Dear Mr. Aragón and Dr. Vargas:

My father was treated by Mr. Alvaro Montealegre Mata regarding urinary frequency and an initial increment of his PSA. Mr. Montealegre stipulated that, if prostate cancer were to be detected any time in the future, that my father’s quality of life would not be affected adversely and that my father would not die of prostate cancer; he would die of anything else but not prostate cancer. Mr. Montealegre refused to authorize an early biopsy to determine the possible presence of cancer. Mr. Montealegre rejected the possibility of using curative procedures which, according to other physicians, my father would have been able to tolerate without any problems. Mr. Montealegre also refused PSA monitoring to measure aggression/progression in light that a possible cancer could be detected later. Mr. Montealegre finally authorized a biopsy in conjunction with a non-curative TURP procedure he performed almost one year after he first saw my father and my father died of an ultra-aggressive prostate cancer 15 months after the time when Mr. Montealegre finally authorized such a biopsy. Mr. Montealegre’s behavior was plagued with episodes of medical negligence, ethical violations, incompetence, and the distortion, obscuring and manipulation of the facts, as well as condescension towards the patient, all of which helped ratify the worst possible decision, one that would take my father to premature death leaving the family without the option of a curative procedure which could have extended his life, judging by his ancestors, who knows, perhaps many more years. In addition, the absolutist medical decrees that Mr. Alvaro Montealegre Mata applied in my father’s case, are in clear and radical contradiction with the urology practices and standards of places like the Mayo Clinic in Rochester, Minnesota and others, as I show in this document.

With the exception of this situation with Mr. Montealegre, the family has received the wonderful benefit of excellent relationships with other physicians in Costa Rica, who have performed surgeries for the family at Clínica Católica and CIMA Hospital, both in San José. We have great admiration and gratitude for them as human beings and physicians, because of their unsurpassed caring and responsibility to defend the patient’s best interests and quality of life. In my father’s words, they were "simply fantastic" and we know my father appreciated them very much.

This document consists of the sections listed below, where Mr. Montealegre’s behavior and actions are explained in detail:

• Error Number 1. Manipulation, Deceit and Hiding of the Truth
• Error Number 2. Manipulation and Blocking Against Curative Treatments
• Error Number 3. Blocking of Early Detection and Quality of Life Improvement Procedures
• Error Number 4. Distortion of my Father’s Physical Condition to Avoid the Questioning of His Diagnostic
• Error Number 5. Systematic Disrespect for Persons of Age
• Error Number 6. Appropriation of the Family Right to Make Decisions
• Error Number 7. Relegation of the Patient’s Well Being to a Secondary Priority
• Error Number 8. Disdain for the Inquisitive Intelligence of the Patient
• Additional Observations
• Complaint to the Clínica Bíblica
• Complaint to the Colegio de Médicos y Cirujanos de Costa Rica

Mr. Alvaro Montealegre Mata used as the fundamental basis for his professional obstination, a fictitious medical position, unrealistic and simplified, stating that our father, for being older than 80 years old, if he were to be diagnosed with prostate cancer, his quality of life would not be affected and he would not die of prostate cancer. Obviously, an asseveration of this magnitude eliminates the need for any kind of risk analysis and courses of action, it eliminates any sense of emergency and immediacy, it changes everything. Mr. Montealegre used to say "your father will die of anything else but he will not die of prostate cancer". Mr. Montealegre used this statement to eliminate a number of actions, such as an early biopsy, PSA monitoring, hormonal treatment prior to a TURP surgery in order to potentially avoid TURP or avoid the PSA to scale up as a consequence of the TURP surgery (TURP, transurethral resection of the prostate is a surgery to reduce the internal size of the prostate without extracting it and thus reduce urinary frequency, obviously it is not a cure because it does not remove the prostate). The extremist militancy of his manipulation of the truth is evident from the following facts:

