October 11, 2023
Surgeons face clear challenges in contemporary healthcare, including growing administrative and economic burdens, workforce issues, and the continuing necessity of improving quality and safety. But some of surgeons’ most persistent dilemmas are often less described, less discussed, and more nebulous—the ethical challenges faced in daily practice.
Surgical ethics has its basis in broader medical ethics, but the unique nature of a surgeon’s work—particularly the necessity of causing some bodily harm to induce greater healing—necessitates a distinct perspective. The ACS has played an important role in defining some of the core ethical issues that surgeons face. For example, the 2006 textbook, Ethical Issues in Clinical Surgery, has served as a lodestar for guiding discussion on surgical ethics for more than 15 years and was further refined in the 2017 ACS textbook, Ethical Issues in Surgical Care.
But are the issues raised by surgical ethicists in these and related texts still relevant to all surgeons?
To answer that question, authors of a recently released Journal of the American College of Surgeons (JACS) article1 interviewed attending surgeons at a single institution to get their thoughts on the primary ethical challenges they face, revealing what has been consistent and what has changed in surgical ethics.
In the JACS article, study authors and experts in the field share their thoughts on modern surgical ethics, the impact that ethical dilemmas can have on surgeons and their well-being, and how education can address surgeons’ burdens.
Ethical Issues in Clinical Surgery identifies six core themes that cover a broader set of topics in surgical ethics: Competition of interests, truth-telling, confidentiality, professional obligations, end-of-life care, and surrogate decision-making. In the JACS article, the interviewed surgeons provided their thoughts on the pressing ethical issues they regularly face, and four of the six core issues were identified by modern practicing surgeons:
Meanwhile, issues related to confidentiality and surrogate decision-making were not identified. These results were largely in line with the expectations of the authors.
“The themes that we found were quite well encompassed by the original six themes laid out in Ethical Issues in Clinical Surgery,” said Katherine Fischkoff, MD, FACS, a general and acute care surgeon at Columbia University in New York, New York, and coauthor of the JACS article. “But the shift away from the confidentiality issue, for example, and the surrogate decision-making suggest effective education and policymaking around those issues.”
Dr. Fischkoff raises a key point regarding the ethical issues that weigh on surgeons: the formerly identified challenges related to confidentiality and surrogate decision-making have been addressed enough through training, institutional policy, or law such that they occupy a less theorical ethical space and a more tangible, consequential one.
“Confidentiality used to be a big deal, but we don’t think of it so much as an ethical issue because now it’s part of the law. If you choose to reveal personal information about a patient to a third party, you will face consequences for it,” said Peter Angelos, MD, PhD, FACS, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics and director of The MacLean Center for Clinical Medical Ethics at The University of Chicago Medicine in Illinois. He also wrote an invited commentary in response to the JACS article.2
“There are major legal ramifications now to breach confidentiality, whereas that used to be primarily an ethical responsibility rather than a legal responsibility,” he said.
Updates to the Health Insurance Portability and Accountability Act provided the legal basis for hospitals and healthcare institutions to demand training and education on the topic. Similarly, surrogate decision-making often is included in hospital procedures, with patients routinely asked about living wills that designate someone as durable power of attorney for healthcare at the time of admission.
The guidelines and practices applied to these two formerly notable challenges suggest that yesterday’s ethical challenges could be tomorrow’s accepted processes, but the nature of the four consistent challenges makes that potential transition more complex.
“I think part of the reason that professional obligations, financial concerns, end-of-life care, and truth-telling persist as challenges is because it’s hard to make a rule about things such as futility at end of life, or when you’re covering a colleague’s patients and you disagree with their management,” Dr. Fischkoff said.
While most of the originally described six core ethical challenges remain extant in surgeons’ practices, and some have faded from attention in law and policy, the JACS study revealed a dilemma that has become more prominent—pressure to provide medically unindicated care, outside of end-of-life scenarios, that comes both from patients and colleagues.
Interviewees noted a tension between what patients want or think they need in scenarios where the surgeon thought the procedure would be of questionable benefit or safety. At the same time, medical or interventionalist colleagues sometimes push surgery aggressively while not considering factors related to a specific surgery on a specific patient.
When considering the reason pressure to provide potentially unindicated care has increased, one can look at the advanced state of modern medicine and the potential afforded by surgery.
