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Annotated Bibliography of Ethics in Surgery Peter Angelos, MD, PhD The ethical issues faced by physicians have never been more challenging than they are today. New technologies and techniques, increased financial pressures, and greater acknowledgment of treatment limits have put increased ethical pressure on practicing physicians. For surgeons, the need to be aware of ethical questions is perhaps even greater than for other physicians. Surgeons are often those who introduce new techniques or technologies. They are often consulted as the last option for the treatment of critically ill patients. Surgeons are the primary physicians involved in emergency procedures for critically injured trauma patients. A certain familiarity with the current literature on medical ethics can help surgeons to deal effectively with many contemporary ethical dilemmas. This annotated bibliography of readings in ethics has been selected specifically for a surgical audience. First, major ethics books are presented. Second, a small sample of videotapes on ethics is listed. The third and largest section is a list of publications on ethics topics that are particularly relevant to surgeons. The list provides a taxonomy of ethical problems in surgical practice. Although the list is not meant to be exhaustive, it is designed to provide surgeons with an understanding of fundamental issues and to assist them in reaching sound clinical ethical decisions. Books In recent years, several books have been published to provide either an introduction to ethics or a comprehensive overview. Although these texts may not be the most recent review of a topic, they are all useful reference works. 1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th ed. New York: Oxford University Press; 1994. This text has influenced much of the contemporary approach to medical ethics. The authors argue that many issues in medical ethics can be analyzed usefully in terms of the principles of beneficence, nonmaleficence, autonomy, and justice. 2. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 4th ed. New York: McGraw-Hill; 1998. This book uses a simple four-part approach and is designed as a practical handbook for physicians, residents, and medical students. Case presentations address most of the ethical issues faced in medical and surgical practice. References for each chapter are particularly complete. 3. LaPuma J. Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics. New York: Hatherleigh Press; 1998. This collection of published essays examines how the contemporary managed care environment affects many of the traditional ethical issues that physicians encounter. 4. McCullough LB, Jones JW, Brody BA, eds. Surgical Ethics. New York: Oxford University Press; 1998. This recent authoritative text focuses on topics of particular concern to surgeons. The editors have covered issues at the end of life, issues in surgical education, and problems in surgical research. Joint authorship of chapters by a surgeon and an ethicist adds to the practicality of the presentations. An outstanding work. 5. Reich WT, ed. Encyclopedia of Bioethics. Rev ed. New York: Macmillan; 1995. This multivolume encyclopedia provides well-written entries on a broad list of topics in bioethics. It is a useful place to start when exploring most major issues in medical ethics. 6. Reiser SR, Dyck AJ, Curran WJ, eds. Ethics in Medicine: Historical Perspectives and Contemporary Concerns. Cambridge, MA: MIT Press; 1977. This book collects the major primary sources from which contemporary medical ethics has developed. It is an invaluable tool for those who wish to explore what is actually contained in a wide range of ethics documents, from the Hippocratic Oath to Percival's Medical Ethics and the Nuremberg Code. 7. Monagle JF, Thomasma DC, eds. Health Care Ethics: Critical Issues for the 21st Century. Gaithersburg, MD: Aspen Publishers; 1998. This volume provides a contemporary exploration of such important topics as human cloning, human experimentation, the care of the hopelessly ill, and rationing in health care. 8. Herter FP, Forde K, Mark LC, et al., eds. Human and Ethical Issues in the Surgical Care of Patients With Life-Threatening Disease. Springfield, IL: Charles C Thomas; 1986. This anthology addresses numerous subjects not often discussed in ethics texts. For example, sections address the preparation of the patient for surgery, the impact of surgery on body image and function, and the disclosure of incurability. Medical Ethics Videos Videotape has become an increasingly helpful medium with which to explore critical issues in medical ethics. Videotapes are available from the organizations that produce them and also may be found in some medical libraries. They serve as a useful means of encouraging discussion on controversial topics. A few examples of the variety and quality of the ethics videos available are listed below. 