Surgical Ethics Research Articles

Ethical aspects of urinary diversion for women with irreparable obstetric fistulas in developing countries: response to comments by Morgan and Husain

Dear Editor, We thank Drs. Morgan and Husain for their interest in our paper [1] and we are pleased to offer a few comments in reply. Drs Morgan and Husain [2] seem to hold the mistaken impression that we are opposed to urinary diversion in all cases in which women are incontinent due to an obstetric fistula. This is certainly not true, as any fair reading of our paper will disclose. If, after a careful consideration of the issues involved, Miriam had decided that she wanted to undergo a diversion operation, it would have been arranged for her. The process of ethical deliberation is sometimes described as “determining what ought to be done, all things considered.” We hope that Drs. Morgan and Husain are insightful and honest enough as surgeons to recognize that not every operation goes as planned, that complications can arise unexpectedly, and that major operations performed under marginal conditions—especially by surgeons who have limited experience with the procedures they are undertaking—may not end well. We say this without casting any aspersions on their own surgical talents, assuming they understand that urinary diversions in Africa have been performed by surgeons other than themselves and that not all of those operations have been successful. Some patients have died from these procedures. Our article presents a series of questions that we believe ought to be answered before one proceeds with urinary diversion in a patient with an obstetric fistula: (1) Is the fistula reparable using another operative technique – and if so, what is the likelihood of success given the risk–benefit ratio in each case? (2) Are there contraindications to a urinary diversion? (3) Can the proposed operation be carried out safely under local circumstances with the resources available? (4) Can the patient receive appropriate post-operative care, both acutely and – in view of the known complications of urinary diversion – over the long term? (5) Does the patient understand the operation and its potential consequences, in terms of both her immediate surgical risk and the long-term consequences that may ensue? We are pretty sure that there is a broad surgical consensus that holds it would be unacceptable to carry out a urinary diversion in the USA unless these questions could be answered satisfactorily. We do not understand why Drs. Morgan and Husain seem uncomfortable with these questions: to us they seem like routine matters of basic surgical ethics. African women with obstetric fistulas are overwhelmingly poor, largely uneducated, culturally stigmatized, and politically powerless in the societies in which they live. They are a classic example of a “vulnerable patient population” at risk of being abused or exploited by others as a result of their marginalized status. We remain adamant Int Urogynecol J (2009) 20:613–614 DOI 10.1007/s00192-008-0799-0

Acute ethics: Risk assessment and the Doctrine of Double Effect in a referral to on-call urology

The Doctrine of Double Effect has been described as often used in medicine and surgery but is seldom described outside the palliative medicine context. This paper presents a possible clinically focussed illustration of the doctrine of double effect used in an acute urological setting. The authors describe the case of an elderly patient with significant dementia and haematuria who required anticoagulation. Implicit double effect reasoning may have helped the surgical team reach their initial decision with regard to a treatment plan, reconciling a duty to beneficence with a duty not to cause harm. This short case is offered as a stimulus for further discussion over the role of duty-based ethical reasoning in the acute surgical setting. It also highlights a possible need for more detailed case-analysis in identifying areas of interest in surgical ethics.

Surgical education: Eschewing the doing

Surgical education: Eschewing the doing

Orlo Clark and the Rise of Surgical Ethics

Orlo Clark and the Rise of Surgical Ethics

Implementing a curriculum in surgical ethics at your institution

Implementing a curriculum in surgical ethics at your institution

Surgical pilgrimage – The need to avoid navigation through drains, medicine or ‘medisin’: Our notes on NOTES

