Ethic Challenges in Orthopedic

Ethical Challenges
in Orthopedic Surgery
 Physicians have been granted the privilege to interact with
individuals in ways that no other citizens can
 On any given day, doctors routinely invade people’s private
lives, ask them decidedly personal questions, touch them,
Our Privilege manipulate their extremities, expose them to radiation, inject

them with potential toxins, prescribe them harmful chemicals,
and even cut into their bodies.
 Ironically, when we are done, most people thank us for the
incursion.
Capozzi, James & Rhodes, Rosamond. (2015). Ethical challenges in orthopedic surgery. Current reviews in musculoskeletal medicine. 8. 10.1007/s12178-015-9274-y.
 We are obligated, as physicians, to use our knowledge of
science and medicine to act for the good of our patients.
Because of our  We have a fiduciary responsibility, from the Latin fiducia,
privilege meaning trust, to place our patients’ interests above all others,
including our own. It is our obligation as physicians to hold our
patients’ interests and well-being as paramount
 Code of professizonal conduct
 Nonmaleficience, “Primum non nocere”
 Beneficience
What do we  Autonomy
 Justice
mean by
“Ethics”?
Holt G, Wheelan K, Gregori A. The ethical implications of recent innovations in knee arthroplasty. J Bone Joint Surg Am. 2006 Jan;88(1):226-9. doi: 10.2106/JBJS.E.8801.eth. PMID: 16391269.
 Surgeons have an obligation not to inflict harm on patients, either
intentionally or carelessly.
 “Primum non nocere,” first do no harm, is one of the most
fundamental aspects of biomedical ethics.
 Harm in terms of bioethics refers to physical harm, including pain,
Nonmaleficence disability, and death. Unfortunately, all surgical interventions
inevitably cause some harm and carry some form of risk, and so
this principle is impossible to guarantee in any surgical procedure.
 It is important to point out that, for nonphysicians, nonmaleficence
is acceptable behavior but, as physicians, we must go beyond
nonmaleficence and act for the good of our patients.
 Beneficence refers to the principle of intervening to benefit the
well-being of an individual. As surgeons, this basic principle is
what we try to achieve in every procedure that we undertake.
 Beauchamp and Childress highlighted the differences between
the \principles of nonmaleficence and beneficence.
 The duty to “do no harm” invariably prohibits actions, while
Beneficence the duty to help generally prescribes intervention.

 The duty of nonmaleficence is more universal than the duty of
beneficence because “it is possible to act nonmaleficently
toward all persons, but it would be impossible to act
beneficently toward all persons.”
 Beneficence and nonmaleficence are inexorably linked to the
principle of autonomy.
 Beauchamp and Childress define personal autonomy as “personal
rule of the self, free from both controlling interferences by others and
from personal limitations that prevent meaningful choice.”
 Autonomy requires that an individual is independent from a
controlling influence and has the capacity for intentional action. The
Autonomy most common way in which a surgeon demonstrates respect for a
patient’s autonomy is by obtaining the patient’s valid consent for a
surgical intervention.
 The consent process demonstrates respect for a patient’s decision-
making capacity
 Beauchamp and Childress define personal autonomy as
“personal rule of the self, free from both controlling
interferences by others and from personal limitations that
prevent meaningful choice.”
 Autonomy requires that an individual is independent from a
controlling influence and has the capacity for intentional
Justice action.
 The most common way in which a surgeon demonstrates
respect for a patient’s autonomy is by obtaining the patient’s
valid consent for a surgical intervention.
 The consent process demonstrates respect for a patient’s
decision-making capacity
 Our conduct must justify our patients’ trust both in us and in
ou profession; it is essential that we are honest about our own
experience and qualifications.
Surgeon ground  Every surgeon should recognise the limitations of his

experience, skill and surgical expertise and be prepared to refer
rule to a more experienced colleague when necessary.
 We must not promise excellent clinical results when the
outcome is often unpredictable.
Benson, M. (2022). Efort Ethical Orthopaedics. Efort.

Resident Training
Case illustration
 A senior resident was assisting attending physician to perform
hip arthroplasty, as the resident has assisted the attending
physician on many occasion, the attending allows the resident
Hip to prepare the femur.

