Ethics and Professionalism in Surgery

“The intimacy between patient and surgeon is short-lived, but closer than between a son and his own father.” Aleksandr Solzhenitsyn, Cancer Ward

The privilege of opening the body of another to manipulate, remove, repair, or implant is a profound endeavor for both the surgeon and patient. The medical team viscerally bears witness to parts of the body the patient never sees. The surgeon’s practice, a culmination of extensive technical training, skill, and technology, renders the patient better off for the experience of being pierced, cut, and violated. High expectations and responsibilities are imposed upon the surgeon due, in part, to the rich history and current elevation in social standing of medical practice. Physician and author Brian Goldman analogizes these expectations to baseball. While referring to a legendary hitter as one with a batting average of 0.400, he poses the question: “What do you think a batting average for a cardiac surgeon or a nurse practitioner or an orthopedic surgeon, an OBGYN, or a paramedic is supposed to be?” The purpose of his inquiry is to highlight the high expectations of perfection; of batting 1.000. Patients do not want to be the exception, the mistake, or the error.

These pressures are not new, in fact, accountability in medical practice has existed since the dawn of recorded history. The ∼4,200 year-old Persian Code of Hammurabi includes schedules of income-based payment and penalties for unsuccessful treatments. Documents from the Ottoman Empire in the sixteenth and seventeenth centuries indicate expectations for treatment, fees, and provision of postoperative care. ^, Threads that connect ancient wisdom and modern practice include trust, vulnerability, and responsibility. Values such as elevating the patient’s benefit above one’s own interest, fidelity to one’s profession, and commitment to training echo through time, from the Hippocratic Oath to codification into professional standards such as the American College of Surgeons’ Code of Professional Conduct. In the latter, more contemporary notions of disclosure and informed consent arise. Entering the surgical profession means that one becomes part of its history, participates in its value-laden decisions that profoundly impacts people’s lives, and contributes to its future innovation. Medicine is as much a moral endeavor as it is a technical one and, as such, we need to reflect upon ways to analyze ethical dilemmas during the course of practice.

Ethical Frameworks

The focus on ethical issues and moral ambiguity in healthcare is due to the increase in technology, our ability to keep bodies alive, and the need to have a reflective and systematic way for us to navigate these dilemmas. One of the most popular conceptions of clinical ethics is that practice should be guided by principles (i.e., autonomy, beneficence/nonmaleficence, and justice). These terms have become familiar to many clinicians and provide a foundational framework to consider when contemplating appropriate medical care. An example of honoring a patient’s autonomy is through the informed consent process by which the team bears the responsibility to provide sufficient information on treatment (or research) options so that the patient himself/herself can decide what is best for him/her based upon his/her values, preferences, and goals. Autonomy, or right to self-determination, is often recognized as a dominant principle in Western culture. However, we must appreciate that we live in an increasingly mobile and diverse global community. Sensitivity to cultural practices and traditions may require us to not necessarily place the individual at the center of concern. While striving for proficiency in cultural competence is a worthwhile endeavor, we cannot not forget to engage with the individual. Having direct conversations and inviting the patient to indicate how best they wish to be informed is a good way to ensure their autonomy is respected.

Beneficence and nonmaleficence are often contemplated together in the form of balancing the provision of benefit with mitigating risks/harms to the patient. The Hippocratic notion of primum non nocere is often invoked as a maxim to convey our commitment to the care and healing of the patient. Clinical risk:benefit analyses should be contextualized to the patient’s goals of care (e.g., the therapeutic options that may offer the “best” clinical outcomes may not be what the patient prefers based upon other considerations).

The final principle is justice, or fairness. We typically think of justice in terms of equitable access to care, even distribution of health benefits and outcomes across society, and nondiscriminatory treatment. At a patient level, an appeal to justice would have the individual practitioner not succumb to the judgments of social worth, to consciously or unconsciously impose stigma based upon race, gender, socioeconomic, mental health status, addiction, country of origin, etc. Taken together, the principles of autonomy, beneficence, nonmaleficence, and justice are the foundational elements by which we view ethical issues.

However, principlism is only one framework within which we can analyze ethical questions in medicine. There are a number of moral traditions one may employ to broaden and enrich reflection on an ethical dilemma. Changing one’s perspective can provide different insights into the resolution of a quandary whether it be from the character of each agent (virtue), the act or duty (deontology), or the results (consequentialism) (see Table 2.1 ). Each framework will have its utility and caveats, but deeper reflection may provide a more robust understanding of the issue at hand. Some have argued ethical inquiry should be “a synthesis of theory and experience, reason and emotion, and philosophy and rhetoric.” What we may strive for is “getting beyond an overreliance upon a single approach…to remind us that ethical problems do not simply have a logic—they have a history; they have narrative meaning; and they occur within a social and cultural context.”

Table 2.1

Examples of moral frameworks.