Mr. G. Buess and Sir A. Cuschieri must be congratulated for initiating the debate on natural-orifice transluminal endoscopic surgery (NOTES) [1]. To do so in the absence of any dissent to NOTES is not only commendable but the fulfillment of a role befitting them. While attending the World Congress 2006, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference 2007, and the European Association for Endoscopic Surgery (EAES) conference 2007, I heard the outlandish propositions about NOTES and wondered if I was intellectually handicapped in not appreciating them in totality. Coming from the developing world, and having a perception of my own anonymity, I could not muster the courage to speak against or question the rationale of transgastric or transcolonic procedures. This is why I felt reassured and proud of whistleblowers like Buess and Cuschieri. It is well established that health intervention should be both effective and safe [2]. Even the word ‘‘safe’’ has to be used with caution while evaluating surgical techniques [2]. Endoscopic surgery has seduced the surgeon as well as society. Its appeal has been maintained by an endeavor to ethically duplicate the wisdom of the accumulated experience of the conventional surgery era [3]. As noted by the authors [1] the surgical breach in gastrointestinal continuity is absurd, unless part of the intended surgical benefit. It is astonishingly inhumane to be even reading things like transvesical thoracoscopy [4] and wondering for the helpless poor animals being wasted, more so in such nonsurvival models. These self-professed heroes have deviated from the basic tenet of our profession: primum non nocere (first, do no harm). Many a time they flaunt supporting statistical data. While statistical support may be an important tool in scientific pursuit it cannot be a substitute for humane clinical decision-making in surgery [5]. While endoluminal procedures, as noted by the authors [1], are a legitimate progress, the nomenclature of NOTES seems a veil to cover unholy transgression of surgical ethics and human dignity. The human body is sacred, while operating, a surgeon is akin to being on holy pilgrimage and you do not navigate through drains while on a pilgrimage. The society respects us and expects a reciprocal respect. In this era of easy access to information no amount of statistical evidence will be able to stand scrutiny in the event of unforeseen complications from a gastric, colonic or vesical leak. Any such leak is a surgeon’s nightmare even in well intended and necessary procedures. To say this will not happen is being dishonest. Things can go wrong when least expected and there is a probability even for the improbable [6]. Surely times are both challenging and exciting. Case volumes and reimbursements might be decreasing [7], forcing upon us the need to be seen as innovators. The lure B. B. Agarwal Journal of International Medical Sciences Academy, New Delhi, India

Does it make sense to speak of neuroethics?

The field of bioethics has been split into subspecialties over the past few decades. In some cases, it was divided in terms of social domains, such as clinical ethics, research ethics and public‐health ethics. In other cases, it was separated in terms of methodological approaches, including principle‐based bioethics, virtue ethics and narrative ethics. Yet more divisions were made in terms of medical specialties, such as paediatric ethics, surgical ethics and psychiatric ethics. A more recent trend is to identify subfields in terms of new lines of scientific or technological investigation, such as genethics, nanoethics and neuroethics. > …the basic ethical concerns about threats to identity are not different in the context of neuroscience or genetics… Given the rich history of bioethics, we would not suggest that there is only one correct way forward or that speaking of new subfields is completely wrong. Indeed, Adina Roskies recently made a strong case specifically for neuroethics: “although neuroethics may appear to consist of a collection of diverse and unrelated concerns, the various issues emerging from the confluence of neuroscience and ethics are so densely interconnected that it is defensible, and may even be profitable, to consider them as a unified whole” (Roskies, 2006). Because no one has the infinite energy necessary to consider all aspects of bioethics, limiting oneself to a quasi‐discrete scientific arena can help to focus attention. Moreover, because studying ethics requires a firm grip on the science—and it will take ethicists time to catch up with the latest research in fields as complex as genetics, nanoscience and neuroscience—we can appreciate the case for speaking of bioethical subfields. Nevertheless, although we grant that speaking in such terms can be reasonable, we also want to call attention to some of the dangers associated with carving up bioethics into ever more specialized subfields that …

