As a medical student, Steven Char, MD, observed surgeons dealing with complex ethical decision-making on a day-to-day basis as part of the standard practice of surgery. However, few surgeons explicitly labeled those choices as ethics.
“The seemingly simple decision of whether to offer a sick patient a surgical intervention, for example, requires careful consideration and evaluation of a patient’s right to autonomy and competing obligations of benevolence and nonmaleficence on the part of the surgeon,” says Char, now a resident physician at Mount Sinai Health.
There were insufficient data on the true range of ethical dilemmas encountered by practicing surgeons and their comfort level in navigating those dilemmas. Thus, Char and colleagues wanted to learn more. They surveyed 30 attending surgeons at an urban academic medical center, including surgeons from 12 general surgery subspecialties, about the ethical dilemmas they encountered most often.1
“Surgeons were generally eager to discuss the ethical challenges they encounter on a day-to-day basis, and the competing principles that they attempt to balance in making those choices,” Char reports.
Most of the reported dilemmas reported reflected four of the six core ethical issues identified by the American College of Surgeons (ACS): Competition of interests, professional obligations, end-of-life care, and truth-telling. None of the surgeons reported ethical dilemmas relating to the other two core ACS ethical issues (confidentiality and surrogate decision-making).
There was no clear topic for which surgeons believed an ethics consultation was always indicated. “There was seemingly a relationship between clinical experience and willingness to consult ethicists,” Char observes.
Older surgeons viewed ethicists as key resources that were available and valuable for difficult decisions. In contrast, some younger surgeons expressed feeling alone in dealing with ethical dilemmas. They struggle to find individuals with ethics expertise to guide them. “This may point toward an opportunity for further education of junior faculty about the availability and utility of ethics consultants,” Char offers.
Some surgeons reported ethical issues that were not well-characterized by any of the ACS core principles. About one-third described feeling pressured by patients or families to provide interventions at the end of life. The surgeons said the interventions were not likely to benefit the patient, and highly likely to cause unnecessary suffering. Surgeons struggled to balance the ethical principles of nonmaleficence and patient autonomy in these cases.
In the absence of consensus during family meetings, surgeons typically honored family wishes despite their own beliefs. One stated, “I took them to the OR, but I thought that was the wrong thing to do. I felt like my hand was forced.”
About one-third of surgeons reported other situations, in addition to end-of-life care, where they felt pressured to perform an intervention they believed was unnecessary, not the safest option, or unlikely to help. The pressure in those cases came from both patients and other providers. Some patients understood an intervention was unlikely to produce a benefit, but really wanted the treatment. In other cases, colleagues pushed for a patient to undergo surgery that was unlikely to work.
All the surgeons expressed comfort in their ability to navigate the ethical dilemmas they encountered. Despite this, few surgeons reported any formal ethics training beyond medical school. Instead, respondents developed ethics expertise by observing mentors and role models. In this way, surgeons learned to translate ethical principles into real-world decision-making.
Some residency programs use the ACS core ethical issues to design surgical ethics curricula. “The gap between what is expounded upon in the ACS core ethical issues and what is encountered by surgeons in actual practice points suggests an opportunity for further education,” Char observes.
Surgeons strongly supported the idea of a formal curriculum during training. One stated, “I would sign up in a heartbeat if there were some kind of series my residents could go through.” The surgeons saw a need for specialty-specific training in surgical ethics that is separate and distinct from general bioethics training in medical school.
“This speaks to the evolving recognition of surgical ethics as a distinct branch of medical ethics with its own unique challenges — and an integral part of surgical practice itself,” Char says.
REFERENCE
1. Char S, Prager K, Dugdale L, Fischkoff K. Surgeon perspectives on daily presentation of ethical dilemmas: A qualitative study. J Am Coll Surg 2023; Jul 10. doi: 10.1097/XCS.0000000000000802. [Online ahead of print].
There is an evolving recognition of surgical ethics as a distinct branch of medical ethics — and an integral part of surgical practice itself.
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