POINT OF VIEW

Mechanical or biological decision?

Max Grinberg

Instituto do Coração do Hospital das Clínicas - FMUSP, São Paulo, SP, Brazil

Mailing Address

Key-words: Valvopathy, valvar prosthesis, bioethics.

"The indications of the Delphi Oracle were not to be received passively; the beneficiaries had to live the message..."

Clarification: in the development of this text, the terms "cardiology" and "cardiologist" also comprise cardiac surgery and the cardiovascular surgeon.

I. Bedside reading book

Highlight: "The study of Medicine begins with the patient,continues with the patient, and ends with the patient..."(William Bart Osler - 1849-1919).

Highly pedagogical medical books – the patient collection –are edited by the bedside; title pages are precisely the faces ofpatients. There are chapters so revealing of the human being thatthe text seems to be written in the patient-author's ownhandwriting; some of them become bedside books in light of theempathy involved in the doctor-patient relationship.

With due permission, we reproduce an extract of a book aboutprosthesis- dependency that started to be written more thanthirty years ago by a person with aortic valvopathy. Currently,he is living with his fourth prosthesis and says that quality oflife "between operations" has always been excellent:

"I never faced the issue from the position of 'exchangingone disease for another'; it's always been clear to me that I wasa participant in a decision-making process and that whatevercould allow me a daily life as close to normal as possible wouldbe the best for me – to work, have and raise children, support myfamily, be able to exercise, have an active sex life, be able totravel, etc., etc., etc...; from a certain angle, the 'decision'process in the four operations I had was situated within thispattern of expectations: to understand the problem, obtain theinformation necessary from my physician and, along with him, makethe best decision for my quality of life. The first time, theweight of the doctor's information was heavy. I was young andunfamiliar with the variables, and had the aortic valve surgerywithout many choices (or maybe alternatives to prostheses werenot presented to me at that time). It was more or less a case ofbeing bound to the risks of surgery versus the risks ofnot having surgery. The other three times, however, when I hadsurgery for a new valve change, the issues of 'life the closestpossible to normality' were decisive and, I confess, had littleto do with the need for anticoagulation. At my second operationit was because I had the experience of a 'normal life' during theperiod of using the duramater prosthesis, and at the third, Ialmost implored to receive a prosthesis similar to the previousone, since I was convinced that the prosthesis I used was'better' for this stage that I call 'normality'. I neverconsidered the possibility of implanting a mechanical valve andit wasn't because of anticoagulation aspects; the decisions werelinked to my positive previous experience, to what I had lived,an experience I considered positive and the type of life I led.At my last operation, I accepted the recommendations to live witha mechanical prosthesis because I became convinced, from theinformation given me, that I possessed a heart that had alreadybeen handled a lot and that my chest was not a zipper that couldbe opened or closed at will. In other words, in the fourthoperation the possibility of having surgery once again, wheneverand in whatever condition that would be, bore a lot of weightjuxtaposed to facing the possibility of PTs [prothrombin times]and use of warfarin. Therefore, it is not a case of thisprosthesis being better than that; circumstances and personalvalues are very important, and the physician can, at best, warn,inform, and present options. I believe that the options/decisionswere the most appropriate, since they fit into my perspective oflife at those moments when I was living them. It is all aboutscientific issues and human aspects and this is whydoctor-patient interaction is so crucial…..."

This declaration is an example of a new state-of-the situationin selecting the type of valvar prosthesis to beused¹. It privileges the impact on quality of life andtherefore, the target is mobile and the use of algorithms isdiscouraged. Hence, simplification of "bioprostheses arepreferred after the age of 70 and mechanical prostheses inyounger age groups..."² should be replaced by amore encompassing appreciation: "besides mortality andmorbidity endpoints related to the prosthesis, one shouldconsider endpoints of postoperative quality oflife¹..."

A recent research noted that, for the aortic position, thebioprosthesis was considered superior to the mechanicalprosthesis (80% versus 70%) as to the endpoint of degreeof satisfaction with prosthesis-dependency. Data included thepatient's desire to maintain the same type of valvar prosthesisin an eventual reoperation³, as had been previouslyshown.

The statement that personifies the center of ourattention, referred to in the second article of the Code ofMedical Ethics, teaches us lessons about opting for quality oflife. "Visualization" of the prosthesis by the patient withvalvopathy is essential; inner reality, according to analogousfacts that are experienced externally, initially advises a choiceand the subsequent commitment to it. The patient's memory, as anaspect of prudence by education and experience, is validespecially in cases of a new valve replacement in which thecontent of the previous chapter infers the "good decision" thatwill be reproduced in a later chapter. The limits of positivememories as counselors occur when the physician's duty ofinforming carries a convincing argument for the patient: themultiplicity of scenarios; that of the fourth operation involvedhim in playing a different role, one better adjusted to him. Itis important to note the value of the lexicon, the key thought inmotivating the decision - zipper.

II. The Navigator and the Pilot

Highlight: In a current view on decisions, the physician isthe navigator and the patient is the pilot^4,5.

To the sound of the beauty and richness of the Portugueselanguage, the mechanical decision, since it is not personalized,or the biological decision, since it is individualized, allow forboth the mechanical and the biological types of prostheses.

Replacing a portion of the heart that was born with you issituated in a medical priority that is surrounded by ambivalencebecause of imperfections that bear a price to be paid. It is anoccasion that makes feelings churn and heightens the sensitivityof the valvopathy patient to acts of humanization. To hold ontothe handle of the gavel represents a gesture of self-alienation,a symbol of integration of the therapeutic method with one's ownvalues.

The core of this gavel is universal scientific knowledge thatincludes solid national experiences. The gavel, however, does notprove to be so compact; there are spaces that still lackrandomization and cases that are more homogeneous for comparison,and require filling-in time – each new model requires aboutfifteen years. On the other hand, we intend its impact surface tobe flexible enough to adapt well to the human being's naturalresistance and to be complacent with the configurations of thehealth system.

As to modeling the handle, one question, which is the essenceof this article: should it be molded to the hand of the physicianor of the patient?

The premises for the gavel handle to be held by thecardiologist are well known; they are the "best in vitro"reinforced or annulled by the in vivo socioeconomicadaptations. For patients they are more complex, since they needto overcome a tendency to abdicate making decisions and bringtogether some traits. These qualities are capacity – beingof age in full control of his/her mental capacities –;instruction – obtaining necessary knowledge –;comprehension – apprehending the basics to be able todecide –; persuasion – being convinced of theauthorization; incoercibility – being free from pressuresregarding authorization –; decision – emitting theauthorization.