Ethics and the pediatric surgeon

Purpose Care of infants and children with life-impairing or life-threatening congenital and acquired disorders often raises ethical concerns for pediatric surgeons. The purpose of this survey was to determine the level of interest in clinical ethics and how respondents would manage ethical dilemmas within several clinical case scenarios. Methods A 12-item validated questionnaire developed by the Ethics and Advocacy Committee was provided for the American Pediatric Surgical Association (APSA; www.eapsa.org) members on the organizational website. General categories of questions included informed consent, patient privacy, and what constitutes research. Results The survey was completed by 235 of the 825 APSA members; a response rate of 28.4%. The majority (62%) were in academic practice, 22% had additional education or an advanced degree in ethics, and 11% were members of a hospital ethics committee. There was a clear majority response for seven questions. Topics generating the most controversy included the impact of consent by minors, decision making in the neurologically devastated child, what constitutes research in pediatric surgery, the use of interpreters for consent, and patient privacy. Respondents chose a well-referenced manuscript as the preferred modality for ethics education of the APSA members. Conclusion Pediatric surgeons have a general interest in clinical ethics as it relates to the care of their patients. An important mission of the Ethics and Advocacy Committee can be to provide education that gives guidance and knowledge to the members of APSA on timely topics in surgical ethics.

A new concept of translational research in surgery

1. M.D., Ph.D., Professor and Director; Centers for Molecular Medicine and ExperimentalMedicine, Jichi Medical School, Tochigi - Japan.2. M.D., Ph.D., Afilliated Professor of the Operative Technique and Experimental Surgery,Escola Paulista de Medicina – Federal University of Sao Paulo, Sao Paulo - Brazil.Translational research (TR) plays an important role for the clinical application ofnovel therapeutic strategies developed through experiments in basic sciences. TR allowsbeing at the forefront of a real and relevant improvement in the management of somediseases. Surgical innovations or new operative techniques must be investigated andelaborated at the TR center, which has the potential for medical training and researchdevelopment by young investigators involved in cutting edge, relevant science. A newconcept of TR on surgery includes various fields of technique and science. Practicalresearches based on high level surgical technique, physiology, immunology, pharmacology,molecular biology, tissue engineering and ethics, are required and must be applied toimprove continuously treatments for patients suffering from severe illnesses.Development of experimental microsurgery opened a wide variety of worldwideresearches and displayed excellent utility in the studies of surgery. Microsurgical techniqueis the basis of surgical experimental models, mainly in the transplant area. Microsurgicalskills to many medical doctors who are postgraduate fellows from the standpoint of TRdefinitely contributed to clinical success.Here, we would like to introduce this new concept of TR in surgery and emphasizethat experimental microsurgery is a key part of TR.

Operative Pediatric Surgery

Operative Pediatric Surgery is the latest single volume pediatric surgery textbook on the market. It is innovative as it combines both the attribute of a detailed textbook of pediatric surgical diseases and a pediatric surgery operative atlas. All important pediatric surgical topics are reviewed and most chapters contained diagnostic and treatment algorithms in addition to detailed accounts of the pathophysiology and embryology of diseases. I was impressed by the additional chapters on the history of pediatric surgery, pediatric surgical ethics, and health informatics in pediatric surgery to the conventional chapter headings. There is a chapter dedicated to fetal surgery, and minimally invasive surgery is well incorporated in most topics but also reviewed in more detail in chapters on thoracoscopy and laparoscopy. Unfortunately, those chapters cover only techniques as there are no studies quoted comparing the minimally invasive techniques to the open techniques. This book includes newer procedures into its operative description such as the perianal pullthrough for Hirschsprung's disease and the Nuss procedure for pectus excavatum. This book will be valuable to the pediatric surgical trainee and to experienced pediatric surgeons but may not totally alleviate the need for a separate surgical atlas. I found the book easy to read and the most of the illustrations are of good quality. The book has been priced at $295 dollars which seems reasonable for the quality of this textbook.

The nature and limits of the physician's professional responsibilities: surgical ethics, matters of conscience, and managed care.

The nature and limits of the physician's professional responsibilities constitute core topics in clinical ethics. These responsibilities originate in the physician's professional role, which was first examined in the modern English-language literature of medical ethics by two eighteenth-century British physician-ethicists, John Gregory and Thomas Percival. The papers in this annual clinical ethics number of the Journal explore the physician's professional responsibilities in the areas of surgical ethics, matters of conscience, and managed care.

Surgical ethics

Surgical ethics

Introducing new technologies: protecting subjects of surgical innovation and research.