1. "Discussions in Bioethics,'' National Film Board of Canada, Ottawa, Ontario, Canada. Although produced approximately 10 years ago, this video provides an excellent introduction to eight important topics in medical ethics. Through a series of eight short, open-ended dramas, critical topics in bioethics are raised and discussion is encouraged. Issues include the right to refuse treatment, allocation of scarce resources, and death through benign neglect. 2. "The Ethical Question: Informed Consent,'' American Medical Association, Chicago, IL. This selection from a three-part series provides surgeons an important opportunity to consider what is entailed in obtaining informed consent from surgical patients. 3. "Out of Control,'' American College of Surgeons, Chicago, IL. This video explores the issue of substance abuse by surgeons and other health care workers by the example of true stories of abuse. Although the topic of substance abuse may seem beyond the scope of medical ethics, it is critically related and must be included for a broader understanding of medical ethics. Further information is available through Ms Linn Meyer at 312-202-5311. Ethics in Surgery–Selected Topics I. Surgical Ethics--An Introduction 1. Hanlon CR. Ethics in surgery. J Am Coll Surg 1998;186:41-49. This recent article explores the historic scope and contemporary breadth of medical ethics. Through a concise review of central themes and writers, Dr Hanlon has grounded many of the current controversies in medical ethics in their historic roots. 2. American College of Surgeons Statements on Principles. Chicago, IL: ACS Board of Regents; 1994. This pamphlet sets forth a series of principles that form the ethical basis upon which fellows of the American College of Surgeons practice surgery. Statements such as the following are included: Appropriate training and qualifications are required to practice surgery. Patients must be treated as the surgeon would wish to be treated. Unnecessary surgery is condemned. The booklet is in no sense a ``code of ethics'' but is rather a collection of statements on pertinent issues, as officially issued by the Board of Regents over the years and periodically updated. 3. Siegler M. Identifying the ethical aspects of clinical practice. Bull Am Coll Surg 1996;81:23-25. This is a concise review of the fundamental principles of contemporary surgical ethics. II. Informed Consent A. Physician-Patient Communication 4. Siegler M. Pascal's wager and the hanging of crepe. N Engl J Med 1975;293:853-857. This early article presents reasons for communicating truthfully with seriously ill patients and their families. 5. Novack DH, Plumer R, Smith RL, et al. Changes in physicians' attitudes toward telling the cancer patient. JAMA 1979;241:897-900. This classic article describes the changes in a single large urban hospital between 1961, when 90% of physicians surveyed stated that they would not tell their patients of a diagnosis of cancer, and 1977, when 97% of physicians stated that they would disclose a cancer diagnosis. 6. Siegler M. Decision making strategy for clinical ethical problems in medicine. Arch Intern Med 1982;142:1899-1902. This article is based on the collaborative model of decision making and presents an easy-to-use four-part approach to make reasonable clinical-ethical decisions. 7. Emmanuel EJ, Emmanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226. A contemporary review of the potential conceptualizations of the physician-patient relationship. The paternalistic model, the informative model, the interpretative model, and the deliberative model are explained and contrasted. 8. Brock DW, Wartman SA. When competent patients make irrational choices. N Engl J Med 1990;322:1595-1599. In this influential article, an attempt is made to distinguish irrational choices from those that simply express different attitudes, values, or beliefs. Based on the concept of shared decision making between physician and patient, the physician should attempt to persuade competent patients to reconsider irrational choices. The complexity of identifying irrational choices is clearly described. B. Confidentiality 9. Siegler M. Confidentiality in medicine: a decrepit concept. N Engl J Med 1982;307:1518-1521. This article questions the contemporary meaning of the concept of confidentiality in an era when many different individuals in a health care institution have legitimate access to the patient's medical record. The author suggests moving beyond the traditional, now largely irrelevant, concept of confidentiality to a more useful notion to benefit patients. 10. McCunney RJ. Preserving confidentiality in occupational medical practice. Am Fam Physician 1996;53:1751-1756. This review article examines United States laws, regulations, and codes of conduct from the medical profession to set forth guidelines for the protection of medical information about patients. Through the use of examples, the author argues that the patient should be the one to decide whether and when to release medical records to employers, unless overruled by public health risks or other pertinent statutes. III. End-of-Life Issues A. Advance Directives and End-of-Life Care 11. Ruark JE, Raffin TA, and the Stanford University Medical Center Committee on Ethics. Initiating and withdrawing life support: principles and practice in adult medicine. N Engl J Med 1988;318:25-30. This excellent review article discusses many of the issues involved in end-of-life care: initiating and withdrawing life support, communication with patients and families, and the importance of advance directives. Several of the most fundamental court cases relating to withdrawing and withholding life support are also reviewed. 