We leaf through the album of experiences and our eyes arecaught by pictures that sometimes show the handle of the decisivegavel in the hand of the valvopathy patient, who is not alwayswell informed, and sometimes in the hand of the cardiologist, whois frequently ambiguous, or in the hands of both in a sharedmanner.

For the person with a valvopathy, the issue of heteronomy orautonomy in decision-making is an enormous burden that is addedto the pre-load and post-load. We could say that it is a crucialmoment in the natural history of the valvopathy, in which theneed for a correction of the hemodynamic overload provokes a'human-dynamic' overload. This type may be more difficult to dealwith, as Fiodor Dostoievski (1821-1881) portrayed in TheBrothers Karamázov: "…because he was crushed bythe terrible burden of freedom of choice...."

How would the valvopathy patient perceive the right to thefreedom of adjusting his choice and commitment priority, thegetting involved with the yes and disposing of theno, when in seeking the basics, conscientious of beingprudent as to his future (because, in fact, the implications arenot exactly immediate, they manifest themselves months or evenyears after the operative act), his cardiologist, who isexperienced in the quotidian and has the memory of analogoussituations, does not have the labels scientifically correctanswer, scientifically incorrect answer?

The reluctancy that is felt by the patient is evident in thefollowing consultation published in the Heart Forum fromthe Cleveland Clinic some years ago:

"I am a 36-year-old man who is going to undergo an aorticvalve replacement in London. The surgeon recommended a mechanicalprosthesis, but admitted that others would have proposed a Rossoperation; however, he considers it has greater risks and merelya few theoretical advantages. What are the disadvantages ofwarfarin? Is Coumadin the same thing? Will I have to reduce myalcohol intake? Does it make a noise? I am a light sleeper. Thismight sound trivial, but it truly is bothering me. Some have toldme I should choose a homograft that lasts for about 20 years, andothers say that I should not fear a new operation. I feelinsecure..."

This patient clearly is not ready to see a decision withinhimself. His physician's clarifications seem to be insufficientin certain details, but especially in making him aware of thefact that there is no perfect decision. Whatever decision ismade, it will be "excellent" considering the variouspossibilities for these circumstances.

In pursuit of answers as to who should hold the handle of thedecision-making gavel, we were touched by the concept ofphysician-navigator and patient-pilot⁴. In this way,the cardiologist is the one who gives course-plottingcoordinates, and the valvopathy patient is the one who pilots thedecision about valvar prosthesis. In this composition, no oneabdicates of his/her values; both remain sovereign at thebedside, each in his own way.

Therefore, the sequence ofinform-opine-decide-concur-act is thus distributed: thefirst two parts essentially belong to the physician, the thirdportion belongs to the patient, and the last two are once againdetermined by the physician. The objective is to individualizemanagement, educate the patient regarding circumstances, elevatehis/her compliance with treatment through sharing, and reduce theprobability of dissatisfaction because of poor communication.

We found this pertinent comparison in a text about the classicfunction of the navigator⁶:

"The navigator is the person responsible for orientationaccording to pre-established norms and identification of criticalpoints. Thus, it is important for the navigator to know the normsin detail and be capable of making reliable interpretations - to"delay" or "not indicate" a reference to risk may result in anundesirable event. The navigator is not permitted to err. Anydoubts that the pilot might have as to the quality of navigationwill result in losses for the decisions on conduct. Therefore, itis the responsibility of the navigator, above all, to transmitSAFETY to the pilot..."

When we declare that the valvopathy patient has the right toan opinion about his/her valvar prosthesis, we don our respectfor the saying: every man to his own taste; we furnish theraw material necessary for forging the gavel – sharing ofinformation – and the patient is the one who pounds the gavel –decision-making.

Our expertise advises us on what needs to be done and if itshould be done (expectations), while the patient's values givethe basis for his/her allowing it to really be done (his/herwill). Thus, we accept the bioethical and anthropologicalparadigm that the approximation to each person should always beindividualized when he/she is in the patient's situation.

It is important to bear in mind the distinction proposed bythe Austrian philosopher Martin Buber (1878-1965), between theME-THIS and the ME-YOU. In this case, the ME-THIS wouldcorrespond to the cardiologist's concerns with the heart that isdeficient because of valvopathy and with the therapeuticprosthesis, and the ME-YOU, would represent the cardiologist'ssupport for the patient in comparisons and in decision-making,and then making it a clinical reality. This complementarity helpsone to see a synthesis of the navigator-pilot relationship at thebedside: nothing just by me, nothing without me.

III. Reality is still not Harken

Highlight: "Daring ideas are like chess pieces that moveforward; they can be eaten, but they can also begin a victoriousgame..." (Johann Wolfgang von Goethe - 1749-1832).

One of the objectives of Cardiology, the ideal valvesubstitute, shall come^7,8. It will bring hemodynamicsand hemocompatibility similar to those of the human body in amechanical prosthesis that does not form thrombi, or in abioprosthesis that does not calcify. Communication at the time ofpounding the gavel on the type of valvar prosthesis will provehighly beneficial.

The ideal valvar prosthesis takes time in laboratories anddoes not yet merit the approval certification signed byHarken⁷, which represents the hope that a not toodistant future generation will pose the progressionist questionof all time "How could it have been [done] that way?". Inthe meantime, seven in ten individuals operated for valvopathyexchange incapacitating valvar stenosis or insufficiency for anartificial open-and-close condition in a ratio of four biologicalprostheses to one mechanical prosthesis (data from InCor).

What is truly available is capable of producing benefits forclasses I or II-A⁹, something we intend to reach byreprogramming intracardiac flow. When the damaged valve isremoved from the path of the blood so that it can pass through avalvar prosthesis, the pathophysiological mechanism remodelsitself inversely, backwardly in the direction of physiologicalflow.

The international demand for valvar prostheses causes agrowing economical and financial implication; the market in theUnited States of America estimated a worldwide profit of morethan one billion dollars in 2005¹⁰.

The manifestation of prosthesis as a material good isnegligible in valvopathy patients, but supreme in itsmanifestation as a benefit for mankind.

We pool low, average, and high-level technology for theexercise of Cardiology. This is not enough. We would like to havemore and be able to prevent and treat heart diseases better. Wedo not consider the justifications for the present limits asfinal. They are a mere semicolon in a moment that willprogress.

