The Devoted Grandma: Is a Social Indication for TAVR Acceptable?

Abstract

Two hallmarks distinguish the U.S. health care system from other countries with developed economies: the availability and widespread use of highly advanced medical and surgical technologies and the enormous expenditure of national wealth on health care, now standing at well over $3 trillion, about 18% of the gross domestic product (GDP). Health care sector economic growth rate has substantially exceeded the overall GDP growth rate for decades; restraining health care sector growth to a level approaching GDP growth has been a goal of U.S. health policy for nearly 50 years, but efforts to achieve that goal have consistently failed. One of the prominent approaches for controlling costs of health care has been encouraging physicians to limit their use of expensive technologies to clinical situations in which they can do the most good. One such expensive technology is transcatheter aortic valve replacement (TAVR), which was initially limited to use for cases of severe aortic stenosis in patients who were not candidates for open valve replacement surgery. The indications have recently been expanding to include less narrowly defined clinical situations [1Baron S.J. Wang K. House J.A. et al.Cost-effectiveness of transcatheter vs. surgical aortic valve replacement in patients with severe aortic stenosis at intermediate risk: results from the PARTNER 2 trial.Circulation. 2019; 139: 877-888Crossref PubMed Scopus (91) Google Scholar], but some guidelines setting boundaries for the use of TAVR have been promulgated. One of those recommendations stipulates that the device should not be used for patients whose comorbidities predict survival of less than 1 year [2Bavaria J.E. Tommaso C.L. Brindis R.G. Carroll J.D. et al.2018 AATS/ACC/SCAI/STS Expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons.Ann Thorac Surg. 2019; 107: 650-684Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. Some clinical situations might challenge that guideline, such as a patient’s desire to survive for a few months to achieve social ends. Such a situation in the form of a fictional vignette was the basis for the Cardiothoracic Ethics Forum debate at the 2018 Annual Meeting of the Southern Thoracic Surgical Association. Anna Mary Moïse is 78 years old and has hemoptysis with shortness of breath and occasional episodes of syncope. On physical examination she is found to have a heart murmur suggestive of aortic stenosis. The chest roentgenogram shows a 2-cm mass in her right lower lobe and a widened mediastinum. Endobronchial ultrasound biopsy of the lung mass demonstrates small cell carcinoma with left paratracheal and subcarinal metastases, and a positron emission tomography scan shows bulky mediastinal lymphadenopathy. She has noted a diminished appetite over the previous 3 months and has had 15 pounds of weight loss. Brain magnetic resonance imaging shows a single temporal lobe metastasis. With chemoradiation therapy, average survival is 6 months. Echocardiogram shows an ejection fraction of 40% and severe aortic stenosis with valve area 0.5 cm2, mean gradient 61 mm Hg, and transaortic velocity 5.9 m/sec. She also has moderate aortic insufficiency. Because of the severity of her aortic stenosis and syncope, the cardiologist believes that Mrs Moïse is at high risk of death within a few weeks, perhaps a month or 2, without an operation. The patient has only 1 grandchild, a granddaughter Lucy with whom she is very close. Lucy is engaged and her wedding will be in 4 months. Although TAVR is generally reserved for patients whose death from a comorbidity will be no less than 1 year, the cardiologist recommends TAVR in the hope of keeping Mrs Moïse alive for her granddaughter's wedding. He refers her to a cardiac surgeon and the institution’s comprehensive multidisciplinary team for evaluation and possible TAVR. Mrs Moïse should be offered TAVR to allow her to survive long enough to attend her granddaughter’s wedding. The patient’s collection of diagnoses indeed suggests a grim prognosis, but as physicians and surgeons we are obligated to make treatment recommendations based on the best data available. We are given convincing data regarding the diagnoses: severe, symptomatic aortic stenosis, and extensive small cell lung cancer (SCLC). The next requirement is a clear understanding of the natural history of the diseases and then to consider objective data regarding the outcome of available treatments. As always, clinical decisions for any given patient are based on consideration of the risks and benefits of the treatment compared with the risks of the disease. Untreated severe symptomatic aortic stenosis results in progressive heart failure and death. As cardiothoracic surgeons we understand this progression well. Independent of her cancer, Mrs Moïse has a 50% probability of death from her heart disease within 2 years [3Varadarajan P. Kapoor N. Bansal R.C. Pai R.G. Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis.Ann Thorac Surg. 2006; 82: 2111-2115Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar]. I posit that her cardiologist’s anxiety that her death from aortic stenosis is imminent within the next few weeks is not likely. Further, we are well experienced in the outcomes of aortic valve replacement (AVR) in this setting and know that successful valve replacement improves symptoms and extends longevity. For purpose of this discussion, however, I will assume that the cardiologist’s prognosis of likely death from aortic stenosis within a few weeks is correct. Untreated SCLC results in progressive wasting, respiratory failure, and death. However, I am less clear about the course of this disease in my own experience and so turn to current literature and the counsel of expert colleagues to better understand the options. Armed with current data, we can best assess the relative risks and benefits for this patient. Stage 4 SCLC is an incurable disease. Current treatment regimens include platinum-based chemotherapy and radiation. There are also immunotherapy options available on protocol with promising results. Mrs Moïse would be eligible for several of these protocols if she did not have life-limiting aortic stenosis. Because SCLC has a rapid cellular turnover, it is quite sensitive to chemotherapy with early response. Unfortunately, recurrence is common and second line therapy for recurrent SCLC is far less effective [4Kahnert K. Kauffmann-Guerrero D. Huber R.M. SCLC-State of the art and what does the future have in store?.Clin Lung Cancer. 2016; 17: 325-333Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. Schabath and colleagues [5Schabath M.B. Nguyen A. Wilson P. Sommerer K.R. Thompson Z.J. Chiappori A.A. Temporal trends from 1986 to 2008 in overall survival of small cell lung cancer patients.Lung Cancer. 2014; 86: 14-21Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar] reviewed changes in SCLC treatment over time. Comparing treatment regimens during the intervals 1986-1999 with 2000-2008 the median survival for Stage 4 disease increased from 8.8 months to 10.4 months. A decade later and with further treatment advances, 12-month survival is not unreasonable. In fact, the first immunotherapy, the checkpoint inhibitor nivolumab, was approved by the Food and Drug Administration for the treatment of SCLC in August 2018. The best evidence at this point, however, is that the patient’s survival of her lung cancer is very likely to be significantly less than 12 months. The next question is whether Mrs Moïse will receive treatment for her cancer at all with severe symptomatic aortic stenosis. For this question, I conferred with 2 medical oncologists in our system who treat SCLC. They each independently agreed that the chemotherapy regimen they believe most effective is difficult to tolerate with symptomatic comorbidity. While neither would state they would not offer treatment, both acknowledged hesitations to offer therapy. In reviewing treatment options on protocol, numerous clinical trials are currently recruiting [6U.S. National Library of MedicineSearch results.https://clinicaltrials.gov/ct2/results?cond=Small+Cell+Lung+Cancer+Extensive+Stage&term=recruiting&cntry=US&state=&city=&dist=&Search=SearchDate accessed: January 10, 2019Google Scholar] for which Mrs Moïse would be eligible despite her age if she did not have severe symptomatic aortic stenosis. Considering the options to treat her aortic valve, few among us would propose surgical AVR (SAVR) in this setting. The Society of Thoracic Surgeons risk model for isolated AVR would place her at 3.6% risk of mortality, 14.8% risk of morbidity, and 8.2% risk of prolonged hospitalization. Certainly SAVR would delay initiation of cancer treatment if her recovery were prolonged. With an incurable cancer, prolonged hospitalization alone would be adequate reason to avoid SAVR. Assuming adequate anatomy for transfemoral TAVR, the expected length of stay would be only 1 to 6 days if no complications occur. TAVR results in prompt relief of stenotic gradient, and Mrs Moïse could potentially proceed with treatment for her cancer within weeks. Admittedly, this is a lot to consider for a woman who has lived 78 years and is in poor health. Palliative care is a reasonable choice, but in the United States today it is a choice for the patient to make. Why is TAVR “generally reserved for patients whose death from a comorbidity will be no less than one year”? With Food and Drug Administration approval of TAVR, this was not a stated requirement, although