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Unravelling ethical challenges in surgery

2009; Elsevier BV; Volume: 374; Issue: 9695 Linguagem: Inglês

10.1016/s0140-6736(09)61692-5

1474-547X

Laurence B. McCullough, James W. Jones,

Palliative Care and End-of-Life Issues

A time-travelling surgeon, regressing but a half-century, would be hard pressed to report back that surgeons were behaving properly, judged by what we accept today as proper moral behaviour. Surgical ethics, especially the collaborative work of surgeons and ethicists, had yet to emerge and probably would have been considered an oxymoron. Patients were told what the surgeon deemed best for them. There was little discussion and patients rarely refused and even more rarely sued. Innovation proceeded without oversight, with occasional positive outcomes from the creativity it unleashed. Michael DeBakey, for example, made the first Dacron vascular graft on his wife's sewing machine and used it to correct an aortic aneurysm the next day. Another internationally renowned surgeon simply started doing a new procedure without prior animal research; when asked why not, he joked, “animals cost too much money”.Things have changed. The exponential availability of surgical technology and its use of resources necessitated the development of surgical ethics to examine problems specific to surgeons. Surgical ethics has emphasised that surgeons have multiple professional roles—clinician, educator, investigator, organisational leader, consultant, or activist in health-care policy—as well as non-professional roles such as spouse, parent, child of ailing parents, and community member. The complexity of these roles and their potential to come into conflict require surgeons to become skilled in unravelling ethical challenges.Ethical challenges in surgery include crafting an adequate informed consent process for patients who are often distressed and anxious about making decisions with serious health and personal consequences, working with family members serving as surrogate decision makers for patients who lack the capacity to take part in the informed consent process, and responding to requests from patients or family members for futile surgical intervention. Additionally, the work of surgeons generally encompasses such things as: the provision of palliative surgical management for patients in the end-stages of terminal illnesses; protecting patients from incompetent surgeons and other health-care professionals; recruiting one's own patients for surgical clinical trials; obtaining informed consent for the involvement of trainees in surgical procedures; responsibly managing conflicts of interest and conflicts of commitment; engaging in serendipitous and planned innovation; running a practice on a sound business basis; dealing honestly with private and public payers; protecting the integrity of clinical judgment and practice from intrusions by managers of health-care organisations and payers; and helping to shape health-care policy that is evidence-based and responsive to the increasing costs of surgical care. The ethical issues that arise for surgeons are, therefore, many and varied.Surgical ethics uses the tools of ethical analysis and argument to provide practical guidance to surgeons. Ethical analysis requires one to become clear about clinically relevant and applicable concepts and use them with consistent meaning. Ethical argument requires one to use clearly formulated ideas to formulate reasons that together support a conclusion that should then guide clinical judgment, decision making, and behaviour. The discipline—and clinical value—of ethical reasoning in surgery, as in other clinical specialties, comes from following arguments where they take one. Submitting to the discipline of ethical reasoning gives one's clinical ethical judgments intellectual and moral authority that they lack when they emanate from mere opinion, “gut” feeling, or the arbitrary exercise of power by those with institutional authority to wield power.The history of medical ethics provides clinically relevant and applicable ideas and reveals how surgeons have made contributions to the repository of our concepts of clinical ethics. British surgeons, for example, pioneered consent processes as early as the 17th century, when they fashioned contracts with patients for operations. 19th-century surgeons in the USA transformed this rudimentary notion of informed consent into the more clinically sophisticated version with which surgeons are now familiar. From a historical perspective, the commonly held view that common law invented informed consent in the early 20th century and imposed it on reluctant surgeons becomes suspect. Perhaps common law simply codified ethical best practices that had already been brought to considerable ethical and clinical sophistication by practising surgeons.Two British physicians made a transformative contribution to the history of surgical medical ethics with the notion that the physician and surgeon should be part of a single profession. John Gregory (1724–73) wrote texts that are among the first about modern medical ethics in the English language. Gregory drew on the “experience”-based