In favor of beneficence, we feel encouraged to transcend; inthe search for that which is even more useful and efficient, weare driven by the mythological symbolism of the wings on Hermes'caduceus – no matter how heretical this may be^11,12;for the pro-ethical connotation, the important thing is thepresence of wings that are absent on Aesculapius's staff. Themere wisdom of the serpent is not enough when the patient is ourguest for the flight.

Dedalus managed to reach his destiny and Icarus did not, inspite of father and son having used the same wax to fix theirwings. In his ambitious enthusiasm, Icarus forgot his father'sadvice about the Sun and rose to such a height that the waxmelted. We should remember that ethics might be defined as thelimits that should be imposed on the search of one'sambition.

In this way, the span of our flights from the air shuttlebetween science and humanism is under the control of ethics –"the physician is prohibited…" constitutes thecaput of 77% of articles in the Brazilian Code of MedicalEthics. Once the flight plan is approved, the cardiologist cantake off the ground the capability for accomplishment,professional endurance, and patient survival.

Technology's inaugural flight in valvar prosthesis happened onSeptember 11, 1952, at the Georgetown University. The artifactwas made of plexiglass with an inner ball and was used to treataortic insufficiency. The implant was made in the descendingaorta (located after the subclavian artery branch) of a53-year-old woman, by the author of the project, the Americansurgeon Charles Anthony Hufnagel (1916-1989). The patientbenefited from his pioneer spirit for eight years without takinganticoagulants. The Hufnagel prosthesis produced a characteristicsound audible one meter away every time the patient opened hermouth.

Development of extracorporeal circulation and oxygenationopened the way for valvar replacement. On September 21, 1960,Philip Amundson, a 52-year-old patient with rheumatic mitralvalve insufficiency gained ten years of life after receiving theimplant of the first commercially available valvar prosthesisdeveloped by Starr – Edwards (Albert Starr, 1926- , and MilesLowell Edwards, 1898-1982, an engineer who had rheumatic diseaseat 13 years of age).

Half a century later, the dramatic element of all the valvarprostheses available – each with its intended plus feature– is that as soon as it fulfills its function, it becomes a seedfor germinating degeneration, calcification, orthrombosis¹³.

IV. A good idea, but...

Highlight: "It's useless to fight for an idea - when it isgood it follows its own path..." (Roger Fournier -1954-1989).

To invest in a non-maleficence effect of pulmonary dependencyon prosthesis is like trying to describe, from the bioethicalpoint of view, the valvar operation of translocating thepulmonary valve as a substitute for the aortic valve. Theoperation idealized about 40 ago by Donald Ross, an eponym bornin South Africa and dubbed Sir, is difficult to reproduceand therefore is one of those surgical techniques that end upacquiring the label of an experience that is successful in thehands of certain teams.

The principle is defensible in light of what we know happenswith a bioprosthesis implanted in the so-called left heart ofyoung people; nevertheless, available data do not allow anyadvancements in analyses of benefits.

What usually happens it that the cardiologist-navigator whoseinstitution does not practice it, does not customarily mention itas an option of choice to the patient-pilot who could meetinclusion criteria for this technique.

V. Withdrawal Syndrome

Highlight: "Those things we cannot do without, we don'tpossess, they possess us..." (Ivern Ball).

Uncertainties provoke effects at the bedside, lure us to abusestate-of-the-art technology, and seduce the "syndrome of thelatest article." It is precisely in conditions of doubt thatgrows the influence of intuition, that obscure short-circuit onreason that resorts to some "personal rules," those diffusenetworks created around life experiences that participate incomposing expertise¹⁴.

We sense each excision of a damaged valve as alea jactaest, cast toward the reality of hemodynamic benefit,submissive to the imperfections of the artifact. This can besynthesized in the old adage: valvar replacement is the exchangeof one disease (already symptomatic) for another (yetasymptomatic).

On the one hand is the clinical benefit, the foundation forquality survival. On the other, the harsh truth noted inobituaries of patients with valvar prostheses: regardless of whattype of prosthesis is used, mortality is superior to that ofindividuals in a corresponding age group that live with theirnatural valves, and around 50% of causes of death are directlyrelated to the valvar prosthesis.

It is under this emphasis of medicine as the science ofprobabilities and the art of uncertainties that a dependencyrelationship is formed, which like any other, combines good andbad experiences that permeate one's lifestyle, many of themfruits of good and bad decisions.

The good experience is the recovery of lost, modified, oravoided activities along the natural history of the cardiacdisease that the valvopathy patient expects to maintain by thebenefits of a prosthesis-dependency¹⁵. It will beoriginal for that patient, but at the same time, a copy of somany others from the professional cardiologist's point ofview.

The bad experience happens when, after a period of well-being,the terrible reality of any dependency is manifested – thewithdrawal syndrome. In the withdrawal syndrome for a prosthesis,the valve function becomes lacking in the circulating blood andthe cardiologist administers a "new dose" called a replacement,but not without first slamming the gavel once again.

VI. "If you kneel, you have to pray"

Highlight: "…difficulty in foreseeing the behavior ofany person, including our own..." (Gustave Le Bon, Frenchpsychologist / sociologist - 1841-1931).

Kneeling

Acts that are initiated require a commitment to a sequence ofinterdependencies. We sought a phrase that would synthesize thisbehavior and we found "If you kneel, you have to pray." Itis a bioethics-friendly proverb.

Adjusting it to the surgical treatment of valve diseases, thisteaching from folk wisdom could use a paraphrase: "If youoperate, you have to PRAY." This is because the one whoexposes the operatory field has to effect combinations ofRepair (prolapsed mitral valve leaflets), Eliminate(a giant auricle), Replace (a valve by a prosthesis),Add (a constrictor ring), or Move (the pulmonaryvalve to the aortic position).

The "R" – replace a valve by a prosthesis – is thethird therapeutic method after many years of clinicalsurveillance on damaged valves (first option), and when there isno recognized chance of repair (second option), the initial 'P'in pray¹⁵.

When we see an indelible change in the valvopathy patient'squality of life, we change our appreciation of non-maleficencethat functional classes I/II saw as predominating over thevirtual benefit of a valvar prosthesis implant^16,17.We immediately invert the benefit/non-maleficence relationship ofthe valvar prosthesis and advise the patient to get rid of thevalve generated in his mother's uterus and accept one that wasconceived in an industrial matrix. This should be made clear:functional class I is a surgical recommendation class III, and afunctional class III is a surgical recommendation class I; thisis the linguistic code of the cardiologist for surgicalindications in valvopathy.

