Surgery Ethics Tamerla Chavis, MD Neurosurgeon CHRISTUS St Elizabeth Hospital

1. Surgery Ethics Tamerla Chavis, MD Neurosurgeon CHRISTUS St Elizabeth Hospital Beaumont, TX Joann Starr, PHD Ethicist System Director of Ethics, CHRISTUS Health

2. “the fundamental contract in surgery is an undertaking by one individual to cure another by operation, in the expectation of reward” J.Cook “The Delegation of Surgical Responsibility”

3. A person in need of health care and the professional health care providerwho accepts that person as a patient enter into a relationshipthat requires, among other things, mutual respect, trust, honesty, and appropriate confidentiality.The resulting free exchange of information must avoid manipulation, intimidation, or condescension. Such a relationship enablesthe patient to disclose personal information needed for effective care and permits the health care provider to use his or her professional competence most effectively to maintain or restore the patient’s health. Neither the health care professional nor the patient acts independently of the other; both participate in the healing process. (Ethical and Religious Directives for Catholic Health Care Services, USCCB Part Three)

4. Typology of Ethical Issues in Surgery • Autonomy: • Respect for Informed consent for surgery • Truth-telling • Consent for involvement of trainees in surgical procedures • Confidentiality • Respecting patient’s requests (for procedures/ particular surgeons) • Good communication skills

5. Typology of Ethical Issues in Surgery • Beneficence: • Surgical competence • Ability to exercise sound judgment • Continuous professional development • Research and innovation in surgery • Responsible conduct • Functioning equipment and optimal operating • conditions • 7. Minimizing harm (including pain control) • 8. Good communication skills

6. Typology of Ethical Issues in Surgery • Nonmaleficence: • Surgical competence • Continuous professional development • Ability to exercise sound judgment • Recognizing the limits of one’s professional competence • Research and auditing • 6. Disclosure and discussion of surgical complications including medical errors • 7. Good communication skills

7. Typology of Ethical Issues in Surgery • Justice: • Allocation of scarce resources • Legal issues • Whistle blowing • “Ethics of Surgical Complications,” World Journal of Surgery • Simisade Adedeji, Daniel K. Sokol, Thomas Palser, Martin McKneally

8. Surgical Ethics The Ethics of Surgical Practice Cases, Dilemmas, and Resolutions By: James Jones, Laurence McCullough and Bruce Richman Oxford University Press, 2008

9. Surgical Ethics • Ethics is an essential discipline in the practice of surgery • Represents your best understanding of moral responsibility • Requires an ability to distinguish degrees of value or lack of • Evolves as reasoned reflection on clinical experience

10. Surgical Ethics • Ethical study investigates what our character and conduct should be • Morality is subject to re-examination and improvement • Ideas of justice and fairness require critical assessment and improvement • Ethical argument should maintain relevance and integrity

11. Surgical Ethics Role of the Surgeon is to act as the patient’s fiduciary Expectations:  patient will get better  patient’s interests are paramount  resolution of the presenting problem Surgical Obligations:  knowledge, technical ability and ethical integrity

12. Surgical Ethics Informed Consent and Disclosure Physician Responsibilities: • Explanation of the patient’s disease • Explanation of untreated natural history • Recommendation of most appropriate treatment • Discussion of risks and benefits • Anticipated outcome • Treatment alternatives

13. Surgical Ethics Informed Consent and Disclosure • Only adult patients are competent to decide which treatments to accept or reject. • Information provided to the patient should be accurate and reasonably complete. • Reasonable person standard “identify clinically salient information about the patient’s condition and it’s management”. • Patient’s do not have the right to dictate treatment.

14. Surgical Ethics Case 1 Unexpected complication’s in treating a Jehovah’s Witness patient Informed consent is obtained for minimally invasive repair of an aneurysm. The patient refuses blood transfusion during the informed consent process. While performing an endovascular repair of an abdominal aortic aneurysm, the patient deteriorates from excessive bleeding and will require an open surgical procedure. His blood pressure becomes difficult to maintain. The patient is sedated and cannot participate in the discussion and amendment of the informed consent. The patient’s wife is not a Jehovah’s Witness and gives permission for transfusion if necessary. Discussion

15. Surgical Ethics Case 1 (A) Assume that the patient did not fully realize that he could die without a transfusion, and proceed to transfuse as clinically indicated. (B) Since it is an open emergency procedure, transfuse. (C) Transfuse on the wife’s authority. (D) Transfuse and do not tell the patient. (E) Do not violate the patient’s autonomy by transfusing even if it means the patient may die.

