Ethics and Professionalism in Surgery

THE IMPORTANCE OF ETHICS IN SURGERY

Although the ethical precepts of respect for persons, beneficence, nonmaleficence, and justice have been fundamental to the practice of medicine since ancient times, ethics has assumed an increasingly visible and codified position in health care over the past 50 years. The Joint Commission, the courts, presidential commissions, medical school and residency curriculum planners, professional organizations, the media, and the public all have grappled with determining the right course of action in health care matters. The explosion of medical technology and knowledge, changes in the organizational arrangement and financing of the health care system, and challenges to traditional precepts posed by the corporatization of medicine all have created new ethical questions.

The practice of medicine or surgery is, at its center, a moral enterprise. Although clinical proficiency and surgical skill are crucial, so are the moral dimensions of a surgeon’s practice. According to Bosk, sociologist, the surgeon’s actions and patient outcome are more closely linked in surgery than in medicine, and that linkage dramatically changes the relationship between the surgeon and the patient. Little, a surgeon and humanist, suggested that there is a distinct moral domain within the surgeon-patient relationship. According to Little, “testing and negotiating the reality of the category of rescue, negotiating the inherent proximity of the relationship, revealing the nature of the ordeal, offering and providing support through its course, and being there for the other in the aftermath of the surgical encounter, are ideals on which to build a distinctively surgical ethics.” Because surgery is an extreme experience for the patient, surgeons have a unique opportunity to understand their patients’ stories and provide support for them. The virtue and duty of engaged presence as described by Little extends beyond a warm, friendly personality and can be taught by precept and example. Although Little does not specifically identify trust as a component of presence, it seems inherent to the moral depth of the surgeon-patient relationship. During surgery, the patient is in a totally vulnerable position, and a high level of trust is demanded for the patient to place his or her life directly in the surgeon’s hands. Such trust requires that the surgeon strive to act always in a trustworthy manner.

From the Hippocratic Oath to the 1847 American Medical Association statement of medical principles through the present, the traditional ethical precepts of the medical profession have included the primacy of patient welfare. The American College of Surgeons was founded in 1913 on the principles of high-quality care for the surgical patient and the ethical and competent practice of surgery. The preamble to its Statement on rinciples states the following:

The American College of Surgeons has had a deep and effective concern for the improvement of patient care and for the ethical practice of medicine. The ethical practice of medicine establishes and ensures an environment in which all individuals are treated with respect and tolerance; discrimination or harassment on the basis of age, sexual preference, gender, race, disease, disability, or religion, are proscribed as being inconsistent with the ideals and principles of the American College of Surgeons.

The Code of Professional Conduct continues:

As Fellows of the American College of Surgeons, we treasure the trust that our patients have placed in us, because trust is integral to the practice of surgery. During the continuum of pre-, intra-, and postoperative care, we accept responsibilities to:

• Serve as effective advocates of our patients’ needs.
• Disclose therapeutic options, including their risks and benefits.
• Disclose and resolve any conflict of interest that might influence decisions regarding care.
• Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.
• Fully disclose adverse events and medical errors.
• Acknowledge patients’ psychological, social, cultural, and spiritual needs.
• Encompass within our surgical care the special needs of terminally ill patients.
• Acknowledge and support the needs of patients’ families.
• Respect the knowledge, dignity, and perspective of other health care professionals.

The same expectations are echoed in the Accreditation Council for Graduate Medical Education core competencies that medicalsurgical training programs are expected to achieve: compassion, integrity, respect, and responsiveness that supersedes selfinterest, accountability, and responsiveness to a diverse patient population.