 Upon broaching the canal, the proximal femur is fractured
Arthroplasty necessitating fixation of the fracture and conversion to a long
stem prosthesis
 In the above scenario, the patient required a more extensive
surgical procedure, likely requiring additional anesthesia,
incurring a greater blood loss, and necessitating a more
complex prosthesis.
 The patient was subjected to greater risk, discomfort, and
potential complications violating the medical dictum of “do no
harm”
 Respect for a patient’s autonomy requires that patients be
informed of their role in the teaching process
 It is essential that patients be made aware of the presence of
residents in the operating room, the extent of resident
involvement in their case, and the level of experience of the
resident.
 Patients must be allowed to make informed decisions regarding
their participation in the medical education process.
 Reasonable people understand that continuing medical
education is essential for having trained physicians available to
their community.
 Everyone would like only the most experienced surgeon to
perform their surgery, only the most knowledgeable clinician to
care for them.
 At the same time, people realize that additional physicians must
continually be trained and that patient involvement is an
integral part of that training.
New Technology
Another case
 New devices or innovative surgical techniques may fill a void
in our armamentarium of patient care options.
 New technology may address a problem that was previously
New unsolvable or may improve upon an existing treatment
modality that had previously been ineffective or incomplete.
Technology  Before embracing new technology, orthopedic surgeons must
carefully examine our reasons for utilizing unproven modes of
treatment with the potential for substantial risks to the patient.
 Many patients, as well as their physicians, want what is new.
 People often equate new with better, new with improved, and
new with the latest technological advances.
 Minimally invasive surgery platelet-rich plasma, anterior
approach to the hip has been touted as being safer, better, and
more effective than more traditional modalities, even though
much of the literature has demonstrated uncertain or conflicting
results
 It is a well validated procedure due to well established
experiments and literature
 It fullfill patient autonomy because we can provide sufficient
evidence regarding predicted benefits and risks to allow patient
Total knee to do informed consent.
arthroplasty  During last decade, improved access to the medical literature

has caused a shift in modern patient’s expectations and
knowledge
 This situation posed ethical issue, mainly by recent innovation in
knee arthropalsty
 It provide early postoperative recovery, reduced length of stay
and rehabilitation, early return to work, improved cosmetic
appearance, and high patient satisfaction
 Despite potential advantage, there are several disadvantage
Minimally such as restricted visual field, issue related to learning a new
invasive exposure and technique. These issues may lead to implant

malposition, intraoperative fracture or neurovascular injury
surgery  Minimally invasive TKR gives rise to several important ethical
question. Can we satisfy the principles of beneficence,
nonmaleficence, autonomy, and justice by introducing this
procedure on a widespread basis?
When does a new technique
One vital question that represent unacceptable
must always be
foremost in our experimentation rather than
thoughts is:
innovation?
 Patients often assume that the outcome of a new procedure
such as minimally invasive total knee replacement will be
better than the outcome of a standard technique
Minimally Actually there are several risks of the new procedure

Invasive vs
Conventional  Patients may not grasp the concept that, although a “minimally
Technique invasive” procedure has a smaller skin incision, the
complications associated with that procedure may be equal to
or even greater than those associated with a standard surgical
approach.
 At present, minimally invasive techniques for total knee
Current situation arthroplasty do not meet the ethical standards that are already
of Minimally met by existing conventional techniques
Invasive Surgery  The widespread use of a new technique should be delayed until
the indications, pitfalls, and potential complications have been
in TKR identified
 Our desire to improve the outcome after surgery is what drives
us to develop innovative surgical techniques.
 A new technique may not be better than the standard procedure.
Therefore, true informed consent is absolutely essential
Take home  Therefore, true informed consent is absolutely essential. It is
message important for the surgeon to have a frank discussion with the
patient about the potential benefits and risks of a new
procedure as well as the surgeon’s experience with that
procedure.

Ethic Challenges in Orthopedic

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ethic Challenges in Orthopedic

Uploaded by

Copyright:

Available Formats

Ethical Challenges

Our Privilege manipulate their extremities, expose them to radiation, inject

Because of our  We have a fiduciary responsibility, from the Latin fiducia,

Beneficence the duty to help generally prescribes intervention.

Surgeon ground  Every surgeon should recognise the limitations of his

Benson, M. (2022). Efort Ethical Orthopaedics. Efort.

Hip to prepare the femur.

arthroplasty  During last decade, improved access to the medical literature

invasive exposure and technique. These issues may lead to implant

Minimally Actually there are several risks of the new procedure

of Minimally met by existing conventional techniques

Take home  Therefore, true informed consent is absolutely essential. It is

You might also like