1. Why didn’t Mr. Alvaro Montealegre Mata make reference to the medical statistics which state that there is a percentage (estimated at 20%) of all prostate cancers that are very aggressive and hormone refractory from the onset ? You don’t have to have any knowledge of medical science to know or master these facts; these statistics are the result of simple historical numerical recollection, like the kind the mayans and other preceding civilizations with enough arithmetic to be able to count used to gather. If Mr. Montealegre would have had the professional decency of letting us know that some 20% of the prostate cancer cases are unstoppable and are the cause of short-term mortality, 5 minutes later we would have been out of his office proceeding to make an in-depth evaluation of surgery comorbidity risks during a radical extraction, or an evaluation for the use of radiation, etc. By hiding this statistical possibility in my father’s case, Mr. Montealegre deprived the patient of his right to consider alternatives as the patient sees fit in order to save his own life.
2. We cannot assume that providing such false an lethal suppositions to the patient is the result of negligence, and we could give Mr. Alvaro Montealegre Mata the benefit of the doubt and instead presume that Mr. Montealegre simply lacks such reading knowledge and experience. In order to review these premises, I spoke with Mr. Montealegre again, once it was clear that my father’s cancer had turned out to be indeed extremely aggressive and that in fact my father would die in a few weeks of prostate cancer and not of any other condition or illness. I called Mr. Montealegre to ask him if he had treated patients before of the same age as my father and with the same level of aggressive and terminal prostate cancer ? He replied conclusively and categorically, "but of course I have". That question was asked in order to evaluate his prior position that my father "would not die of prostate cancer". Then it becomes very clear that when Mr. Montealegre was providing his first very categorical answer (that my father would not die of prostate cancer), Mr. Montealegre was indeed very aware of these very aggressive types of cancer in men the same age as my father, he was withholding information, and leaving it abundantly clear that his behavior was the result of medical negligence and neglect for the life of his patient. Where was Mr. Montealegre when we asked him of the risks of not pursuing any form of curative procedure (e.g. radical extraction or radiation) for the potential cancer ? Why did Mr. Montealegre very conveniently hid the truth ? why that obsession, that compulsion to always establish maximum certitude from his intellectual pulpit ? Why does he conveniently hide these statistics at the expense of the patient’s well being ?

There are ways of destroying a prostate cancer when it is still localized inside the prostate. Tipically these treatments include radical prostate extraction or radiation. In my father’s case, Mr. Alvaro Montealegre Mata was completely against these treatments, which, according to his logic, his ruling was completely justified due to the premise that my father would never die of prostate cancer and thus the priority became to preserve his "quality of life’" avoiding the discomfort of unnecessary procedures. There are several problems with Mr. Montealegre’s postulates:

1. That no curative procedure is necessary because according to Mr. Alvaro Montealegre Mata, "don Marcial is not going to die of prostate cancer, he is going to die of anything else, but not prostate cancer". To have lifted such premise would have forced the opening to the possibility of a radical prostatectomy or radiation therapy.
2. That "radical extraction is a crazy thought and that under no circumstance or under no point of view should be considered". It is very difficult to argue against such an absolutist logic as that of Mr. Alvaro Montealegre Mata’s, which carries that much more weight because it comes from an urologist approved, affiliated and who routinely performs surgeries at the Clinica Biblica in San Jose, Costa Rica, an urologist who works at Hospital Calderón Guardia in San José, Costa Rica, and has been a member for many years of the Colegio de Médicos y Cirujanos de Costa Rica. If this were an opinion presented under a more sober perspective, one that considers the risks and tradeoffs of all alternatives, the patient would then be clear that there is a decision that he needs to evaluate and assume responsibility for. How can a urologist that represents the prestige of the Clínica Bíblica and the Hospital Calderon Guardia make such an implausible, unreal, dangerous and irresponsible asseveration ? Mr. Montealegre’s militant language seems to suggest that this is a case of systematic, chronic negligence. The fact that Mr. Montealegre makes this asseveration in such a radical and absolutist fashion, strongly suggests to the patient that it is crazy and ridiculous to think that there would be another physician in the world that could think otherwise and thus discourages the patient from pursuing second opinions.
3. That my father would not tolerate a prostatectomy at his age, older than 80 years old. There is an informal statistic that, when there is not an individual medical evaluation of a patient, suggests the general preference that, men older than 75 years old should not get a prostatectomy. There are several problems with the use of such statistic as a replacement of the individual medical evaluation:

• It is well known that it is a very rough and informal conclusion because it does not come from a formal, well-designed statistical study in which independent comorbidity variables are properly separated. In other words, it is a conclusion that results from assigning to prostate surgery the bad results caused by comorbidity side-effects which are totally unrelated to the prostate, such as heart failure, liver disease, etc.

• As a statistic, it is obviously impersonal, and it is the physician’s obligation derived from his hipocratic oath, from the articles of the Medical Morality Code of the Colegio de Médicos y Cirujanos de Costa Rica and from the international standards of the Joint Commission International adhered to by the Clínica Bíblica, to correlate such statistic with the patient’s individual scenario, as it is with such patient that the physician has contracted his hipocratic obligation. What these statistics offer is the opportunity to correlate them to the individuality of each patient so as to avoid dangerous and unnecessary surgeries due to comorbidity side-effects, etc., and to properly profile older patients who need and can undergo a curative procedure in order to avoid an unnecessary premature death.

