Ernesto L. Villavert, M.D.,F.P.O.A.

Objectives
 To introduce the moral importance of autonomy to good surgical
practice
 To evaluate the moral and legal boundaries of the doctrine of informed
consent
 To explain and lllustrate some practical difficulties in implementing
the doctrine of informed consent.
 To outline good surgical practice in withholding and withdrawing life-
saving treatment
 To specify the importance of boundaries of confidentiality in good
surgical practice
 To indicate why surgical research should be subject to independent
evaluation and how to differentiate between such research and minor
surgical innovation
 To assess moral importance of rigorous training and a willingness to
criticize fellow surgeons in the face of bad practice
Principles of code of medical ethics
 First principle calls for physicians to practice
competently and with respect for patient’s dignity and
rights.
 Second principle calls for professionalism and
unwillingness to tolerate unprofessional behaviour of
colleagues.
 The third calls for compliance with the laws of the land.
 Fourth principle safeguards patient confidentiality.
 Fifth principle calls for physicians to maintain their
own education and to make their own knowledge and
observations freely available for the benefit of other
physicians, patients and the public.
 Sixth principle specifies doctors are free to choose
their patients, their colleagues and the clinical
setting they feel most appropriate for their
practice. However,this right can be set aside in
times of emergency.
 Seventh principle states that physicians have a
responsibility to contribute to the health of their
community and improvement of public health.
 Eight principle declares that physicians, are, above
all, responsible to the patients under their care.
 The ninth principle calls for universal access to
medical care.
Geneva declaration out of respect
to patients and the community
 I will respect the autonomy and dignity of
my patient
 I will share my medical knowledge for the
benefit of the patient and the advancement
of healthcare
 I will attend to my own health, well-being,
and abilities in order to provide care of the
highest standard
Surgical ethics
 Both surgeons and attempted murderers use
knives to accomplish their goals; What is the
difference?
 Why patient’s are willing to take the risk
allowing surgeons to cut them at times at
potential lethal way whom they have not even
met yet.
 Surgeons of their respective specialties are competent
in the skills and knowledge of their respective
specialties –they underwent residency training and
passed their regulatory board examinations.
Central premise
 Surgical ethics has features distinctive from other
areas of medical ethics which warrant specific
attention.
 Three distinctive features of surgical ethics :
1. Informed consent
-Tell all the pros and cons during and after surgery
2. The nature of responsibility
-Must have the experience and have done enough surgical
procedures; and if not, to be honest enough to ask the help of
colleagues
3. Surgical innovation
-Will it benefit the surgeon or the patient?
Respect for autonomy
 Respect for human autonomy is respect for
human dignity
 The surgeon’s additional duty for patient’s care is
to respect the autonomy of their patients-their
ability to make choices of their treatment and to
evaluate potential outcomes in the light of their
future life plan.
 The patients have always the right of choice over
their treatment even with life-saving surgical
procedures even in their moments of
incompetence to refuse them.
Autonomy of patient
1. We are careful enough at best of about
whom we allow to touch us and see us
unclothed.
2. For all of these reasons, there is a wide
moral and legal consensus that patients
have the right to exercise choice over their
surgical care.
3. It then follows that they should be allowed to
refuse treatments that they do not want, even
when surgeons think that they are wrong.
- For example, patients can even refuse surgical
treatment which will save their lives, either at
present or in the future through formulation of
advance directives specifying the types of life-
saving treatments which they do not wish to
have if they become incompetent to refuse
them.
Informed consent
 Surgeons have as a legal as well as moral
obligation to obtain consent for treatment
based on the appropriate levels of
information failure to do so could result to
in one of two civil proceedings, assuming
the absence of legal intent :
1. First, in law, intentionally to touch a
person without their consent is a battery
2. Negligence is the second legal action that
may be brought up against the surgeon for
not obtaining appropriate consent for
treatment
3. Patients are expected to sign a consent
form of some kind. Surgeons should place
notes on patient’s records of significant
risks of procedure. Signed consent is not
necessarily a proof of valid consent.
Informed consent
 For agreement to count as consent to treatment,
patients need to be given appropriate and accurate
information about:
1. Their condition and reason why it warrants
surgery.
2. What type of surgery is proposed and how it
might correct their condition.
3. What the proposed surgery entails in practice.
4. The anticipated prognosis of the proposed
surgery.
5. The expected side-effects of the proposed
surgery.
6. The unexpected hazards of the proposed
surgery.
7. Any alternative and potentially successful
treatments for their condition other than the
proposed surgery, along with similar
information about these.
8. The consequences of no treatment at all.
For consent to be valid
1. Be competent to give it- to be able to understand,
remember, deliberate about and believe whatever
information is provided to them about treatment
choices.
