Surgical Ethics: Relationships with Patients, the Profession, and Society

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Surgical EthicsRelationships with Patients,the
Profession, and Society

• Martin McKneallyUniversity of TorontoDept. of
  Surgery
• Joint Centre fo Bioethics
• Foundations of Surgery
• September 25, 2012

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• 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

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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

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Plan of talk

• Whats an Ethic?
• Teaching Ethics
• The Ethic of Surgery
• Obligations
• to patients
• to the team
• to society

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Ethics.Whats 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

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Ethics
should
Policy
Law
usually
must
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Ethics
censure
Policy
Law
disapproval
fines/prison
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Contemplation before surgery Joe Wilder, MD
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Thou Shalt Teach Bioethics

• RCPSC 1995

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Ethical Issues Taught FormallyConsent,
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

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Ethic of Surgery

• Trustworthiness
• Competence
• Commitment

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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

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Surgical Competence

• Knowledge - 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

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Commitment
Personal responsibility uniquely
intensified Constancy warrior energy
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Fiduciary Obligation

• Put patients interests above all others,
  including the physicians
• Trustworthy care
• competence, commitment
• Respect
• dignitary rights
• privacy, confidentiality

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Confidentiality

• Patients and the profession expect physicians not
  to disclose private information learned in the
  course of care

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Team Obligations

• Maintaining the integrity of the team
• Coworker care attention to the needs and
  concerns of team members

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Societal Obligations

• Implicit contract with society
• Duty to treat
• Explicit contract
• with individual patient
• emergency care
• public agencies
• Challenges AIDS, SARS, Avian flu,
• COI, hypocompetent surgical care,
• suboptimal system of care

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Societal Obligations of Surgeons

• Effective subsystems of care
• Trauma system
• Cardiac Care Network
• Cancer Care Ontario
• CritiCall

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Societal Obligations of Surgeons

• Developing subsystems
• Coaching teams
• Critical care Tom Stewart
• General surgery Ori Rotstein, Andy Smith,
  Bernie Langer, Richard Reznick
• Orthopaedics Alan Gross

Coach Alan Hudson
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Summary Ethic of Surgery

• Trustworthiness
• Competence
• Commitment
• Obligations
• Patients
• Team
• Society

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• martin.mckneally_at_utoronto.ca
• Cell 416.918.5032

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Ethical Issues Taught FormallyConsent,
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

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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

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Circumstance Culture Religion Politics
Ethics
should
Policy
Law
must
usually