• There are other more serious, well known and reputable statistical studies which contradict these older statistics. A physician is incompetent if he has no knowledge of these newer studies, and negligent if he knows them and do not share this information with his patients. An urologist is not obligated to recommend or carry out a prostatectomy or radiation therapy. However, he does have the moral obligation to let the patient know that, contrary to his own views, there are these studies as well as reputable physicians in the region which could possible offer a recommendation in favor of a curative procedure. For example, it would be shameful if a urologist does not know of studies such as the ones published by Dr. Shabbir M. H. Alibhai of the University of Toronto, as Dr. Alibhai has dedicated many years and published many articles on the subject. We are referring to reputable studies on the subject area which will directly affect the patient’s mortality, we are not talking of aromatherapy procedures from Tibet. The following quote is from one of Dr. Alibhai, et.al.’s articles from the year 2003, which directly contradicts the absolutist conclusions of Mr. Alvaro Montealegre Mata: "Conclusion: Potentially curative therapy results in significantly improved LE (life expectancy) and QALE (quality-adjusted life expectancy) for older men with few comorbidities and moderately or poorly differentiated localized prostate cancer. Age should not be a barrier to treatment in this group." Mr. Montealegre intends to shower with credibility his absolutist decrees, washing his hands with his slogan "it is not me who says that, it is science". That swells ! to appropriate science’s pulpit, sober, reasoned, reflective and evolutionary, and from that place emit his inflexible, intransigent and militant diagnostics by decree !. Wouldn’t then the reader conclude that Mr. Montealegre’s slogan is a hypocrisy, because science contradicts Mr. Montealegre and Mr. Montealegre does not really speak for science?.

• The Mayo Clinic in Rochester, Minnesota, offers as part of their urology services and policies, the radical extraction of the prostate for men aged in their eighties, provided they are healthy enough to sustain the surgery. This practice invites to conclude the following: 1) that obviously, this surgery is performed when there is an assumption that the cancer is localized within the prostate, 2) this implies that there is a prediction that in these cases the cancer is going to be sufficiently aggressive, despite the patient’s advanced age, so as to be the cause of the patient’s eventual death, 3) that it is estimated that life expectancy for this patient is probably in the mid nineties, and 4) that these decisions can only be made when each patient is evaluated individually, as a unique and different case, setting aside any statistics that only blur the quest for a clear evaluation of the patient, and the Mayo Clinic urologists state openly that they throw away these statistics in order for them to make their recommendations, and that to them, each patient is unique and deserving of an individual evaluation appropriate for their own unique circumstance. This Mayo Clinic postulates contradict, conceptually and massively, and under every point of view, including medical and ethical, Mr. Alvaro Montealegre Mata’s absolutist decrees. These Mayo Clinic practices are the same practices that Mr. Montealegre considers to be insane and a medical irresponsibility. These are the same practices which are seen by Mr. Montealegre as an insult to the medical profession when they are proposed by the patient.
• My father’s personal doctors have stated a posteriori that they are of the opinion that my father would have tolerated a radical extraction of the prostate without a problem.

• The interventional hemodynamist cardiologist who was consulted by Mr. Alvaro Montealegre Mata with respect to the non-curative TURP surgery but not for a radical prostate extraction or anything else, has no doubt that my father would have tolerated the extraction without a problem. Even 3 months before his death, my father was still running and walking 5 kilometers a day, and before then playing tennis until his friends, 30 years younger, would tire under the Managua 34C heat. It is impressive to see the respect that these friends had for my father’s physical condition, because it was they who had to deal with him under the sun at the tennis courts. My father had an enviable physical condition that I have not seen in another person his age. Our cardiologist does not make this asseveration based on my father’s physical stamina, or on a circumstantial stress test, but based on a coronary and carotid angiogram where he had the opportunity to actually see, visualize the state of his vascular system. Our cardiologist made the following comment, "I have been performing this procedure (catheterism) about 10 times a week for about 7 years and I don’t recall seeing a vascular system as good as your father’s. Your father’s coronaries are as clean as those of a 25 year old man, and I hope that you have inherited his genes." It is this clear and precise information that allows our cardiologist to state this opinion. This catheterism procedure was performed to place a stent in a narrowing of the carotid, and the study demonstrated that such narrowing was an isolated case, which allowed our cardiologist to make the statements above.
• My father’s primary doctor is the director of intensive care at a local hospital. He was with my father during my father’s acute pancreatitis caused by gallbladder calculi in 2004. This pancreatitis took my father to the intensive care unit for a week under multi-organic failure. One month later my father endured without a problem a surgery to drain a 15 cm pancreatic pseudo-cyst and extract the gallbladder. This 4 and a half hour surgery exhibited maximum complications because of the cyst’s localization and extreme vascularization, and because the gallbladder was atrophied and its conduits incarnated in neighboring tissue. My father came out of this surgery without any problems despite the fact that he had not fully recovered from the pancreatitis and was barely able to walk before the surgery. Despite the fact that my father lost three fourths of his pancreas, he did not become diabetic and went back to normal life, playing tennis, running, repairing leaks in the roof and going up our mango tree.