Pray

The communicative force of hears everything well (inthe physician-patient sense) and says what interestshim/her (in the patient-physician sense) is the stabilityfactor of the physician-patient bond in face of the impossibilityof any prognosis coursing across a perfect sky on board an ideal"valve clone".

"Routine" communication without adaptations in feedback meansrunning on an automatic pilot that is insensitive to theturbulence of the route projected for the longitude of theplurality of authorized prostheses and the latitude of thescarceness of endorsable options according to the viewpoint ofeach team. Being thoroughly imposing, information ends upcreating more than an opinion - a belief.

The cardiologist knows the turbulence. It happens amid theformation of clouds heavy with complications caused byprosthesis-dependency and with many lightning bolts of chargedfrustration. There is no lack of acmes and nadirs; that whichseems a good thing for cardiology can have negative repercussionsfor the valvopathy patient. Good and ethical communication is thesafety belt when the forces of Nature show their superiority overscience and incite, for example, a terrorizing shower ofthrombi.

The priority of our profession is the endeavor for the goodresult to happen; the priority of the patient is the result thathas already happened, that is, the prosthesis functioning as avalve standard. Therefore, even if a decision were maderationally in the preoperative phase according to clear criteria,the intellectual comprehension of the subject might not be enoughin the postoperative phase. In other words, the anticipatedunderstanding about the pros and cons of an implanted prosthesismay not be enough to help the patient deal with his moreimmediate desires to return to his life routine.

When we transmit probabilities, the patient may do"simultaneous translation" and consider it as a promise, sincethat is his/her wish. In the name of harmony, we need to bewilling to go through as many decoding processes as necessary inthe waiting room of the decision-making; the objective is to keepthe hemodynamic swirling from becoming an ethical eddy, or eventhe transformation of the heart murmur into a din in thecardiologist's conscience.

The natural valve is lost and commitments with the valvarprosthesis are gained; one of the challenges here, maybe the mostcritical, is the daily balance between anti-thrombosis andanti-hemorrhage concerns.

Healing and postoperative clinical improvement mark thebeginning of observance of commitments with theprosthesis-dependency made during the preoperative phase. That iswhen the burden for many misunderstandings about legitimity,representativeness, reproducibility, and validity of knowledgeabout valvar prostheses starts to weigh. That is when thepreoperative information content contributes to eliminating afeeling of being surprised by reality.

The commitment with the prosthesis-dependency needs to be asample as possible, which is why it includes good life habits; oneof them, abstaining from smoking, increases in importance as itshows to be a risk factor for new operations for thebioprosthesis and thromboembolic phenomena along theprosthesis-dependency³. Knowledge about one's ownvalve disease contributes to the patient's giving up smoking; 48%of 215 patients with valve disease who became former smokersassociated the change of habit with their heart disease, eitherbecause "those who have heart problems should not smoe" (36%) orbecause they "had had an operation" (12%) (data from InCor).

VII. Emotionally variegated

Highlight: "I have phases like the moon..."(Cecília Meirelles - 1901-1964).

One of the first lessons in clinical medicine is thedifference between a symptom and a sign. The subjective aspect ofdyspnea is felt a lot more by the patient with valve disease; theobjective of the valvopathy murmur worsening that justified thesymptom is sensed a lot better by the physician. In this context,it is simple. But simplicity disappears when a strabismus infocus occurs: the patient with a valve disease reinforces theapprehension of the moment as he/she is dominated by the anguishof not being able to breathe; the cardiologist considers thelong-term benefit of prosthesis-dependency (in a new valvereplacement operation, the experience gained enhances thepatient's objectivity).

The environment is therefore subjected to the effects of aninterpersonal dissociation meaning that does not mean more orless human warmth, since it results from a composite of emotionsnecessary for clinical resolve. In face of his discomfort, thepatient is emotionally "hot", prone to the immediatism ofimpulsive decisions with an emotional state that blunts anyprecaution with the future; the cardiologist, on the other hand,who was trained to maintain his focus on the atemporal and stayalert to all angles around him, is professionally "cold"(hot-cold empathy gap)¹⁸.

This bears a lot of weight in the decision-making process inwhich responsibility is the price to pay for the right to makeone's own decisions. The "hot" emotional state provokes a falsesense of stability because the anguish of the situation seems tofreeze the future and the valvopathy patient reacts byoverestimating the resolution of the worrisome moment andunderestimating the vision of a valvar prosthesis as a long-termpreference. This behavior can create impasses when the patient,who is now in a "cold" affective condition in a comfortable "dayafter" situation of the late postoperative period, has toexperience the day-to-day reality of his prosthesis-dependencyand finds himself faced with vital commitments.

Short- and long-term focus adjustments and zigzags in theperception of priorities justify the scenes where protagonistsare patients with mechanical prostheses who abhor the quotidianof anticoagulation, a daily carrousel of pill ingestion, periodiclaboratory controls, adaptation to dosages and drug-foodinteractions, and a temptation toward poor compliance. Similarly,patients with bioprostheses anguish over the inexpiable panoramaof approaching expiration dates and feel they are moving "back tothe future."

VIII - New custom: Access by the bridge

Highlight: "Morals are the science of customs and changewith them. They are different from one country to another and donot remain the same in one place for the space of tenyears..." (Anatole France, pseudonym for Jacques AnatoleThibault - 1844-1924).

William Bart Osler (1849-1919) was a skillful captor ofbedside angst without technology and therapeutic resources. Todaythe lack of options is gone, but the anguish remains.

Paul Wood (1907-1962) expressed distress over the progressiveincorporation of technology at the bedside that "shocked clinicaltraditions" and predicted paradigm changes, in the preface of thefirst edition of Diseases of the Heart and Circulation(1950). He said, "I sought the balance between men andinstruments, an expert opinion and statistics, traditionalconcepts and heterodoxy, bedside clinical practice andspecialized tests, the practical and the academic, that is, toconnect past and present..."

In 1971, the concerns of the American oncologist vanRensselaer Potter (1911-2001) with the effects of technologicalprogress that had brought efficiency to the bedside on humannature made him realize the need for creating a safety bridge tothe future: bioethics.

Ethics control the traffic on the bridge with deontological lights that may be green for information on scientific databases, and red for the style of resolution. In this regard, we thought it would be helpful to set up Chart 1 with the articles from the Code of Ethics in Medicine in which the words "decision" and "decide" are used explicitly¹⁹.

