Schwartz’s Principles of Surgery

WHY ETHICS MATTER

 Ethical concerns involve not only the interests
of patients, but also the interests of surgeons
and society
 Aristotle described practical wisdom
(Greek: phronesis) as the
capacity to choose the best
option from among several
imperfect alternatives
DEFINITIONS AND OVERVIEW

 Biomedical ethics is the system of analysis

and deliberation dedicated to guiding
surgeons toward the “good” in the practice of
surgery
 the principalist approach as articulated by
Beauchamp and Childress : moral dilemmas
are deliberated by using four guiding
principles: autonomy, beneficence,
nonmaleficence, and justice
 The case-based paradigm for bioethics is
used when the clinical team encounters a
situation in which two or more values or
principles come into apparent conflict
 Choosing wisely requires the virtue of
practical wisdom first described by Aristotle
 “postgraduate training of surgeons is above
all things an ethical training.” by Charles Bosk
SPECIFIC ISSUES IN SURGICAL ETHICS
Informed Consent
 the doctrine of informed consent is one of the most
widely established tenets of modern biomedical
ethics.

 it is difficult to prosecute a case of inadequate

informed consent so long as the clinician has made a
concerted and documented effort to involve the
patient in the decision-making process
Adequate informed consent entails at least four
basic elements:
 (a) the physician documents that the patient or
surrogate , has the capacity to make a medical
decision;
 (b) the surgeon discloses to the patient details
regarding the diagnosis and treatment options
sufficiently for the patient to make an informed
choice;
 (c) the patient demonstrates understanding of
the disclosed information before
 (d) authorizing freely a specific treatment plan
without undue influence
The Boundaries of Autonomy: Advanced
Directives and Powers of Attorney

 Living wills are written to anticipate

treatment options and choices in the event
that a patient is incapacitated by a terminal
illness.
 Proponents of this approach hope that the
surrogate will be able to make decisions that
reflect the choices that the patients
themselves would make if they were able
 Patients should be encouraged to clearly
identify their surrogates, both formally and
informally, early in the course of treatment,
and before any major elective operation
Withdrawing and Withholding
Life-Sustaining Therapies
 The implementation of various forms of life support
technology raise a number of legal and ethical
concerns about when it is permissible to withdraw or
withhold available therapeutic technology
 The difference between “ordinary” and
“extraordinary” care, and whether there is an ethical
difference in withholding or withdrawing “ordinary”
vs. “extraordinary” care
 Withholding or withdrawing of life-sustaining
therapy is ethically justified under the principle of
double effect if the physician’s intent is to relieve
suffering, not to kill the patient
some important principles to consider when
considering withdrawal of life-sustaining therapy
include:
(a) Any and all treatments can be withdrawn. If
circumstances justify withdrawal of one therapy
(e.g., IV pressors, antibiotics), they may also
justify withdrawal of others;
(b) (b) Be aware of the symbolic value of continuing
some therapies (e.g., nutrition, hydration) even
though their role in palliation is questionable;
(c) (c) Before withdrawing life-sustaining therapy,
ask the patient and family if a spiritual advisor
(e.g., pastor, imam, rabbi, or priest) should be
called; and
(d) (d) Consider requesting an ethics consult
PALLIATIVE CARE
General Principles of Palliative Care
 Palliative care is a coordinated, interdisciplinary
effort that aims to relieve suffering and improve
quality of life for patients and their families in
the context of serious illness
 The World Health Organization defines palliative
care as “an approach that improves the quality of
life of patients and their families facing the
problems associated with lifethreatening illness,
through the prevention and relief of suffering by
means of early identification and impeccable
assessment and treatment of pain and other
problems, physical, psychosocial, and spiritual
Indications for palliative care consultation in surgicaln practice
include:
(a) patients with conditions that are progressive and life-
limiting, especially if characterized by burdensome
symptoms, functional decline, and progressive
cognitive deficits;
(b) assistance in clarification or reorientation of
patient/family goals of care;
(c) assistance in resolution of ethical dilemmas;
(d) situations in which a patient/surrogate declines
further invasive or curative treatments with stated
preference for comfort measures only;
(e) patients who are expected to die imminently or
shortly after hospital discharge; and
(f) Provision of bereavement support for patient care
staff, particularly after loss of a colleague under care
Concepts of Suffering, Pain,
Health,and Healing
 The relief of pain has been the clinical
foundation for hospice and palliative care
 This reorientation of the goals of medical
care from a focus on disease and its
management to the patient’s experience of
illness focuses attention on the purpose of
medicine and the meaning of health and
healing
Effective Communication and
Negotiating the Goals of Care
 Changing the goals of care from cure to
palliation near the end of life is both
emotionally and clinically challenging, and it
depends on a clear prognosis and effective
communication
 Patient assessment in these conversations
should give the highest priority to identifying
and responding to the most immediate
source of distress.
CARE AT THE END OF LIFE
The Syndrome of Imminent Demise
 The process of dying and the care of a patient
at the time of death is a distinct clinical entity
that demands specific skills from physicians
 The process of dying and the care of a patient
at the time of death is a distinct clinical entity
that demands specific skills from physicians
Common Symptoms at the End of
Life and Their Management
 The three most common, major symptoms that
threaten the comfort of dying patients in their
last days are respiratory distress, pain, and
cognitive failure
 General principles that are applicable to
symptom management in the last days of life
include:
(a) anticipating symptoms before they develop;
(b) minimizing technologic interventions (usually
manage symptoms with medications); and
(c) planning alternative routes for medications in case the
oral route fails
Pronouncing Death

