By Wydell L. Williams, Jr.
Recently I was asked to give a talk on ethics to my surgical colleagues. The Nevada Chapter of the American College of Surgeons has regular meetings and there are usually one or two speakers giving talks that are relevant to surgeons and their practice. The speakers are usually academic surgeons or residents talking about their research or someone from the national level discussing policies that will affect our practices. I was excited to be offered this opportunity because I felt that it was an acknowledgement of my recent degree in bioethics and would allow me to share with my surgical colleagues the concepts I learned. Suddenly I realized that I was going talk to surgeons who sometimes view themselves as being compassionate, self-sacrificing, methodical, and confident but also can be dominant, brash, impersonal, egocentric, difficult and demanding. So, I needed to find a topic that would appeal to the diverse surgical specialties and personalities that would be present. I decided to look at the principles of bioethics and consider how they apply to surgery and do they apply differently from other specialties…
Surgeons traditionally have been granted great discretion in determining when or when not to operate, sometimes with little questioning of that decision. We tend to seek immediate results rather than wait for the pathophysiology of medications to take effect. There seems to be less discussion of bioethical dilemmas in the surgical literature than the medical literature and we have been singled out as discussing ethical issues less than other specialties. All of this may appear to create a gap in surgical bioethics.
Surgeons can be authoritarian and may feel that ethical principles are ingrained in our training but the principles of bioethics need to be understood because they impact our practice daily. Beginning with the initial discussions and recommendations for surgical interventions, we need to be able to obtain informed consent from the patient. This requires respecting their autonomy and allowing them to make the decisions that are best for their situation. Although autonomy and shared decision making are important for the patient to make appropriate decisions, there are times when nudges and paternalism may be necessary. Nudging may benefit and serve as a safety net for those patients whom authentic preferences cannot be discovered via careful joint deliberation with clinicians. Using it appropriately can help patients make quality decisions in their surgical care. During an operation situations may arise that are different from what was anticipated or expected. The patient is not able to participate in the decision concerning what to do and the surgeon needs to be able to decide at that time what is best for the patient. The surgeon is not usurping the patient’s autonomy but deciding in the best interest of the patient; this may be viewed as using selective paternalism.
As scientific knowledge and the efficiency of medical technology grows, the ethical dilemmas for surgeons have increased. We are seeing older patients with more comorbidities that require surgery. We are asked to perform surgery on patients at the end of life or when there are no other options. Understanding when surgical care may be a futile effort or provide palliative intervention is essential for the surgeon. Understanding a patient’s end of life wishes will allow us to help the patient make the best decision for them without being paternalistic.
The unique clinical circumstances of surgery impose special ethical obligations on the surgeon during the preoperative, operative and postoperative periods. In the end surgeons need to be involved in doing what is right for the patient, without harming them, without undue outside influence, guiding the patient in the appropriate direction, respecting the patient’s choices, and being able to make appropriate decision on the behalf of the patients without their input in the operating room.
Wydell L. Williams, Jr., MD, MA, FACS has practiced oncologic and general surgery for more than twenty years. He holds a graduate degree in bioethics from Loyola University Chicago.