it has become common practice. Should we consider that the cost of TAVR mandates some minimum survival to be cost effective? The most recent Medicare data available comparing the cost of treating aortic stenosis by TAVR versus SAVR finds that the difference is less than might be expected. Hospital costs in 2012 were $50,200 for TAVR and $45,500 for SAVR [7McCarthy F.H. Savino D.C. Brown C.R. et al.Cost and contribution margin of transcatheter versus surgical aortic valve replacement.J Thorac Cardiovasc Surg. 2017; 154: 1872-1880Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar]. The cost difference has certainly not slowed the adoption of TAVR. The number of TAVR implants more than doubled from 2011 to 2012 [6U.S. National Library of MedicineSearch results.https://clinicaltrials.gov/ct2/results?cond=Small+Cell+Lung+Cancer+Extensive+Stage&term=recruiting&cntry=US&state=&city=&dist=&Search=SearchDate accessed: January 10, 2019Google Scholar]. The number of TAVR procedures continues to increase annually with improving outcomes: for patients recorded in the Transcatheter Valve Treatment (TVT) registry from 2012 until the end of 2015, in-hospital mortality declined from 5.7% to 2.9% [8Grover F.L. Vemulapalli S. Carroll J.D. et al.2016 Annual Report of The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.Ann Thorac Surg. 2017; 103: 1021-1035Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. At present, no national decision has been made to limit health care based on cost per year of life, although this would certainly be a worthy topic for consideration. For example, Medicare ensures dialysis for any eligible resident with end-stage renal disease regardless of age or other life-limiting comorbidity. It is the duty of the surgeon and the heart valve team make decisions regarding treatment based on the risk-to-benefit ratios of the considered therapies and have honest discussion with the patient and family regarding these options. In this case, the patient has a good chance of symptom relief from her valvular heart disease with TAVR. Her battle with cancer is therefore a separate consideration. The patient and her family should consider whether to proceed with any therapy only with full knowledge of the potential outcomes of both therapies. If the desire to see her granddaughter marry plays into her decision, so be it. It is possible for her to have that experience and even possible, if unlikely, that she could see her first great grandchild. The cardiac surgeon as part of the institution’s comprehensive multidisciplinary heart valve team should offer TAVR to Mrs Moïse. Mrs Moïse, the devoted grandmother, should not be offered TAVR, as this would be an inappropriate expenditure of resources. The obvious solution to this medicosocial issue would be for the granddaughter to move her wedding ceremony to accommodate her grandmother’s dying wish! However, this may be an unrealistic request. The survival of Mrs Moïse to and through the wedding ceremony is the goal of this intervention as her cardiologist has suggested that she has weeks or at most 2 months to survive without the TAVR. Let’s review her current medical situation. We are told her cardiologist gives her weeks to as much as 2 months before death and that she can survive 3 to 6 months with chemoradiation therapy for her small cell carcinoma, which is stage IV. The real question is, can we accurately predict death from her heart disease and her response to therapy for her stage IV SCLC? Moreover, if these assumptions are correct, what will be her quality of life? What if she suffers complications from her TAVR that require additional procedures or length of stay in the hospital which would delay her SCLC treatment? Additionally, will she develop more cerebral metastasis during her SCLC therapy, and need inpatient care for seizures or cerebral edema? What, if any of this, can we as clinicians predict, especially in the narrow window of 4 to 6 months? Here is why we should not agree to provide the TAVR. We know that women undergoing TAVR have a higher vascular complication rate than men do (8.27% versus 4.39%; p < 0.001) and require conversion to open surgery more often (1.74% versus 0.96%; p < 0.001); certainly, just 1 of these complications would extend her intensive care unit stay. Additional procedural factors that would increase her length of stay include nonfemoral access requiring mini-thoracotomy (33.25%) or mini-sternotomy (7.3%), or unplanned other cardiac surgery (2.4%), which could have been secondary to coronary obstruction (0.7%), all of which are significantly more common in women compared with men. The net adverse cardiac events associated with TAVR in women approaches 20% (18.96), with a hospital mortality of 5.6% [9Chandrasekhar J. Dongas G. Yu J. Vemulapalli S. et al.Transcatheter aortic valve therapy: TVT Registry from 2011 to 2014.J Am Coll Cardiol. 