“I think the complexity of medical care has made these issues come up more, particularly around surgery,” Dr. Fischkoff said. “We have more interventions that we can offer. Patients are kept alive longer, particularly when we’re talking about futility at the end of life. The issue has grown exponentially because of technology and our general advancement in the surgical world.”
Growing pressure to provide care intersects with several of the other consistent ethical challenges that surgeons face, such as the professional obligations to support their colleagues when cross covering patients. In these situations, surgeons are faced with potentially operating on a patient, without having pre- or postoperative continuity or, conversely, being forced to choose whether to operate on a patient whom they may not have advised for surgery.
“If I’m cross covering at night for my partner who has told the patient that they ought to have an operation, which is scheduled for tomorrow, and I get called in the middle of the night because of an issue and I’m not sure that operating is the right thing to do, I’m in a tough spot,” Dr. Angelos said. “I don’t really have a long-term relationship with this patient. I’m just cross covering, but I’m being asked to justify a course of action that I may not have chosen.”
Further complicating these ethical queries are economic and financial considerations. There often is a financial incentive to operate on someone as opposed to not operate on someone, and health systems are increasingly pressured to be cognizant of the bottom line.
“These are ethical dilemmas about wanting to support the economic health of the places we work, which is natural. But, feeling that those decisions sometimes don’t center on the patient and aren’t in alignment with our principles, is distressing,” said Carter Lebares, MD, FACS, a general surgeon and director of the University of California, San Francisco Center for Mindfulness in Surgery.
As Dr. Lebares and the authors of the JACS study note, that lack of alignment—the friction between the guiding principles of beneficence that generally drive physicians, and the realities of working in modern healthcare that increasingly focuses on an economic bottom line—can create moral distress for surgeons. Moreover, such misalignment of values and motivations can dramatically effect surgeon well-being and increase the risk of burnout.
Navigating this unique dynamic and attempting to give patients exactly what they need within the constraints of a health system, whether that is surgery, mental health services, medical weight management, and so on, can exact a heavy toll. And, unfortunately, daily ethical dilemmas present themselves against a backdrop of other increasing burdens.
“In combination with everything else that is difficult about modern practice, like documentation, handoffs, and case volume among the other necessary items on your task lists, these difficult ethical cases can be very time consuming and emotionally draining, and I think that’s why they feel extra hard,” said Dr. Fischkoff.
“To maintain well-being, we need to pay attention to things that amplify burdens as well as those that amplify rewards. Moral distress has a significant negative impact,” Dr. Lebares said, whereas relationships in medicine are often at the heart of our deepest rewards. “At the hub of many of our ethical issues is our deep respect for the physician-patient relationship, and the profound value we derive from belonging to the fellowship of surgeons. These relationships give us so much,” Dr. Lebares said.
Therefore, focusing on systems, guidance, and resources that facilitate relationships—colleague to colleague, and surgeon to patient—especially in the realm of ethical dilemmas, can help us discern between our personal opinions and our professional responsibilities. Education, guidelines, and built-in support systems (such as standardized practices surrounding living wills and confidentiality), can reflect ethical principles agreed upon by the medical community. Support scaffolds like this can help surgeons maintain relationship trust while ameliorating the burden of navigating these dilemmas alone.
The JACS study suggests that practicing surgeons are grappling with ethical dilemmas in the regular course of their work. However, the ability for surgeons to navigate these challenges can be hindered by a lack of awareness of ethical guidance from institutions both in training and while in practice.
Healthcare institutions have a powerful role in creating an atmosphere that promotes discourse and taking time to consider the ethical implications of patient care.
Is the setup of the system one that encourages ethical activity and ethical behavior, or is it one that tends to discourage it? Is it an institution where physicians feel like they are going against the flow if they’re trying to make decisions on behalf of their patients that they think are ethical? These questions are at the heart of institutional ethics, according to Dr. Angelos.
“The comfort that a surgeon has in advocating for a patient in the face of economic pressures is more an influence on the part of a health system, rather than an individual surgeon making recommendations for an individual patient,” he said.
The foundation of a supportive institution—as well as any policies or laws that alleviate the burden of surgical ethical challenges on practicing surgeons—is education.