Those who value the connection between biology and humanismbecame enthusiastic passers-by of Potter's bridge; for example,cases where it is necessary to interconnect the force ofcardiology, aspirations of the valvopathy patient, andprecautions of the cardiologist. This is the same directionperceived by the Dutchman, Baruch Espinosa (1632-1677). He wrote(parentheses are ours): "…it is by force that peace is produced (therapeutic efficacy), it is by desirethat that which is right is born (doctor-patientrelationship), and it is because of qualms that we run aftersafety (professional defense)..."

IX. Maxillary temperature

Highlight: "Words have the energy of sound, books aremerely paper..." (Paul Claudel -1868-1955).

When we acquire knowledge from scientific articles, such asthey are today, we introject the writing style with a distancefrom the physician-patient relationship, with results reduced totables and graphs and the conclusions iced up in the freezer ofstatistics. In our professional freezer, we preserve knowledgeand skill, but it is advisable not to freeze attitude, thatmanner which those wistful lessons in clinical medicinetaught us, the person of the patient of the author anticipatingour patient.

Bedside words, anxious to symbolize a social conscience in thedoctor-patient relationship, do not tolerate the same scientificknowledge formatting for the paper or the coldness of theoriginal article as to structuring evidence.

Medicine as an applied discipline – the usefulness ofknowledge – rejects the impersonal forms of science-medicine thatwe file as knowledge; cardiologist-cardiopathic patientcommunication differs from the cardiology-cardiologistcommunication, and requires an adaptation to the proximity of thebedside that values the warmth of humanization.

In this aspect, it seems useful to describe microwave oventechnology at the bedside: its use defrosts stored knowledge andmakes it palatable for verbal exposition.

X. The heart has the Law of Starling
The cardiologist has Law No. 10,241/99

Highlight: "Things are not just because they are law, butshould be law because they are just..." (Charles-Louis deSecondat, Baron de La Brède et de Montesquieu -1689-1755).

We are free doing everything that the laws allow, and theresulting right should not remain merely symbolical as themonumental, cold, and immobile statue of Liberty (1886. TheAlsatian sculptor, Frédéric Auguste Bartholdi,1834-1904, used his own mother as model).

In Sao Paulo, representativeness, warmth, and mobility in thefree and informed doctor-patient communication are set forth inthe State Law No. 10,241/99. This law intends to provide afoundation for consents and refusals in a clear way:"…the patient has the right to receive clear, objective,and comprehensible information, including on whatever he/sheconsiders necessary beyond what is routine...."

Therefore, navigation by the physician and piloting by thepatient is legal in the State of Sao Paulo.

XI. Physician's word, patient's ear

Highlight: "There must be two people in order to speak thetruth, one to speak, and the other to listen..." (Henry DavidThoreau - 1817-1862).

Communication on valvar substitutes is a part of the ethicalresponsibility of cardiologists, a sign of respect for thedignity of whoever will find, in the prosthesis-dependency, acontinuity of life. It stands out among the themes that provokecriticism and auto-criticism on sharing information incardiology.

Each physician-patient relationship is a moral cell with itspeculiarities. Since there are no two patients alike for a giventype of valvar prosthesis, after the diagnosis of valvopathy isconfirmed without much influence from individualizations, wesupply the therapeutic message taking into consideration thecultural and religious plurality that concurs for the way inwhich each one interprets health, sickness, and moralobligations²⁰.

Since we understand the patient with valve disease as being apart both of the problem and of the solution, we put our "cars onthe road" and fill up with high-octane moral fuel; in this way,we can get the ethical performance to construct a traffic rotaryfor a better distribution of information. The result is that thepatient's world, which under the ironic point of view ofHonoré de Balzac (1799-1850) begins at the headboard andends at the foot of the bed, starts to have access to severaldirections of knowledge and distinct distances ofrepercussions.

A language of conveniences and inconveniences of valvarprosthesis is transported to the bedside, an orchestral spacethat harmonizes the complex of information and admits solos. Itmakes the valvopathy patient aware of the fact that the valvesubstitute will not be a "soul mate" of the birth valve; itdiscourages the patient's reveries by using cut and driedtruth.

If we can be versatile within the limits allowed by scientificknowledge, cautious to not pass on arguments of "absolute truth"or being seen as prophets of the path, concerned with usinglanguage that facilitates comprehension and attentive to a finaldeadline for the decision, we will cover important steps for thequality of communication between navigator and pilot as to theroads of prosthesis-dependency.

It is valid to "write and rehearse the script," althoughwhenever "the heart speaks," as the German philosopher GottholdEphraim Lessing (1729-1781) said, there is no need to prepare aspeech. One should avoid the lack of clarification that behavesas if we were lying to the patient, since we would be feedingmistaken expectations. The verbal tour should not neglect tovisit both significant places and emphases and pedagogical pausesto call our attention as to "how we are doing."

To do well is not to carry on a one-person dialogue; it meansto analyzing how we are speaking and listening with each sentencespoken; it means making adjustments in face of the unforeseeableevents of the journey.

In order to clarify and make things clear, the availability oftime is contagious. Additionally, hearing us speak avoids verbalhyperflow or hypoflow, and hearing us hear protects us from otherconcerns of the mind during the dialogue with the patient.

It is worth pointing out, however, that the patient'spro-activity in sharing information is heterogeneous.

There are occasions when we feel like that professor beforestudents with stimulating interactivity, awakened by the interestof the valvopathy patient in knowing his valvar prosthesis well,which makes him ask, research and opine.

There are other occasions when we feel like we are practicinga desolate archival obligation, nothing more than "notarizing asignature" of an acceptance, since what predominates in thepatient is a reaction of passivity, denial, and distancing.

The navigator-pilot relationship admits heterogeneity in theaspect of interest that the valvopathy patient will favor ininformation about the type of valvar prosthesis^21,22 .For some, this is the assumed risk – for example, family membersof elderly people make a distinction of it in order to expressthat the life expectancy does not justify the operation. Forothers, this is the awaited benefit – for example, a youngdisabled person understands that the perspective of being able toransom his quality of life surpasses any dimension of risk.Consequently, it is prudent to avoid projecting onto thepilot-valvopathy patient the same plural reasoning aboutrisk-benefit that we commit ourselves to as to the whys, wheres,hows, and whens. Each patient can see the issue according to theparable of the blind men and the elephant.

In brief, excellence of physician-patient communicationimplies taking into account the conjuncture in which problems andsolutions present themselves, the reason why their stereotypedpresentation is not enough, or, as some would have it, thewritten presentation of what will or may happen, that will notnecessarily provoke discussion.