 There are a number of physical signs of death

a physician should look for in confirming the
patient’s demise: complete lack of
responsiveness to verbal or tactile stimuli,
absence of heart beat and respirations, fixed
pupils, skin color change to a waxen hue as
blood settles, gradual poikilothermia, and
sphincter relaxation with loss of urine and
feces
PROFESSIONAL ETHICS: CONFLICT OF
INTEREST, RESEARCH, AND CLINICAL ETHICS

 Conflicts of interest for surgeons can arise in

many situations in which the potential
benefits or gains to be realized by the
surgeon are, or are perceived to be, in conflict
with the responsibility to put the patient’s
interests before the surgeon’s own
Research Ethics

Emanuel and colleagues52 described seven

requirements for all clinical research studies to be
ethically sound:
(a) value—enhancement(s) of health or knowledge must
be derived from the research;
(b) (b) scientific validity—the research must be
methodologically rigorous;
(c) (c) fair subject selection—scientific objectives, not
vulnerability or privilege, and the potential for and
distribution of risks and benefits, should determine
communities selected as study sites and the inclusion
criteria for individual subjects;
(d) favorable risk-benefitratio—within the context of
standard clinical practice and the research protocol,
risks must be minimized, potential benefits
enhanced, and the potential benefits to individuals
and knowledge gained for society must outweigh
the risks;
(e) Independent review—unaffiliated individuals
must review the research and approve, amend, or
terminate it;
(f) informed consent—individuals should be
informed about the research and provide their
voluntary consent; and
(g) respect for enrolled subjects—subjects should
have their privacy protected, the opportunity to
withdraw, and their well-being monitored
Special Concerns in Surgical
Research
 A significant issue for clinical surgical
research is that it is often analyzed in a
retrospective manner and not commonly
undertaken in a prospective double-blind,
randomized fashion
 A second major issue for surgical trials is
whether it is ethically acceptable to have a
placebo-controlled surgical trial
Surgical Innovation and
Surgical Research
 An important issue is whether surgical
innovation should be treated as research or
as standard of care
 if a surgeon decides to use a new technique
on several occasions and to study the
outcomes, Institutional Review Board
approval and all other ethical requirements
for research are necessary
Clinical Ethics: Disclosure
of Errors
 Disclosure of error is consistent with the ethical
tenets of openness with patients and the
involvement of patients in their care
 Information regarding a medical error may be
needed so that patients can make independent
and well-informed decisions about future
aspects of their care
 Declaring a finding as an “error” may be
inaccurate, however, and a nonjudgmental
assessment of the situation is usually advisable