ETHICAL CONSIDERATIONS IN LEARNING AND TEACHING SURGERY

Abstract

Even in antiquity, practitioners of the healing arts developed and recorded remarkably specific codes of conduct to govern not only professional behavior in the care of patients, but also transfer of professional knowledge to the next generation. The familiar Oath of Hippocrates, believed to have been written circa 470 bc, best demonstrates the ancient origins of modern medical ethics by addressing the primacy of the patient's welfare, the value of honesty and confidentiality, and the mutual obligations in the relationship of professional teacher and student. 11 Later, with the acceptance of medicine in the university curricula of fifteenth century Europe, medicine became regarded as a scholarly pursuit, although it also included practical training analogous to the apprenticeship of other trades. Even after graduation, additional training was undertaken with established practitioners to gain additional experience, much like journeyman status common in craft guilds of the era. 5,14 Although the motivation to perpetuate medical guilds was probably political and economic in origin, these organizations doubtless recognized that sustainable influence in society depended in large measure on their collective ability to engender public trust: if an individual physician exploited patients for personal gain, this sufficiently threatened the interests of the group so that the unprofessional behavior was discouraged. Assimilation of a new member was, therefore, contingent not only on their diligent study and practice of specific skills but on doing so within the approved standards of conduct, most important, including a pledge to act in the best interest of those served. The same traditions of uncompromised respect for the welfare of the patient and commitment to achieving true professional competence are the essence of all subsequent codes of medical ethics and remain of paramount importance when and teaching today's surgical techniques. 1,4 As with other technical knowledge, it is reasonable to assume that achieving competence in surgery is not instantaneous but incremental and that inexperience confers additional risks to patients that are expected to diminish with greater experience. The profession would clearly falter, however, if only experienced surgeons were permitted to render care. In a residency training program, apprentice status is assumed, and curricula can be carefully designed to develop mastery of surgical skills under close supervision, with rates of complication that are minimized by involvement of experienced mentor surgeons. 6,18 Beyond residency, continuing education in new procedures and accreditation of new expertise is important to the profession and society, 8 although access to adequate resources may be more difficult. After formal training, the adverse effects of a learning in a personal program of study are therefore potentially exaggerated, and individual respect for standards of ethical conduct becomes especially important as a guide to the process. 3 In this article, the ethical implications of the curve are explored, with emphasis on concerns that arise when developing new procedural competence after formal residency training. Some ethical responsibilities of more experienced colleagues and institutions that monitor the progress of less experienced surgeons are also reviewed.