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

Mohs micrographic surgery (MMS) is a safe and effective treatment for non-melanoma cutaneous carcinomas, but clinical indications alone do not establish ethical appropriateness. Social barriers, treatment and functional limitations, plus patient preferences can complicate an otherwise straightforward treatment recommendation. Through three cases, we examine challenges that arise when MMS is not pursued, despite meeting appropriate use criteria. The first considers physician responsibility when substantial social barriers disrupt continuity of care, and a patient defers the 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 of alternative treatments. In each case, physicians should balance tumor control with patient autonomy, nonmaleficence, quality of life, and responsible use of healthcare resources. Ethical Mohs practice requires recognizing when advocacy for definitive treatment remains appropriate and when individualized care should take precedence.