The system for protecting human research subjects is under increasing pressure. Under the currently dominant Regulatory Ethics Paradigm, clinical research protocols must be reviewed and approved by an institutional review board (IRB) or equivalent. Although the IRB was introduced into health care in part to protect patients and investigators from the inherent conflict between the best clinical interest of the individual patient and the interest of science and society in answering a clinical question, its rigorous standards and rigid framework discourage surgeons from seeking potentially valuable early IRB consultation. Most of the important advances in the history of medicine, such as anesthesia, appendectomy, antibiotics, intensive care, and immunization, were introduced through an informal, unregulated innovation process that has been enormously productive but can lead to ratification of ineffective or harmful treatment by credulous physicians and patients. We propose a surgical innovation ethics paradigm that is a more nimble, flexible source of institutional and public oversight and approval of innovations that are in the gray zone prior to their conversion to formal protocols that then require IRB approval. We also discuss the management of personal and institutional conflicts of interest.

RETRACTED: Ethical issues in surgical treatment and research

This article has been retracted at the request of the Editor-in-Chief and Author. Please see http://www.elsevier.com/locate/withdrawalpolicy . Reason: There are problems with this monograph. Multiple passages from the sections entitled, “Ethics and End-of-Life Issues” (pp. 357–379) and “Ethics and Research in Surgery” (pp. 379–398), authored by Rene Lafreniere were taken from the following sources without appropriate attribution given the original authors: (1) Jonsen AR, Siegler M, Winslade WD. Clinical ethics: a practical approach to ethical decisions in clinical medicine. New York: McGraw Hill, 1992. (2) Troidl H, McKneally MF, Towards a definition of clinical research, In: Troidl H, McKeally MF, Mulder DS, Wechsler AS, McPeek B, Spitzer WO, editors. Surgical Research, Basic Principles and Clinical Practice, 3rd Edition, New York: Springer-Verlag; 1998, pp. 3–7. (3) Macklin R. The ethical problems with sham surgery in clinical research. New Eng J Med 1999; 341: 992–996). (4) Medical Futility in End-of-Life Care: Report of the Council on Ethical and Judicial Affairs, American Medical Association. JAMA. 1999; 281:937–941. (5) Younger SJ and Shuck JM, Advanced directives and determination of death, in Surgical Ethics. Eds. McCollough LB, Jones JW and Brody BA. 1st Edition. New York, Oxford University Press, 1998, pp. 57–77. (6) Frader JE and Caniano DA, Research and Innovation in Surgery, in Surgical Ethics, Eds. McCollough LB, Jones JW and Brody BA. 1st Edition. New York, Oxford University Press, 1998, pp. 216–241. (7) Margo CE, Towards an Operational Definition of Human Research. J Med Ethics. 2001; 27: 40–43 This monograph is thus retracted with apologies to the authors of the unattributed works. Sincerely, Peter Angelos, MD, PhD; Rene Lafreniere, MD; Timothy F. Murphy, PhD; Wayne Rosen, MD; November 15, 2006

Withdrawal of operative consent

Surgery 2003;133:692-3.

The fivefold root of an ethics of surgery.

Surgical ethics have generally been framed as general medical ethics applied to surgical contexts. This model is helpful, but may miss some of the special features of the surgical process and relationship. It is suggested in this paper that there are five categories of experience and relationship which are especially important in surgery--rescue, proximity, ordeal, aftermath, and presence. The sense of rescue, the feeling of relational proximity, the ordeal and aftermath of surgery are things which the patient experiences. Understanding these experiences allow surgeons to understand what may be asked of them in an ethical sense. Recognition of the reality and validity of each category in the surgical process highlights the importance of presence, the acts by which the surgeon demonstrates that he is present to the patient throughout the surgical process and its aftermath. While the teaching of communication skills may never compensate for insensitivity, the ideal of presence as virtue and duty can be taught by precept and example.

