Should Your Doctor Tell You Which Hospital Is Safest for Cancer Surgery? A Medical Ethics Debate

Table of Contents

• Key Points
• Why This Debate Matters
• What Research Shows About Hospital Volume and Outcomes
• Viewpoint 1: Doctors Have an Ethical Duty to Inform Patients
• Viewpoint 2: Practical Hurdles and Unintended Consequences
• Viewpoint 3: More Work Needed Before Outcomes Data Are Routinely Used
• Key Findings at a Glance
• What This Means for Patients
• Limitations of the Evidence
• Recommendations for Patients
• Frequently Asked Questions
• Source Information

Key Points

• High hospital volume is linked to lower mortality for pancreatic and esophageal cancer resections.
• Viewpoint 1: Physicians have an ethical duty to disclose hospital outcome differences to patients.
• Viewpoint 2: Mandatory disclosure faces practical hurdles and risks unintended consequences like hospitals avoiding high-risk patients.
• Viewpoint 3: More work is needed before outcomes data are routinely used in clinical decision-making.
• Patient preferences vary: many would travel for better outcomes, but a substantial number accept higher risk to stay local.

Why This Debate Matters

When a patient is diagnosed with cancer, one of the most important decisions is where to receive treatment. For decades, researchers have known that some hospitals achieve better outcomes than others for certain complex procedures.

Yet when doctors obtain "informed consent" before surgery—the formal process of explaining a procedure's risks, benefits, and alternatives—they typically discuss the procedure itself. Rarely does the conversation include whether the patient might have significantly better odds at a different hospital. This gap between what patients know and what they might need to know is the heart of this debate.

The article features three distinct expert viewpoints:

• Nadine Housri and Leonidas Koniaris (University of Miami) argue that physicians have an ethical obligation to inform patients of hospital outcome disparities for select cancers.
• Dr. Robert J. Weil (Cleveland Clinic) contends that such discussions face significant practical hurdles and risk unintended consequences.
• David Shalowitz (University of Michigan) believes more work is needed before outcomes data should be routinely used in clinical decision-making.

What Research Shows About Hospital Volume and Outcomes

The link between hospital procedure volume and patient outcomes has been studied for nearly 50 years. In 1979, Luft and colleagues published a landmark study examining mortality rates for 12 surgical procedures of varying complexity across 1,498 hospitals.

That study found that the mortality rates for open-heart surgery, vascular surgery, transurethral prostatectomy, and coronary bypass were inversely related to hospital volume—meaning patients had lower death rates at hospitals that performed more of these procedures. Since then, numerous studies have confirmed an association between improved outcomes and high hospital procedure volume, as well as teaching hospital status.

In 2000, an Institute of Medicine (IOM) workshop examined the evidence on the "volume–outcome relationship." The National Cancer Policy Board concluded that this relationship was strongest and most consistent for two types of cancer surgery: resection (surgical removal) of the pancreas and of the esophagus. These are complex, high-risk operations where the experience of the entire surgical team can dramatically affect survival.

This evidence has changed how some organizations direct care. The Agency for Healthcare Research and Quality (AHRQ) currently lists hospital volume as an inpatient quality indicator only for pancreatic and esophageal cancer resections. Similarly, the Leapfrog Group—an alliance of large and small corporations representing more than 20 million employees—requires that employees undergoing one of five high-risk procedures be cared for at high-volume centers. Two of those five procedures are pancreatic and esophageal cancer resections.

As early as 1980, Charles Culver and Bernard Gert argued that patients should be informed of volume–outcome disparities where they exist. Yet nearly 30 years later, there is little evidence that this information is routinely disclosed during the informed consent process.

Viewpoint 1: Doctors Have an Ethical Duty to Inform Patients

Housri and Koniaris argue that physicians have a clear ethical obligation to disclose hospital outcome disparities to cancer patients. Their argument rests on the foundational principles of informed consent, which aims to protect the autonomous choice of the patient.

Informed consent is traditionally defined by two components: (1) disclosure of information about a procedure, leading to the patient's comprehension of that information; and (2) authorization by the patient to proceed with treatment. Disclosure typically includes the nature of the procedure, potential risks and benefits, and alternative treatments.

