The Importance of Ethics in Surgery

Although the ethical precepts of respect for persons, beneficence, nonmaleficence, and justice have been fundamental to the practice of medicine since ancient times, ethics has assumed an increasingly visible and codified position in health care over the past 50 years. The Joint Commission, the courts, presidential commissions, medical school and residency curriculum planners, professional organizations, the media, and the public have all grappled with determining the right course of action in health care matters. The explosion of medical technology and knowledge, changes in the organizational arrangement and financing of the health care system, and challenges to traditional precepts posed by the corporatization of medicine have all created new ethical questions.

The practice of medicine or surgery is, at its center, a moral enterprise. Although clinical proficiency and surgical skill are crucial, so are the moral dimensions of a surgeon’s practice. According to sociologist Charles Bosk, the surgeon’s actions and patient outcome are more closely linked in surgery than in medicine, and that linkage dramatically changes the relationship between surgeon and patient.¹ Surgeon and humanist Miles Little has suggested that there is a distinct moral domain within the surgeon-patient relationship. According to Little, “testing and negotiating the reality of the category of rescue, negotiating the inherent proximity of the relationship, revealing the nature of the ordeal, offering and providing support through its course, and being there for the other in the aftermath of the surgical encounter, are ideals on which to build a distinctively surgical ethics.”² Because surgery is an extreme experience for the patient, surgeons have a unique opportunity to understand their patients’ stories and provide support for them. The virtue and duty of engaged presence as described by Little extends beyond a warm, friendly personality and can be taught by both precept and example. Although Little does not specifically identify trust as a component of presence, it seems inherent to the moral depth of the surgeon-patient relationship. During surgery the patient is in a totally vulnerable position and a high level of trust is demanded for the patient to place his or her life directly in the surgeon’s hands. Such trust, in turn, requires that the surgeon strive to act always in a trustworthy manner.

From the Hippocratic Oath to the 1847 American Medical Association statement of medical principles through the present, the traditional ethical precepts of the medical profession have included the primacy of patient welfare. The American College of Surgeons was founded in 1913 on the principles of high-quality care for the surgical patient and the ethical and competent practice of surgery. The preamble to its Statement on Principles states the following³:

The Code of Professional Conduct continues⁴:

These same expectations are echoed in the Accreditation Council for Graduate Medical Education core competencies that medical-surgical training programs are expected to achieve: compassion, integrity, respect, and responsiveness that supersedes self-interest, accountability, and responsiveness to a diverse patient population.⁵

Historically, the surgeon’s decisions were often unilateral ones. Surgeons made decisions about medical benefit with little if any acknowledgment that patient benefit might be a different matter. Current surgical practice recognizes the patient’s increasing involvement in health care decision making and grants that the right to choose is shared between surgeon and patient. A focus on informed consent, confidentiality, and advance directives acknowledges this changed relationship of the surgeon and patient. However, the moral dimensions of a surgeon’s practice extend beyond those issues to ask how the conscientious, competent, ethical surgeon should reveal damaging mistakes to a family when they have occurred, balance the role of patient advocate with that of being a gatekeeper, handle a colleague who is too old or too impaired to operate safely, or think about surgical innovation. Jones and colleagues,⁶ in a helpful casebook of surgical ethics, have noted that even a matter as mundane as the order of patients in a surgical schedule may conceal important ethical decisions.

End-of-Life Care

Care of patients at the end of life has garnered increasing attention in recent years. The decade of the 1990s was characterized by the expansion of efforts to educate physicians and inculcate palliative care practices into medical institutions. Surgeons who often are best known for their ability to be decisive—to do something—began to recognize their role in appropriate end-of-life care and to develop standards for palliative surgical care. In February 1998, The American College of Surgeons approved “The Statement of Principles of Care at the End of Life,” which includes a responsibility to provide appropriate palliative and hospice care and respect a patient’s right to refuse treatment and the physician’s responsibility to forgo futile interventions.⁷ A Surgeons Palliative Care Workgroup met in 2000 to foster awareness, education, and research in palliative care. In the first of a series of articles concerning palliative care by the surgeon in the Journal of the American College of Surgeons, Dunn and Milch⁸ have explained that palliative care provides the surgeon with a “new opportunity to rebalance decisiveness with introspection, detachment with empathy.” They also suggested that although surgeons might appreciate cognitively the need for palliative care, it also presents surgeons with difficult emotional challenges and ambiguities. In recognition of his leadership in the areas of hospice and palliative care, Robert A. Milch received the inaugural Hastings Center Cunniff-Dixon Physician Award in 2010 for leadership in care near the end of life. Dr. Milch said, in accepting the award, that “to the extent that we are able to play a part in that wonder, helping to heal even when we cannot cure, tending the wounds of body and spirit, we are ourselves elevated and transformed.”⁹