2016; 68: 2733-2744Crossref PubMed Scopus (125) Google Scholar]. If she survives, there is a very significant chance that she will suffer an event that will keep her hospitalized, thus delaying the start of her chemoradiation therapy for her SCLC. If we presume that she is going to avoid death and any complications and sail through her TAVR and get immediate relief from her impending cardiac demise, what does the next 4 months mean after TAVR? The occurrence of death, stroke, or myocardial infarction continue to rise in the first 3 months postdischarge and range from 12% to 15% [4Kahnert K. Kauffmann-Guerrero D. Huber R.M. SCLC-State of the art and what does the future have in store?.Clin Lung Cancer. 2016; 17: 325-333Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. The readmission rate after TAVR 17% to 22%, further adding to the chances that Mrs Moïse will not be available for the wedding as a direct result of the TAVR alone [10Tripathi A. Flaherty M.P. Abbott J.D. et al.Comparison of causes and associated costs of 30-day readmission of transcatheter implantation versus surgical aortic valve replacement in the United States (a national readmission database study).Am J Cardiol. 2018; 122: 431-439Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. Notwithstanding the issues with the TAVR, Mrs Moïse must undergo therapy for her stage IV SCLC. The fact that she has lost 15 pounds recently and is requiring significant medical care for her heart disease adversely affects her score on the Karnofsky scale and based on her current medical issues, she would rate a 40 to 50 on the Karnofsky Performance Scale [11Crooks V. Waller S. Smith T. Hahn T.J. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients.J Gerontol. 1991; 46: M139-M144Crossref PubMed Scopus (248) Google Scholar, 12de Haan R. Aaronson A. Limburg M. Hewer R.L. van Crevel H. Measuring quality of life in stroke.Stroke. 1993; 24: 320-327Crossref PubMed Scopus (255) Google Scholar, 13Hollen P.J. Gralla R.J. Kris M.G. et al.Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies.Cancer. 1994; 73: 2087-2098Crossref PubMed Scopus (191) Google Scholar]. There is evidence that she would probably not survive until the wedding based on her lower Karnofsky score [14Videtic G.M.M. Adelstein D.J. Mekhail T.M. et al.Validation of the RTOG recursive partitioning analysis (RPA) classification for small cell lung cancer-only brain metastasis.Int J Radiation Oncol Biol Phys. 2007; 67: 240-243Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar]. Median survival was 2.3 months for those with Karnofsky score of less than 70 in this retrospective study. Although several publications report median survivals of 6 to 7 months for stage IV SCLC, they are not stratified by Karnofsky score. We know that clinicians overestimate survival in cancer patients [15Glare P. Virik K. Jones M. et al.A systematic review of physicians' survival predictions in terminally ill cancer patients.Brit Med J. 2003; 327: 195-198Crossref PubMed Google Scholar]. We as physicians want what is best for our patients in terms of survival and quality of life, regardless of the time they have left. However, we are also charged with “first, do no harm.” Based on the data cited previously, how can we truly think that we are going to avoid harm in this patient or provide her with a reasonable quality of life over the next 2 to 4 months? Perhaps the last issue to consider is the financial aspect of what we would be adding to our national health care expenditure. One patient is not going to make a serious addition to our $3.2 trillion in health care spending, but each patient contributes to this ever-increasing number. The cost of the initial TAVR varies by regional location [16Gupta T. Kalra A. Kolte D. et al.Regional variation in utilization, in-hospital mortality, and health-care resource use of transcatheter aortic valve implantation in the United States.Am J Cardiol. 2017; 120: 1869-1876Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. The range is between $56,000 and $149,000 [17Minutello R.M. Wong S.C. Swaminathan R.V. et al.Costs and in-hospital outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in commercial cases using a propensity score matched model.Am J Cardiol. 