Beyond appropriate use criteria: Ethical considerations when forgoing Mohs micrographic surgery

Mohs micrographic surgery is a safe and effective treatment for nonmelanoma cutaneous carcinomas, but clinical indications alone do not establish ethical appropriateness. Social barriers, treatment, functional limitations, and patient preferences can complicate an otherwise straightforward treatment recommendation. Using three cases, we examine challenges that arise when Mohs micrographic surgery is not pursued despite meeting appropriate use criteria. The first considers a physician's responsibility when substantial social barriers disrupt continuity of care, and a patient defers treatment decisions to the medical team. The second addresses how procedural burden, frailty, and surrogate insight should inform treatment decisions in geriatric patients. The third explores treatment refusal shaped by a patient's lived experience and misconceptions about alternative treatments. In each case, physicians should balance tumor control with patient autonomy, nonmaleficence, quality of life, and responsible use of health care resources. Ethical Mohs practice requires recognizing when advocacy for definitive treatment remains appropriate and when individualized care should take precedence.