If I tell Mr. Alvaro Montealegre Mata that I have 100 anonymous cases with prostate cancer which will not be reviewed individually and need to be treated, it may very well be that the solution would be to appeal to statistics to decide on the procedure to follow for each case. But my father went to Mr. Montealegre only with his own individual case and it is Mr. Montealegre’s hipocratic obligation to evaluate him individually and not become blinded by his obstinate insistence of considering him as good as dead by other natural made-up causes contrary to the evaluations of the specialists which were consulted by Mr. Montealegre himself. Under the "quality of life" slogan, Mr. Montealegre’s procedures seem to be more consistent with the "generous" administration of euthanasia to my father. Mr. Montealegre can use as reference any and all the statistics he wishes to use, but at the end of the day it is his obligation to specifically correlate each aspect of patient comorbidity with the statistics, in order to emit an educated evaluation which is sufficiently transparent so that the patient and his family can make their own decision.

• After my father’s first visit to Mr. Alvaro Montealegre Mata, there was a prolonged period of time (almost a year) before my father could go back to Costa Rica for the performance of the TURP surgery prescribed by Mr. Montealegre as the only procedure to follow. Because of this delay, the family proposed to Mr. Montealegre a number of options to follow and to alert us for more pressing solutions during such period of time as follows:

• A) Measure PSA periodically to monitor its trajectory. This was discarded by Mr. Montealegre considering it unnecessary due to the fact that an eventual prostate cancer would not affect my father’s quality of life nor would it be the cause of his death. It should be noted that despite the PSA variability and volatility for different patients, as a surrogate marker the PSA is still part of prostate monitoring in the US and it is used in most if not all clinical studies for new treatments (e.g. Sipuleucel-T) as a factor in the determination of progress and prostate cancer aggression. The family has knowledge of recent cases at the Mayo Clinic in the US, where the decision to perform a radical prostatectomy was based exclusively on the movement of the PSA.
• B) To perform a prostate biopsy to determine if there was cancer or not. Mr. Montealegre’s answer was the same: Mr. Montealegre expressed that performing a biopsy represented an unnecessary discomfort for my father and that even if there were already a cancer in the prostate, it would not be a factor in his quality of life nor the cause of his death so he considered this unnecessary. It should be noted that there is the opinion of prestigious urologists in Costa Rica with whom we spoke after the fact, who recommend biopsy as soon as the PSA begins to rise in a 9 month period regardless of how low, for patients of any age and regardless of age, in order to make an early determination of a possible cancer.
• C) In light of Mr. Montealegre’s negative to proceed with a biopsy, the family suggested then to prescribe my father hormonal therapy so that in case this were already a cancer situation, we could have initiated the steps to control it, but Mr. Montealegre denied our requests and deemed it unnecessary. Although it is true that there is no consensus in the medical community about the advantages of hormonal therapy during the localized stage vrs the metastatic stage of the cancer, there are urologists in Costa Rica which were consulted after the fact, who prefer to use hormonal therapy before a TURP in order to attempt to reduce prostate size and possibly avoid a TURP, given the additional fear that in some cases prostate cancer growth shoots up as a consequence of the TURP intervention, a cancer that perhaps otherwise might have been dormant before the TURP. This was my father’s case, that after the TURP, his PSA multiplied by a factor of 7 and continued to increase. It is my opinion that it is medical negligence not to warn a patient about these alternatives, especially when the patient is already suggesting them.

• Even after the biopsy was finally performed from tissue extracted during the TURP and it was concluded that my father had prostate cancer, a PSA reading of more than 30 normally suggests to physicians that there may be bone metastasis. The protection of the patient’s "quality of life" is Mr. Montealegre’s strong argument not to prescribe an early biopsy, not to consider a radical prostatectomy, not to prescribe radiation. In reality, "quality of life" is a constant slogan in support of Mr. Montealegre’s narrow selection of blind treatments for the patient. If we know that bone cancer is one of the most painful forms of cancer, then we would assume that 1) Mr. Montealegre would want to know of that condition at the earliest time, and 2) given that there are very effective medications in the protection of bone against cancerous lesions, such as Zometa, that Mr. Montealegre would be looking for the earliest opportunity to protect patients with Zometa. Even then, Mr. Montealegre never suggested a gamma scan or an X ray in order to detect such condition. It was until my father had come back to Nicaragua, that in a separate remote consultation with a costarican oncologist, he suggested that it was standard practice to make a bone revision for PSAs greater than 30. By then, a gamma exam could not be performed in Nicaragua and we had to travel again to Costa Rica in order to perform such an exam. We are clear that a gamma bone scan shows any bone lesion and therefore reading it requires an element of judgement, but at the same time there must be a proactive attitude and perhaps complement it with an X ray so as to determine if there is metastasis and begin treatment with Zometa. What is the reason why Mr. Montealegre did not bother to detect bone metastasis and waited for the patient to exhibit bone pain before possibly prescribing Zometa ?
• We conclude that Mr. Montealegre’s "quality of life" slogan, does not reflect a sense of conviction in the protection of the patient’s interests, but is instead an empty slogan which only serves to justify the obstination, militancy and careless over-simplification of the treatments recommended by Mr. Montealegre, at the expense of the patient’s health and well being.
• Mr. Alvaro Montealegre Mata evangelizes the patient with his own concept of "quality of life" which I see in our case as no more than a form of euthanasia for the patient who has been left for dead. The fact that my father could not at some point climb on the roof to repair leaks or drive through the hectic Managua streets, or run, play tennis and do pilates, buy his own groceries in the open markets, etc. would have constituted a severe and unacceptable decline for him in his quality of life which would have impacted his desire to live (as it really happened during the last couple of months of his life). Mr. Montealegre defines "quality of life" in his own sedentary terms as being able to sit on a rocking chair watching TV. Instead of defining "quality of life" for his patients as a way to seal and certify his decisions, Mr. Montealegre should concentrate instead on explaining the risks and levels of discomfort and pain associated with each possible alternative.