However, the authors identify a critical gap: while patients are given information to help them decide whether to be treated, they are given very little, if any, information to guide their decision on where to be treated. How often does the informed consent process include a discussion of the risks and benefits of treatment at a low-volume or nonteaching hospital—or the possibility of an alternative treatment at a high-volume or academic center?

Two Legal Standards for Disclosure

How much information must a doctor legally disclose? The article explains two prevailing standards used by courts and ethicists:

• The "professional practice" standard: Adequate disclosure is determined by what the professional community customarily practices. At the conclusion of the 2000 IOM workshop, the National Cancer Policy Board determined that the volume–outcome relationship was strongest and most consistent for pancreatic and esophageal resections. Because AHRQ and the Leapfrog Group already recognize this relationship, the authors argue that the professional practice standard would, at the very least, support disclosure of volume–outcome differences for these procedures.
• The "reasonable person" standard: The relevance of information is based on what a reasonable person would consider significant in making a decision, regardless of professional customs.

Under the reasonable person standard, the authors pose powerful questions: What value would a reasonable woman with metastatic breast cancer (cancer that has spread) place on knowing that treatment at a teaching hospital is associated with a significantly higher chance of five- and ten-year survival? Would a man with rectal cancer want to know that a local low-volume hospital may give him a significantly higher risk of needing a postoperative colostomy (a surgical opening in the abdomen to eliminate waste) or even death—and might he seek care elsewhere if he knew?

What Patients Actually Say About Traveling for Care

Research by Finlayson and colleagues on patient preferences for location of care reveals complex attitudes. The study found that nearly half of surveyed patients said they would rather travel four hours to a distant center for a Whipple procedure (a complex operation to remove pancreatic tumors) than be treated at a local hospital—provided that care at the distant center was associated with half the risk of operative mortality.

However, the same study found striking limits to this preference:

• 45 out of 100 patients would not travel to a distant center even if their local hospital carried double the risk of operative mortality.
• Almost one quarter of patients would rather face a six-times higher risk of operative mortality than travel for treatment.

These findings show that while many patients value outcome data in choosing where to have surgery, a substantial number prefer local treatment despite meaningful risk differences. The authors argue this is precisely why disclosure matters—patients cannot weigh risks they do not know about, and many will rationally choose local care once informed.

Legal Precedents That Shape the Debate

Housri and Koniaris note that in the United States, courts continue to differ in their definitions of adequate disclosure, with states split evenly between the professional practice and reasonable person standards. Yet failures to inform patients of alternatives that could have yielded better outcomes have led to successful legal action in recent years.

In the case of Johnson v. Kokemoor, a neurosurgeon was successfully prosecuted for failing to accurately disclose the risks of a basilar bifurcation aneurysm (a bulging blood vessel deep in the brain) surgery when performed by a surgeon with his level of experience. The Wisconsin Supreme Court ruled that information about other centers and physicians better able to perform the procedure would have facilitated the plaintiff's awareness of "all of the viable alternatives" and her ability to make an informed choice.

A similar conclusion was reached in the Australian case of Chappel v. Hart, where a treating physician was found liable for failing to disclose the availability of a more experienced surgeon for a particular procedure. The article also discusses the "loss of chance of a better outcome" concept in Australian law, which permits negligence claims without needing to prove causation. This concept has been rejected by British courts, but more claims based on loss of chance are expected in Australia.

Trust, Honesty, and the Fear of Losing Patients

The authors acknowledge that physicians may hesitate to disclose hospital outcome disparities for fear that cancer patients will migrate from low-volume and nonteaching hospitals to high-volume and teaching hospitals. But they argue that armed with knowledge, patients will not necessarily change hospitals—they may prefer to remain at a local hospital, or they may simply lack access to high-volume centers.

Ultimately, the authors write: "It is an ethical duty, and not fear of litigation, that should motivate physicians to provide full disclosure to their patients." Full disclosure of outcomes research—whether during the mandated informed consent process or the recommended shared decision-making part of care—is essential to maintaining trust and honesty in the physician–patient relationship. Most importantly, they argue, it protects the cancer patient's autonomy and sense of control, "a value of paramount importance for a patient battling a potentially lethal disease."