Moral Framework	Guiding Principles
Consequentialism	Results of Action
Utilitarian	Maximize the good with the least harm
Common good	Maximize the good of the whole; mindful of the vulnerable
Nonconsequentialism	Intentions of the Agents
Duty-based	Moral obligations are binding irrespective of consequences; the categorical imperative
Rights	The best action is the one that protects the rights of those affected by the action
Fairness	Social contract, equity
Agent-Centered	Overall Status of the Individual
Virtue	Good ethical decision-making is based upon good character
Feminist	Particularly focused on gender-related oppression and the perspectives of the vulnerable and marginalized; ethics of care

With respect to qualities of character, renowned physician bioethicist, Edmond Pellegrino, indicated that essential virtues of medical practice include fidelity to trust, suppression of self-interest, intellectual honesty, compassion, courage, and prudence. The recognition of qualities that are inherent to the practice of medicine underscores the privileged space by which the physician is allowed to enter and the responsibility bestowed upon them.

Another mechanism for ethical inquiry is casuistry or case-based analysis. In this method, one would attempt to derive principles from previously resolved cases and apply them to the issues or conflicts at hand. ^, Problems may arise when attempting to abstract grand notions from a single or handful of instances; however, an advantage of a casuistic approach is that it is steeped in clinical reality, which may offer concrete, pragmatic solutions to ethical dilemmas. Whichever moral framework resonates with the physician, it can be helpful to have a general approach to ethical dilemmas which encourages practical thinking and reflection.

A General Approach for Ethical Issue Resolution

1.
Recognizing a Need for Ethical Inquiry

We are constantly making judgments, often unconsciously, ranging from the mundane, for example, deciding what to eat for lunch, to the life-changing, for example, what treatment modality am I going to recommend to my patient? The foundation of our practice is built upon judgement through training, knowledge, and experience as well as our own agency, values, and principles. Most of the time we do not even think about the ethical milieu that underpins our actions; for example, the patient comes to you with a problem, you offer a solution, the patient agrees, and hopefully all goes well. However, there are times when real conflicts arise and it may be unclear as to the preferred course of action, where technical training or experience fails to provide a concrete solution to an issue. Examples include when to consider the transition from curative intervention to palliative, encountering a colleague whose ability/judgment appears compromised, or a patient, who by your estimation, is making decisions that seem irrational or imprudent. These are all situations in which uncertainty can impose significant moral distress.

It may seem an obvious point, but the initial step in analyzing an ethical dilemma is the recognition that there exists value conflict or moral ambiguity either in the patient’s care, within/between the care team(s), or in the organization/operation of the health care facility. The next step is to then take action in gathering the necessary information to resolve the issue.

2.
Collecting Significant Facts and Understanding the Perspectives of Relevant Stakeholders

One useful, and most commonly used, tool to collect relevant information to analyze an ethical dilemma is the four topics method, which captures information within the domains of medical indications, patient preferences, quality-of-life factors, and contextual features ( Table 2.2 ). Sometimes we may focus on the clinical disposition of the patient when there are other externalities that may be impacting the patient’s decision-making process. What we may identify as the clear medical recommendation may not be greeted with enthusiasm by the patient due to other circumstances. A conversation with the patient that delves into illuminating their values, preferences, motivations, etc. may reveal key insights that will aid in facilitating a solution to the dilemma. The four topics method includes prompts to consider within each domain that may evoke pertinent information. It is important to speak with all relevant parties involved in the dilemma, including other team members, other services, and significant family and loved ones, if appropriate. Reflecting upon a diversity of perspectives and opinions is a thorough approach to complex, value-laden issues.

3.
Identify the Ethical Issues/Values at Conflict

Table 2.2

The four topics commonly used to analyze ethical dilemmas in health care.

From Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine . 8th ed. New York: McGraw-Hill Education; 2015.

Topic	Ethical Principle(S)	Considerations
Medical Indications	Beneficence Nonmaleficence	What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal? What are the goals of treatment? In what circumstances are medical treatments not indicated? What are the probabilities of success of various treatment options? In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
Patient Preferences	Respect for Autonomy	Has the patient been informed of benefits and risks of diagnostic and treatment recommendations, understood this information, and given consent? Is the patient mentally capable and legally competent, and is there evidence of incapacity? If mentally capable, what preferences about treatment is the patient stating? If incapacitated, has the patient expressed prior preferences? Who is the appropriate surrogate to make decisions for the incapacitated patient? What standards should govern the surrogate’s decisions? Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
Quality of Life	Beneficence Nonmaleficence Respect for Autonomy	What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds? On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment? Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life? What ethical issues arise concerning improving or enhancing a patient’s quality of life? Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment? Are there plans to provide pain relief and provide comfort after a decision has been made to forgo life-sustaining treatment? Is medically assisted dying ethically or legally permitted? What is the legal and ethical status of suicide?
Contextual Features	Justice (Fairness)	Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients? Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions? What are the limits imposed on patient confidentiality by the legitimate interests of third parties? Are there financial factors that create conflicts of interest in clinical decisions? Are there problems of allocation of scarce health resources that might affect clinical decisions? Are there religious issues that might affect clinical decisions? What are the legal issues that might affect clinical decisions? Are there considerations of clinical research and education that might affect clinical decisions? Are there issues of public health and safety that affect clinical decisions? Does institutional affiliation create conflicts of interest that might influence clinical decisions?

