1. The Ethic of Surgery Professional Obligations of Surgeons Surgical Competence Martin McKneally University of Toronto Dept. of Surgery & Joint Centre for Bioethics Principles of Surgery April 27, 2010

2. Case 1 Dr. Innovatore is performing a new minimally invasive procedure. Tension rises in the operating room as he struggles with the technical aspects of the operation. The operating team becomes increasingly concerned that Dr. Innovatore is unable to complete the procedure.

3. Question 1 What should the resident do to resolve the moral quandary of participating in Dr. Innovatore’s operation when he is not meeting the standard of competence?

5. Question 2 What is the standard of competence to which Dr. Innovatore should be held?

6. Question 3 Is Dr. Innovatore behaving unethically?

7. Ethic Values, principles and beliefs that guide the behaviour of a specified group “What we should do” Codes of conduct

8. Ethic of Surgery Trustworthiness: Competence Commitment

9. 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 in the right way Technical Skill - sufficient to perform the surgical intervention - minimum of risk - high probability of benefit

10. Question 4 Do residents bear moral and legal responsibility for the outcome of operations in which they participate? In other words, are they surgeons, or are they students?

12. Graded Responsibility Resident (adj.) a resident surgeon resides in the hospital to provide on site care & emergency treatment Residents are responsible for the procedures performed at their level of proficiency Graded Responsibility in Operative Surgery U of T Dept of Surgery

13. What do patients think about you?

14. Case 1 continues Dr. Innovatore is performing a new minimally invasive procedure. Tension rises as he struggles with the technical aspects of the operation. The team becomes increasingly concerned that Dr. Innovatore is unable to complete the procedure, and that he may be operating under the influence of alcohol, a problem that has troubled him in the past.

15. Question 5 How should deficiencies in competence related to alcohol, chemical dependency, or illness (stress, depression…) be managed?

16. Case 1 continues As Dr. Innovatore ages, his judgment seems to be failing. The team feels he tends to perform unnecessary surgery, perhaps to maintain his income… He has become dependent on residents to complete the more challenging components of his operations….

17. Question 6 How should deficiencies in competence related to age be managed? Departmental policy Review by SIC Report to trustees

18. Surgeon in chief responsible and accountable to the community through the hospital trustees for the safety of the operating room and the competence of surgeons on the staff. Hospital trustees accountable to the community for the safety of health care at their institution; obliged to verify the competence of practitioners under their supervision or employment.

19. Question 7 Are residents competent to operate independently? Residents are morally and legally responsible for the outcomes of the interventions that are deemed by their supervisors to be appropriate to their level of training.

20. Graded Responsibility Residents are expected to be able to operate as independent specialists at the completion of their training. Staff surgeons are expected to supervise the independent operative experience of residents according to their level of proficiency. Graded Responsibility in Operative Surgery U of T Dept of Surgery

21. Question 8 How can I justify performing an operation when there is a surgeon available who is more experienced or skilled than I am?

22. Competence is a threshold attribute drive, fly, operate Expertise is a graduated attribute Natural limits determine appropriate distribution of expertise: distance, volume, resources

23. Most patients rely on trust.

24. Trust: Reliance on others’ competence and willingness to look after rather than harm things one cares about. Annette Baier

25. Trust provides an alternative to vigilance and rational calculation of risks, benefits, and alternatives. Annette Baier

26. Contemplation before surgery Joe Wilder, MD

27. Department of Surgery website: www.surg.med.utoronto.ca RCPSC ethics curriculum in surgery: http://rcpsc.medical.org/ethics/surgery/index.php

28. martin.mckneally@utoronto.ca Surgical ethics Certification of ethics education

29. Acknowledgements Paintings by Robert Pope and Joe Wilder Deborah McKneally, The Ravine Research and Education Centre