Slides on Surgical Ethics

1. Surgical Ethics
Dr.Kamalakannan.K

2. Points to discuss
❖ Define Ethics - Modern Oath
❖ Surgical Ethics - Framework & its Virtues
❖ Ethical Issues & its Considerations
❖ Principles of Surgical Ethics
❖ Four Box Model Approach
❖ Patients Expectations
❖ Implications & Perspectives

3. Ethics means Character !!! (Ethics
word dervied from greek word –Ethos)
● To put it formally - Ethics is the
branch of philosophy that defines
what is good for the individual
and for society and establishes
the nature of obligations, or
duties, that people owe
themselves and one another.

4. Ethics …
● Greek healers in the 4th
Century B.C. drafted the
Hippocratic Oath and pledged
to – “prescribe regimens
for the good of my patients
according to my ability and
my judgment and never do
harm to anyone”

5. Medical Ethics may be traced to guidelines on the duty of
physicians such as the Hippocratic Oath

6. Noble Profession
Possessing outstanding qualities
like eminence,dignity,commanding
excellence of mind,character or
high ideals or morals.
“The very term Doctor demands
Respect.
The very term Surgeon demands
Greatness.

8. Percival Thomas (1849)
Medical Ethics
Helsinki meet - Declaration of Geneva
“Nuremberg Code”
The International Code of Medical Ethics in 1948

9. Surgical Ethics - Prior to 400 B.C
Ayurvedic Surgical Practices is like
“Guru - Sishiya tradition”
Helped to design principles in surgical
academics and ethics

10. Surgery
❖ The practice of surgery is based on the technical capabilities
of the surgeon (techne), their knowledge (episteme) and
their capacity of judgment (phronesis).
❖ Surgeons face situations that call into question moral
choices and face ethical difficulties in their daily practice.
❖ In fact, innovation is increasing, and as operations become
more complex and the risks become greater, the tools
necessary to approach an ethically challenging surgical case
become more important.

11. Surgical Ethics - Framework for
Surgeons/Patients/Society
● Surgical ethics can be distinguished from other medical
ethics fields because of its unique characteristics and goals.
● Ethics lie at the core of professionalism: a proficient surgeon
is considered to be not only competent to perform the art and
science of surgery as traditionally understood, but also to be
ethically and morally reliable.

12. Virtue in Surgical Ethics
● Ethics is an essential discipline in
the practice of surgery.
● Represents your best understanding
of moral responsibility.
● Evolves as reasoned reflection on
clinical experience.
● Role of the Surgeon is to act as the
patient’s fiduciary (person to whom
property or power is entrusted for
the benefit of another).

13. Virtue in Surgical Ethics …
● Ethical study investigates what should be our character and
conduct.
● 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.

14. Ethical Issues in Surgery
Surgical decision-making can be viewed as a two-part process.
1. Firstly, there is the ‘is it possible to treat’ or ‘how to treat’
aspect, which is a matter of knowledge and technique (i.e.
surgical science).This is translated into an evidence-based
practice.
2. Secondly, the ‘why treat’ or ‘what should be done’ issues,
which are a matter of surgical ethics and should be based on
moral philosophy.

15. Ethical Considerations - New Techniques/Technology
• How is the safety of a new technology or technique ensured?
• What is the timing and process by which a new technology or technique is
implemented at a hospital?
• How are patients informed before undergoing a new technology or technique?
• How are surgeons trained and credentialed in a new technology or technique?
• How are the outcomes of a new technology or technique tracked and
evaluated?
• How are the responsibilities to individual patients and society at large balanced?

18. The paramount responsibility of physicians when caring for patients is to the patients,
placing their interests ahead of all other interests, personal and professional .
One of the fundamental principles of medical ethics is respect for the right of individuals
to make decisions about what will happen to their own bodies and to act upon those
decisions; this is known as the principle of respect for patient's autonomy.
The manifestation of this principle in the practice of medicine is informed consent, which
comprises three essential elements:
1. the preconditions for decision-making (capacity to make decisions and
voluntariness),
2. the provision of information (disclosure of relevant facts and recommendations)
and
3. consent (including both the decision itself and authorization for others to act on the
patient's decision) .

20. Respect for Autonomy
Patients should be treated as autonomous agents. This means
recognizing the individual's capacity for self-determination,their
ability to make independent decisions and authentic choices
based on personal values and beliefs.
● Patients with diminished autonomy are entitled to protection.
● Autonomy does not mean that a patient has the right to obtain
any treatment he or she wishes or requests if this particular
treatment is not medically indicated.
● Autonomy can only be exercised after having obtained full and
appropriate information as well as having understood it. The
● decision has to be taken without any undue coercion or pressure.