After pertinent information has been gathered, the next step is to identify which principles or values may be in conflict. The four topics method mentioned above maps each category of information to the ethical principles. Itemizing conflicting principles or competing obligations/duties will help formulate a spectrum of ethically appropriate options. Those options can then be prioritized into those that are ethically obligatory, ethically permissible, and ethically prohibitive. For example, abandoning the patient would clearly be ethically prohibitive, and ensuring the patient’s voice is heard or not denying basic care and hygiene would be things that are ethically obligatory. Often, the challenge is selecting options that are ethically permissible as there may be disagreement as to which option(s) is(are) the “right” one(s) with which to move forward.

4.
Discuss Options and Develop a Plan

Emerging from the previous step with a selected set of options, stakeholders are reengaged when the plan to move forward is realized. Generally, it would be advisable for the team to be on the same page with regard to a treatment plan (if that is the issue) prior to sitting down with the patient and/or family. Having a unified presentation typically provides for a more productive meeting than if the team(s) are debating issues in front of the family.

5.
Implement Decisions and Reflect Upon Outcomes

The final step is to realize the plan of action. An important consideration here is to have the tolerance for uncertainty. “The best laid schemes of mice and men, go often askew…” Words from an old Scottish poem ring true here as even despite careful reflection, consideration, and planning, things may not proceed as envisioned. Taking the time to contemplate how events could have been better planned, thinking about alternative scenarios, or contingency planning may better prepare for future care needs of the patients and/or refine one’s thinking should a similar case present itself in the future. See Box 2.1 for a scenario that highlights this process.

Box 2.1

Ethics scenario—palliative surgery.

Ms. Smith is a 78-year-old woman with advanced breast cancer who presents with a fungating malodorous lesion. The cancer is treatment-refractory and her current goals of care, in coordination with the palliative care team, include a focus on quality of life and comfort. She was referred to surgery for lesion resection. She is currently not receiving therapeutic interventions and has an Out-of-Hospital Do Not Resuscitate (DNR) order. Ms. Smith informs the team that someone told her the DNR order must be rescinded or she cannot have the procedure. Ms. Smith is unsure if she is willing to agree.

Case Analysis:

1.
Recognition

The decision to offer Ms. Smith a surgical intervention may be complicated by reluctance to perform the procedure if she is imposing unreasonable restraints on its proper outcomes.

2.
Facts

Using the four topics method, we would consider whether or not the intervention is appropriate from a medical perspective. Clearly, Ms. Smith’s preference is to undergo the procedure to improve the quality of her life. Perhaps she wishes to comfortably interact with her family during her remaining time or maybe she is embarrassed by the smell and feels family will not attend to her. Contextual features could include liability exposure if the team agrees to not resuscitate her and she dies during the procedure. Important perspectives to understand are those of Ms. Smith, the palliative team, the surgical team, and her family (if she consents).

3.
Issue Conflict

There is an obvious risk:benefit (nonmaleficence:beneficence) conflict in that the procedure may not be safe to perform or the team may feel unduly constrained by Ms. Smith’s DNR order. Ms. Smith’s autonomy interest is at stake in that she is willing to accept potential risks for the prospect of reducing her illness burden and, hopefully, enjoy a better quality of life. A team’s denial of this intervention is denying her that prospect.

4.
Discuss/Plan

The possible options include: do not offer surgery unless Ms. Smith agrees to full resuscitation; offer surgery with the explicit agreement and Ms. Smith’s consent that no attempts at resuscitation will be made during the procedure; reach an agreement with Ms. Smith that limited attempts at resuscitation can be made, if appropriate. The first option seeks to maximize outcomes by offering the most flexibility to the team but may impose interventions that are contrary to Ms. Smith’s goals of care. What if she would not want prolonged intubation because that would negate her desire to spend what time she has interacting with family? Then again, not having the procedure may also compromise her goals. The second option may best honor her preferences, but the team may be unwilling to agree to such a plan, particularly if a transient, relatively easily correctable condition manifests. A risk of requiring resuscitation is always present under anesthesia, and it may be reasonable for the team to not offer the intervention rather than allowing a patient to die on the table, even if the patient agreed to such risk. The third option offers a compromise in having a more nuanced conversation with Ms. Smith. Instead of an all-or-nothing approach, the team may offer limited interventions during the perioperative period that are defined by her goals and expectations. ∗

∗ Sumrall WD, Mahanna E, Sabharwal V, et al. Do not resuscitate, anesthesia, and perioperative care: a not so clear order. Ochsner J . 2016;16:176–179.

After discussions with all relevant stakeholders, it was decided that Ms. Smith would rescind her DNR order allowing limited interventions during the time of the procedure and recovery. The order would then be reinstated.

5.
Act/Reflect

How did the case turn out? What could have been done differently, if anything?

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