Viewpoint 2: Practical Hurdles and Unintended Consequences

Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, agrees that improving health care delivery and enhancing shared decision-making with patients is commendable. However, he argues that mandating disclosure of hospital outcome data faces significant logistic hurdles and risks "unanticipated consequences"—a concept borrowed from sociologist Robert Merton's seminal 1936 paper, The Unanticipated Consequences of Purposive Social Action, which outlined how well-intentioned actions can lead to unintended and sometimes harmful outcomes.

Practical Barriers to Disclosure

Weil raises several practical questions that complicate the proposal:

• Who should disclose the data? Does the burden fall upon the surgeon or the hospital?
• What exactly should be disclosed, and which hospitals should be compared? Should local teaching or high-volume hospitals be compared with local community hospitals, across states, populations, nations, or all three?
• How do we account for changes over time? Given advances in devices, medicine, surgical approaches, and technology, is it possible to compare outcomes from different hospitals or recent time periods—especially for disease courses that may extend over years?
• How do we compare patients of different risk levels? It remains unclear how to fairly compare surgical complication rates or successful outcomes in patients with variable surgical risk.

Perhaps most fundamentally, Weil notes that there are major hurdles in understanding, computing, and then conveying to the patient the difficult concept that statistics apply to populations, not to any single individual. A hospital's average outcome does not predict any one patient's result.

Unintended Consequences of Mandatory Disclosure

Weil warns that one possible unintended consequence of mandating outcomes disclosure is that hospitals or physicians might engage—overtly or subconsciously—in practices designed to boost their hospital's rating rather than improve genuine patient care. For example:

• Will community hospitals begin referring high-risk patients to teaching hospitals simply to keep their own outcomes data looking good?
• Will surgeons perform less radical or less morbid operations that may have little effect on cancer outcome but substantially improve complication rates?
• What happens if a hospital is found to have poor surgical outcomes, no specific cause is identified by careful audit, and the individual surgeon's personal outcomes are actually better than average—should that surgeon switch hospitals?

Weil also highlights a sobering finding from Finlayson's research: many patients do not fully grasp the strengths and limitations of outcomes measures. In fact, many patients wish—for a variety of reasons and sometimes against their physician's advice—to obtain care at a facility with worse-than-average outcomes.

Weaknesses in Outcomes Studies

Weil argues that outcomes studies remain incomplete for most cancers and frequently lag behind evolving standards of care. He cites research by Koniaris and colleagues on breast cancer treatment, which found that teaching hospitals were superior to community hospitals in terms of five-year mortality (p < 0.001, meaning there is less than a 0.1% chance this finding was due to random chance).

However, the actual disparity was only 3%–6% depending on the type of community hospital—a difference that may not be clinically meaningful, especially for a single patient making a personal decision.

Weil also identifies a potential selection bias in outcomes data. As Pfister and colleagues observed, teaching hospitals tend to enroll more patients in clinical trials. Enrollment in these trials requires extensive evaluation to exclude metastatic disease, which may use technology available only at specialized centers—for example, PET imaging (positron emission tomography, a specialized imaging test). In many cases, when patients do not qualify for a clinical trial because previously unsuspected advanced or metastatic disease is found, they return to their community hospital and may be reported from that hospital, at their original stage, to the cancer registry. This creates a bias in favor of teaching hospitals in registries with respect to "initial stage" and overall outcomes.

Weil concludes that the time may not yet be ripe to insist upon incorporating outcomes data into the informed consent process. Instead, efforts should focus on helping physicians improve patient care and outcomes through better processes, and on more incisive studies that identify the individual and organizational actions that lead to positive outcomes—interventions that can be applied universally.

Viewpoint 3: More Work Needed Before Outcomes Data Are Routinely Used

David Shalowitz, from the University of Michigan's Bioethics Program, takes a more cautious middle-ground position. He acknowledges the importance of outcomes data but argues that considerably more work is needed before it becomes a routine part of clinical decision-making.

Shalowitz points to a crucial insight from the National Cancer Policy Board: "Volume per se does not result in good outcomes in health care but is instead a proxy measure for other factors"—potentially including physician skill, experienced interdisciplinary teams, or well-organized care processes.

