Infective endocarditis (IE), brought on by introduction of pathogens into the bloodstream, is a serious, potentially lethal condition affecting approximately 12.7 out of 100,000 individuals annually (Bor et al., 2013). Complications of IE include stroke, organ damage, secondary infections, heart failure, and almost certain death if infected valves are not replaced and/or aggressively treated with antibiotics. A significant risk factor for IE is intravenous drug abuse. Some individuals respond well to aggressive antibiotic therapy; however, others require early or even emergent surgery (Nishimura et al., 2014). Recurrent IE is common in intravenous drug abusers (IVDAs). This paper addresses the ethical dilemma associated with repetitive valve replacements in patients who use injection drugs.
Should IVDAs be denied a second valve replacement – When is enough, enough?
DiMaio et al. (2009) published a hypothetical case of a young man in his early twenties, with two young children. The man started smoking marijuana as a teenager, and by the age of 20, he was using cocaine regularly, including intravenously. The latter led to endocarditis affecting his aortic valve, requiring open-heart surgery and valve replacement followed by a lengthy antibiotic regimen. He was warned that he would not be allowed a second valve replacement if the new valve became re-infected due to recurrent IV drug use. The patient followed up with cardiology regularly; however, eventually he started using again, his valve became re-infected and he required another valve replacement. While the patient in the aforementioned scenario was fictional, this situation is very common.
Current guidelines by the American College of Cardiology (ACC) for native and prosthetic valve endocarditis call for early surgery (Nishimura et al., 2014). The question, however, arises, whether relapsing IVDAs should be allowed a second valve. What about a third or even fourth valve replacement? Where is the line to be drawn?
DiMaio (2009) argues that noncompliance and relatively low survival rates make valve replacement surgery futile. Dr. DiMaio further states that redundant valve replacements for this patient population pose a burden on society, as resources are not unlimited. Human capital, medical supplies and labor result in high consumer costs and often times IVDAs lack health insurance and other means to pay for their surgery. A utilitarian perspective must be considered and healthcare resources should be allocated more wisely. Moreover, DiMaio (2009) argues that the entire healthcare team is at greater risk while taking care of a patient who may carry infections such as hepatitis C or HIV. Lastly, according to DiMaio (2009), surgeons have an obligation to consider circumstances, probabilities, and likely outcomes of a procedure. They do not, however, have an obligation to operate if they deem the procedure futile. DiMaio (2009) concludes that given the burden on society, the healthcare team, and a likely negative outcome like in the case of the above-described scenario, a surgeon should have the right to refuse operating.
Ethical Obligations in Todays’ Healthcare System
Salerno (2009) counter-argues that the issue at hand is more complex and drug addiction should be considered a disease. Salerno argues that the patient in this case did not receive the full benefit of a comprehensive treatment plan, which would include appropriate mental health services. The patient should have been considered a dual-diagnosis patient, and rehab options should have been presented. The patient’s problem is not his heart it is his drug addiction. Unless the addiction is addressed, Salerno (2009) argues, the heart cannot be repaired.