Biomedical Ethics and the Vision Industry: Shared Decision-Making is Key

Evra Taylor

Biomedical ethics is a relatively new field that is founded largely on dialogue and interpretation, rather than on the black and white conclusions that characterize other medical specialties. In biomedical ethics, the art of medicine meets the science of medicine.

Dr. Eugene Bereza, director of McGill University’s Biomedical Ethics Unit, teaches practicum courses in the Masters program, as well as medical school residents. According to Bereza, biomedical ethics emerged in order to find an alternative to an old-style model of medical paternalism.

Another impetus for the specialization was organ transplantation, which raises issues around how decisions are made about who receives organs. “As technology exploded, questions arose about how to use it,” explained Bereza. “For example, transplanting organs required a new definition of ‘brain dead’ and answers to questions like, ‘Who receives life support and what are the criteria for its cessation?’ The decisions being made weren’t keeping pace with the technologies at hand – and these issues came under the umbrella of medical ethics.”

Dr. Bereza is interested specifically in the doctor-patient relationship and how it has changed over the past 40 years. “Forty years ago, the doctor told the patient what to do. Now, doctors are supposed to listen to patients and take into account their preferences.” This is a newer model of care based on joint decision-making. How does this changing medical landscape affect the optical profession? “I would think that ophthalmologists and optometrists would have had to change like most other medical professions. Whether it’s diabetes or your eyes, the role of the physician is to properly diagnose and suggest appropriate treatments, and not to be perceived as the sole decision-maker.”

Dr. Bereza presented the following scenario: a 94-year-old woman visits her doctor’s office and says, “I’m having trouble with my vision.” The doctor says, “You have cataracts and we should remove them – then you’ll see better”. In the old days, the doctor would have said, “I’m scheduling surgery next month,” without considering the patient’s preferences and lifestyle. However, the patient might say, “I’m 94 years old. I’d rather not have the surgery. I’d rather stumble around the house.”

In another scenario, a 94-year-old woman asks her eyecare professional, “I can’t see. Can you do something?” She has arthritis and moderate dementia. The modern-day doctor ponders, “Am I going to do surgery on a 94-year-old woman with moderate dementia, who has limited mobility?” The doctor considers her likelihood of complying with treatment, plus her elevated risk of post-operative infection. “It’s quite appropriate for an eyecare professional to offer an opinion or advice, but ultimately the decision is going to lie with the patient. Two 94-year-olds might have two different preferences. Eyecare practitioners have to think about how this procedure fits into their patients’ lives,” explained Dr. Bereza.

In the above scenarios, the ocular professional shouldn’t be the only one making the decision, he said. Furthermore, it would be wrong for the practitioner to assume that because the patient has dementia, she doesn’t need to see. Naturally, the physician should want to improve the patient’s quality of life. “However, it’s valid for the ophthalmologist to say, ‘She’s in a nursing home with dementia. She has no visitors and no TV, and she stares at blank walls all day. What is the purpose of performing surgery, with the possibility that she’ll develop a post-operative infection, become septic and die?’”

“There has to be a shared exploration of the way the treatment fits into the patient’s life,” added Dr. Bereza. In this facet of biomedical ethics, the key point is shared decision-making, which must be integrated into a rapidly evolving healthcare landscape, and the unfortunate reality of shrinking human resources and budgets.