12.Cox DM, Sachs GA. Advance directives and the patient self-determination act. Clin Geriatr Med 1994;10:431-443. This review article explains the history of advance directives, their impact, and limitations to their current use. It then explains how the federal Patient Self-Determination Act may affect future practice. 13. The SUPPORT Principal Investigators for the SUPPORT Project. A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995;274:1591-1598. This influential article is based on a multicenter study of preferences, outcomes, and decision making of seriously ill hospitalized patients. This study confirmed the observation of important shortcomings in the care of seriously ill hospitalized patients. 14. Lo B. Improving care near the end of life: why is it so hard? JAMA 1995;274:1634-1636. This author suggests that even though the intervention described by the SUPPORT study may not have changed practice, it does raise important issues. For example, he suggests that only by improving the ability of physicians to communicate with patients about end-of-life issues will the care of seriously ill patients by improved. 15. Wenger NS, Oye RK, Bellamy PE, et al. Prior capacity of patients lacking decision making ability early in hospitalization: implications for advance directive administration. J Gen Intern Med 1994;9:539-543. This report is based on data analyzed from the SUPPORT study (see item no. 13). Because many severely ill hospitalized patients lack decisional capacity even early in their hospitalization, the authors suggest that discussions about advance directives be moved into the outpatient setting and not be delayed until an acute hospital admission. 16. Emmanuel LL, Emmanuel EJ, Stoeckle JD, et al. Advance directives: stability of patients' treatment choices. Arch Intern Med 1994;154:209-217. This prospective cohort study empirically examines the assumption justifying the use of advance directives, which is that a patient's previous treatment choices accurately represent his or her future choices. In this study, most people made moderately stable decisions regarding treatment choices in four different illness scenarios. These empiric data support the use of advance directives. B. Do-Not-Resuscitate (DNR) Orders 17. Blackhall LJ. Must we always use CPR? N Engl J Med 1987;317:1281-1285. This early article reviews the history of cardiopulmonary resuscitation and suggests situations in which resuscitation is not beneficial to patients. The author argues for writing DNR orders on the basis of medical condition alone. 18. Council on Ethical and Judicial Affairs, AMA. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991;265:1868-1871. This set of AMA guidelines reviews the success rates for CPR. On the basis of this review, the Council suggests that both patient preference and medical futility be used as the basis for withholding CPR. 19. American College of Surgeons. Statement on advance directives by patients: ``do not resuscitate'' in the operating room. Bull Am Coll Surg 1994;79:29. This statement on a controversial topic is based on discussions among members of the American College of Surgeons, the American Society of Anesthesiologists, and the Association of Operating Room Nurses. C. Futility 20. Lantos JD, Singer PA, Walker RM, et al. The illusion of futility in clinical practice. Am J Med 1989;87:81-84. This early article showed that the concept of futility includes two different elements: quantitative probability and qualitatively determined goals. The key issue in futility is who has the right to establish the goals of treatment. 21. Schneiderman LJ, Jacker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med 1990;112:949-954. The authors suggest a largely quantitative definition of medical futility. They propose that if a treatment has a less than 1:100 chance of success, it should be considered futile. This article generated much controversy and comment in the literature. 22. Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med 1992;326:1560-1564. This article argues against a purely quantitative definition of futility. The authors suggest that a treatment can be considered futile only on the basis of a particular set of values. As a concept, futility cannot be objectively determined because it requires an individualized and subjective comparison to the value system of a patient. 23. Ethics Committee of the Society of Critical Care Medicine. Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997;25:887-891. This recent consensus statement of the Ethics Committee of the Society of Critical Care Medicine attempts to allow a place for values in defining futility. It defines futile treatments as those that will not accomplish their intended goals. Recommendations are made for implementing policies to limit futile treatments. D. Palliative Care 24. AMA Council on Scientific Affairs. Good care of the dying patient. JAMA 1996;275:474-478. In this policy statement, the AMA Council on Scientific Affairs concludes that further research is necessary on the care of dying patients to understand better the needs of dying patients. More educational programs must be encouraged for all health care professionals. 25. Fox E. Predominance of the curative model of medical care: a residual problem JAMA 1997;278:761-763. This editorial concisely reviews the differences between a palliative-care model of medicine and the more commonly used curative model. The author suggests that the palliative-care model be more widely integrated into medical education and training. 26. Milch RA, Dunn GP. The surgeon's role in palliative care. Bull Am Coll Surg 1997;82:14-17, 48. This article argues convincingly for surgeons to be involved in palliative care. The authors suggest that surgeons are uniquely positioned to have a positive impact on patients even when cure is no longer possible. E. Physician-Assisted Suicide 27. Quill TE. Death and dignity: a case of individualized decision making. N Engl J Med 1991;324:691-694. In this influential article, Dr Quill describes his assistance in the suicide of a personal patient who suffered from leukemia. In very specific and personal terms, the patient's case is described, and Dr Quill's rationale for assisting in her death is presented. This article prompted much of the attention to the issue of physician-assisted suicide in the contemporary medical literature. 28. Brody H. Assisted death–a compassionate response to medical failure. N Engl J Med 1993;327:1384-1388. This review article sets forth several important considerations about the issue of physician-assisted suicide. The author argues that if physicians provide optimal palliative care to relieve terminal suffering and respect the advance directives of patients, the number of patients who request a physician's aid in dying will be considerably reduced. 29. Batavia AI. Disability and physician-assisted suicide. N Engl J Med 1997;336:1671-1673. This article outlines the implications projected for patients with disabilities if physician-assisted suicide is legalized. The arguments are constructed in relation to the 1997 Supreme Court cases involving physician-assisted suicide. 30. Burt RA. The Supreme Court speaks: not assisted suicide but a constitutional right to palliative care. N Engl J Med 1997;337:1234-1236. This editorial examines the Supreme Court's recent decisions in Washington v. Glucksberg and Vacco v. Quill. The author lauds the court's endorsement of palliative care as a required alternative to physician-assisted suicide. 31. Orentlicher D. The Supreme Court and physician-assisted suicide: rejecting assisted suicide but embracing euthanasia. N Engl J Med 1997;337:1236-1239. In this companion editorial to the previous entry, the author argues that by endorsing terminal sedation, the Supreme Court has essentially accepted a form of euthanasia. (Note: This editorial was followed by provocative letters to the editor in N Engl J Med 1998;338:1230-1231.) F. Euthanasia 32. Kinsella TD, Singer PA, Siegler M. Legalized active euthanasia: an aesculapian tragedy. Bull Am Coll Surg 1989;74:6-9, 56. These authors argue against any endorsement of active euthanasia by physicians. They claim that the professional virtue of physicians demands opposition by the profession to the legalization of active euthanasia. 33. van der Maas PJ, vander Wal G, Havercate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;335:1699-1705. This influential study examines changes in the Netherlands between 1990 and 1995 in the practice of euthanasia and physicianassisted suicide. Both opponents and proponents of euthanasia in the United States have used the findings in this empiric study as support for their respective arguments. IV. Research in Surgery A. Randomized Clinical Trials 34. Leffall LD Jr. Ethics in research and surgical practice. Am J Surg 1997;174:589-591. The author reviews the abuses of medical researchers in human radiation experiments in the 1940s and 1950s and the Tuskegee syphilis experiment. He then argues that by maintaining loyalty to one's patient as a central principle, surgeons can maintain high levels of ethical conduct in both practice and research. 35. Lumley J, Bastian H. Competing or complementary? Ethical considerations and equality of randomized trials. Int J Technol Assess Health Care 1996;12:247-263. This review article clearly presents the numerous ethical questions raised in randomized clinical trials. The authors assess ethical issues that pertain to such topics as subject recruitment, communication and consent, and special subject populations including pregnant women, children, and people with mental illnesses. The authors also survey the ethical questions surrounding the issue of when to stop a randomized clinical trial. 