Mr. Alvaro Montealegre Mata always minimized my father’s life expectancy, contradicting physicians to whom he had requested an evaluation and making up a fictitious symptomatology, which allowed Mr. Montealegre to avoid a sober and realistic evaluation of his decision to disregard curative alternatives. Examples:

• As we mentioned earlier in detail, my father’s hemodynamist cardiologist stated very clearly that cardiovascularly, my father was in excellent condition, that "his coronaries were like those of a 25 year old man" and that it was very rare to find a vascular system of that quality in a person that age. However, when Mr. Alvaro Montealegre Mata would speak of my father’s life expectancy, he would always make reference to "your father’s coronary problem", as a predictor for early death and contrary to our clarifications. Once Mr. Montealegre was confronted more seriously so that he would respect the cardiologist’s opinion, then he answered that "at any rate Marcial has his cerebral microvascularity problem anyway". We all recognize the pervasive impact of aging in the human body, but how did Mr. Montealegre come up with such diagnostic ? There was no prior evidence or evaluation to justify the isolation of such a diagnostic. Mr. Montealegre continued to invent diagnostics and we see that for his obstinate mentality there may not be a cure. Why does Mr. Montealegre request evaluations from cardiologists who are personally approved by him, if Mr. Montealegre is going to make up his own cardiology diagnostics contrary to the cardiologist’s opinion ?
• On a certain occasion and once my father had started using Zoladex for testosterone suppression, we noticed a sudden and drastic change in my father’s physical endurance, as my father was experiencing fatigue and shortness of breath during exercise, which was totally contrary and the opposite of his normal physical condition. We explained the situation to our cardiologist, who stated that there was no cardiovascular reason whatsoever why my father would suddenly loose his physical conditioning. Then we asked Mr. Alvaro Montealegre Mata if Zoladex could be causing such shortness of breath, to which Mr. Montealegre replied that the reason was my father’s age. We were extremely surprised by his answer, we contradicted him and we asked him specifically if Zoladex could cause such shortness of breath, to which Mr. Montealegre insisted once again that this was a problem related to his age and the normal aging process, which we thought was ridiculous. It was not until we asked him one more time, point blank, whether Zoladex’s side-effects included fatigue and/or shortness of breath yes or no, that he was forced to admit that yes, Zoladex indeed causes those symptoms. How can it be possible that a physician, under the hipocratic oath, keeps his obstinate professional positions as a higher priority than the well being of his patient ? It is worrisome to see that by responding in this fashion, a physician fails to perceive that his own credibility before his patients is immediately destroyed and that from that moment the physician has revealed officially that his patient’s well being is not one of his highest priorities.

In order to perform a fair patient evaluation, a physician must recognize individual variations and characteristics. Of course this does not exclude cardiovascular conditions, given that is possibly one of the essential characteristics in the determination of surgical procedures.

There are men more than 80 years old that still run marathons like the New York and Boston marathons. It is possible that someone could view these individuals as suicidal psychopaths with a death wish. However, if they accomplish these goals time and time again we would have to conclude that they have contracted a failed suicidal path, or that instead they are fine athletes with excellent vascular and muscular conditioning, that they know their bodies very well and that for them, a marathon may be a routine exhibition of their physical condition. As a physician, it is the moral obligation of Mr. Alvaro Montealegre Mata, to understand these individual differences instead of criticize them with obstination.

