Published 10 March 2009, doi:10.1136/bmj.b753
Cite this as: BMJ 2009;338:b753

Analysis

Commentary: A call for preventive ethics

¹ Berman Institute of Bioethics and Department of Medicine, 624 N Broadway, Baltimore, MD 21205, USA

The current practice of sending reduction mammoplasty specimens for routine histological examination can result in a complicated set of circumstances that raise important ethical issues. As described by Keshtgar and colleagues, a small but measurable subset of these specimens show malignancy of uncertain clinical significance.¹ Since patients undergoing this reconstructive procedure apparently are not informed about screening of the tissue removed during surgery, they may be understandably surprised that cancer was found and also face difficult questions about management. This situation is an opportunity for preventive ethics—which seeks to avoid vexing ethical issues by taking steps to avert them.

The authors wonder whether patients should be told explicitly about histological examination and the potential consequences if it turns out to be positive. It would be hard to imagine a justification for not including this sort of information in the consent process for reduction mammoplasty. Even though the likelihood of the specimens being malignant is small, discussing this issue in advance should help to prepare patients to receive the news and to face the complex decisions that follow.

The authors also describe that clinical management may be complicated by the fact that most specimens are not orientated and they ask whether surgeons should make an effort to orientate the specimens as far as possible. If the tissue is going to be analysed the answer seems to be an unequivocal yes. The primary intent of mammoplasty is cosmetic, but it is a medical procedure, taking place in a medical setting, and those performing it have a fiduciary obligation towards their patients’ health and wellbeing. Orientating the specimen would seem to need little extra work and would seem to increase the clinical utility of the information.

Nevertheless, since the proper management of incidentally detected early stage breast cancer is unsettled, there is a crucial lingering important question regarding the appropriateness of routine histological review of these specimens. This matter warrants careful, expert review of available data and the potential implications of alternative approaches. In the meantime, obtaining informed consent for the histological examination of mammoplasty specimens and orientating these specimens should help to mitigate some of the difficult ethical issues that are encountered in practice.

Cite this as: BMJ 2009;338:b753

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Keshtgar M, Hamidian Jahromi A, Davidson T, Escobar P, Malluci P, Mosahebi A, et al. Tissue screening after breast reduction. BMJ 2009;338:b630.[Free Full Text]

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