36. Emmanuel EJ, Patterson WB, Hellman S. Ethics of randomized clinical trials. J Clin Oncol 1998;16:365-371. This article begins with a detailed case presentation to which Dr Hellman then responds. Dr Hellman raises difficult ethical issues surrounding how the physician may be both an agent of the patient and an agent of society. Questions and answers are included at the end of the article in a Grand Rounds format. 37. Levine RJ. Ethics of clinical trials: do they help the patient? Cancer 1993;72:2805-2810. This article reviews many of the ethical issues facing physicians who participate in clinical trials. Dr Levine argues that randomized clinical trials should be constructed such that patients are given access either to the best standard therapy or to a new treatment that is considered at least equivalent or possibly superior to the standard treatment. If so constructed, clinical trials should be beneficial to patients. B. Informed Consent for Research 38. Silverman HJ. Ethical considerations of ensuring an informed and autonomous consent in research involving critically ill patients. Am J Respir Crit Care Med 1996;154:582-586. This review article explores the quality of the informed-consent process in clinical research. The author examines the issues involved in disclosure, competence, and voluntariness when the research subject is a critically ill patient. 39. Schaeffer MH, Krantz DS, Wichman A, et al. The impact of disease severity on the informed consent process in clinical research. Am J Med 1996;100:261-268. This study examines the ethics of informed consent among subjects with differing disease severity. The authors found that severely ill patients retain the least amount of information in the informed-consent process. The authors suggest that the informed-consent process should include means to ensure subjects' understanding of the inherent risks and alternative interventions available. C. Scientific Integrity 40. Rosenberg SA. Secrecy in medical research. N Engl J Med 1996;334:392-394. This National Cancer Institute researcher outlines four situations in which researchers are often asked to keep confidential information that might be of value in the treatment of disease or illness. In each case, the secrecy was requested to benefit a company or researcher by giving them a competitive edge over other groups working on the same problem. The author argues for scientists to refuse to keep information confidential and refuse to sign any agreements for the transfer of information or reagents that include a requirement of keeping the information confidential from other researchers. 41. Blumenthal D, Causino N, Campbell E, Louis KS. Relationships between academic institutions and industry in the life sciences–an industry survey. N Engl J Med 1996;334:368-373. The authors surveyed senior executives in companies in the fields of agriculture, chemicals, and pharmaceuticals. They found that 90% of companies conducting life-science research in the United States had relationships with an academic institution. More than 60% of the companies reported that their arrangements with universities often included an agreement to keep the results of research secret for the time beyond that which is needed to file a patent. D. Innovative Surgery 42. Moore FD. Three ethical revolutions: ancient assumptions remodeled under pressure of transplantation. Transplant Proc 1988;20:[Suppl 1]:1061-1067. Dr Moore emphasizes that surgical innovation should be based on three key elements: scientific progress and developments, the "field strength'' of the surgical team, and the ethical climate of the institution. 43. Moore FD. The desperate case: CARE (costs, applicability, research, ethics). JAMA 1989;261:1483-1484. In this insightful editorial, Dr Moore comments on two reports of multiple visceral organ transplantations published in the same issue of JAMA. He argues that the claim that desperate times demand desperate remedies is flawed. Dr Moore suggests that there must be some likelihood of success based on early animal studies before such innovative procedures should be tried on humans. He also calls for openness, public display, and community discussion. 