Hacettepe University Faculty of Medicine, Medical Intern, Ankara, Turkey**
Adnan Menderes University Faculty of Medicine, Department of General Surgery, Aydın, Turkey
The field of ethics, also called moral philosophy, involves systematizing, defending, and recommending concepts of right and wrong behavior. Ethics is an established system of moral principles that govern the rules of conduct. Medical ethics define what the physician ought to do and how he or she should behave. Some of us may think that ethics are unimportant in surgery, however, we should be aware that surgeons operate daily in the theater of moral choice. Ethical considerations, such as diagnosis and treatment, are essential features of the surgical care for each patient (1). Surgeons working in surgical units increasingly face ethical problems owing to growth in scientific knowledge and technology, and the availability of new diagnostic equipment and treatment opportunities. The applications become more complex and the decisions more difficult as advancing technology provides greater opportunities to save lives and relieve pain and suffering. More and more surgical procedures are now carried out in older patients who have multiple and more serious diseases than ever before (2). Doctors often face with ethical dilemmas related to providing care that maintains patients’ dignity while attending their advanced medical treatment. Organizational and financial constraints in hospitals, and professional relationships with colleagues and other healthcare providers also create ethical problems for surgeons as they try to act appropriately towards patients and relatives (3). Studies have shown, however, that physicians often are in doubt about the best and correct actions to take for the patients in specific situations (2-4). In fact, the majority of surgeons with little or no education in bioethics face many ethical challenges in daily practice. The overall aim of this article was to analyze surgeons’ experiences of living with ethical difficulties in their work, and highlight the importance of ethical requirements in surgical practice.
Four Principles of Medical Ethics
During the 1970s, the American philosophers Tom Beauchamp and James Childress introduced the highly influential “Four Principles” of medical ethics. The principles of biomedical ethics as described by Beauchamp and Childress (2001) are today the most generally accepted school of thought in medical ethics (3). The principles are neither hierarchically ordered nor invariably binding. They are “prima facie”, meaning that they are binding unless they conflict with another principle. When this occurs, the individual must balance the competing moral obligations against each other and, through sound judgment, determine which most morally compelling is (5).
A brief description of the principles follows:
1) Respect for autonomy (voluntas aegroti suprema lex): It means respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices. People have the right to control what happens to their bodies. This principle is the basis for the practice of “informed consent” in the physician/patient transaction regarding healthcare (6). Informed consent for surgery, truth-telling (to patients, relatives, and colleagues), consent for the involvement of trainees in surgical procedures, and confidentiality and respecting patient’s requests (for procedures/particular surgeons) are some of important ethical issues in the context of respect for autonomy.
2) Beneficence (salus aegroti suprema lex): It requires that the procedure be provided with the intent of doing good for the patient involved. A practitioner should act in the best interest of the patient. Surgical competence, continuous professional development, research and innovation in surgery, responsible conduct; functioning equipment and optimal operating conditions, and minimizing harm (including pain control) are some of important ethical issues in the context of beneficence.
One of the most well known examples of ethical dilemma in surgical practice is the need for a blood transfusion in a Jehovah’s Witnesses. In this case, there is a conflict between the principles of beneficence and respect for autonomy. Jehovah’s Witnesses consent to all medical interventions but refuse blood and blood product transfusions. This refusal is worthy of the surgeon’s respect since their religious beliefs may be as sincere as the beliefs of any other of this world’s religious traditions. For this reason, there is nowadays an increasing tendency to favor respect for patient’s autonomy over beneficence in such cases (1).
3) Non-maleficence (primum non nocere): “First, do no harm” is the bedrock of medical ethics. Recognizing the limits of one’s professional competence, research and auditing, disclosure and discussion of surgical complications, including medical errors, and good communication skills are some of ethical issues in the context of non-maleficence.
4) Justice (fairness and equality): It is the moral obligation to act on the basis of fair adjudication between competing claims. You should be able to justify your actions in every situation. Ethical decisions should be consistent with the ethical theory unless extenuating circumstances that can be justified exist in the case. Allocation of scarce resources, legal issues and respecting human rights are some of ethical issues in the context of justice.