When to refer to another surgeon

You are a busy vascular surgeon located in a large community hospital 2 miles from a world-renowned cardiovascular center specializing in complex aortic surgery. A patient whom you have previously treated just presented in your emergency department with a tender but hemodynamically stable 10-cm thoracoabdominal aortic aneurysm. A computed tomography scan shows extravascular blood. The patient and his family trust you and insist that they want the patient to remain under your care. You are an excellent technical surgeon, but you haven 't repaired a thoracoabdominal aneurysm since residency. What is the most ethical course of action? 1.Send the patient directly to the specialty center.2.If you believe that the outcome will be satisfactory, take the patient to the operating room.3.Explain the situation to the patient, and let him choose where he wishes to have his surgery.4.You must understand your limits, and you base your decision accordingly.5.Recommend that a more qualified surgeon perform the operation and, with the patient's consent, arrange transfer to the specialty center. The best answer is E. The least appropriate response is C. Choice A, immediate direct transfer, would not be appropriate without careful clinical evaluation to ensure that transportation to another center would not aggravate the patient's condition. The patient's consent to transfer must be sought and obtained, and the referring surgeon should personally ensure that a duly qualified surgeon is available and willing to treat the emergent condition before the patient leaves your center. Choice B places the patient at undue risk when the surgeon is not current in the skills required to perform a highly difficult operation. Choice C places an unfair burden upon the patient. Clinical studies have shown that patients are excessively trusting of the surgeon's skills, particularly in life-threatening situations.1McKneally MF Martin DK An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy.J Thorac Cardiovasc Surg. 2000; 120: 264-269Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar This patient has been treated successfully by you in the past and is likely to believe that you will be equally capable of treating any surgical situation. Although you have done your best to fully explain all elements of the current situation to him, his judgment may be adversely affected by the anxiety and duress of acute illness. Most patients cannot appreciate the subtleties of treating a complex condition enough to make an informed distinction between variously capable surgeons. Recommending, rather than simply offering, transfer is a more appropriate approach to the management of this problem. Evaluation of one's limitations, Choice D, should not be performed at the expense of patients requiring urgent care. When outcomes cannot be reasonably predicted, the independent surgeon's efforts to expand his armamentarium can be rightly considered reckless experimentation.2Jones JW Ethics of rapid surgical technological advancement [editorial].Ann Thorac Surg. 2000; 69: 676-677Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Furthermore, the emergent nature of the patient's condition does not permit the quiet reflection on alternatives typically available before elective operations. Choice E, recommending referral, obtaining the patient's consent, and arranging transfer to a surgeon with the current skills and knowledge to treat the condition, meets the ethical and clinical needs of this situation. When a dangerous condition requiring special skills presents, and a better qualified surgeon is readily available, a referral should be strongly urged if transfer will not increase the patient's risk. This reflects the physician's obligation in the process of informed consent: when evidence supports one alternative as clearly superior, it should be recommended.3McCullough LB Jones JW Brody BA Informed consent: autonomous decision making of the surgical patient.in: Surgical ethics. : Oxford University Press, New York1998: 15-37Google Scholar In 1996, the Wisconsin Supreme Court (in Johnson v. Kokemoor) ruled that information about the informed consent process includes disclosure to patients of information about the availability of other physicians with better outcomes.4Icenogle DL Update on informed consent law: the Johnson V.Kokemoor decision. Wis Med J. 1997; 96: 58-61PubMed Google Scholar The transfer of care must be surgeon to surgeon to ensure that the exchange of pertinent information is complete, the specialized care required is available, and another surgeon accepts responsibility for the patient.

