Surgical Justice.

Abstract

Sir: Historically, surgeons have been viewed as physicians for the singular, cast at the opposite end of the spectrum from epidemiologists and public health experts. Surgeons treat case by case, one patient at a time. However, we posit that the impact of surgery frequently surpasses what is cut or sutured on individual patients, resulting in more profound changes in them and their communities. Surgical justice embodies the idea that a surgical intervention can bring about broader social empowerment and equity. From the earliest roots of plastic surgery, an affinity for, and focus on, the socially marginalized prefigures our conception of surgical justice. Gillies and Morestin enabled soldiers with unprecedented facial mutilation to return to duty amidst the devastation of war. McIndoe pioneered “surgical reintegration” after realizing that surgical burn treatment was only the initial step in his patients’ journey back into society. As access to plastic surgery expands, evidence of its transformative power in a community is profound. Recently, as a young girl underwent cleft lip repair in a remote region, it was discovered that she had actually been buried alive shortly after birth because of the stigmata of her deformity.1 It stands to reason that the impact of her lip repair transcended the reapproximation of her cleft. The justice that her surgery conveyed on her and in the changing attitudes of her community may not be accounted for in a typical cost-benefit analysis. Surgery offers a powerful medium to affect change for the most marginalized people. Economist Amartya Sen considers the “expansion of freedom” from destitution and oppression and to express agency “both as the primary end and as the principal means of development.”2 Surgical justice, both through the expansion of a patient’s physical and functional capacity, and the broader socioeconomic freedoms the patient and the patient’s community derive from it, would seem a particularly effective instrument with which to achieve development as freedom.2 The impact of surgical treatment also starkly illuminates the deprivation of those who lack access: a family without income after a hand injury, or cancer survivors shunned for their disfigurement. Although conventional wisdom holds that surgery is expensive, the increasing relative burden of traumatic injury and chronic disease coupled with more reliable and safe surgical outcomes is changing that calculus. Recent analyses find that the cost-effectiveness of surgery in developing countries meets or exceeds that of other health interventions.3 Cleft lip and palate repair are particularly beneficial.4 But might surgery by its nature surpass these analyses, with the potential to definitively liberate victims of suffering in a way that conveys additional forms of freedom? (This embodies the focus on broader social and economic determinants of health recently advocated by World Bank president Dr. Jim Kim and extends it to the impact of good health on social and economic circumstances.5) Plastic surgeons have a unique vantage point from which to expand societies’ conceptions of healing and outcomes, and to use technical surgical interventions as a means to address social empowerment and equity; in effect, to create surgical justice. As McIndoe extended the imperative of burn treatment beyond the operating room to include social reintegration, we may better care for our patients by extending our view toward the societal impact of each operation. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Shane D. Morrison, M.D., M.S. Division of Plastic Surgery University of Washington School of Medicine Seattle, Wash. Jordan W. Swanson, M.D., M.Sc. Division of Plastic Surgery Perelman School of Medicine at the University of Pennsylvania The Children’s Hospital of Philadelphia Philadelphia, Pa.