44. Singer PA, Siegler M, Whitington PF, et al. Ethics of liver transplantation with living donors. N Engl J Med 1989;321:620-622. Six months before performing the first operation, the authors published ethical guidelines for liver transplantation using living donors. They propose that surgical innovation use a system of prospective "research ethics consultation'' that encourages clinical investigators and ethicists to analyze ethical issues in a collaborative fashion and anticipate ethical issues before protocols are submitted to an IRB. 45. Ross LF, Rubin DT, Siegler M, et al. Ethics of a paired-kidney-exchange program. N Engl J Med 1997;336:1752-1755. The authors describe the process by which they assessed the ethical merits of an innovative approach to increase the numbers of kidneys available for transplantation. The issues of benefits and risks to donors and recipients, coercion and informed consent, privacy and confidentiality, and risks of commercialization and exploitation were all considered before undertaking a pilot study of a paired-kidney-exchange program. V. Ethics in Surgical Education 46. Newton MJ. Moral dilemmas in surgical training: intent and the case for ethical ambiguity. J Med Ethics 1986;12:207-209. The author suggests the importance of surgical residents' developing "correct intent.'' Correct intent is defined as an ethical sensibility that depends on a constant and often painful awareness of the consequences inherent in human interaction. He argues for the importance of medical ethics in providing a systematic approach to help guide actions. He sees difficult choices as creating an opportunity for the fullest expression of moral behavior. 47. Peterson LM. AIDS: the ethical dilemma for surgeons. Law Med Health Care 1989;17:139-144. The author examines the ethical issues involved in decisions to treat or not treat AIDS patients. Although much has been learned about AIDS since this article was published, the ethical exploration of the issues of obligation and medical duty of surgeons is applicable in other situations. He argues that surgeons cannot be expected to take unreasonable risks to their own health. "Reasonableness'' is not a personal preference, but is defined in terms of the likelihood of injury, its adversity, the role played by the surgeon, and the public benefit to be gained. 48. Rappaport W, Prevel C, Witzke D, et al. Education about death and dying during surgical residency. Am J Surg 1991;161:690-692. The authors report the results of a survey of surgical residents in Arizona in 1989. They found that although most surgical residents care for dying patients on a regular basis, few have had any substantive education about death and dying during surgical residency. 49. Holloran SD, Starkey GW, Burke PA, et al. An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery 1995;118:294-299. This article presents the results of an ethics education program on patients in a surgical intensive care unit. The authors found that after the ethics education program, surgical residents showed increased knowledge and skill in addressing and integrating ethical issues into their clinical practices. In addition, patient length of stay decreased in the surgical intensive care unit, and costs were reduced. 50. Downing MT, Way DE, Caniano DA. Results of a national survey on ethics education in general surgery residency programs. Am J Surg 1997;174:364-368. This report presents the findings of a survey questionnaire sent to general surgery program directors in the United States. The authors found that 28% of programs offered no formal ethics education. Forty-eight percent held one teaching event in ethics and 24% conducted two or more such activities. Residencies with a faculty surgeon having expertise or special interest in ethics had a statistically greater number of ethics teaching activities. VI. Resource Allocation A. Ethics and Organ Transplantation 51. Council on Ethical and Judicial Affairs, AMA. Ethical considerations in the allocation of organs and other scarce medical resources among patients. Arch Intern Med 1995;155:29-40. This position paper by the Council on Ethical and Judicial Affairs of the American Medical Association reviews criteria for allocating organs and other scarce medical resources. Issues such as quality of life, expected benefit, urgency of need, and patient behavior that may have contributed to the disease process are considered as factors. The Council specifically rejects the use of social worth as a factor in the allocation of scarce resources, including organs. 52. Glannon W. Responsibility, alcoholism, and liver transplantation. J Med Philos 1998;23:31-49. This author fully examines the issue of patient responsibility for alcoholic liver disease. He argues that the cause of alcoholism may involve enough control for the alcoholic to be responsible for his or her condition; such a patient would have a weaker claim to receive a new liver than someone who acquires the disease through no fault of his or her own. 53. Ubel PA, Arnold RM, Caplan AL. Rationing failure: the ethical lessons of the re-transplantation of scarce vital organs. JAMA 1993;270:2469-2474. The authors examine the rationale for giving patients who have previously received a transplant a higher ranking on the priority list to distribute organs. The authors argue that because the efficacy of retransplantation is less than for primary transplantation, the system for allocating organs should be revised so that primary-transplant candidates have a better chance of receiving organs than do retransplant candidates. 