Surgical Ethics: Relationships with Patients, the Profession, and Society Martin McKneally University of Toronto Dept. of Surgery & Joint Centre for Bioethics Principles of Surgery October 5, 2010

“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

“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

Plan of talk What’s an Ethic? Teaching Ethics The Ethic of Surgery Obligations to patients to the team to society

Ethics….What’s 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

Ethics PolicyLaw usuallymust should

Ethics PolicyLaw disapprovalfines/prison censure

Contemplation before surgery Joe Wilder, MD

“Thou Shalt Teach Bioethics” RCPSC 1995

Ethical Issues Taught Formally: Consent, 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

Ethic of Surgery Trustworthiness: Competence Commitment

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

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

Commitment Personal responsibility – uniquely intensified Constancy – warrior energy

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

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

Team Obligations Maintaining the integrity of the team Coworker care: attention to the needs and concerns of team members

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

Societal Obligations of Surgeons Effective subsystems of care Trauma system Cardiac Care Network Cancer Care Ontario CritiCall

Societal Obligations of Surgeons Developing subsystems “Coaching teams” Critical care – Tom Stewart General surgery – Ori Rotstein, Andy Smith, Bernie Langer Orthopaedics – Alan Gross Coach Alan Hudson

Summary: Ethic of Surgery Trustworthiness: Competence Commitment Obligations: Patients Team Society

Office:

Ethical Issues Taught Formally: Consent, 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

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

Ethics PolicyLaw Circumstance Culture Religion Politics should usually must