Similarly, we knew very well my father’s excellent physical state because we would see him daily, day in and day out, running and walking 5 kilometers a day, in addition to lifting weights, and doing pilates. He would also climb up the roof to fix leaks, go up our mango tree for ripe mangoes, etc. His tennis friends, 30 years younger, knew my father’s physical condition and what it meant to be able to play with them for hours under a 34C heat and still ask them to continue to play even longer. We communicated his condition to Mr. Alvaro Montealegre Mata early on and in repeated occasions but Mr. Montealegre ignored it systematically.

During the time that Mr. Alvaro Montealegre Mata was treating my father, my family took my father to La Paz waterfalls in Costa Rica and there they ran into Mr. Montealegre. This is a sequence of 5 waterfalls that you can visit by walking down sets of stairways embedded in the bluffs by the side of the river bed. This was a route that normally would not pose an out of routine effort for my father. Later on, Mr. Montealegre strongly criticized the family, essentially scolding the family, for having allowed my father, an elderly person of more than 80 years old, to walk the entire route. He added that no person of similar age should be allowed to perform a physical effort of that kind. How can it be possible that someone with this type of medical prejudice and taboos be in charge of deciding life or death for his patients, specially when the great majority of his patients are elderly ? How trustable can a physician’s opinion be when he or she denies the reality of the physical condition of his / her patients ? how trustable will his judgement be to determine if the patient is capable of tolerating a curative procedure ? How can a patient trust the judgement of such a physician ?

We understand that the aging process is pervasive, comprehensive and inescapable, but given the evidence corroborating that my father’s vascular condition was enviable, we consider a devaluation of the patient’s life and professional negligence for Mr. Alvaro Montealegre Mata to assume that my father is ready to die and that his responsibility as a urologist is to facilitate the euthanasia for him.

Behind Mr. Alvaro Montealegre Mata’s euthanasic paradigm, there seems to be a disguised condescension towards the elderly, and a systematic discrimination by not awarding them the physical merits which they have already demonstrated to themselves routinely as well as their right to be respected and evaluated objectively and with intellectual sobriety.

If Mr. Alvaro Montealegre Mata were to present real statistics, with sobriety, as they are, as it is its moral obligation under his hipocratic oath, the articles of the Moral Code of the Colegio de Médicos y Cirujanos de Costa Rica, and the standards of the Joint Commission International, this would have allowed the family to take early action in the matter so as to measure and monitor cancer aggression and to evaluate the probabilistic risks of extraction, radiation, etc., according to the specific and individual characteristics of this case. All this is impossible under Mr. Montealegre’s presumed credibility, when he tells us that this potential cancer was never going to be a problem for my father, and by not authorizing PSA monitoring saying "I don’t want you to be performing exams that I have not authorized". A risky decision of life and death must be made by the family, with knowledge of cause, and not appropriated arbitrarily by the obstination of a physician that rejects the recognition of the basic statistics surrounding the case.

We are not asking Mr. Alvaro Montealegre Mata to be a good physician or one that accepts or executes our decision for course of action. The only one thing we ask of Mr. Montealegre is that he adheres to the ethical code in his relationship with the patient so that he does not hide nor distorts basic statistics which will allow the family to make the decisions that our inalienable right to our free will allows us to make as human beings and with respect to our most precious possessions which are our own lives. We are not asking Mr. Montealegre to be a good physician, but simply to exhibit a minimum of professional decency to inform the patient accurately and objectively and to follow the example, not only of other physicians that adhere to their hipocratic oath, but also of illiterate labor workers who routinely state timely warnings regarding their customer expectations.

In addition, each family has its own financial considerations, which Mr. Montealegre does not take the time to detail. It is of no use to leave a cancer in place, if the subsequent therapy to control it will be financially out of reach for the patient. A family that opts to leave a prostate cancer in place may need to be ready to spend up to $15,000 per year on medications and others, and that is certainly a factor in the decision making process.

Mr. Montealegre must remember that as a physician he is in a position of service to the patient and it is not the patient who is at the service of Mr. Montealegre’s intellectual posturing and statistical experimentation. Mr. Montealegre needs to decide to whom to serve, whether to the individuality of each patient, or to his compulsion to exercise with intellectual militancy his distorted version of reality to blindly impart it to his subjects.

Mr. Alvaro Montealegre Mata always refused the intelligent dialogue, the one which starts with precise questions that need to be explored and answered seriously, and he did so underestimating the question’s intention, by letting it seem instead, that the questions and doubts came from the imbecility of the patient’s family caused by their lack of understanding of sophisticated concepts such as "quality of life", or the inexorable consequences of aging. This was used by Mr. Montealegre as a license to distort the family’s concerns and thus avoid sober, precise and serious dialogue deserving of a potential cancer situation. That is, Mr. Montealegre seems to have the norm of underestimating the intelligence and emotional quality of the patient and his family, in order to escape his responsibility to inform and confront with sobriety, rationality and individuality the evaluation process.

