ETHICS IN SURGERY

Peter Johannes Manoppo

Bioethicist and General Surgeon

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science is gold mine, ethics is mine field
3rd DEGREE BIOETHICS STUDY, KU LEUVEN, BELGIUM

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science is gold mine, ethics is mine field
 BACK GROUND
 Ethics: multi-disciplinary, inter-disciplinary, trans-
disciplinary, critical & scholarly study on morals,
virtues, norms, and values, as the ground of how to
behave in a context.
 Ethics in surgery is the ethical ground for education,
training, care delivery, and research, in the context of
surgery.
 Ethics judges the law, but law does not judge ethics.
 Working in operating theater is working in ethical
theater, based on ethical concerns-dilemmas-tensions.
 Without ethics, there is no profession.
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science is gold mine, ethics is mine field
 OBJECTIVES
 Understanding appropriate ethical ground for
surgery.
 Creating ethical problem solver.
 Protecting care-receiver dignity and promoting
care-giver competency & responsibility.
 Providing ability for casuistry ethical deliberation
in surgical education and training.
 Promoting ethical clearance in surgical research &
avoiding unethical or questionable research
practices (wrong authorship, falsification,
fabrication, plagiarism).
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science is gold mine, ethics is mine field
 METHODOLOGY
 Ethical approach based deliberation: autonomy,
beneficence, non-maleficence, justice,
vulnerability, dignity, attentiveness, caring-for,
competency, responsibility.
 Questioning ethical problem: stake-holders, facts,
conflicts, norms (ethical, legal, institutional,
professional, social).
 Justification assessment: interference,
proportionality, necessity, suitability, rule of
double effect (RDE).
 Conclusion: acceptable, unethical, advice.
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science is gold mine, ethics is mine field
 FACTS AND FIGURES
 Primum non nocere (Hippocrates, 370 BC).
 Deontology (Immanuel Kant, 1804).
 Utilitarianism (Jeremy Bentham & JS Mill, 1832 ).
 Human experimentation (Nuremberg Code, 1947).
 Human subjects research (Belmont Report, 1976).
 Principlism (Beauchamp & Childress, 1983).
 Ethics of care (Joan Tronto, 1993).
 Declaration of Helsinki (WMA, 1964).
 CIOMS (WHO & UNESCO, 1949).
 15 ethical principles (UNESCO, 2005)
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science is gold mine, ethics is mine field
 TAKING INTO ACCOUNT
 Ethical problem: 2 obligatory options, equal
acceptable or unethical, best interest choice.
 Justice: equals to be treated equally, unequals to be
treated unequally.
 Surgical practice: experiential & individual case,
raising inevitable tensions with evidence based
medicine (community based clinical research).
 Virtues: moral & intellectual, integrity, compassion,
self-effacement, self-sacrifice, empathy, care.
 Surgeon: competent, humble, realistic, self-critical.
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science is gold mine, ethics is mine field
 ELABORATING
 The extent of ethical approaches for avoiding and
mitigation of unethical behavior and consequences.
 Casuistry: case based reasoning, ethical deliberation
incorporated with case bed side teaching.
 Surgeon life: competitive, science & art, second
opinion acceptable, when to quit, incompetent
surgery, business issues, up-to-date, withholding &
withdrawing in end-of-life care, paternalism, RDE.
 Ethical education & training: all behavioral sciences,
medicine, law, philosophy, anthropology, sociology,
from the beginning until completed.
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science is gold mine, ethics is mine field
 CASE 1

Respect for autonomy or privacy, informed

consent/reconsent/assent/dissent, confidentiality,
truth-telling, disclosure.
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science is gold mine, ethics is mine field
 CASE 2

Difficult surgery, severe illness, unexpected situation,

family witness, informed reconsent, consulting.
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science is gold mine, ethics is mine field
 CASE 3

Transplantation surgery, ethical approach on donor &

recipient,_______________________________________
altruistic, compensated, reverse condition.
science is gold mine, ethics is mine field
 CASE 4

Unexpected result, end-of-life care, withholding,

withdrawing, when to quit, surrogate informed consent.
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science is gold mine, ethics is mine field
 CASE 5

Hospital ethics committee, independent out-siders,

bioethicist, lawyer, GP, nurse, intensivist, pharmacist.
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science is gold mine, ethics is mine field
 CONCLUSION
 Ethics and surgery are indivisible.
 Ethics in surgery education is needed since early
medical student until completed.
 Surgical informed consent/reconsent, truth-telling,
decisional capacity, patient understanding,
voluntariness, surrogate decision, should be clear.
 Capacity building to figure-out & to fix the ethical
dilemmas should be sustainable.
 Focus on patient’s autonomy, best interest, quality
of life, length of life.
 Surgeon should behave ethically.
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science is gold mine, ethics is mine field
 REFERENCES
 Anji Woll et al. Ethics in Surgery. Current Problems in
Surgery 50, 2013, pp 99-134.
 G. M. Stirrat. Ethics and Evidence Based Surgery.
Journal of Medical Ethics 30, 2004, pp 160-165.
 James W. Jones et al. The Ethics of Surgical Practice:
Cases, Dilemmas, and Resolutions. Oxford University
Press, New York, 2008, p 354.
 Joan Tronto et al. An Ethic of Care. Ethics in Community
Based Elder Care, 2001, ch 5, pp 60-68.
 Tom L. Beauchamp et al. Principles of Biomedical
Ethics, 5th ed, Oxford University Press, 2001, pp 57-224.
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science is gold mine, ethics is mine field
 HIPPOCRATES

THANK YOU
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science is gold mine, ethics is mine field