Surgeons often face challenges when patients who may need elective procedures present with modifiable risk factors for surgical complication, such as obesity or smoking.

Although mitigating these risk factors may improve surgical outcomes, authors of an ethics case presented in the New England Journal of Medicine question a physician’s responsibility when a patient accepts the increased risk for postsurgical complications.

Lisa S. Lehmann, MD, PhD, of the National Center for Ethics in Health Care, Veteran’s Health Administration, in Washington, DC, and the Harvard TH Chan School of Public Health in Boston, and colleagues explored the ways in which surgeons may act as “gatekeepers” where patients with modifiable risk factors are concerned.

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Obesity, smoking, and diabetes are modifiable risk factors that have all been shown to predict postoperative complications. If such factors are present but are mitigated preoperatively, the odds of a successful surgical outcome increase.

Still, Dr Lehmann and colleagues point out that when surgery is deferred in order to optimize risk posed by such factors, it can cause a continuance of the patient’s suffering, and yet, if a physician decides to operate on a patient whose condition poses significant risk factors without attempting to mitigate those risks, it will mean that resources for other patients are diminished. Additionally, physicians are obligated to ensure that the potential benefits of an operation outweigh any risk to the patient.

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To this end, Dr Lehmann and colleagues suggest that professional societies develop guidelines to help physicians strike a balance between their own values, those of the patient, and of society. This would further discourage rationing of care by physicians against the wishes of a patient who sees a risky surgery as worth the potential increase in quality of life.


Leeds IL, Efron DT, Lehmann LS. Surgical gatekeeping — modifiable risk factors and ethical decision making. N Engl J Med. 2018;379:389-394.