philosophy of Francis Bacon (1561–1626) and the “science of man” or “science of morals” and the ethics generated on this basis by his contemporary and acquaintance, David Hume (1711–76). Thomas Percival (1740–1804) wrote the first text entitled Medical Ethics, and he drew on Bacon's “experience”-based philosophy of medicine. Percival's source for philosophical ethics was mainly Richard Price (1723–91), the progenitor of what is known as moral realism in the history of philosophical ethics, an ethics based on the scientific identification and conceptual analysis of the obligations that constitute social roles.Gregory and Percival were concerned about the harmful consequences for patients, especially infirmary (indigent) patients, of the then-longstanding separation of physicians and surgeons and often unbridled competition between them for market share. Both men used the tools of ethical analysis and argument to promote the notion of medicine and surgery as a single profession, bringing physicians and surgeons together around a set of common scientific and moral commitments, which had three components. First, physicians and surgeons should commit to becoming and remaining scientifically and clinically competent, by practising, doing research, and teaching on the basis of Baconian “experience”-based medicine. Second, physicians and surgeons should protect and promote the patient's health-related interests as their primary concern and keep their economic and other forms of self-interest systematically secondary. Finally, physicians and surgeons should maintain and strengthen medicine as a public trust that exists for the benefit of future patients and not as a merchant guild that exists to protect the economic, political, and social interests of its privileged members.Gregory and Percival were self-conscious reformers who sought to change medicine and surgery from what they regarded as largely self-interested, unscientific guilds competing for privilege and power into one profession ethically worthy of the name. The history of surgical medical ethics pivots on the contribution of these two remarkable physician-ethicists. Indeed, the ethical notion of medicine as a profession shaped the development of the 1847 Code of Ethics of the American Medical Association and British professional medical ethics later in the 19th century. Today, the influence of Gregory and Percival is present in the American College of Surgeon's Code of Professional Conduct and in A Physician's Charter, an international statement of the ethical concept of medicine and surgery as a profession.The ideas of Gregory and Percival are relevant for ethical challenges in surgery today. We illustrate the task of surgical ethics by considering two ethical challenges that have recently come to prominence: conflicts of interest and innovation. Changes in the organisation and financing of surgical care create economic conflicts of interest for surgeons. They should objectively identify the intensity of the economic conflict of interest and also objectively identify the potential for conflicts of interest, especially those of considerable intensity, to distort clinical judgment and decision making. This is a crucial ethical consideration in surgery, because patients are often referred once a decision to consider surgery has already been made and because surgeons usually self-refer for surgical procedures that they are qualified, by training and experience, to undertake. Surgeons should ethically assess the conflict of interest in terms of their ability to keep intact the three components of the ethical concept of medicine as a profession. Conflicts of interest are intrinsically ethically unstable and, if not rigorously understood and managed, even minor violations are liable to accelerate. To protect professional integrity, surgeons should put the burden of ethical proof on the judgment that a conflict of interest is acceptable. The history of surgery is full of cautionary tales of the unacceptable consequences that befall patients, professional integrity, and the integrity of health-care organisations when conflicts of interest are poorly or, worse, irresponsibly managed.Innovation occurs when surgeons use new techniques for the first time, as DeBakey did on his wife's sewing machine and then in the operating room. An important source of improvement, surgical innovation should now be undertaken with deliberate scientific and ethical discipline. The purpose of surgical innovation should always be kept clearly in mind: to try initially a procedure or modification of a procedure that seems to be clinically promising. Given the potential for distorting bias introduced by self-interest in professional, academic, or financial rewards, surgical innovators should submit their innovation to retrospective peer review (for serendipitous innovation) and prospective peer-review (for planned innovation). This review should focus on the scientific formulation of a hypothesis and the ethical justification for further testing of that hypothesis in clinical research, which should be prospectively reviewed as required by applicable national research regulations. We should nurture the legacy of Gregory