Intended for healthcare professionals

Observations Ethics Man

Lessons from the front line

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4624 (Published 06 October 2017) Cite this as: BMJ 2017;359:j4624

Ethical dilemmas still need to be evidence based

Daniel Sokol has given an interesting account on what surgeons should do when encountered with surgical time-critical dilemmas.

His dilemma on nickel allergy in knee replacement is however founded on no clinical evidence. There is no doubt that skin allergy to nickel may occur in certain individuals, however there is no evidence either clinically or via known biological mechanisms that links nickel allergy with joint replacement failure (1).

The ‘metal allergy’ debate has led to an industry in expensive nickel-free implants, but this is based on no biological evidence.

In my opinion, the ethical debate in this case is how to discuss the risks, benefits and expectations from surgery, when the patient is convinced that the presence of nickel may lead to a poor outcome. Should the surgeon use a more expensive, unfamiliar implant for such cases? I think not.

References
1. Middleton S, Toms A. Allergy in total knee arthroplasty. A review of the facts. Bone Joint J 2016; 98-B(4):437-41.

Competing interests: No competing interests

20 October 2017
Jonathan R Phillips
Consultant Knee Surgeon
Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital
Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter