based on the patient's untreated addiction, probability of relapse, and co-morbidities due to the effects of IVDU (e.g. the inherent risks of recurrent overdoses), rather than on the patient's survivability on the surgical table and success of the valve replacement itself. A surgeon may also exhibit conscious biases toward her patient when considering the continued burden of having to provide ongoing treatment, which increases the financial and personnel cost to the medical institution. Thus, such attitudes and feelings lead to a biased clinical judgment, but may also be generated

out of concern for professional evaluation and outcomes-based, performance measures.

required for the care of this patient.

disrespectful treatment of patients.

**the limits of justice**

mental health disorders, the first step is to understand why.

Similar to the first case, discussions surrounding addiction stigma, the need for social support, a need for the patient's commitment to seek addiction treatment, and a team-based approach to patient care were presented. However, unlike the first case, this particular patient is suffering from a number of medical issues that each need to be taken into consideration in the evaluation for a replacement valve, as well as an acknowledgment of the patient's lack of commitment to comprehensive mental health treatment. The ethical guidance sought is grounded in the principles of beneficence and non-maleficence, as well as a narrative-based justice approach that details the specifics of the patient's medical history, social support, quality of life, and his preferences and commitment to recovery. The goals of the medical team, from an ethical perspective, are to very carefully look at his medical condition, and whether he even has a chance for survival and future quality of life with a second valve replacement surgery. Second, it is critical for the medical team to revisit the topic of comprehensive mental health care, including treatment for depression and chemical dependency. Objective consideration must also be given if there are overwhelming evidence of medical/surgical futility but this concept can be extremely difficult to determine in young patients.

The need for aggressive inpatient chemical dependency treatment is essential to this patient's recovery. However, unlike the first case in which valve replacement surgery and addiction treatment are simultaneously discussed as a holistic approach to patient care, for this patient, the addiction treatment becomes an interesting topic of discussion due to the gravity of his medical condition and his resistance to treatment. That is, the first case had less medical ambiguities in terms of the surgical candidacy for valve replacement combined with a clear indication of the patient's commitment to recovery. Thus, due to the immediate and justifiable medical need, the decision to move forward with surgery came simultaneously with a team-based plan and patient contract for recovery. Here, the patient's condition warrants an initial discussion about whether replacement valve surgery would be non-beneficial treatment. Causing further harm either during surgery or postoperatively should be avoided so as to ensure the best quality of life while living with a terminal condition. Furthermore, if the replacement valve surgery would be deemed beneficial, there remains the issue of the patient's lack of commitment to recovery. If there is persistent resistance to mental health care, ethically it would be unjust to proceed with a surgical intervention.

Following the ethics consult, the patient's valves with small vegetation were functioning, and his bacteremia was responding well to antibiotic therapy. The surgical team determined that after he completed extended care, he then should seek aggressive inpatient chemical dependency treatment to limit the risk of relapse and recurrence. However, the medical team may be at an impasse given the patient's current resistance and lack of commitment to addiction recovery.

to work together toward mutual recovery. Without mental health treatment, his depression, suicidal ideations, and addiction will continue. One of the primary problems with this case is the patient's reluctance (which might be confounded by potential neurologic dysfunction due to his embolic strokes) to mental health treatment, feeling as though he does not need it despite the magnitude of health complications arising from his pervasive drug use. Specifically, the IVDU has led to multiple hospitalizations, a mitral valve replacement, and multiple, serious co-morbidities that have left him with ongoing physical pain and cognitive impairment. Prior to testing for valve functionality, this patient, too, was presented to an ethics committee, which prompted discussion regarding whether valve re-operation would be beneficial to this patient with serious comorbidities that may increase his surgical risk and lead to a poorer quality of life. Similar to the first case, discussions surrounding addiction stigma, the need for social support, a need for the patient's commitment to seek addiction treatment, and a team-based approach to patient care were presented. However, unlike the first case, this particular patient is suffering from a number of medical issues that each need to be taken into consideration in the evaluation for a replacement valve, as well as an acknowledgment of the patient's lack of commitment to comprehensive mental health treatment. The ethical guidance sought is grounded in the principles of beneficence and non-maleficence, as well as a narrative-based justice approach that details the specifics of the patient's medical history, social support, quality of life, and his preferences and commitment to recovery. The goals of the medical team, from an ethical perspective, are to very carefully look at his medical condition, and whether he even has a chance for survival and future quality of life with a second valve replacement surgery. Second, it is critical for the medical team to revisit the topic of comprehensive mental health care, including treatment for depression and chemical dependency. Objective consideration must also be given if there are overwhelming evidence of medical/surgical futility—

