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Surgical Ethics:Relationships with Patients,the Profession, and Society
Martin McKneallyUniversity of Toronto
Dept. of Surgery & Joint Centre for Bioethics
Principles of Surgery
October 5, 2010
“Dr. McKneally, this is Jerry Wilson of the FBI. Can you answer some questions for me?”
“What kind of ethics education or training is given to surgeons?”
The Moon/Realyvasquez case
“Doctors accused of performing unnecessary heart surgeries at Redding Medical Center agree to pay millions to settle fraud allegations and accept restrictions on their medical practice”
U.S. Department of Justice, 2005
Plan of talk
What’s an Ethic?
Teaching Ethics
The Ethic of Surgery
Obligations
to patients
to the team
to society
Ethics….What’s an Ethic?
• A set of values, principles, and beliefs, standards of conduct
• Guides the behaviour of a specified group – journalists, lawyers, mafiosi, monks, physicians, surgeons.
• “What we should do” – codes of conduct
Ethics
Policy Lawusually must
should
Ethics
Policy Lawdisapproval fines/prison
censure
Contemplation before surgery
Joe Wilder, MD
“Thou Shalt Teach Bioethics”
RCPSC 1995
Ethical Issues Taught Formally:Consent, end-of-life, disclosure, surgical competence, surgical decision-making, COI, resource allocation, research/innovation
Ethical Challenges Not in Formal Curriculum:
Intra- and inter-professional conflict, lack of experience, training issues, perceived unethical staff behaviour
Ethic of Surgery
Trustworthiness:
Competence
Commitment
Trustworthiness
We are trusted to live up to our obligations
Professional: competence, commitment
Fiduciary: what is best for the patient
Team: integrity, coworker care
Societal: community need for surgical care
Surgical CompetenceKnowledge - timely and appropriate
Judgment - balanced
- attentive to the particular needs and circumstances of the individual patient
- the right operation for the right patient at the right time
Technical Skill - sufficient to perform the surgical intervention
- minimum of risk
- high probability of benefit
Commitment
Personal responsibility – uniquely intensified
Constancy – warrior energy
Fiduciary Obligation
Put patients’ interests above all others, including the physicians
Trustworthy carecompetence, commitment
Respectdignitary rightsprivacy, confidentiality
Confidentiality
Patients and the profession expect physicians not to disclose private information learned in the course of care
Team Obligations
Maintaining the integrity of the team
Coworker care: attention to the needs and concerns of team members
Societal Obligations
Implicit contract with societyDuty to treat
Explicit contractwith individual patientemergency carepublic agencies
Challenges – AIDS, SARS, Avian flu, COI, hypocompetent surgical care
Societal Obligations of Surgeons
Effective subsystems of care
Trauma system
Cardiac Care Network
Cancer Care Ontario
CritiCall
Societal Obligations of Surgeons
Developing subsystems
“Coaching teams”
Critical care – Tom Stewart
General surgery – Ori Rotstein, Andy Smith, Bernie Langer
Orthopaedics – Alan Gross
Coach Alan Hudson
Summary: Ethic of Surgery
Trustworthiness:CompetenceCommitment
Obligations:PatientsTeamSociety
Ethical Issues Taught Formally:Consent, end-of-life, disclosure, surgical competence, surgical decision-making, COI, resource allocation, research/innovation
Ethical Challenges Not in Formal Curriculum:
Intra- and inter-professional conflict, lack of experience, training issues, perceived unethical staff behaviour
RCPSC Bioethics Curriculum: Surgery
• Consent:Capacity, Disclosure, Surrogates
• Professional Conduct:Duty to treat, Confidentiality
• Conflict of Interest• Surgical Competence• End of Life• Truth Telling• Resource Allocation• Research Ethics
Ethics
Policy Law
Circumstance
Culture
Religion
Politics
should
usually must
