By Farzana Paleker

An uptick in the use of heroin (and the sharing of dirty needles) has resulted in a 50% increase in the number of cases of recurrent heart valve disease. This phenomenon has presented Florida heart surgeons with an ethical dilemma: continue to provide these patients with expensive treatment, or turn them away.

This increase, surgeons say, places a huge burden on the state: tax money is used to provide uninsured addicts a treatment that costs over $500,000 a pop.

Many surgeons refuse to operate on addicts more than once, and hardly any provide the treatment a third time. “We try to scare them,” says Tampa-based surgeon Scott H. Bronleewe. “We tell them that if they come back in with a reinfected condition, [they] more than likely are going to die.”

Surgeons attribute the increase in recurrent infective endocarditis to the surge in heroin usage that followed Florida’s crackdown on opiate pill mills. According to Bronleewe, the pill mills provided addicts with easy access to opiates; most of his patients with heart valve disease are opiate addicts who have resorted to injecting heroin.

Bronleewe’s group of surgeons, along with the state surgical society, have decided to limit valvular replacement to one procedure per patient where the valves have been damaged by intravenous drug abuse. Their policy is to turn away addicts who return with reinfected endocarditis from sustained abuse of heroin. This decision was made in consultation with the clergy and the hospital’s medical ethics committee. For James Orlowski, chief of pediatrics at Florida Hospital Tampa and chairman of the hospital’s ethics committee, the surgeon has the autonomy to refuse treatment, especially when individuals engage in behavior that places them at risk. The policy, though not supported by all cardiac surgeons, should create an incentive for addicts to change their behavior.

At this stage no medical malpractice suits have been filed. The courts have supported the surgeons’ stance, indicating this refusal to treat is legal because it is a form of resource rationing.

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