142 Advanced Concepts in Endocarditis

but this concept can be extremely difficult to determine in young patients.

care, ethically it would be unjust to proceed with a surgical intervention.

The need for aggressive inpatient chemical dependency treatment is essential to this patient's recovery. However, unlike the first case in which valve replacement surgery and addiction treatment are simultaneously discussed as a holistic approach to patient care, for this patient, the addiction treatment becomes an interesting topic of discussion due to the gravity of his medical condition and his resistance to treatment. That is, the first case had less medical ambiguities in terms of the surgical candidacy for valve replacement combined with a clear indication of the patient's commitment to recovery. Thus, due to the immediate and justifiable medical need, the decision to move forward with surgery came simultaneously with a team-based plan and patient contract for recovery. Here, the patient's condition warrants an initial discussion about whether replacement valve surgery would be non-beneficial treatment. Causing further harm either during surgery or postoperatively should be avoided so as to ensure the best quality of life while living with a terminal condition. Furthermore, if the replacement valve surgery would be deemed beneficial, there remains the issue of the patient's lack of commitment to recovery. If there is persistent resistance to mental health

Following the ethics consult, the patient's valves with small vegetation were functioning, and his bacteremia was responding well to antibiotic therapy. The surgical team determined that after While it is recommended the medical team should have ongoing dialog with the patient to understand his reluctance at undergoing mental health treatment, and continuing to identify providers, care facilities, etc., that could aid in his recovery, additional steps may be needed before proceeding with any future medical interventions (e.g., valve replacement). If medical therapy alone fails e.g. progression of disease, worsening valve functioning, or recurrent emboli that lead to further complications, treatment options will need to be re-evaluated. Depending on his medical state, the patient may not be a future candidate for a replacement valve, and thus other medical resources and personnel, such as palliative care, may be required for the care of this patient.

In our first case, it is recommended the patient sign a behavioral contract to strengthen her existing commitment toward recovery, which further illustrates she does not have to go through recovery alone, i.e., the medical team will not give up on her if she maintains her commitment. In this second case, however, a behavioral contract may not be enough, since such non-legally binding contracts are symbolic gestures of the medical team's medical/ social/legal relationship to a patient the shared responsibilities of both parties. When a patient is not willing to share responsibilities in the relationship and is resistant to addressing serious mental health disorders, the first step is to understand why.

## **4.3. Addressing the ethical and social problems of repeat valve replacements and the limits of justice**

Valve replacements in IVDU must be administered regardless of the negative connotations associated with addiction or illicit drug use, with the patient's health, surgical success, and access to comprehensive addiction treatment being the goals of treatment. Both conscious and unconscious biases can affect clinical judgments that lead to unjust decision-making and disrespectful treatment of patients.

Similar to the health disparities we see in organ transplantation cases, where racial and ethnic biases have affected the length of time on a transplant waiting list, or lifestyle behaviors (e.g., alcohol addiction) have affected judgments about probability of success for organ replacement surgeries, medical judgments are not immune to bias when determinations about medical outcomes are being made. That is, it is all too easy for a surgeon to determine that her patient does not qualify for a valve replacement because of the high surgical risk, which may be based on the patient's untreated addiction, probability of relapse, and co-morbidities due to the effects of IVDU (e.g. the inherent risks of recurrent overdoses), rather than on the patient's survivability on the surgical table and success of the valve replacement itself. A surgeon may also exhibit conscious biases toward her patient when considering the continued burden of having to provide ongoing treatment, which increases the financial and personnel cost to the medical institution. Thus, such attitudes and feelings lead to a biased clinical judgment, but may also be generated out of concern for professional evaluation and outcomes-based, performance measures.

