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13 January 2019
By Prof Ali Al Dameh, Associate Professor, General Surgery and Thoracic and Laparoscopic Surgery - Consultant Surgeon, Emirates Speciality Hospital, Dubai Healthcare City (DHCC), Dubai
Why do surgical ethics matter? The short answer is that surgery is not just a purely technical discipline. Technical mastery is absolutely necessary, but it is not sufficient in and of itself to bring complete benefit or comfort to our patients. Surgical Ethics (SE) is part of the core of surgical professionalism and as such significantly impacts the everyday life of surgeons and the care they provide to their patients. As Charles Bosk noted in Forgive and Remember (The University of Chicago Press, 1979), “when the patient of an internist dies, the natural question his colleagues ask is “What happened?”, while when the patient of a surgeon dies his colleagues ask, “What did you do?”. By the nature of their craft and beliefs about it, the surgeon is more accountable than other physicians and they also have much more to account for.”
The central question to surgeons has changed. It is not just “What can we do for this patient?”, but today’s question is, “What should we do for this patient?” And this question is the challenge of SE.
The encounter between a patient and their surgeon is unique for several reasons. The surgeon inflicts pain upon a patient for the patient’s own good. An operative intervention is irreducibly personal, such that the decisions about and performance of operations are inseparable from the idiosyncrasies of the individual surgeon. Furthermore, there is a chasm of knowledge between the patient and surgeon that is difficult to cross. Hence, training in the discipline of surgery includes the inculcation of certain virtues and practices to safeguard against abuses of this relationship and to make sure that the best interests of the patient are prioritised. The stories in this issue are evidence that in contemporary practice this is not quite enough, as surgeons reflect on instances, they felt were ethically challenging. Common themes include the difficulty in communicating surgical uncertainty, patient-surgeon relationships, ethical issues in surgical training, and the impact of the technological imperative on caring for dying patients.
Ethical challenges in surgery include crafting an adequate informed consent process for patients who are often distressed and anxious about making decisions with serious health and personal consequences, working with family members serving as surrogate decision makers for patients who lack the capacity to take part in the informed consent process, and responding to requests from patients or family members for futile surgical intervention.
Additionally, the work of surgeons generally encompasses such things as: the provision of palliative surgical management for patients in the end-stages of terminal illnesses; protecting patients from incompetent surgeons and other healthcare professionals; recruiting one’s own patients for surgical clinical trials; obtaining informed consent for the involvement of trainees in surgical procedures; responsibly managing conflicts of interest and conflicts of commitment; engaging in serendipitous and planned innovation; running a practice on a sound business basis; dealing honestly with private and public payers; protecting the integrity of clinical judgment and practice from intrusions by managers of healthcare organisations and payers; and helping to shape healthcare policy that is evidence-based and responsive to the increasing costs of surgical care. The ethical issues that arise for surgeons are, therefore, many and varied.
Tools of Ethical Analysis
Surgical ethics uses the tools of ethical analysis and argument to provide practical guidance to surgeons. Ethical analysis requires one to become clear about clinically relevant and applicable concepts and use them with consistent meaning. Ethical argument requires one to use clearly formulated ideas to formulate reasons that together support a conclusion that should then guide clinical judgment, decision making, and behaviour. The discipline and clinical value of ethical reasoning in surgery, as in other clinical specialties, comes from following arguments where they take one. Submitting to the discipline of ethical reasoning gives one’s clinical ethical judgments intellectual and moral authority that they lack when they emanate from mere opinion, “gut” feeling, or the arbitrary exercise of power by those with institutional authority to wield power.
The history of medical ethics provides clinically relevant and applicable ideas and reveals how surgeons have made contributions to the repository of our concepts of clinical ethics. British surgeons, for example, pioneered consent processes as early as the 17th century, when they fashioned contracts without patients for operations. On the other hand, 19th century surgeons in the U.S. transformed this rudimentary notion of informed consent into the more clinically sophisticated version with which surgeons are now familiar. From a historical perspective, the commonly held view that common law invented informed consent in the early 20th century and imposed it on reluctant surgeons becomes suspect. Perhaps common law simply codified ethical best practices that had already been brought to considerable ethical and clinical sophistication by practising surgeons in clinical practice. Recent astonishing advances in medical technology have opened up new frontiers and created options for surgical treatment that have often led to vigorous debate about what constitutes right and wrong. What is achievable has to be limited by what is acceptable.
I believe that the primary challenge for each of us in the future is to become a complete surgeon. For a complete surgeon, technical expertise is necessary but not sufficient. The complete surgeon must be an excellent technician and even more importantly a great doctor that is, someone who can communicate well with patients and who is adept at engendering trust.
Increasingly, in the future, surgeons will have to withstand the temptation to become purely technicians because if we allow ourselves to be purely technicians, we will cease to be true physicians. We should never let that happen. We should never let anyone push us to be purely technicians. If anyone says, “We will work up all the patients, work up all the pre-ops, and see all post-ops. You can just operate all day, every day,” we should withstand the temptation to go along. In an environment in which Relative Value Units (RVUs) are becoming the measure of achievement and where the focus on finances seems ever present, we must withstand the temptation to become pure revenue-generating technicians.
Another essential challenge for surgeons will be to ensure that informed consent for surgery continues to be a meaningful exchange. Surgeons today face the challenge of overcoming the impediments to the surgeon–patient relationship and engendering the patient’s trust. Only by becoming adept at engendering the trust of our patients can we achieve success as surgeons. This is perhaps something on which we do not focus enough in our training programmes, but it will be increasingly critical to succeed in a career in surgery. We must make a concerted effort to train our medical students and residents to become good communicators and give them tools to engender trust.
Apart from the challenges to the surgeon–patient relationship, I think the central question in surgery has changed. The central question for surgeons in the past was, “What can we do for this patient?” This was the central question asked for centuries when the therapeutic options that surgeons could offer their patients were quite limited.
In contrast, as the options for what we can offer even critically ill patients has expanded, the question today, and increasingly in the future will be, “What should we do for this patient?” This is a very different question. This question of what “should” we do for a patient is really a question of surgical ethics. To answer what should be done, surgeons must take into account not only the surgical problem at hand, but also the patient’s goals and values. “What should be done?” always requires us to attend to the ethical dimension of care in order to provide an answer.