XII – A guideline is a pre-concept
Experience is a post-concept

Highlight: "The wise man does not have inflexible concepts,he adapts himself to those of others..." (Lao-Tsé-570-490).

Should we transmit information to the patient as experience wehave gathered, or as the best evidence reported in literature bystructured clinical observation?

The bedside situation is too complex for us to limit ourselvesto a simple copy-paste of a guideline that serves as oursupervisor, since a recommendation for a disease may notguarantee the correct decision for all who are ill. Guidelinesgive us the map to the main road; they are, therefore, useful tothe navigator, but they do not indicate the precious shortcuts ofexperience.

Conflicts between scientific knowledge about a guideline andattitudes of humanization generate reflections on the bestadjustment that should be practiced between the objectives ofmedicine – of which we are agents – and the objectives of society– of which the valvopathy patient is a member. An ethicallycorrect exposition does not allow room for dissimulations as tovalve prostheses. There is definitely no opportunity forhalf-truths, as in marketing that offers a product as being"semi-new", enhancing benefits and trying to hide thecorresponding "semi-old." Many have certainly already had thefollowing type of thought²³: "I spend a lot of timeanalyzing each guideline that is published, but none explains howto behave with my tougher patients..." and "I can notforce this resolute woman to accept the latest guideline of theAmerican Heart Association, but she wishes to commit as long asit is on her terms..."

The recognition that the guideline indication may differ fromthe patient's preference and with individual heterogeneities hasa great impact on bedside humanization. Guidelines are,undoubtedly, of great value in reducing our habitual intoleranceto uncertainties and transforming them into reasonablecertainties (benefits); but since individual uncertainties (thatdemand non-maleficence) cannot be eliminated by them in the sameway, it is wise to recognize that the guideline is not ataskmaster of our reputation.

XIII. Sensibleness in one generation
Foolishness in the next, or vice-versa

Highlight: "Humanity that should have six thousand years ofexperience, falls back into infancy in each generation..."(Tristan Bernard - 1866-1947).

Those who deal daily with specialization in cardiology cannotgo without recognizing that there is a generation gap as to thevision of basing information given to the patient on evidence ofcardiology or the cardiologist's life experience²⁴. Itis time that adjusts the scientific vision that accepts thedouble-blind and the clinical eye that demands that both eyes bekept wide open.

Cardiologists who are more experienced on the subject ofprosthesis-dependency reach the patients carrying their handluggage full of "meta-analyzes" from a single source – that oftheir work scenario. Those who are not so experienced tend toprioritize information from literature and reduce reliability toexperience, describing it as "experiences of one single case." Inthis way, the communication style used with the patient movesmore towards the side of human sciences or more towards the sideof exact sciences.

The combination of the young and the not-so-young in healthservices is Hippocratic: "the one who taught me this art... toconsider his sons as my own brothers... teach them thisart..." For 25 centuries (one hundred generations), it hasbeen a proficuous practice to bring together intellectualagitation and stabilization because their CRM [Regional MedicalCouncil] numbers reciprocally correct their misunderstandings.The seesaw of efficiency is thus balanced.

XIV. Layman, pero no mucho

Highlight: "Knowledge is of two kinds. We know a subjectourselves, or we know where we can find information upon it."(Samuel Johnson - 1709-1784).

In spite of having given rise to the risk ofdeprofessionalization and a drop in the physician's authority,electronic libraries have been a strategic tool for those whoseek health-related information.

For valve disease patients, there are special websites such asValveReplacement.com/Forums, which allow participation ofvalvopathy patients on several levels of discussion about thetheme:

"I am a 27-year-old woman... I have mitral insufficiency...I need to decide between a biological and a mechanicalprosthesis... the doctor said that anticoagulants would bedangerous in a future pregnancy... on the other hand, who wouldlike to go through another operation in a few years?... I amdepressed, afraid of making the wrong choice, not only formyself, but also for planning my family...I need advice…Ifthere is anyone who has been through the same situation... pleaseand thank you!.."

University centers also have electronic contacts availablewith information and orientation for valve disease patients, suchas the Harvard University²⁵: "I am about to receivean implant of an aortic valvar prosthesis. I appreciate thegreater durability of the mechanical prosthesis over thebioprosthesis, but I am fearful about the need to use oralanticoagulants for preventing thrombi. I have heard that thereare new options for mechanical prostheses that dispense the useof an anticoagulant where you only take aspirin. Is thistrue?...".

How many patients could use this resource? The answer isdifficult, but we suppose that there would be a growing demandamong us; the essential thing in this information reality is thatthe information be qualified, as much as possible, by renownedinstitutions experienced in prosthesis-dependency.

XV. Valvar filter

Highlight: "Many times it's necessary to change one'sopinion in order to remain in the same party..."(Jean-François Paul, Cardinal de Retz - 1613-1679).

Medical literature is not exactly a law, but it iscategorical. It so happens that what is academically respectableis not always consensual at the cardiology bedside.

Assuming we are experienced navigators as to the courses ofvalvar prosthesis, we funnel down the coordinates as much aspossible while still maintaining acceptable levels ofbenefit/non-maleficence for the patient. An example of this is todiscourage the implantation of the mechanical prosthesis in themitral position for a young person with a high risk ofhemorrhage, since it is xiphopagus with anticoagulants.

At the bedside, there is an ethical-scientific filter withpores adjusted for obtaining an ultrafiltrate of options that isclear for the circumstances.

This filtering of the available valvar prosthesis types shouldbe done, theoretically, in an impartial manner free from partyinterests; nevertheless, we practice personal biases geminatedwith scientific analyses of literature and critical accruals atthe side of the bed.

We sustain true ideologies that compel us, whether we want itor not, towards filiations with the BPP (Biological ProsthesisParty) or the MPP (Mechanical Prosthesis Party), with a right toexchange sides when convinced by a new scientific communication.The BPP representatives seem to maintain majority in the nationalcongress of Brazilian cardiology.

XVI. Open communication
Closed type prosthesis

Highlight: "The men we talk to are not those with whom weconverse..." (Jean-Jacques Rousseau - 1712-1778).

It seems a welcome idea to consider the communication between navigator-cardiologist and valvopathy patient-pilot through the Johari Window²⁶.This is a useful tool for amplifying visibility on personal aspects in the process of inform-opine-decide-concur and contributing towards perfecting the interaction (Chart 2).

