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14 Jul 2021

Navigating tough terrain in cancer treatment

  • VCCC Alliance

The questions that keep us awake at night

A series of three online ethics seminars have been developed by the VCCC Research and Education Lead, Head and Neck Cancer program to look at ethically tough cases in the management of patients with the disease.

Led by Professor David Wiesenfeld and facilitated by Professor Clare Delany, a clinical ethicist at Peter Mac and Royal Children’s Hospital, the series is bringing people from multiple disciplines together to discuss and share experiences of ethically tough cases and to increase awareness of the ethical dimensions of clinical decisions for patients and clinicians.  

Features of ethically tough cases in clinical practice are that all options are bad; all choices are legal; reasonable people will disagree about which choice is ethically preferable; fundamental principles of bioethics are in conflict, and yet, a decision must be made, something must be done. 

The series encourages clinicians to consider diverse views and to become aware of their own as well as others’ reactions and values including which benefits, risks and aspects of well-being are emphasised. This awareness assists in being able to recognise and consider the ethical complexity inherent in treatment decisions.

Some domains are tougher than others 

In head and neck cancer, ethically tough cases are common. The consequences and in many cases, the treatment of the disease may have serious and life-altering impacts on appearance and function. 

Treatments are often medically and surgically complex and patients may end up depending on medical technologies. Decisions about management strategies are particularly challenging where there is a lack of consensus or uncertainty about outcomes.

Ethics of treatment decisions

The first seminar, held in June focused on the ethics of treatment decisions. Questions sought to answer… What do clinicians take into account when deciding to offer a particular treatment pathway? How are patients’ interests framed and considered in the decision-making process? Even if it is possible to treat, should treatment always be offered? What would trigger a change in treatment goals?

Case studies shed light on the complexity 

Hypothetical case examples used in the seminar series aimed to prompt discussion… 

Mary is an 85-year-old reasonably fit woman who presented with an ulcer inside her cheek which was biopsied as moderately differentiated squamous cell carcinoma. She is married to Jim who is 94, has severe osteoarthritis in both knees and relies on her for care. She remains independent, and manages all the household duties including grocery shopping, and still drives. Mary has smoked most of her life. 

The treatment options recommended are radical therapy (surgery and radiotherapy) with Mary likely to be in hospital for a long time or require a long period of rehabilitation or a more palliative approach of primary radiotherapy. Mary assumes she will bounce back from surgery just like she managed to recover from a heart attack three years earlier. 

Mary’s daughter is an ICU nurse and contacts her mother’s surgeon. She says her mother doesn’t understand the risks or the likely effects of this treatment. She says this surgery is futile for her mother. 

What do you think is ethically important in this case example? 

  • Mary’s right to choose?
  • Mary’s capacity/sufficient understanding to choose (informed consent)?
  • Whether and how to include Mary’s daughter’s views?
  • Identifying the risks and benefits of radical therapy vs primary radiotherapy for Mary? 

Register for forthcoming seminars

In the second seminar on August 24, the focus will be on the moral distress that clinicians experience when encountering and dealing with ethically tough cases.  Case examples will again be used to identify different types of moral distress and how clinicians can recognise and be supported to address such feelings.  

The final seminar on 19 October, will focus on the ethics of progress in head and neck cancer. Like many other areas of cancer care, the capacity to treat head and neck cancers is constantly progressing and evolving. In most situations, progress in available surgeries, immunotherapy and robotic treatments are welcomed. But their efficacy may not always be well known, they may be unproven and they may prolong suffering or add to the uncertainty of treatment decisions. 

For more information on the VCCC Research and Education Lead, Head and Neck Cancer program, please contact Program Manager Dr Jasper De Boer or Professor David Wiesenfeld.

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