54. Burdick JF, Klein AS, Harper AM. The debate over liver allocation in the United States: the UNOS perspective. Clin Transpl 1996;322-324. The authors present the perspective of the United Network for Organ Sharing on the appropriate means to allocate the small number of livers available for transplantation. 55. Ubel PA, Caplan AL. Geographic favoritism in liver transplantation--unfortunate or unfair? N Engl J Med 1998;339:1322-1325. The authors suggest that the discrepancy among lengths of waiting lists in different areas of the country is unfair to patients on those lists. They argue for a single national waiting list for livers and the critical examination of data to maximize the efficacy of the transplants. B. Rationing of Care 56. Pellegrino ED. Rationing health care: the ethics of medical gatekeeping. In: Monagle JF, Thomasma DC, eds. Health Care Ethics: Critical Issues for the 21st Century. Gaithersburg, MD: Aspen Publishers; 1998:413-420. Dr. Pellegrino examines the conflicts of interest inherent in the physician's role as gatekeeper. The physician's traditional role of ordering appropriate tests and treatments is compared with the negative gatekeeper role seen in managed care environments, where typically a primary care physician must limit tests and hospital days for the financial benefit of the managed care system. The negative gatekeeper role is ethically problematic because the physician's interests are in conflict with those of the patient. 57. Hackler C. Is rationing of health care ethically defensible? In: Monagle JF, Thomasma DC, eds. Health Care Ethics: Critical Issues for the 21st Century. Gaithersburg, MD: Aspen Publishers; 1998:371-377. This article examines the concept of rationing. The author explains different understandings of the concept of rationing and then questions what situations would make rationing ethically justifiable for health care. He argues that rationing will be defensible if funding is truly needed for other essential social goods and services, if alternative ways of limiting medical spending have been attempted, if money saved will be directed to more compelling needs, and if limits to resources are applied equitably to everyone. 58. Mariner WK. Rationing health care and the need for credible scarcity: why Americans can't say no. Am J Public Health 1995;85:1439-1445. This article examines the reasons why Americans refuse to accept limitations to spending on their own health care. First, the complex public and private health insurance financing mechanisms in the United States do not limit the total health care resources generally available. A second reason is the general belief that everyone is entitled to a long life of unlimited good health. Real scarcity of health care may be necessary before Americans are willing to set limits on their own use of medical care. C. Third-Party Issues 59. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-329. To consider the potential impact of managed care on the physician-patient relationship, the authors construct an ideal conception of this relationship. The ideal can be summarized by six C's: choice, competence, communication, compassion, continuity, and (no) conflict of interest. When considering these six aspects of an ideal physician-patient relationship, the authors identify numerous potential threats in a managed care environment. 60. Christensen KT. Ethically important distinctions among managed care organizations. J Law Med Ethics 1995;23:223-229. This article examines the different varieties of managed care organizations. The author suggests that managed care is not a single entity but a broad category that includes a variety of health care delivery structures and practices, relationships with physicians, and physician incentives. The author argues for an ideal HMO to be a nonprofit organization with physician income based on salary where the clinical practice is managed by physicians. VII. Medical Genetics A. Research Issues 61. Clayton EW, Steinberg KK, Khoury MJ, et al. Informed consent for genetic research on stored tissue samples. JAMA 1995;274:1786-1792. This multidisciplinary panel was asked to make recommendations about obtaining informed consent for genetic research on tissue samples that have been stored previously. The authors identify several benefits and risks to individuals, researchers, and society when genetic research is undertaken on stored tissue samples. The panel recommends that informed consent be required for all genetic research using samples that can be linked to individuals. Informed consent is not required for genetic research using anonymous samples. 