The first step in reducing the need for repeat valve replacement and improving patient health outcomes and survivability is to understand the patient's own unique story that prompted the IVDU, their goals for treatment, and their overall understanding of their own responsibilities toward successful, comprehensive treatment. By motivating them with a behavioral contract that speaks to the healthcare team's responsibility to the patient's care and the patient's own commitment, this may be a positive step.

The American Medical Association's *Code of Medical Ethics* states that is the physician's ethical obligation "to place patients' welfare above their own self-interest and above obligations to other groups and to advocate for their patients' welfare" [23]. It is the duty of physicians to promote the health of their patients through comprehensive, beneficial treatment based on evidence-based medicine, and to respect them as persons with dignity, uninfluenced by social stigma and clinical bias. For patients with IE secondary to IVDU, it is important to treat both the psychiatric, social and infectious etiologies: the substance use disorder, homelessness, and food insecurity, as well as the IE, along with any additional comorbidities that are present. Although every patient with IE secondary to IVDU differs in the severity of presentation and comorbid conditions, patients with a positive prognosis should have the opportunity to

Unfortunately, it is not unusual for patients with recurrent IE secondary to IVDU to experience social stigmatization and bias at the hands of the healthcare system and to be denied the comprehensive care that is needed in such cases. While some patients are justifiably denied due to a significant medical risk over benefit, patients are also denied simply because they are perceived as non-compliant, or because their potentially risky surgical treatments may negatively affect the health reviews and ratings of the surgeons performing the valve replacements. It is not ethically just to penalize viable surgical candidates when their addiction has neither been addressed nor treated. Citing high rates of treatment failure and non-compliance is not a valid excuse when the substance use disorder has not been treated as aggressively as the IE, especially when taking into considerations the lack of resources available for these

, Cyril Harfouche1

[1] Cami J, Farre M. Drug addiction. The New England Journal of Medicine. 2003;**349**:975-986

and Michael S. Firstenberg1,2

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 145

achieve health and life with medical assistance.

patients to seek and maintain recovery.

The authors have no conflict of interest.

\*, Emanuela Peshel1

\*Address all correspondence to: jmaultma@neomed.edu

2 The Medical Center of Aurora, Aurora, CO, United States

1 Northeast Ohio Medical University, Rootstown, Ohio, United States

**Conflict of interest**

**Author details**

Julie M. Aultman1

**References**

Second, patients will not have a chance for successful recovery if they are not provided with needed resources and appropriate guidance to motivate them to seek long-term treatment. Such treatment should involve methods ranging from psychotherapy to pharmaceutical interventions.

Unfortunately, most current care is focused on the infective pathology; in IE patients only the acute problem is addressed, but no effort seems to be placed on preventing readmissions or improving the patient's quality of life. Addressing the lack of care and support IVDU patients are receiving, rather than trying to limit patient access to replacement procedures provides the just treatment these patients deserve, in addition to reducing the financial burden on healthcare systems and society. Health care providers often fail to identify addiction as the significant comorbidity that it is, and do not treat it as aggressively and appropriately using drugs that specifically target opioid use disorders; this results in under-treatment of addiction [16]. Such a limited care approach needs to change.

Third, surgeons and the healthcare team also require the support of ethics teams when complex social and ethical questions arise with patients. Personal biases lead to social stigmatization of patients with IVDU, influence medical decisions, lead to provider burnout, moral distress, and cynicism among health care providers. Having ongoing team-based discussions about these negative experiences, attitudes, and emotions is one step in the right direction, Recognizing the ethical and social issues that penetrate the medical problems can also help navigate and resolve dilemmas and elicit a deeper understanding of the individual patient and their illness narrative. It is important for healthcare providers to engage in self-care, and to have the opportunity to address issues before they devolve into negative emotions and attitudes that can be harmful to self and other.

Finally, it is critical for the health care team to know when additional treatment is futile. There are limits to justice. However, such limits to therapies must be based upon objective evidence supported by the medical literature rather than poorly grounded assumptions, biases, and outdated, or erroneous knowledge or datasets.