2015; 115: 1443-1447Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 18Indraratna P. Ang S.C. Gada H. et al.Systematic review of the cost-effectiveness of transcatheter aortic valve implantation.J Thorac Cardiovasc Surg. 2014; 148: 509-514Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar] and the readmission costs are between $51,000 and $59,000. The cost of the TAVR and readmission will exceed $100,000 no matter the region, and could be as high as $208,000. Outpatient therapy for stage IV SCLC with chemoradiation therapy will exceed $17,000/month [19Bremner K.E. Krahn M.D. Warren J.L. et al.An international comparison of costs of end-of-life care for advanced lung cancer patients using health administrative data.Palliat Med. 2015; 29: 918-928Google Scholar]. If we consider that Mrs Moïse will need at least 4 months of therapy, then $75,000 to $80,000 is what we can expect if she does not require hospital admission. However, in the last 3 months of life, nearly 50% of the month is spent in-hospital, which would further increase costs and of course she could potentially be hospitalized preventing her attendance to the wedding [20Park M. Son I. Medical care costs of cancer in the last year of life using national health insurance data in Korea.PLoS One. 2018; 13e0197891PubMed Google Scholar]. The conservative cost for the TAVR and chemoradiation therapy would exceed $300,000 without substantial complications with either therapy or intervention. Survival beyond 1 year is less than 5% for stage IV SCLC, so we are not talking about substantial lifetime benefits even if she makes it to the wedding, which is less than a 50-50 proposition. When one looks at U.S. health care spending, it has increased beyond GDP growth since the initiation of Medicare and Medicaid [21Sawyer B. Cox C. How Does Health Spending in the U.S. Compare to Other Countries? Kaiser Peterson Health System Tracker.https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/?_sft_category=spending#item-since-1980-gap-widened-u-s-health-spending-countriesDate accessed: January 10, 2019Google Scholar]. The spending is also disproportionately apportioned to the last months or years of life [22Bell M. Why 5% of Patients Create 50% of Health Care Costs. January 10, 2013.https://www.forbes.com/sites/michaelbell/2013/01/10/why-5-of-patients-create-50-of-health-care-costs/#5333fc9128d7Date accessed: January 10, 2019Google Scholar]. Moreover, health care spending increases are above annual inflation rates, albeit they have slowed over the last decade, but are still increasing [23Sawyer B. Cox C. Peterson Kaiser Health System TrackerTotal Health Care Expenditures as Percentage of GDP. Kaiser Peterson Health System Tracker.https://www.healthsystemtracker.org/chart/total-health-expenditures-as-percent-of-gdp-1970-2017-2/#item-startDate accessed: January 10, 2019Google Scholar]. Why? Technology is driving health care expenses upward. We are now able to replace an aortic valve via the femoral artery, but at increased cost. We can use the Gamma Knife with stereotactic location to irradiate tumors, but at a higher cost than whole-brain irradiation. Technology is providing us with the ability to perform procedures in a less invasive fashion, with shorter length of stay, increased patient comfort, and decreased rehabilitation times, but at increased expense. The estimate that 25% of Medicare expenditures occur in the last year of life equates to over $200 billion in 2018-dollar equivalents [24Aldridge M.D. Kelly A.S. The myth regarding the high cost of end-of-life care.Am J Public Health. 2015; 105: 2411-2415Crossref PubMed Scopus (96) Google Scholar, 25Einav L. Finkelstein A. Mullainathan S. Obermeyer Z. Predictive modeling of U.S. health care spending in late life.Science. 2018; 360: 1462-1465Crossref PubMed Scopus (69) Google Scholar]. A reduction in this very significant portion of total Medicaid spending would dramatically decrease overall national health care expenditures. Our duty is to our patients first and foremost. However, we should not and cannot forget that we must think about fiscal health care responsibilities. Advancing the science of our art is critical to providing better care to our patients; this is what the constant march of technology gives us. Reasonable ground rules regarding the usage of newly developed expensive technology should be established by us, the clinicians, rather than a governmental body with no expertise or experience. The use of expensive interventions in a patient who has limited to no chances for 1-year survival and a very significant possibility of an actual decrease in the quality of life is precisely the type of situation we should not support. Moreover, the use of this type of expensive intervention for a social issue for someone in their last 6 months to year of life is fiscally irresponsible. We can no longer be compassionate participants in the spiraling costs of health care. In closing, I want to stress that we as physicians remain committed to our patients and their well-being. However, with the ever-evolving technology opening new treatment options for us we need to be cognizant of the spiraling health care expenditures and use these innovations wisely, with a sense of fiscal sanity. Establishing sound institutional standards for the use of technologies such as TAVR is a start, but when the patient can simply cross the street for the procedure then there are no standards and no fiscal accountability. The American College of Cardiology and American Heart Association should work in concert with the cardiac surgical associations and societies in the United States to establish strict criteria for the use of these expensive interventions, before the government imposes rules [26Otto C.M. Kumbhani D.J. Alexander K.P. et al.2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.J Am Coll Cardiol. 