Medicine is based on a morally demanding fiduciary duty of the physician to protect and promote the interests of his/her patients (7). Medical problems are always existential problems too because suffering, anxiety, life, death, and cure involve the core of human existence (8). Patients may also elicit emotions of anger and frustration, fear, and despair in physicians (9). While fulfilling their professional requirements in a proper way, surgeons have to sustain good communication with their patients.
The narratives of surgeons concerned ethical challenges and decision making in situations when patients’ life and quality of life are at stake. The lives of patients are fragile; undergoing surgery has risks as well as benefits, and the aftermath of surgery is often impossible to predict. The surgeons live and work with the inherent uncertainty of the course of the disease, patients’ chances of survival, the risk of serious and fatal complications, and the possibility of diminishing patients’ quality of life after major surgery. The surgeons are personally challenged by the existential realities of human life in practice. Ethically difficult situations are experienced as inherent in practicing surgery, and surgeons have to live with them in ways that are confirmed both socially and personally. Living with the ethical challenges of surgery made surgeons both confident and vulnerable in their professional role (10).
The main ethical dilemmas experienced by surgeons concerned finding the right level of treatment that most beneficial for patients in situations of uncertainty. Performing high-risk surgery on fragile patients with poor chances of a positive outcome give rise to ethical dilemmas concerning starting or withholding treatment, continuing or withdrawing treatment and overtreatment. The surgeons feel responsible for providing sufficient information about the disease, the risks and benefits of surgery; presenting treatment recommendations and assisting patients in making the ‘right’ decision about treatment and care. To determine the risks and benefits of surgery in individual cases is experienced as difficult. Surgeons experience ethical problems about whether they should act according to their own ethical convictions or according to the opinions of other surgeons or physicians from other departments. To determine whether a colleague is performing adequately or not is difficult, as the standards of surgical performance are high, practicing surgery involves risks of errors and even the best surgeon is fallible (11).
Patients seeking alternative treatment, medicines and drugs where the effects are uncertain and impossible to control are experienced as a dilemma for surgeons. Although surgeons respect the patients’ right to decide their own treatment, they fear that some alternative treatment might harm the patients’ standardized medical treatment. In some cases, patients with incurable cancer even have alternative operations in private clinics (11).
On the other hand, new technological developments in surgery education are involved in ethical problems. Surgical conferences often include live surgical broadcasts (LSBs) (LSBs, also known as live surgical demonstrations, or a live surgical event), as the lead event, where an experienced surgeon demonstrates his/her technique to an audience of keen peers via a video link. These events are becoming increasingly popular in surgical conferences. These activities can provide excellent training opportunities, as they allow the audience to view an operation conducted by world-renowned surgeons, and have the ability to interact with them in real time. However, several ethical considerations have been raised with this practice, which the participating surgeons and conference organizers must appreciate and address carefully. The potential risks to patients associated with LSBs have been discussed extensively previously. Our goal was to promote the advancement of science and technology for the common good. We must highlight the ethical considerations related to LSBs (12).
In their study including five male and five female surgeons at a University hospital in Norway, Torjuul et al. (10), the main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The meaning of “living with” ethical challenges seemed to be related with an understanding of ethics as an inherent and inescapable feature of their everyday activities and professional life. Surgeons should face all clinical decisions with some ethical reasoning. This attitude is frequently not time-consuming and may help the surgeon to unmask potential conflicts of interest, and to approach real ethical dilemmas with honesty, sensibleness and reasoning (1). In the expectation that all surgeons will be inspired to engage in these ethical issues in greater depth and ethics education will be provided in surgery residency programs in so doing raise the ethical standards of surgery even higher.
Informed Consent: Consent form was filled out by all participants.
Peer-review: Externally and internally peer-reviewed.
Surgical and Medical Practices: V.M.Ö., E.M.Y., Concept: E.M.Y., Design: V.M.Ö., Data Collection or Processing: E.M.Y., Analysis or Interpretation: E.M.Y., Literature Search: V.M.Ö., E.M.Y., Writing: V.M.Ö., E.M.Y.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
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