Historically, the surgeon’s decisions were often unilateral ones. Surgeons made decisions about medical benefit with little, if any, acknowledgment that patient benefit might be a different matter. Current surgical practice recognizes the patient’s increasing involvement in health care decision making and grants that the right to choose is shared between the surgeon and patient. A focus on informed consent, confidentiality, and advance directives acknowledges this changed relationship of the surgeon and patient. However, the moral dimensions of a surgeon’s practice extend beyond those issues to ask how the conscientious, competent, ethical surgeon should reveal damaging mistakes to a family when they have occurred, balance the role of patient advocate with that of being a gatekeeper, handle a colleague who is too old or too impaired to operate safely, or think about surgical innovation. Jones and colleagues, in a helpful casebook of surgical ethics, have noted that even a matter as mundane as the order of patients in a surgical schedule may conceal important ethical decisions.

END-OF-LIFE CARE

Care of patients at the end of life has garnered increasing attention in recent years. In the first of a series of articles concerning palliative care by the surgeon in the Journal of the American College of Surgeons, Dunn and Milch explained that palliative care provides the surgeon with a “new opportunity to rebalance decisiveness with introspection, detachment with empathy.” They also suggested that although surgeons might appreciate cognitively the need for palliative care, it also presents surgeons with difficult emotional challenges and ambiguities. In recognition of his leadership in the areas of hospice and palliative care, Robert A. Milch received the inaugural Hastings Center Cunniff-Dixon Physician Award in 2010 for leadership in care near the end of life. In accepting the award, Dr. Milch stated, “to the extent that we are able to play a part in that wonder, helping to heal even when we cannot cure, tending the wounds of body and spirit, we are ourselves elevated and transformed.” Gawande noted that physicians too often suffer the emotional reaction of failure when dying patients seek quality rather than quantity of life and often make decisions that worsen the problem by failing to ask patients their basic wishes. In one controlled study of patients with advanced lung cancer, patients randomly assigned to receive a palliative care intervention had better quality of life and lived an additional 2 months on average.

Resuscitation in the Operating Room

One of the most difficult issues in end-of-life care for the surgical patient concerns resuscitation. Informed decisions about cardiopulmonary resuscitation (CPR) require that patients have an accurate understanding of their diagnosis, prognosis, likelihood of success of CPR in their situation, and the risks involved. Surgeons sometimes are reluctant to honor a patient’s request not to be resuscitated when the patient is considering an operative procedure. Patients with terminal illness may desire surgery for palliation, pain relief, or vascular access yet not desire resuscitation if they experience cardiac arrest. The American College of Surgeons and the American Society of Anesthesiologists have rejected the unilateral suspension of orders not to resuscitate in surgery without a discussion with the patient, but some physicians believe that patients cannot have surgery without being resuscitated and view a do not resuscitate (DNR) order as “as an unreasonable demand to lower the standard of care.” Providers may worry that an order to forgo CPR may be extended inappropriately to withholding other critical interventions, such as measures required to control bleeding and maintain blood pressure. They also may fear being prevented from resuscitating patients for whom the cardiac arrest is the result of a medical error.

Discussions with the patient or surrogate about his or her goal for care and desires in various scenarios can help guide decision making. Such conversations allow a mutual decision that respects the patient’s autonomy and the physician’s professional obligations. On one hand, a patient who refuses resuscitation because the current health status is burdensome can clearly be harmed by intervening to resuscitate while in the operating room. On the other hand, a patient who refuses because of the (presumed) low likelihood of success may change this decision once he or she understands the more favorable outcomes of intraoperative resuscitation. A physician can choose to transfer the care of the patient to another physician if he or she is uncomfortable with the patient’s decision about interventions but should not impose this decision on the patient. CPR is not appropriate for every patient who has a cardiac or pulmonary arrest, even if the patient is in the operating room. Physicians need to develop skills in communicating accurate information about the risks and benefits of resuscitation with patients and families in light of the patient’s condition and prognosis, make this discussion a routine part of the plan of care, and develop an appropriate team relationship between the surgeon and anesthesiologist to implement the decision.