We can accompany the pertinence of using the Johari Window bythe case of STN, a tradesman of 42 years of age, the last 25 ofwhich were spent living with a diagnosis of double mitraldysfunction. Four months ago, STN heard that his case would soonsatisfy the criteria for surgical treatment of the mitral valve.In this period, STN shared a lot of information with hiscardiologist. Currently, they are doing an immediate preoperativeconsultation; what each one of them already knows about the othercorresponds to the open conjunction of the Johari Window. Wecould say that the "old friends" removed enclosure boards, butnot all that ideally would be necessary to get rid of. STN andhis cardiologist are emphasizing dialogue as to the type ofvalvar prosthesis to be implanted; new technical information ispassed on to STN, increasing the dimension of this openconjunction. It is important to reduce the gray zone in order toattain a fullness of communication that depends on how many otherboards can be removed by the expansion of open conjunction in thedirection of secret and blind conjunctions. Because of theimminence of the operatory act, STN felt at home to revealcertain personal values that he considered free within himselffor such a disclosure. These things could never be known by thephysician any other way (secret conjunction) - STN's identitybecame better known by the cardiologist and a few more enclosureswere brought down, increasing the open conjunction. Thephysician, on the other hand, perceived that STN showed bodylanguage expressions in conflict with the verbal language. It wasonly after the physician pointed them out that STN recognizedthem (blind conjunction) – the process of becoming aware ofdefense mechanisms can be useful in eliminating behaviors,feelings, and negative motivations; other boards fell in thisway, widening the open conjunction. On the eve of the operation,the interpretation of a dream that STN had had revealed animportant aspect for the transoperative phase of thedoctor-patient relationship that had been ignored up until thenby both of them (unknown conjunction).

Through this window of communication, thecardiologist-navigator came to know the patient-pilot better, andthe patient, the physician; this dynamics contributed towards thequality of information in the decision-making process.

XVII. Decide, conjugating in the future

Highlight: "We desire to learn how to swim and keep onefoot on the ground at the same time..." (Marcel Proust -1871-1922).

"Welcome to the world of prosthesis!" When it is timeto say this to the patient, will we proceed as a compass,feeling that we are the navigator and avoiding behaving likehandcuffs on the patient-pilot?

It is important that the medical institutions make thisassessment: how does one decide who decides on the type of valvarprosthesis to be used? Repetition is not merely reinforcement bysemantics. Advantages and disadvantages are differences that canhave a correct option on a multiple-choice test applied to thephysician, but that can also admit all of the above ornone of the above when the patient is giving theanswers.

Indefinitions about the valve prosthesis to be implanted soundlike preoperative omission, infidelity with professionalresponsibility, and a path towards divorcing ethics by thephysician.

One starts with the principle that the cardiologist has thesupremacy and the patient with valve disease, the preference.Supremacy is in the force of science supporting benefits, andpreference represents the right to obtain the advantage. Inassociating force and justice in its own way, decision-making onvalvar prosthesis is also a political actuation. It managesvariables not directly related to the illness, ones we could callnon-medical factors, that participate in the decision process;they include characteristics of the patient (social class, ethnicgroup, gender, age group, degree of optimism, emotionalmaturity), style of the medical institution, health system, andthe environment of the sequence of facts²⁷.

I will decide

The heteronomic dialogue at the bedside usually is in harmonywith the Esperanto of norms and guidelines; it is the language ofassistance protocols that generally does not promote amplefreedom of decision by the patient.

In Brazil, where rheumatic streptococcus remains and valvaraging grows, the green-yellow gavel that sentences which of thevalvar prostheses will spend a number of years under "forcedlabor", incessant systoles and diastoles, for a multifactor arrayof reasons seems to be more in the hand of the cardiologist thanin the hand of the valvopathy patient. The figure of thecardiologist, heteronomic as a tutor, would prevail over theautonomic figure as a counselor; after all, cardiology is writtenby cardiologists, according to what seems to be the best"temporary truth", just as history is written by the victor whodoes not seem to hesitate over what is proper and improper.

The medical institution that limits the decision-makingprocess of the patient by means of an institutional routine isdefining a stereotype between benefit and non-maleficence validfor valvopathy, regardless of who bears the ailment. It would beas if the navigator prefers the impersonal identity of theautomatic pilot. Regional peculiarities justify a responsiblereductionism; one common example is the deficient reliability oforal anticoagulation control in many regions of our country.

Uncertainty reinforces the concept that circumstances ofcrises increase the weight of the load felt in a choice andcompel towards the safe harbor of fitting into routinespre-determined by a concept that is more collective thanindividual. In addition, habit passes on a positive view ofconduct whose construction usually is seasoned by an egocentricbias synthesized as: physicians believe their own patients evolvebetter than those of their colleagues²⁸.

Bedside intimacy whispers to us that there is a certainrelationship between the degree of confidence and the use ofheteronomy. A high level of safety, according to the physician'sopinion, including the extreme of the so-called blind confidence,the coziness that neutralizes discomfort, the patient's fear orphobia of the techno-scientific and moral posture of thephysician, favors the heteronomic.

It is worth pointing out that in instances when theinstitution-illness relationship predominates over thephysician-patient relationship, the patient tends to be insertedinto the man-mass concept of the Spaniard José Ortega yGasset (1883-1955): his clinical interests are more radicallyrepresented by a higher instance and there are feweropportunities for options and choices.

You will decide
He will decide

To position ourselves in favor of autonomy is not to thinkthat our opinion as a physician will be placed in the backgroundbecause of the "respect for diversity." On the contrary, it is tofight to preserve the right to an opinion, except that both sidesare appreciated, just as in the exercise of doubt (duality ofone's own opinion), because it ponders the best treatment for thediagnosis and prognosis.

It is one thing to be sure of an opinion (private); it isanother thing to respect an opinion (of another person). It isone thing to make a selection based on actuarial curves; anotherto renounce the rest of the actuarial curves. It is one thing toconsider a decision "good"; it is another to witness the awaitedgood result.

In the role of navigator we reduce the asymmetry ofinformation, compose the latent action, and await the decision ofthe patient responsible for piloting in the decision; thisprerogative should be carried out in a free and informed manner,according to the guide that he/she feels is more beneficial thanharmful (objective of medical ethics).

This form of thinking seems conceptually valid to us becausethe decision on the type of valvar prosthesis is habitually madein an elective way. Thus, there seems to be adequate time for thevalvopathy patient to reflect on the lack of an ideal situation,within the concept that there will be no health benefit without alife risk and without paying a price – a new operation of thebioprosthesis or anti-thrombotic care.

