While performing a preoperative assessment on a patient scheduled for elective surgery, I learned that he drinks 6 to 8 ounces of hard liquor a day. I documented this appropriately and alerted the surgeon, who talked with the patient about how alcohol use increases surgical risks and referred him to social services. When a social worker called the patient to recommend a detoxification program, he shouted that he's not an alcoholic and the surgeon was just trying to scare him. Then he slammed down the phone. The surgeon went ahead with the surgery anyway.

Since denial is such a large part of addictive disease, shouldn't the surgeon have insisted that the patient be treated for alcoholism before performing elective surgery?-P.C., WASH.

The surgeon must decide, based on his professional judgment, whether the patient's behavior or health status puts him at excessive risk for complications. If so, he should take steps to help ensure a good outcome or refuse to perform the procedure.

Making the right decision can be difficult when substance abuse is a factor because denial is a powerful force. In some cases, clinical lab values may support the need for detoxification, in which case the surgeon probably shouldn't proceed with an elective procedure. But legally and ethically, he can't force the patient into a substance abuse treatment program as a condition for surgery; this would be a form of coercion. The patient has the right to refuse treatment, even if it seems contrary to his best interests.