2. Not be coerced into decisions which reflect the
preferences of others rather than themselves.
3. Be given sufficient information for these choices
to be based on an accurate understanding of
reasons for and against proceeding with specific
treatments .
Confidentiality
 Such respect for autonomy does not entail
only the right of competent patients to
consent to treatment.
 Their entitlement to exercise control over
their life and future corresponds to the duty
of surgeons to respect their privacy - not to
communicate information revealed in the
course of treatment to anyone else without
their consent.
 Generally speaking, such respect means that
surgeons must not discuss clinical matters with
relatives, friends, employers and others unless the
patient explicitly agrees. To do otherwise is
regarded by all of the regulatory bodies of
medicine and surgery as a grave offence, incurring
harsh penalties.
 Breaches of confidentiality are not only abuses of
human dignity, they again undermine the trust
between surgeon and patient on which successful
surgery and the professional reputations of
surgeons depend.
Confidentiality
 Respect for confidentiality is, however, not
absolute.
 Surgeons are allowed to communicate private
information to other professionals who are part
of the health-care team provided that the
information has a direct bearing on treatment.
 Here the argument is that patients have given
their implied consent to such by communication
when they explicitly consent to a treatment
plan.
 Certainly , patients cannot expect strict
adherence to the principle of confidentiality if it
poses a serious threat to the health and safety of
others. There will be some circumstances in
which confidentiality either must or may be
breached in the public interest.
 For example, it must be breached as a result of court
orders or in relation to the requirements of public
health legislation.
 It may be ignored in attempts to prevent serious
crime or to protect the safety of other known
individuals who are at risk of serious harm.
For matters of life and death
 The determination of best interests in these
circumstances will rely on one of three objective
criteria, over and above the subjective perception
by the surgeon that the quality of life of the patient
is poor. There is no obligation to provide or to
continue life-sustaining treatment :
 If doing so is futile-when clinical consensus dictates that
it will not achieve the goal of extending life. Thought of
in this way, judgments about futility should not be
linked to evaluations of a patient’s quality of life.
 If patients are imminently an d irreversibly close to
death-in such circumstances it would not be in the
patient’s best interest to prolong life slightly (e.g.
Through the application of the intensive care)when
again, there is no hope of any sustained success. Not
needlessly interfering with the process of a dignified
death can be just as caring as the provision of curative
therapy.
 If patients are so permanently and seriously brain
damaged that, lacking awareness of themselves or
others, they will never be able to engage in any form of
self-directed activity. The argument here is backed up by
morally and legally reasoning that further treatment
other than effective palliation cannot be in the best
interests of patients as it will provide them with no
benefit.
Maintaining standards of
excellence
 To optimise success in protecting life and health to
an acceptable standard, surgeons must only offer
specialized treatment in which they have been
properly trained. To do so will entail sustained
further education throughout the surgeon’s career
in the wake of a new surgical procedures. While
training, surgery would be practised only under
appropriate supervision by someone who has
appropriately levels of skills.
 Such skill can be demonstrated only through
appropriate clinical audit, to which all surgeons should
regularly submit their results. When these reveal
unacceptable levels of success, no further surgical
work of a kind should continue unless further training
is undergone under the supervision of someone
whose success rate is satisfactory. To do otherwise
would be to place the interest of the surgeon above
that of their patient, an imbalance which is never
morally or professionally appropriate.
Research
 As part of their duty to protect life and health to an
acceptable professional standard, surgeons have a
subsidiary responsibility to strive to improve
operative techniques through research, to assure
themselves and their patients that care proposed is
the best that is currently possible.
 Yet, there is moral tension between the duty to act
in the best interests of individual patients and the
duty to improve surgical standards through
exposing patients to unknown risks which any
form of research inevitably entails.
 For this reason surgeons now accept that their
research must be externally regulated to ensure
patients give their informed consent, that any
known risks to the patient are far outweighed by
the potential benefits, and other forms of
protection are in place( indemnity) in case they are
unexpectedly harmed.
 Research is subjected to regulatory bodies to see
what constitutes a minor innovation from a major
one or just as an incremental improvement on
personal practice and not come out as legitimate
research.
Conclusion
 The two general duties of surgical care are to
protect life and to respect autonomy, both to
an acceptable professional standard. The
specific duties of surgeons are shown to
follow from these :
 Acceptable practice concerning informed
consent
 Confidentiality
 Decisions not to provide, or to omit life-
sustaining care,
 Surgical research
 To exercise and maintain good
professional standards with fairness,
justice and without arbitrary prejudice to
the extent that the practice of each and
every individual surgeons is a reflection of
such sustained conduct that deserve the
civil respect which they often receive.