62. Reilly PR, Boshar MF, Holtzman SH. Ethical issues in genetic research: disclosure and informed consent. Nat Genet 1997;15:16-20. These authors raise several potential ethical issues related to the consent process associated with genetic research. They argue for full disclosure and consent from subjects. Such disclosure should include: a general description of the nature of the study; identification of the research team; privacy guidelines for the study; the plans, if any, to distribute and use the subjects' DNA for other projects; the potential development of products for commercial gain; the potential that other sensitive biologic information (such as nonpaternity) will be revealed; and the potential consequences of the findings of the study. B. Clinical Issues 63. Dickens BM, Pei N, Taylor KM. Legal and ethical issues in genetic testing and counseling for susceptibility to breast, ovarian and colon cancer. Can Med Assoc J 1996;154:813-818. This review article explores several of the ethical issues associated with genetic testing and counseling currently used to determine susceptibility to breast, ovarian, and colon cancer. The authors suggest that individual consent should be obtained to pursue genetic testing. This consent process should involve a discussion of the potential risks to the subject when genetic susceptibility to a disease is diagnosed. 64. Callahan TC, Durfy SJ, Jonsen AR. Ethical reasoning in clinical genetics: a survey of cases and methods. J Clin Ethics 1995;6:248-253. This article reports the results of a review of the literature for cases in clinical genetics used to illustrate ethical issues. The authors found that most ethics cases presented in the clinical genetics literature were used to illustrate an ethical dilemma. In few cases was a resolution to the dilemma suggested, and in only a small portion of those cases was the resolution supported by ethical reasoning. The authors recommend that ethical reasoning in clinical genetics will be improved if all presentations of cases include recommendations or resolution of the case and an explicit description of the mode or modes of ethical reasoning used in the case. 65. Juensgst ET. The ethics of prediction: genetic risk and the physician-patient relationship. In: Monagle JF, Thomasma DC, eds. Health Care Ethics: Critical Issues for the 21st Century. Gaithersburg, MD: Aspen Publishers; 1998:212-227. The author examines the implications of genetic information about patients and family members. A new vocabulary is proposed when discussing genetic testing. The author wishes to distinguish among diagnostic genetic tests, prognostic genetic tests, predictive genetic tests, prophylactic genetic tests, probabilistic genetic tests, and genetic profiling. VIII. Special Topics in Surgical Ethics 66. Wilder BL. Ethical issues related to the new reproductive technologies. Curr Opin Obstet Gynecol 1995;7:199-202. This review article explores the central ethical issues raised by new reproductive technologies and how these affect physicians' personal ethical values. 67. Andrews L, Stocking CB, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997;349:309-313. This article is the only prospective study of surgical error. Over a 9-month period, the authors studied 10 surgical services on 3 surgical units, including a surgical intensive care unit. 68. Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations. J Clin Ethics 1997;8:330-335. These authors suggest guidelines for physicians to use when responding to medical errors. They argue for full disclosure to patients, honesty in communication, and apology to uphold the ethical responsibilities of the medical profession after an error has occurred. 69. Peppin JF. Pharmaceutical sales representatives and physicians: ethical considerations of a relationship. J Med Philos 1996;21:83-99. The author reviews the history of pharmaceutical sales representatives and their interactions with physicians. He explores the assertion that this relationship may jeopardize the physician-patient relationship. 70. de Chalain TM. Ethical resource allocation and the quest for normalcy: is pediatric reconstructive surgery justified? Plast Reconstr Surg 1997;99:1184-1191. The author, a plastic surgeon, argues that there are ethical concerns with expending resources for reconstructive plastic surgery on children with non-life-threatening congenital anomalies. He concludes, however, that it is ethically defensible to apply resources for the correction of minor congenital anomalies in children. 71. Castor TD, Meier DE, Levy RN. Ethical aspects of care of the geriatric orthopaedic patient. Clin Orthop 1995;316:93-98. The authors explore the conflict between offering the elderly the functional enhancement permitted by modern orthopaedic techniques and the financial incentives to limit surgical interventions in a managed care environment. Appendix–Selected Medical Ethics Journals For those who are interested in a more detailed analysis of many contemporary issues in medical ethics, a variety of excellent journals are available. The following journals can be found in most large medical libraries. Cambridge Quarterly of Healthcare Ethics Hastings Center Report Journal of Clinical Ethics Journal of Medical Ethics Medicine, Health Care and Philosophy Journal of Theoretical Medicine Kennedy Institute of Ethics Journal Linacre Quarterly Medical Humanities Review Acknowledgment: Received January 25, 1999; Accepted January 25, 1999. Journal of the American College of Surgeons
Online February 29, 2000
by the American College of Surgeons, Chicago, IL 60611-3211 |