When to refer to another surgeon

You are a busy vascular surgeon located in a large community hospital 2 miles from a world-renowned cardiovascular center specializing in complex aortic surgery. A patient whom you have previously treated just presented in your emergency department with a tender but hemodynamically stable 10-cm thoracoabdominal aortic aneurysm. A computed tomography scan shows extravascular blood. The patient and his family trust you and insist that they want the patient to remain under your care. You are an excellent technical surgeon, but you haven 't repaired a thoracoabdominal aneurysm since residency. What is the most ethical course of action? 1.Send the patient directly to the specialty center.2.If you believe that the outcome will be satisfactory, take the patient to the operating room.3.Explain the situation to the patient, and let him choose where he wishes to have his surgery.4.You must understand your limits, and you base your decision accordingly.5.Recommend that a more qualified surgeon perform the operation and, with the patient's consent, arrange transfer to the specialty center. The best answer is E. The least appropriate response is C. Choice A, immediate direct transfer, would not be appropriate without careful clinical evaluation to ensure that transportation to another center would not aggravate the patient's condition. The patient's consent to transfer must be sought and obtained, and the referring surgeon should personally ensure that a duly qualified surgeon is available and willing to treat the emergent condition before the patient leaves your center. Choice B places the patient at undue risk when the surgeon is not current in the skills required to perform a highly difficult operation. Choice C places an unfair burden upon the patient. Clinical studies have shown that patients are excessively trusting of the surgeon's skills, particularly in life-threatening situations.1McKneally MF Martin DK An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy.J Thorac Cardiovasc Surg. 2000; 120: 264-269Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar This patient has been treated successfully by you in the past and is likely to believe that you will be equally capable of treating any surgical situation. Although you have done your best to fully explain all elements of the current situation to him, his judgment may be adversely affected by the anxiety and duress of acute illness. Most patients cannot appreciate the subtleties of treating a complex condition enough to make an informed distinction between variously capable surgeons. Recommending, rather than simply offering, transfer is a more appropriate approach to the management of this problem. Evaluation of one's limitations, Choice D, should not be performed at the expense of patients requiring urgent care. When outcomes cannot be reasonably predicted, the independent surgeon's efforts to expand his armamentarium can be rightly considered reckless experimentation.2Jones JW Ethics of rapid surgical technological advancement [editorial].Ann Thorac Surg. 2000; 69: 676-677Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Furthermore, the emergent nature of the patient's condition does not permit the quiet reflection on alternatives typically available before elective operations. Choice E, recommending referral, obtaining the patient's consent, and arranging transfer to a surgeon with the current skills and knowledge to treat the condition, meets the ethical and clinical needs of this situation. When a dangerous condition requiring special skills presents, and a better qualified surgeon is readily available, a referral should be strongly urged if transfer will not increase the patient's risk. This reflects the physician's obligation in the process of informed consent: when evidence supports one alternative as clearly superior, it should be recommended.3McCullough LB Jones JW Brody BA Informed consent: autonomous decision making of the surgical patient.in: Surgical ethics. : Oxford University Press, New York1998: 15-37Google Scholar In 1996, the Wisconsin Supreme Court (in Johnson v. Kokemoor) ruled that information about the informed consent process includes disclosure to patients of information about the availability of other physicians with better outcomes.4Icenogle DL Update on informed consent law: the Johnson V.Kokemoor decision. Wis Med J. 1997; 96: 58-61PubMed Google Scholar The transfer of care must be surgeon to surgeon to ensure that the exchange of pertinent information is complete, the specialized care required is available, and another surgeon accepts responsibility for the patient.

Historical Review of Pediatric Surgical Ethics

This study provides important updates to the epidemiology of pediatric trauma in the United States.Age-specific epidemiologic analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, representing 2.4 million pediatric traumatic injury discharges in the US from 2000 to 2011. We present yearly data with overlying loess smoothing lines, proportions of common injuries and surgical procedures, and survey-adjusted logistic regression analysis.From 2000 to 2011 there was a 21.7% decline in US pediatric trauma injury inpatient discharges from 273.2 to 213.7 admissions per 100,000. Inpatient case-fatality decreased 5.5% from 1.26% (95% CI 1.05–1.47) to 1.19% (95% CI 1.01–1.38). Severe injuries accounted for 26.5% (se = 0.11) of all discharges in 2000 increasing to 31.3% (se = 0.13) in 2011. The most common injury mechanism across all age groups was motor vehicle crashes (MVCs), followed by assaults (15–19 years), sports (10–14), falls (5–9) and burns (< 5). The total injury-related, inflation-adjusted cost was $21.7 billion, increasing 56% during the study period.The overall rate of inpatient pediatric injury discharges across the United States has been declining. While injury severity is increasing in hospitalized patients, case-fatality rates are decreasing. MVCs remain a common source of all pediatric trauma.Level III.

Invited commentary: Is there a distinctively surgical ethics?

Surgery 2001;129:668-71.