and Percival so that surgical ethics continues to be an essential component of surgical practice, research, education, and leadership. A time-travelling surgeon, regressing but a half-century, would be hard pressed to report back that surgeons were behaving properly, judged by what we accept today as proper moral behaviour. Surgical ethics, especially the collaborative work of surgeons and ethicists, had yet to emerge and probably would have been considered an oxymoron. Patients were told what the surgeon deemed best for them. There was little discussion and patients rarely refused and even more rarely sued. Innovation proceeded without oversight, with occasional positive outcomes from the creativity it unleashed. Michael DeBakey, for example, made the first Dacron vascular graft on his wife's sewing machine and used it to correct an aortic aneurysm the next day. Another internationally renowned surgeon simply started doing a new procedure without prior animal research; when asked why not, he joked, “animals cost too much money”. Things have changed. The exponential availability of surgical technology and its use of resources necessitated the development of surgical ethics to examine problems specific to surgeons. Surgical ethics has emphasised that surgeons have multiple professional roles—clinician, educator, investigator, organisational leader, consultant, or activist in health-care policy—as well as non-professional roles such as spouse, parent, child of ailing parents, and community member. The complexity of these roles and their potential to come into conflict require surgeons to become skilled in unravelling ethical challenges. Ethical challenges in surgery include crafting an adequate informed consent process for patients who are often distressed and anxious about making decisions with serious health and personal consequences, working with family members serving as surrogate decision makers for patients who lack the capacity to take part in the informed consent process, and responding to requests from patients or family members for futile surgical intervention. Additionally, the work of surgeons generally encompasses such things as: the provision of palliative surgical management for patients in the end-stages of terminal illnesses; protecting patients from incompetent surgeons and other health-care professionals; recruiting one's own patients for surgical clinical trials; obtaining informed consent for the involvement of trainees in surgical procedures; responsibly managing conflicts of interest and conflicts of commitment; engaging in serendipitous and planned innovation; running a practice on a sound business basis; dealing honestly with private and public payers; protecting the integrity of clinical judgment and practice from intrusions by managers of health-care organisations and payers; and helping to shape health-care policy that is evidence-based and responsive to the increasing costs of surgical care. The ethical issues that arise for surgeons are, therefore, many and varied. Surgical ethics uses the tools of ethical analysis and argument to provide practical guidance to surgeons. Ethical analysis requires one to become clear about clinically relevant and applicable concepts and use them with consistent meaning. Ethical argument requires one to use clearly formulated ideas to formulate reasons that together support a conclusion that should then guide clinical judgment, decision making, and behaviour. The discipline—and clinical value—of ethical reasoning in surgery, as in other clinical specialties, comes from following arguments where they take one. Submitting to the discipline of ethical reasoning gives one's clinical ethical judgments intellectual and moral authority that they lack when they emanate from mere opinion, “gut” feeling, or the arbitrary exercise of power by those with institutional authority to wield power. The history of medical ethics provides clinically relevant and applicable ideas and reveals how surgeons have made contributions to the repository of our concepts of clinical ethics. British surgeons, for example, pioneered consent processes as early as the 17th century, when they fashioned contracts with patients for operations. 19th-century surgeons in the USA transformed this rudimentary notion of informed consent into the more clinically sophisticated version with which surgeons are now familiar. From a historical perspective, the commonly held view that common law invented informed consent in the early 20th century and imposed it on reluctant surgeons becomes suspect. Perhaps common law simply codified ethical best practices that had already been brought to considerable ethical and clinical sophistication by practising surgeons. Two British physicians made a transformative contribution to the history of surgical medical ethics with the notion that the physician and surgeon should be part of a single profession. John Gregory (1724–73) wrote texts that are among the first about modern medical ethics in the English language. Gregory drew on the “experience”-based philosophy of Francis Bacon (1561–1626) and the “science of man” or “science of morals” and the ethics generated on this basis by his