2017; 69: 1314-1346Google Scholar]. “The good of the many outweigh the good of the few …. or the one” [27Spock FO (Leonard Nimoy)Star Trek II: The Wrath of Khan. Paramount Pictures. 1982. Quoted in Enk B. The 15 Most Surprising Deaths in the Movies. Yahoo! Entertainment. May 7, 2014.https://www.yahoo.com/entertainment/blogs/movie-news/15-most-surprising-deaths-movies-221144160.htmlDate accessed: January 10, 2019Google Scholar]. The vignette that opened this article and the essays arguing opposite viewpoints of what should be done for Mrs Moïse illustrate the tension between physicians’ obligations to individual patients and their obligations to society, especially with regard to controlling health care costs. As noted previously, the pressures to help reduce costs by withholding expensive technologies have intensified as other means to reduce expenditures in health care have failed. Carpenter insists that whether TAVR is provided to Mrs Moïse is a choice for the patient to make, but we wonder how the essayist would react to the recent joint report by national organizations (American Association for Thoracic Surgery/American College of Cardiology/Society for Cardiovascular Angiography and Interventions/The Society of Thoracic Surgeons) that recommended withholding TAVR from patients who are likely to survive less than 1 year [2Bavaria J.E. Tommaso C.L. Brindis R.G. Carroll J.D. et al.2018 AATS/ACC/SCAI/STS Expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons.Ann Thorac Surg. 2019; 107: 650-684Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. The guidance is a recommendation, not a requirement—should it be mandated? Novick asserts that physicians must “be cognizant of the spiraling health care expenditures and use these innovations wisely, with a sense of fiscal sanity,” but he does not explain the conditions under which the physician’s obligation to society can outweigh her obligation to a particular patient; instead, he points to some future time when professional standards for implementing technology guide a physician’s decision making. Such guidance currently exists [2Bavaria J.E. Tommaso C.L. Brindis R.G. Carroll J.D. et al.2018 AATS/ACC/SCAI/STS Expert consensus systems of care document: operator and institutional recommendations and requirements for transcatheter aortic valve replacement: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons.Ann Thorac Surg. 2019; 107: 650-684Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar], but in the absence of a mandate, why should a surgeon abide by it? Both essayists agree that the primary responsibility of physicians is to the patients under their care, but an important question remains, one that has not been explored by most commentators on this issue: what specific conditions or calculations could be used to justify elevating social responsibility above obligations to patients? Several years ago in the pages of this journal, Governor Richard Lamm, a nationally prominent proponent of rationing health care resources, argued that external guidelines should be set at the local, regional, or national level to limit access to expensive technologies to help control health care costs [28McCarthy P. Lamm R. Sade R. Medical ethics collides with public policy: LVAD for a patient with leukemia.Ann Thorac Surg. 2005; 80: 793-798Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. This is similar to Novick’s position, with an important difference: Lamm also endorsed the position taken by Carpenter, that physicians should not ration at the bedside, but rather should remain loyal to the patient’s best interests over society’s needs. Neither the medical profession nor the political establishment has made much progress in this area since Lamm’s essay of 14 years ago. Dr Sade’s role in this publication was supported by the South Carolina Clinical & Translational Research Institute, Medical University of South Carolina’s Clinical and Translational Science Award Number UL1TR001450. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Advancing Translational Science of the National Institutes of Health.