Professional
 Is a member of a profession or any person
who earns a living from a specified
professional activity.
 Also describes the standards of education
and training that prepares members of the
profession with particular knowledge and
skills necessary to perform their specific
roles within that profession.
 Most professionals are subject to strict codes
and conduct, enshrining rigorous ethical
and moral obligations. Example, code of
ethics among physicians as they make an
oath as licensed physicians.
 Professional standards of practice for a
particular field are typically agreed upon
and maintained through widely.
Professionalism
 There is no group or institution that tells or
determines whether a new technique
benefits a patient
 A professionalism of surgeon is necessary to
ensure that what is new is not automatically
assumed to improve
 With no oversight, surgeons must make
individual decisions about what to offer
patients.
Basics of professionalism
 “In return for professional autonomy,
self –regulation and a recognition of
their unique place in the society, the
public demands of physicians
accountability, ethical standards and an
altruistic manner 0f delivering care”
Overview
 Innovation and surgery
 Lure of innovation
 Assessing innovation and improvement in
patients
 The hip surgery in orthopedics (a concrete
example of professionalism)
Ethical issues in surgical
management
 Ethical behaviour of surgeons must be
encouraged and enhanced by thoughtful
self-awareness
 Informed consent must be improved by
clearly defining uncertainties of innovation
 Surgeons must carefully gather the data to
determine if patients truly benefit from
surgical innovation
Surgical progress
 A paradigm shift
 Surgical progress is not solely determined by
objective reductions in morbidity and
mortality
 If the only benefit is improved patient
satisfaction, this may be surgical progress
 A purely cosmetic benefit may improve
quality of life enough to constitute surgical
progress
Quality of life
 Importance of quality of life in
assessing surgical advancement
 Quality of life and patient’s reporting
Technology and innovation in
surgery
 Innovation may lead to development of new
technology
 New technology may be used by surgeons in
innovative ways
 Dissemination of innovation beyond the initial
center
 “Innovation “ sells :
 Great for marketing
 “new and improve”
 Marketing value of innovation in surgery
“Innovation” is assumed to be
good
 What patients want :
 The “greatest and the latest”
 Innovative surgeons
 What surgeons want:
 Wants the latest in technology
 The “greatest and the latest”
 However, it remains difficult to always know
when an innovation is an improvement.
“Surgical progress” and “Surgical
benefits
 Benefit is used to be defined by doctors on the
basis of increased longevity or decreased
morbidity and mortality
 Today “benefits” is considered to be defined
relative to the patient’s values
 The question of whether the patient will benefit
from an operation depends on the patient’s goals
and values
 For example, a procedure that shortens patient’s
life but improves the quality of life might be
seen by the patient as beneficial.
Traditional criteria of surgical
progress
 Defined by reductions in morbidity and
mortality
 Objectively determined
 Can be directly measured
Are these approaches surgical
progress?
 Little change in morbidity
 No change in mortality
 Only a cosmetic difference
 Is a cosmetic difference any less important
than other differences
Ethical issues in surgical innovation
 Risks of new procedure is unknown at the
outset
 1-2 % complications means that one would
have to study thousands of patients to
rigorously assess safety
 Can the true risks of the new technique be
readily known at the outset
 Ensuring patient’s safety :
 How do we address the lack of experience
in the new procedure of the surgeon
 The issue of learning curve
 Should it be discussed with the patients, if
so, how?
Can surgeons and patients
objectively assess benefits of new
procedures ?
 Surgeon has decided a new technique is
worth learning and has spent time learning
the new technique
 How can such a surgeon offer objectively
options to patients who already think that
“new” and “high tech” may be much better
Tension
 Should we be encouraging more new
innovation and technology to help
patients ? Or-
 Should we be more protective of
patients from unbridled enthusiasm of
surgical innovators?
Ethics and cost
 New technology is usually costly than the
old
 Innovation is too dependent on the new
technology
 Operative time and cost
 First impressions may not be true
Concerns
 Individual surgeons are faced with challenges of
what innovative technique is best for the patient.
 Quality of life of a patient can only be determined
by asking the patient because surgeons cannot
adequately determine the quality of life by just
looking at the patient.
 Quality of life in assessing surgical advancement is
important with patient’s reporting
Conclusions
 Not all new technology is good for the patient
 Improving quality of life must be balanced with
potential risks of new technology or procedure
 Surgeons must honestly discussed with their
patients advantages and disadvantages of the
procedure
 We must ensure that new technology and
treatment would benefit the patients and not just
the surgeons. This is the epitome of
professionalism