contemporary and acquaintance, David Hume (1711–76). Thomas Percival (1740–1804) wrote the first text entitled Medical Ethics, and he drew on Bacon's “experience”-based philosophy of medicine. Percival's source for philosophical ethics was mainly Richard Price (1723–91), the progenitor of what is known as moral realism in the history of philosophical ethics, an ethics based on the scientific identification and conceptual analysis of the obligations that constitute social roles. Gregory and Percival were concerned about the harmful consequences for patients, especially infirmary (indigent) patients, of the then-longstanding separation of physicians and surgeons and often unbridled competition between them for market share. Both men used the tools of ethical analysis and argument to promote the notion of medicine and surgery as a single profession, bringing physicians and surgeons together around a set of common scientific and moral commitments, which had three components. First, physicians and surgeons should commit to becoming and remaining scientifically and clinically competent, by practising, doing research, and teaching on the basis of Baconian “experience”-based medicine. Second, physicians and surgeons should protect and promote the patient's health-related interests as their primary concern and keep their economic and other forms of self-interest systematically secondary. Finally, physicians and surgeons should maintain and strengthen medicine as a public trust that exists for the benefit of future patients and not as a merchant guild that exists to protect the economic, political, and social interests of its privileged members. Gregory and Percival were self-conscious reformers who sought to change medicine and surgery from what they regarded as largely self-interested, unscientific guilds competing for privilege and power into one profession ethically worthy of the name. The history of surgical medical ethics pivots on the contribution of these two remarkable physician-ethicists. Indeed, the ethical notion of medicine as a profession shaped the development of the 1847 Code of Ethics of the American Medical Association and British professional medical ethics later in the 19th century. Today, the influence of Gregory and Percival is present in the American College of Surgeon's Code of Professional Conduct and in A Physician's Charter, an international statement of the ethical concept of medicine and surgery as a profession. The ideas of Gregory and Percival are relevant for ethical challenges in surgery today. We illustrate the task of surgical ethics by considering two ethical challenges that have recently come to prominence: conflicts of interest and innovation. Changes in the organisation and financing of surgical care create economic conflicts of interest for surgeons. They should objectively identify the intensity of the economic conflict of interest and also objectively identify the potential for conflicts of interest, especially those of considerable intensity, to distort clinical judgment and decision making. This is a crucial ethical consideration in surgery, because patients are often referred once a decision to consider surgery has already been made and because surgeons usually self-refer for surgical procedures that they are qualified, by training and experience, to undertake. Surgeons should ethically assess the conflict of interest in terms of their ability to keep intact the three components of the ethical concept of medicine as a profession. Conflicts of interest are intrinsically ethically unstable and, if not rigorously understood and managed, even minor violations are liable to accelerate. To protect professional integrity, surgeons should put the burden of ethical proof on the judgment that a conflict of interest is acceptable. The history of surgery is full of cautionary tales of the unacceptable consequences that befall patients, professional integrity, and the integrity of health-care organisations when conflicts of interest are poorly or, worse, irresponsibly managed. Innovation occurs when surgeons use new techniques for the first time, as DeBakey did on his wife's sewing machine and then in the operating room. An important source of improvement, surgical innovation should now be undertaken with deliberate scientific and ethical discipline. The purpose of surgical innovation should always be kept clearly in mind: to try initially a procedure or modification of a procedure that seems to be clinically promising. Given the potential for distorting bias introduced by self-interest in professional, academic, or financial rewards, surgical innovators should submit their innovation to retrospective peer review (for serendipitous innovation) and prospective peer-review (for planned innovation). This review should focus on the scientific formulation of a hypothesis and the ethical justification for further testing of that hypothesis in clinical research, which should be prospectively reviewed as required by applicable national research regulations. We should nurture the legacy of Gregory and Percival so that surgical ethics continues to be an essential component of surgical practice, research, education, and leadership.