The patient is the only one who can distribute information,according to how it sounds to him, toward the positive ornegative side of his values²⁹. This distributiondemands the initiative and courage of decision responsibilities,according to the reflection of Englishman Bertrand Russell(1872-1970): "Freedom is an indispensable requisite forobtaining many valuable things; but these valuable things have tospring up from the impulses, desires, and beliefs of those whoenjoy this freedom...."

Nevertheless, it is fact that reveals the habit; the patientmay not be accustomed to going ahead amid many details, as thephysician is, and gets caught up in minutiae. That is why manyprefer to wash their hands and fully endorse so they do not haveto face the dilemma, and in doing this, they rob themselves ofthe pilot's license. We can agree that nothing is as exhaustingin the doctor-patient relationship as indecision; for thisreason, there are decisions that are mere formalities.

The following conclusion from a recent Canadian articlereinforces the current tendency³⁰: "The type ofbioprosthesis does not influence mid-range survival andprosthesis-dependent morbidity for ages 45 to 65 years; thereforethe choice as to which bioprosthesis to use should be determinedby patient/surgeon preference...."

Chart 3 exhibits essential data for the decision-making process on valvar prosthesis by the patient-pilot, according to the proposal for ethical valuation in making a decision³¹.

A pilot usually has a co-pilot, and a large percentage ofpatients, each in his own way and under cultural influence,literally give up the gavel handle when they place family membersin an expressive status of decision-making power.

From this angle, it does not matter how much the familymembers are in tune among themselves; we should not neglectascertaining the opinion of the patient himself, if he is indeedcapable; however, if he is incapable of doing so, it is notalways clear who should be considered the legal representativeexpressed in article 46 of the Code of Medical Ethics: "Thephysician is prohibited to perform any medical procedure withoutprevious information and consent of the patient or his legalrepresentative, except in cases of imminent life risk." Whatwe have observed is that there usually is a leader that functionsas a family spokesperson.

In exercising co-piloting, family members increase the openconjunction of the Johari Window in the direction of the secretconjunction of their own values. Who has not heard from a familymember something like "Doctor, my husband has horrible veins, Iwouldn't like him to have to keep drawing blood forever..;" or "Iwould not like to see my father having surgery again..;" or"…it doesn't matter, he will not lack anything..."

In this way, family members "exchange seats with the pilot"and can dominate the Manichaeism as to what is good and what isevil for the patient, thus directing the permission (passiveacceptance) or choice (active).

This behavior occurs with a certain frequency in cases ofelderly valvopathy patients, precisely the age group mostsensitive to the physician's opinion^23,32. Familymembers take the initiative and allege that this is necessary inlight of the decline in decision-making capacity and emotionalguarding in old age. This communication with the person who playsthe part of son-father ordaughter-mother³³ is ever more relevant inBrazil because of the increase in prosthesis-dependency duringthis so-called "third age" [senior citizens]. Over the last twoyears, this age segment has represented 29% of interventions forvalvopathy correction, a universe with a growing distribution inthe 65-69 years (34%) to 85-95 years (2.4%) age range (data fromInCor).

XVIII. Epilogue

Highlight: "The one who writes has the right to invent afable, not the morality of this fable..." (Rudyard Kipling,1865-1936, an Englishman born in India, Nobel Peace Prizewinner).

The patient may not accept the operation

Faith in the authority of cardiology guarantees us a way ofseeing "the clinical case"; the expectation ofbenefit/non-maleficence hypnotizes Narcissism; and caution as tothe limits of the patient's freedom are called to our attentionby the Swiss Jean-Jacques Rousseau (1712-1778), who said "Manis born free but is always in chains..."

Zeal and prudence in the physician-patient relationshipantecede and succeed the autonomic decision on valvar prosthesis;initially, because of the quality of information; posteriorly,because of the wisdom of agreement.

We respect the point of view of the patient who, except in asituation of imminent life risk, refuses the recommendation ofsurgical treatment for his valvopathy even though, in a way, itplaces bioethics as being anti-Hippocratic; Hippocrates gave muchemphasis to the patient's well-being and his oath carries certainimpositions.

We avoid interpreting the anti-surgical attitude of thepatient (who is the end) as disobedience to cardiology (that isthe means); the conflict has more chances of having been with theform of good and not with our formulation itself. Going the wrongway on the road that we consider the most correct conduct doesnot give us the right to demerit the patient's choice; itstimulates us to go back to the source of information, even toencourage a second opinion.

If he accepts, he commits himself to prosthesis-dependency

When the virtual aspect of the surgical indication becomes areal preoperative preparation, in pertinent cases it is mandatoryto select the type of valvar prosthesis, a definition thatusually occurs on the eve of the operatory act as a fruit of ourcultural aspects. Early planning, during consultations in whichthe valvar prosthesis is merely a perspective, is not one of ourhabits. As homework, we usually give the patient the immediaterevelation of a clinical change, but not the reflection onprosthesis-dependency. Therefore, clarification to the patient ateach office visit makes it easier to identify the ideal momentfor the surgical indication, but customarily it does not provokethe choice of valvar prosthesis.

The honesty we transmit through information about the pros andcons of the various prosthesis possibilities heard as pleasant orunpleasant by the patient, is a preoperative variable of thepostoperative quality of life. The success markers of the valveprosthesis decision are not merely those dependent oncardiological objectivity as to technical results, but includethose of a subjective nature that measure the perception by whichthe patient resumes living physically, mentally, and socially ina way similar to when he was a functional class I. In thisaspect, one positive side of prosthesis-dependency is that,apparently, the loss of the cardiac valve does not bring negativeemotional impacts as happens with excisions of other bodystructures.

This is how we do it here

The ethical excellence of Brazilian cardiology involvesongoing perfecting of structured strategies in order to minimizethe evils of prosthesis-dependency.

The common objective of the different medical institutionsthat multiply throughout the national territory should be theaplomb between hypertrophy of personal values recorded in theethics-gram and the clinical remodeling available bybenefit/non-maleficence.

Each green-yellow road that leads to a bioethical identity ofprosthesis-dependency, in harmony with our cultural traditions,represents a fruit that ripens on the genealogical tree, richlyramified with so many pioneers of the cardiology family of ourcountry.

Considering the highlight above, this question remains foreach medical institution: do the clinical progress uncertaintiesreflecting on the professional responsibility recommend that thedecision on prosthesis-dependency be a previously preparedplate or an à la carte choice?

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Mailing Address:
Max Grinberg
Rua Manoel Antônio Pinto, 04/21A
05663-020 – São Paulo, SP, Brazil
E-mail: max@cardiol.br

Received on 11/22/05
Accepted on 12/08/05