Mr. Alvaro Montealegre Mata gave us the impression that he was upset every time the family made a reference to the fact that an elderly patient, my father in this case, had the vitality and the conditions to live a long life. It almost seems that for Mr. Montealegre, once a person reaches a certain age, they are assumed to be finished with life and he wants to see them just sitting in a rocking chair waiting for their ultimate and nearing fate, and he sees his professional roll as euthanasic though superficially because he does not even seem to defend with actions his "quality of life" banner in order to protect their descent to their graves.

Mr. Alvaro Montealegre Mata must be capable of explaining his decisions in simple and clear terms, which go in accordance with the equally simple questions and observations made by my father’s friends. For example, they say, "how can that be possible that Marcial has died ? If only three months ago he was full of life and with a vitality that we all envy. Why didn’t they extract the prostate if they did it for X and Y when they were already past eighty years old, and they never were even the shadow of Marcial’s vitality and physical condition. I mean, they look like 15 years older than Marcial. If they extracted the prostate for these guys and they are still going to the club and playing tennis, they could have extracted it for Marcial without a problem. Gosh ! how could Marcial not tolerate a surgery like that ! And who told you that in Marcial’s case, you could not extract his prostate ? and I thought that I was going to die 10 years before Marcial !". I would like for Mr. Montealegre to be present in those groups so that he can respond to those questions with equal clarity.

Because of the arrogant fashion in which Mr. Alvaro Montealegre Mata adheres to his prejudices and his decision making, and the easy way in which he becomes detached when his militant professional bets turn out to be false, we hope that institutions that hire or certify him understand above all, that it is their responsibility to look after the well being of patients to come.

should we then conclude, for the good of his patients to come, that Mr, Montealegre is a charlatan ?

I am not a urologist and I am not a physician, but it would not occur to me to accept a patient with movement in his PSA indicator and not present him with the following:

1. A map or tree of possibilities with known statistics so that any possible future outcome be contemplated within these possibilities and therefore had been explained, pondered and considered a priori and with knowledge of cause, and therefore does not produce a shocking surprise for the patient in the future. By contrast, Mr. Alvaro Montealegre Mata, launches the patient into a utopic vision of a fictitious outcome, but such that when things complicate and the result is exactly the opposite of the prediction, then Mr. Montealegre washes his hands, detaches from the situation without regrets nor apologies and tells the family, "oh no, don’t call me for that, because that is not my field of expertise, my specialty is urology, and you need to find an oncologist now, but you’d better make it like right now".
2. Give the patient a road map, a sense of direction regarding what other doctors in the region do, standard and not so standard practices and levels of success, specially for Costa Rica being such a small country and closed community. This gives a patient a perspective about the alternatives available to him, range of options, and the degrees of dissention among the members of the urology community. By contrast, Mr. Montealegre ridicules the other options to the extreme that, if we assign Mr. Montealegre a dab of credibility, such alternatives should never be considered by the patient, and to even explore them would be a waste of time counter productive with the advance of the mythological solution stipulated by Mr. Montealegre.

I understand that the Clínica Bíblica (http://www.clinicabiblica.com) wishes to enjoy a good reputation in and out of Costa Rica as an organization with high standards and under his auspice it intends to infuse confidence and a sense of consistent medical practice contrary to the uncertainty of medical malpractice. One of the primary obligations of a physician and a medical institution towards the patient is that of providing clear, concise, realistic and timely information to the patient with respect to risks and alternatives regarding his medical condition. These are obligations which have been clearly established by all international health institutions, specially in the United States, Canada and Europe, such that a departure from this obligation can trigger millionaire lawsuits against the institution. Therefore, it is really difficult to find physicians in the United States, for example, who omit clarifications of risks, side-effects and available alternatives to a patient, or who assign to themselves a decision that belongs to the patient. This practice is so obvious and fundamental, that it has become the abc and the starting point of the physician-patient dialogue. I imagine then, that this practice gains even more importance at the Clínica Bíblica, given the following:

• That this practice is enunciated in the Clínica Bíblica’s statues of patient’s rights.
• That the Clínica Bíblica offers its services to the international clientele, a clientele that demands that these basic practices of undistorted information transfer be uniformly and comprehensively abided by throughout the Clínica as it occurs in the clientele’s countries of origin. This clientele rests on the presumption that such a prestigious accreditation as that of the Joint Commission International JCI (http://www.jointcommissioninternational.org) protects them from dangerous practices as the ones described in this document. The JCI’s position with respect to the patient’s rights is clearly delineated on their website by one of their accredited organizations in Austria which states that the goal of the accreditation process is to bring the rights and safety of patients to the motivational center of all efforts.
• That the Clínica Bíblica advocates the creation of prestigious international relationships, such as the ones they have established with UCIMED, Tulane University and the Universidad de Argentina.