This distinction matters for patients. If volume is merely a stand-in for other qualities, then patients choosing a cancer treatment site would benefit more from actual outcomes data from potential treating institutions than from raw volume figures. And the causes of differences in outcomes—whether case volume, teaching status, or other factors—are far less likely to matter to a patient than the concrete outcomes themselves.

Three Strategies for Communicating Outcomes Data

Shalowitz outlines at least three possible strategies for communicating outcomes data to patients:

1. Ensure public access to hospital data. This approach would make hospital outcomes data on different medical and surgical procedures publicly available, allowing the informed patient-consumer to select the best site for treatment.
2. Have physicians communicate outcomes data directly. When a patient has an established relationship with a primary care physician or specialist, outcomes data could be included in the process of determining what treatment course, if any, will be selected and where treatment will take place. The shared decision-making interaction would likely best allow physicians to elicit patients' preferences—such as whether they value the best outcomes or proximity to home. However, this strategy requires physicians to obtain and interpret up-to-date outcomes data, which may be difficult and time-consuming.
3. A third strategy is also mentioned,

   Frequently Asked Questions

   Should my doctor tell me if my local hospital has worse outcomes than a larger center for cancer surgery?

   Some medical experts argue doctors have an ethical duty to disclose such hospital outcome differences during informed consent. Others say the data are not yet reliable enough, and mandatory disclosure could cause unintended problems. Currently, this information is rarely discussed routinely, but the debate centers on your right to know where outcomes may be better.

   Why does hospital surgery volume matter for cancer treatment?

   Research over nearly 50 years links higher hospital procedure volume with better outcomes, especially for complex surgeries. The strongest evidence is for pancreatic and esophageal cancer resections, where patients at high-volume hospitals tend to have lower death rates. However, volume is only a proxy for factors like skill and team experience, not a guarantee for any individual.

   What are the legal standards for what a doctor must disclose?

   Two standards are used. The professional practice standard bases disclosure on what doctors customarily do. The reasonable person standard asks what a typical person would want to know in making a decision. Courts differ by state, but failure to inform about better alternatives has led to successful lawsuits, such as Johnson v. Kokemoor.

   Would patients actually travel to another hospital for better outcomes?

   In a study by Finlayson, nearly half of patients would travel four hours if operative mortality risk was halved. Yet 45 out of 100 would not travel even if their local hospital had double the risk, and almost a quarter accepted six times higher risk. Many value local care, highlighting why disclosure matters.

   Who should be responsible for telling patients if a hospital has poor outcomes?

   The article presents no clear answer. One viewpoint suggests physicians should disclose during informed consent. Another raises practical questions about whether surgeons or hospitals should share the burden, what to compare, and how to handle changes over time and differences in patient risk. No consensus exists.

   Can a hospital's average outcome predict what will happen to me personally?

   No. Statistics apply to populations, not single individuals. A hospital's average outcome does not predict any one patient's result. This is one major hurdle to mandatory disclosure, along with difficulties in fairly comparing patients with different risk levels and comparing outcomes across time and institutions.

   Should I get a second opinion about which hospital is safest for my cancer surgery?

   If you are facing pancreatic or esophageal cancer surgery, a second opinion can help you weigh the choices. Research over decades shows that hospitals performing higher volumes of these complex operations tend to have lower death rates. Doctors do not always discuss these differences during informed consent. A second opinion focused on where to have surgery—not just whether to have it—can clarify the risks and benefits of staying at a local hospital versus traveling to a high-volume center. It can also support your autonomy in making this deeply personal decision. Diagnostic Detectives Network provides independent expert second opinions.

Frequently Asked Questions

When should a patient facing pancreatic or esophageal cancer surgery get a second opinion about which hospital to use?

A second opinion focused on where to have surgery is worth considering when you are facing pancreatic or esophageal cancer resection. Higher hospital procedure volume is linked to lower death rates for these two operations, and this is the strongest and most consistent volume-outcome evidence. Informed consent discussions rarely cover whether another hospital might offer better odds. Nearly half of surveyed patients would travel four hours for half the operative mortality risk, yet 45 of 100 would not travel even if local risk doubled. Diagnostic Detectives Network provides independent expert second opinions.