CULTURAL SENSITIVITY

Much has been said about the culture of surgery and the personality type of surgeons. The slogan “when in doubt, cut it out” is representative of the surgeon’s imperative to act. Harsh generalizations of surgeons as egotistical, having a “God complex,” and acting as “playground bullies” are frequent. As an often-stereotyped specialty, surgeons should have an astute appreciation for the impact of culture in the clinical encounter. The interaction between the surgeon who recommends operative treatment and the patient who believes that the pain is from a spiritual source and cannot be treated by surgery is unlikely to go well unless the surgeon has the tools to understand and respect the patient’s cultural beliefs, values, and ways of doing things.

Training for cultural competence in health care is an essential clinical skill in the increasingly diverse U.S. population and has been recognized and integrated into the current education of medical professionals. Strong evidence of racial and ethnic disparities in health care supports the critical need for such training. Patient-centered care must recognize culture as a major force in shaping an individual’s expectations of a physician, perceptions of good and bad health, understanding of the cause of a disease,methods of preventive care, interpretation of symptoms, and recognition of appropriate treatment. Being a culturally competent surgeon is more than having knowledge about specific cultures; cultural knowledge must be carefully handled to avoid stereotyping or oversimplification. Instead, cultural competence involves the “exploration, empathy, and responsiveness to patients’ needs, values, and preferences.” Self-assessment is often the first step to developing the attitude and skill of cultural competence. Honest and insightful inquiry into one’s own feelings, beliefs, and values, including assumptions, biases, and stereotypes, is essential to awareness of the impact of culture on care.

The Association of American Medical Colleges’ statement on education for cultural competence lists the following clinical skills as essential for medical students to acquire:

1. Knowledge, respect, and validation of differing values, cultures, and beliefs, including sexual orientation, gender, age, race, ethnicity, and class
2. Dealing with hostility and discomfort as a result of cultural discord
3. Eliciting a culturally valid social and medical history
4. Communication, interaction, and interviewing skills
5. Understanding language barriers and working with interpreters
6. Negotiating and problem-solving skills
7. Diagnosis, management, and patient-adherent skills leading to patient compliance

Various models for effective cross-cultural communication and negotiation exist to assist the physician in discovering and understanding the patient’s cultural frame of reference. The BELIEF instrument by Dobbie and colleagues is one such model:
Beliefs about health: What caused your illness/problem?
Explanation: Why did it happen at this time?
Learn: Help me to understand your belief/opinion.
Impact: How is this illness/problem impacting your life?
Empathy: This must be very difficult for you.
Feelings: How are you feeling about it?

These models demand the skills of good listening, astute observation, and skillful communication used within the framework of respect and flexibility on the part of the physician. Bridging the cultural divide uses the same skills and traits that engender patient trust and satisfaction and improve quality of care. As Kleinman and associates explained in a classic article, BELIEF types of questions are excellent to ask during every patient encounter, not only those with patients from markedly different cultures. These questions stress the usefulness of regarding every patient interaction as a type of cross-cultural experience.

SHARED DECISION MAKING

Ethically and legally, informed consent is at the heart of the relationship between the surgeon and the patient. The term informed consent originated in the legal sphere and still conveys a sense of legalism and bureaucracy to many physicians. The term shared decision making has become more popular in more recent times. It is, for all purposes, essentially synonymous with the idea of informed consent, but it suggests a clinical and educational context that most physicians find more congenial.

Shared decision making is the process of educating the patient and assessing that he or she has understood and given permission for diagnostic or therapeutic interventions. The underlying ethical principle is respect for persons, or autonomy. Informed consent reflects the legal and ethical rights people have to make choices about what happens to their body in accordance with their values and goals and the ethical duty of the physician to enhance the patient’s well-being.

There is no absolute formula for obtaining informed consent or a procedure, treatment plan, or therapy. A common error is to confuse the signing of a consent form with the process of informed consent. At best, the form is documentation that the process of shared decision making has occurred; it is not a substitute for that process. The process should include explanations from the physician in language the patient can understand and provide the opportunity for the patient to ask questions and consult with others, if necessary. Clarification of the patient’s understanding is an important part of the decision making process. Asking patients to explain in their own words what they expect to happen and possible outcomes gives a much better indication of their understanding than having them merely repeat what the physician has stated (“What do you understand about the surgery that has been recommended to you?”). Ideally, the process allows the physician and patient to work together to choose a course of treatment using the physician’s expertise and
the patient’s values and goals.

