The Ethics of Optimization: An Evaluation Framework for Arthroplasty Surgeons

The practice of patient optimization seems to be straightforward, logical, and not controversial, but ethical issues may arise. This most commonly occurs when the desire for risk reduction competes with concerns regarding access to care. There is no uniformity in how patient optimization is defined or achieved, and thus the outcomes of optimization programs are highly variable. The ethical tenets of beneficence, nonmaleficence, autonomy, and justice can help to guide decision making. The framework proposed helps the surgeon to consider a potentially modifiable risk factor that involves three questions: (1) What is the relationship between the risk factor and complications? (2) Is this risk factor modifiable, and to what degree can it be changed or improved? (3) If the risk factor is modified, does this actually result in reduced risk? To demonstrate application of this framework and the ethical tenets, we consider body mass index as a possible optimizable risk factor for total joint arthroplasty.