Therefore it follows that the Clínica Bíblica should be asked the following questions:

• How can the Clínica Bíblica rest in Mr. Alvaro Montealegre Mata’s judgement, an urologist in their medical body who asseverates to a patient that he will not die of prostate cancer and 15 months later this patient, otherwise in exceptional health, completely full of life and vitality, and with no comorbidity factors whatsoever, has already died of prostate cancer ?
• How can it be possible that the Clínica Bíblica after a long term relationship with Mr. Alvaro Montealegre Mata, one of the physicians in their medical body, has not advised Mr. Montealegre of the most fundamental standards regarding the provision of undistorted information to the patient, description to the patient of risks and alternatives, etc., which constitute the abc of the physician-patient relationship, specially in consideration to the fact that the Clínica represents itself as an international health destination ? International standards on this subject include articles IFR.8.1 and IFE.1.2 specified by the Joint Commission International.
• Given that the Clínica Bíblica is an organization that takes pride in the uniformity of its high standards throughout its entire medical body, and which should be so in a clinic with international projection as specified in the standard CAS.1 of the Joint Commission International, should we then assume that Mr. Alvaro Montealegre Mata’s behavior and methods represent the same behavior and methods we should expect from the rest of the urologists and physicians at the Clínica Bíblica ?
• Given that we don’t see anything particular about my father’s case that narrows Mr. Alvaro Montealegre Mata’s list of errors to only certain isolated cases, how can the Clínica Bíblica reassure us that these errors have not been occurring in the past in some 20% of Mr. Montealegre’s patients, under the premise that statistically, some 20% of prostate cancer cases are aggressive and/or hormone refractory ?
• Given that Mr. Alvaro Montealegre Mata states that he has seen cases of prostate cancer in men the same age as my father and with the same degree of aggression, in how many of those cases did Mr. Montealegre reassured his patients that they would not die of prostate cancer ?
• Given that these errors were produced according to what Mr. Alvaro Montealegre Mata simply considers to be his inexcrutable professional judgement, how can the Clínica Bíblica reassure his national and international clientele that these mistakes will not occur again in the future ?
• What corrective measures can the Clínica Bíblica announce to repair the confidence of its patients, affiliates and the Joint Commission International ? Is the Clínica Bíblica going to publish a statistic indicating how many of Mr. Alvaro Montealegre Mata’s patients have died of prostate cancer after they were persuaded of not taking any action in favor of curative procedures because they would not die of prostate cancer ?
• The Clínica Bíblica states in their website, that the Joint Commission International "helps hospitals… demonstrate accountability…". In which way is their relationship with the Joint Commission International going to help the Clinic demonstrate accountability and initiative in this case ?
• In the same way that the Clínica Bíblica benefits from the credibility of the Joint Commission International’s accreditation, the Joint Commission International depends on the successful and consistent representation of their quality and ethical principles by the accredited organizations. An accreditation awarded to a hospital that does not represent such principles, affects the credibility of the JCI and that of the other accredited hospitals.

• Article 2. "The patient’s needs must occupy a prominent place in the professional behavior of the physician". As it has been shown in this document, Mr. Alvaro Montealegre Mata’s professional priorities which include his obstination to perpetuate his mythical version of the realities of prostate cancer in general and of my father’s physical condition in particular, clearly occupied a higher ranking in Mr. Montealegre’s value scale than my father’s well being, in clear violation of this article.
• Article 10. "The respect for human life constitutes the primordial obligation of the physician. Clearly for Mr. Alvaro Montealegre Mata, his compulsions towards his intellectual incursions force his behavior to create a false reality with respect to 1) cancer behavior, "which would not be the cause of death for my father", 2) my father’s comorbidity conditions (which in actuality were none), wrongly inferring contrary to other specialists, that my father had inescapable vascular diseases of the coronaries and at the level of cerebral microvascularity, and 3) my father’s athletic condition. This behavior clearly demonstrated to the family that Mr. Montealegre did not have any loyalty towards the exploration of the preservation of my father’s life.
• Article 21. "With the exceptions established by law, the physician shall be obligated to inform his or her patients about the present or eventual risk from any medication, medical or surgical procedure…". Mr. Alvaro Montealegre Mata’s violations of this article are massive, abundant and varied in nature. Mr. Montealegre never informed the family of the risk that my father’s prostate cancer, if one were to be found, could kill my father prematurely, and therefore, when he did not suggest nor authorize early PSA monitoring, early biopsy, early detection of bone metastasis, he did not inform the family of the risks of not performing these early discovery procedures, risks which includes premature death. He did not inform the family of the risks of possible cancer acceleration after a TURP, and the risk of premature death when choosing TURP instead of a curative procedure. The information distortion presented by Mr. Montealegre could not be in more direct and massive violation of this article.

Sincerely,