22. Informed Consent
● Informed consent plays a highly significant role in the patient-surgeon relationship.
● For patients waiting to undergo surgery, obtaining informed consent is the surgeon’s
final step in the information process, and giving informed consent is an important
decision that the patient must make freely and independently.
● For informed consent in surgery, the legal principle emphasizes that the patient is an
independent adult who has the capacity and the competence to authorize that which
is going to be done to their body and mind.
● Therefore, any operation that may infringe upon this principle is not only considered to
be illegal and liable to result in lawsuits for unlawful injury caused to the patient, it is
also ethically unacceptable.

24. Beneficence
The principle of beneficence imposes an obligation to act for
the benefit of the patient.
● Surgeons have to follow professional obligations and standards.
● Surgeons should provide appropriate surgical intervention in response
to a medical indication and following the consent of the patient.
● Each decision must be taken on an individual level.

26. Nonmaleficence
The principle of nonmaleficence imposes an obligation not to
inflict harm on others.
● Surgery should minimize possible harm.
● Surgeons must assess the nature and scope of the risks and
benefits.
● If the risks and burdens of a given surgery for a specific patient
outweigh the potential benefits, then the surgeon has an
obligation not to operate.

28. Justice
The principle of justice refers to equal access to health care for all.
● Limited resources including the time surgeons and other health
personnel and caregivers devote to their patients must be evenly
distributed to achieve a true benefit for the patient.
● Resources should be distributed fairly without any discrimination.
● With regard to limited resources, there must be proper use of ethically
appropriate and transparent criteria.

29. Four Box Model Approach

30. Patients Expectations
Surgical ethics were defined by the English
surgeon Miles Little in five categories within
the moral domain of the surgical relationship:
1) Rescue
2) Proximity
3) Ordeal
4) Aftermath and
5) Presence

31. Patients Expectations…
According to Pellegrini, the tenets of a modern
competent surgeon include the following
characteristics:
1) good clinical skills and appropriate surgical
judgment;
2) good technical skills, including knowledge of
and expertise in the performance of operations;
3) knowledge and practice of humanism, ethics,
and solid moral values

33. Implications & Perspectives
● Surgical ethics are an essential component in contemporary
surgical practice. The success of even the most
technically skillful surgery requires an ethical approach.
● In fact, what makes a good surgeon is the balance of
technical questions and surgical ethics reasoning.
● The acknowledgement of the importance of surgery ethics
should have implications to patients, surgeons, and society

34. Implications & Perspectives - Surgeons
● Surgeons must stop being regarded as callous, tireless and
invincible professionals.
● Surgeons should be skilled in the art and science of surgery
and be trustworthy from an ethical and moral standpoint.
● Surgeons should rely upon their judgment and their values
and beliefs to make ethical decisions, and if necessary, to
take difficult decisions to an ethical consultation or
committee

35. END OF LIFE -ISSUES
● In unusual circumstances (close to death) that no evidence shows
that a specific treatment desired by the patient will provide any
benefit from any perspective, the physician need not provide such
treatment.
● If there are no treatment options ie the patient is brain dead and the
family insists on treatment - If there is nothing that a physician can do
, treatment MUST BE STOPPED.
*Note - Updates must be in case sheet along with senior physician
comment.

36. Research
● Surgeons have a subsidiary
responsibility to improve operative
techniques through research, to
assure their patients that the care
proposed is best.
● The administration of such regulation
is through research ethics
committees, and surgeons should not
participate in research that has not
been approved by such bodies.

37. Good Standards
● To optimise success in protecting life and
health to an acceptable standard, surgeons
must only offer specialised treatment in
which they have been properly trained.
● To do so will entail sustained further
education throughout a surgeon’s career in
the wake of new surgical procedures.
● To do otherwise would be to place the
interest of the surgeon above that of their
patient, an imbalance that is never morally
or professionally.

38. The greatness of Surgeon is measured beyond Qualification !!!
Skill
Academic Brilliance
Intelligence
Creativity
Courage
Perseverance
Leadership Qualities
Professionalism
Ethical Practice
Successful Surgeon

39. ★ A good Surgeon knows how to Operate
★ A better Surgeon knows when to Operate
★ The best Surgeon knows when not to Operate

40. Righteousness
&
Wrongfulness

41. Few Takeaways
❖ The practice of surgery is based on the technical capabilities of the
surgeon (techne), their knowledge (episteme) and their capacity of
judgment (phronesis).
❖ The principlism and the four-box model approaches to clinical
ethics could serve as a guide to the surgical ethics discussion.
❖ There are five categories of experience and relationships that are
especially important in surgery-rescue, proximity, ordeal, aftermath
and presence.
❖ Ethical reasoning should help surgeons to gives answers to the
questions: What should be done? Has the right decision in this
situation been made?

42. “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