Currently, there are few options for individuals or institutions to engage in standardized surgical ethics education. Rather, much of how surgeons learn about moral and applied ethics in practice comes through mentors and colleagues in what is described as the “hidden curriculum.”1 However, because this informal process may not be sufficient to help guide surgeons through difficult ethical challenges, a standardized curriculum could be a powerful tool.
Interviewees in the JACS article were broadly supportive of a dedicated surgical ethics curriculum that goes beyond the ethics taught in medical school. Even surgeons who might be initially skeptical of formal ethics training often reveal their interest in the field simply through conversation.
“We love to talk about ethics—we talk about it in in the hallways, we talk about our really difficult cases, the ones that weigh on our minds, the ones that are stressful,” Dr. Fischkoff said. “When we interviewed people, they would relay all kinds of experiences, from the challenge they faced 10 years ago or the argument they had 1 week ago.”
Harnessing that interest and packaging it into a practical, useful form is the ask, and the theoretical nature of the field leaves education or a curriculum up to a broad range of ideas. Dr. Fischkoff suggests basing education within real cases, and it could be folded into Morbidity and Mortality Conferences, dissecting cases that had surgical or medical complications.
“I think it would be very useful both within case complications already being presented to talk about the ethical issues, as well as to talk about a case specifically because it had really complicated ethical issues,” she said. “Maybe we’re not focusing on the death of that patient but discussing the ethical difficulties of the case. Perhaps the patient was dying, and the family wanted me to do everything I could, and I did a laparotomy, but then she died that night, and I wonder if she didn’t need to have that procedure at all.”
These experiences tend to resonate with fellow surgeons, and it can be particularly important to share them with residents, since younger surgeons often are at the frontline of communicating with patients.
“Understanding that there is a steep learning curve in medicine in general and that many of the ethical issues that go along with it make some cases more difficult, will get better over time,” Dr. Fischkoff said.
And because of the connection between managing ethical challenges and surgeon well-being, Dr. Lebares suggests that an ethics curriculum could reasonably fall under a longitudinal well-being curriculum for trainees and/or those in early practice.
“We know there is a mind-body connection at the heart of stress and well-being. Equipping people with cognitive skills to recognize their own distress and create space between their feelings and their reactions, can allow surgeons to look at challenging situations with less reactivity, entanglement, and suffering,” she said.
With the added guidance of experts—especially surgeon-ethicists who understand the issues that surgeons face daily—and the development of consensus guidelines, the field of medicine can improve surgeons’ abilities to meet ethical challenges head on with equipoise.
“Ethical decision-making is a skill. What is the branching pathway through our thinking and decisions to determine the right thing to do?” Dr. Lebares asked. “If we learn some emotional regulation and have experts teach us underlying principles, we simultaneously improve well-being by reducing the stress of feeling like we’re in the middle of the ocean, where the water is deep and the waves are big, and we don’t know how to get to shore.”
The ACS is one of the only organizations dedicated to exploring surgical ethics that are broadly applicable throughout the field. According to Dr. Angelos, the College can contribute strongly to further defining and responding to surgeons’ ethical challenges.
“There is no group that speaks for the world of surgery like the ACS,” he said, adding that the College is in position to create and promulgate basic minimal curricular requirements in surgical ethics.
“It isn’t for the ACS to tell a surgeon what is right and wrong, but rather that these are issues that everybody ought to be conversant in,” said Dr. Angelos. “We ought to know that they are challenging, that they require a lot of thought, and that if, as a new surgeon, we feel some moral ambiguity about what the right thing to do is in a certain scenario, we can refer to examples or resources from the College and talk to our colleagues about it.”
The ACS is well-known as a leader in developing best practices for surgeons across the continuum of care, Dr. Lebares said, and could take on a similar role in ethics.
“The ACS historically has been involved in establishing standards for the field, with the National Surgical Quality Improvement Program, for example, changing how surgeons define and incorporate best practices,” she said. “Having an organization that supports ethics and gives it a level of seriousness is something the College is critically positioned to do.”
There is a spectrum of ethical challenges that surgeons face in their daily practice. However, these shared themes suggest that a collective voice could lead surgeons across disciplines to better understand their own needs and the needs of their patients, as well as equip surgeons with tools to navigate the sometimes winding path of how to do best by their patients and their profession.
Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.