Beyond the Appropriate Use Criteria: Ethical Considerations When Forgoing Mohs Micrographic Surgery

Area of Science:

• Dermatology
• Medical Ethics

Background:

• Mohs micrographic surgery (MMS) is a standard treatment for non-melanoma skin cancers.
• Clinical appropriateness does not always equate to ethical justification for MMS.
• Social, functional, and patient-specific factors can complicate MMS recommendations.

Purpose of the Study:

• To examine ethical challenges in MMS when it is not pursued despite meeting indications.
• To explore physician responsibilities in cases with social barriers, geriatric patients, and patient refusal.
• To analyze the balance between tumor control and patient-centered care in MMS decisions.

Main Methods:

• Case study analysis of three complex clinical scenarios.
• Examination of ethical considerations in MMS decision-making.
• Discussion of physician's role in navigating patient autonomy and medical recommendations.

Main Results:

• Social barriers can disrupt care continuity and influence patient deferral of treatment.
• Geriatric patient frailty and surrogate input necessitate careful consideration of procedural burden.
• Patient's lived experiences and misconceptions can shape treatment refusal, challenging standard protocols.

Conclusions:

• Ethical MMS practice requires evaluating tumor control alongside patient autonomy, nonmaleficence, quality of life, and resource allocation.
• Physicians must advocate for definitive treatment when appropriate but prioritize individualized care when necessary.
• Recognizing the limits of clinical indications in ethical decision-making is paramount.