Discussing Treatment Options with a Minor: The Conflicts Related to Autonomy, Beneficence, and Paternalism

Abstract

A seventeen-year-old male, high-school football player presents to an orthopaedic surgeon because of recurrent right knee pain after having undergone an arthroscopic meniscal repair one year previously. The patient did well initially but now has recurrent medial joint-line pain in the knee, which developed when he planted the right leg to throw a pass during summer training camp. He was evaluated by the team's athletic trainer and by an orthopaedic surgeon, both of whom, on the basis of their physical examination of the boy, believe that he may have sustained a recurrent meniscal tear. A magnetic resonance arthrogram is acquired, which confirms the presence of a large longitudinal tear of the medial meniscus in the "red-red" zone, with no signs of degenerative change, articular cartilage damage, or other ligamentous pathology. The patient had just started summer training camp before his senior year of high-school football, and he is considered to be a potential high-level candidate for a Division-I football scholarship.The orthopaedic surgeon presents the patient and his mother with three treatment options: nonoperative management, arthroscopic partial meniscectomy, and arthroscopic meniscal repair. He also presents the relevant risks and benefits of each choice, including, for meniscectomy, the risk of the future development of osteoarthritis if a large portion of the meniscus were to be excised and, for meniscal repair, the need for an extended (four to six-month) rehabilitation period. Both the patient and his mother are apprised of the limitations of preoperative magnetic resonance imaging (MRI) in determining if a meniscal tear can be repaired1-3. The patient states that, on the basis of his symptoms of pain, intermittent locking, and swelling, he does not believe that he would be able to play football if nonoperative management was chosen. He voices a strong preference for meniscectomy, as this would allow him the most rapid return to play. He states that he is not concerned with the future risk of osteoarthritis but is fearful that missing his senior football season will place his scholarship in jeopardy. His mother states that her son would likely not attend college without a scholarship, considering the family's financial situation. The patient states that he therefore wishes to have a meniscectomy, given the likely quicker recovery and faster return to play.The patient's mother was initially in favor of a meniscal repair, if possible. However, over the course of the patient's visit with the surgeon, she is persuaded by her son to favor a meniscectomy. The surgeon again discusses in detail the risks involved with meniscectomy in an adolescent-primarily the higher risk of future knee osteoarthritis. The patient remains persistent in his choice, mainly due to his desire to avoid the prolonged postoperative course of limited weight-bearing and physical therapy and thus the loss of his final high-school season. The mother, who is the patient's legal guardian for consent, ultimately follows her son's wishes and elects to consent to only an arthroscopic meniscectomy.