16. Surgical Ethics Case 1 Additional comments: • Jehovah’s Witness refuse to be transfused with red blood cells that have been separated from their bodies. • Watchtower Society does not prohibit the use of plasma or albumin. • Jehovah’s Witness will accept treatment with erythropoietin. • The advance directive they carry is renewed annually. • Parents do not have the right to refuse life-saving treatment for minor children.

17. Surgical Ethics Professional Self-Regulation is the responsibility of: • Hospital based peer review • Specialty certification board • Specialty’s professional society • State medical board • Malpractice tort system

18. Surgical Ethics Case 2 Disagreements between attending and consultant physicians A prominent internist has referred a mutual friend for carotid angioplasty for treatment of severe carotid artery narrowing. The patient has asked that you be consulted regarding this treatment decision. You (the surgeon) suggest a carotid endarterectomy ( an open surgical procedure). Carotid endarterectomy is a relatively new procedure at your institution. Your recommendation has been dismissed by the attending physician. Discussion

19. Surgical Ethics Case 2 (A) Inform the patient and his family of your opinion. (B) Consult another surgeon and do not relate the impasse. (C) Make your recommendation to the internist in writing and inform him that you are withdrawing from the case immediately. (D) Negotiate with the internist on how to present both alternatives to the patient. (E) Place an anonymous note on the patient’s food tray.

20. Surgical Ethics Case 3 Surgeons Obligation to the Noncompliant Patient A 61-year-old gentleman is referred with severe peripheral vascular disease marked by disabling ischemic rest pain. He is obese, diabetic, alcoholic, and smokes heavily. You have been following him for 6 months and have attempted to reduce his operative risk by referring him to specialist for diabetes control, alcoholism and smoking cessation. He is noncompliant with the treatment plans. Today, he is requesting either bypass surgery or amputation to relieve severe pain not controlled with analgesics. Discussion

21. Surgical Ethics Case 3 (A) Discharge him from your practice after referral to a competent colleague. (B) Encourage him to participate actively in the recommended nonsurgical therapies. (C) Admit him and amputate the affected limb. (D) Admit him and do the necessary revascularization surgery. (E) Consult your institutional ethics committee.

22. Surgical Ethics Case 4 Fiduciary Economization A 64-year-old is referred to clinic with a large asymptomatic abdominal aneurysm detected on a screening study at the mall. He is in good health however his father died from the same type of aneurysm and he is requesting repair as soon as possible. He is presently unemployed. In 6 months he will be eligible for Social security and a modest pension. What do you do?

23. Surgical Ethics Case 4 (A)Explain the economics of waiting until he can enroll in Medicare. (B) Go ahead and operate. The hospital will write it off as bad debt. (C) Call the hospital administrator and negotiate the price down. (D) Go ahead and operate. If you don’t and the aneurysm ruptures, you could be sued. (E) Operate. He will just get someone else and you will lose the case.

24. Surgical Ethics End of life issues An ambulance brings an unconscious 41-year-old man to the ER following an automobile accident. CT scans show rupture of the liver, spleen, and superior mesenteric artery. He is being prepped for surgery when his business partner arrives with what he claims is the patient’s signed advance directive, specifying that in the event of cardiac arrest the patient wishes no resuscitative measures. During surgery the patient suffers an acute hypotensive episode and arrest. How do you proceed?

25. Surgical Ethics Case 5 (A) Do not resuscitate (B) Resuscitate and continue the operation (C) Limit your resuscitative efforts to closed chest massage (D) Consult the business partner (E) Ignore the advance directive

26. Surgical Ethics Case 6 A 90 year old diabetic man with unresectable esophageal cancer, COPD, arthritis pain and severe disability asks to have his implanted pacemaker deactivated. To do so would precipitate his demise. He is aware of this and has been evaluated by a psychiatrist and found to be mentally competent. He has been treated by pain management with no significant relief . What do you do?

27. Surgical Ethics Case 6 (A)Comply with his request (B) Inform him that barbiturates are the preferred form of suicide and give him a prescription (C) Refer him to a physician practicing in Oregon who will comply (D) Seek emergent commitment to a psychiatric inpatient unit, with suicide precautions (E) Tell him that you cannot violate good medical practice by an action that would be harmful

28. Bibliography The Ethics of Surgical Practice: Cases, Dilemmas, and Resolutions James W. Jones, Laurence B. McCullough, Bruce W. Richman, Oxford University Press, 2008 “Ethics of Surgical Complications,” Simisade Adedeji, et.al. World Journal of Surgery Published online: 01 February 2009. “Ethics in Surgery: Historical Perspective” Thomas Tung, MD, Claude H. Organ Jr.MD ARCH SURGIcal/ Val 135, January 2000, p. 10-13.

29. QUESTIONS AND COMMENTS