Focus on areas of expertise

If you subscribe to our sister publication Theology Times, you may have enjoyed the recent article by the Archbishop of Canterbury on the relative merits of bilateral implantation with the same multifocal IOL versus the "mix-and-match" approach with refractive and apodized diffractive lenses. Or you may have seen the discussion by His Holiness Pope Benedict XVI on whether LASIK flaps are best created with the femtosecond laser or with mechanical microkeratomes.

If they don't ring a bell, that's because the magazine does not exist, and neither do the articles. And that's not really surprising. Both of these gentlemen are respected for their knowledge of theology and spirituality, not for their expertise in ophthalmic surgery. It makes sense, therefore, that they would focus their attentions on the theological and moral issues confronting their flocks and the world, not on controversies in vision correction.

Two occasions

On the first occasion, 10 or more years ago, I was asked to speak on the topic of refractive surgery. I delivered an update on the data our group had generated on photoablation for high postkeratoplasty astigmatism. The data showed (I thought) that this approach was reasonably successful, with an acceptably low risk of inducing graft rejection or other complications, providing that certain techniques and adjunctive medical therapies were used.

The first comment made about my presentation was memorable. "Refractive surgery is immoral," said the ophthalmologist, "because it is never acceptable to operate on an eye that can see with glasses or contact lenses. You must not have tried hard enough to fit these patients with contacts."

On the second occasion, I presented data from several studies my colleagues and I had performed over a few years of investigating the roles of gram stains and cultures in the management of presumed infectious keratitis. Our data showed that comprehensive ophthalmologists rarely obtained gram stains and cultures; when these were obtained, the results rarely altered therapy; and the empirical therapy with fluoroquinolones was remarkably successful. As a result, I opined that empirical therapy without gram stains and cultures was reasonable, unless clinical history or slit lamp appearance suggested the possibility of an unusual pathogen (such as fungus or Acanthamoeba) or the lesion was clearly threatening the visual axis.

To the best of my recollection, the next speaker began with the words: "What you have just heard is immoral." He asserted that failure to perform gram stains and cultures always is wrong and that to suggest otherwise was to deny patients quality care so as to give more money to managed care organizations.

These experiences led me to a few thoughts about ophthalmologists denouncing-I think this word fits-scientific presentations as immoral:

Established over time

Some may think otherwise, but my belief is that time has established that refractive surgery is not immoral, that it can be quite safe and effective, and that it can improve the quality of life for properly selected patients. Similarly, I think that most cases of keratitis are treated empirically in this country and around the world, that this practice is the standard of care, and that it is not immoral.

Certainly, the pope and the archbishop of Canterbury should be concerned that people receive the best health care possible, just as all physicians should endeavor to practice in an ethical and moral manner. Although many of us may hold strong views in this area, relatively few are formally trained in techniques and processes of ethical and moral analysis.