Determining a patient’s capacity to participate in decision making is an important role of the physician and inherent in the process of informed consent. Although capacity is generally assumed in adult patients, there are numerous occasions when the capacity for decision making is questionable or absent. Illness, medication, and altered mental status may result in an inability to participate independently in medical decision making. Capacity for decision making occurs along a continuum, and the more serious the consequences of the decision, the higher the level of capacity that it is prudent to require. Decision making capacity also may change; an individual may be capable of medical decisions one day and not another day or even at a particular time of day but not at another time. Probably the most common reason for questioning a patient’s capacity is patient refusal of a treatment, procedure, or plan that the physician thinks is indicated. A patient’s refusal raises a red flag and may be an appropriate indicator for an evaluation of capacity, but it should not be the only one. Determination of capacity should be an essential part of the informed consent process for any decision.

How does a physician best evaluate a patient’s capacity? There is no one definitive assessment tool for capacity. Although there are many guides and standards for evaluating capacity, it is most generally a common sense judgment that arises from a clinician’s interaction with the patient. Mental status tests that assess orientation to person, place, and time are less useful than direct assessment of a patient’s ability to make a particular medical decision. Simple questions such as the following assess the evaluation of capacity in the clinical setting more directly:

• What do you understand about what is going on with your health right now?
• What treatment (or diagnostic test or procedure) has been proposed to you?
• What are the benefits and risks?
• Why have you decided …?

PROFESSIONALISM

Within medical ethics, the topic of professionalism has received increasing attention more recently. Although the more usual approaches to ethics focus on what decisions one ought to make in a particular situation, professionalism instead addresses questions of enduring moral character—what sort of physician one is, rather than only what one does or does not do.

A common way to address professionalism is to list a series of desirable character traits. However, almost all discussions of professionalism ultimately rely heavily on two simple points.25 First, physicians are presumed, by virtue of entering into practice, to have made a moral commitment to place the interests of their patients above their own self-interests, at least to a considerable degree. Second, approaching medicine as a profession is commonly contrasted with viewing medical practice as merely a business.

Common challenges to surgeons’ professionalism arise during interactions with the pharmaceutical and medical device industries, in which one may earn a substantial monetary reward for activities that promote the marketing interests of companies, even if those activities fail to promote better health for patients. If care is to remain affordable for most patients, the need to control U.S. health care costs represents another major challenge to professionalism. Will physicians and their professional societies act like special interest lobbies, mainly interested in maintaining generous reimbursements for their favored procedures, regardless of evidence about the efficacy of procedures? Or will physicians rise to the challenge of supporting evidence-based medicine and take leadership in identifying low-efficacy procedures the restricted use of which could conserve scarce health care resources?

CONCLUSION

The challenges of contemporary surgical practice not only necessitate attention to the lessons of the past but also contemplation of the future. Traditional codes and oaths provide guidance, but reflection, self-assessment, and deliberation about what it means to be a good surgeon are essential. Educational efforts must inculcate the professional attitudes, values, and behaviors that recognize and support a culture of integrity and ethical accountability.

A good deal of the discussion in his chapter might be summarized in the following sentence: “Have a searching conversation with the patient and discover what he or she really wants.” Surgical practice today is marked by more busyness, as bureaucratic tasks such as electronic medical records constantly distract physicians from meaningful contact with their patients. Some people have even proposed “slow medicine” as a necessary corrective. Ethics and professionalism in surgery will require a firm commitment and a willingness to make sacrifices and not merely the desire to fit in with everyday practice.

摘选自Sabiston text book of surgery, 20th edition.