Jerry’s Ethical Framework Analyzes Nonhuman Animal Use in Surgical Skill Development

This viewpoint article examines the ethical implications of using nonhuman animals in surgical training, drawing on personal and professional experiences.

Reflecting on my interactions with animals, I explore my past involvement in live tissue training (LTT), from medical school to surgical residency and beyond. I critique the traditional justification for animal use in training and surgery, highlighting the moral standing of animals and the limitations of utilitarian reasoning. The article also evaluates the effectiveness of LTT in preclinical, nonsurgical, and surgical settings, questioning its educational value and ethical justification. It advocates for alternatives that respect animal welfare while advancing medical education.

In addition, this article critically examines the moral implications of using LTT in three scenarios: preclinical training, nonsurgical specialist training, and surgeon training. It evaluates whether these practices align with evolving ethical standards and explores alternatives that respect the intrinsic value of all sentient beings.

As I write, Jerry, a Husky adopted by my son during the pandemic, rests beside my desk. Jerry has become an integral part of our family, embodying the bond and values that many place on companion animals. His presence prompts me to reflect on my experiences in medical training and research.

As a medical student in the 1980s, I participated in a “surgical techniques” lab that used dogs. Later, as an instructor for the same course, I taught others these methods. During my year of surgical research, I conducted kidney transplants in hypertensive rats and performed biliary and intestinal reconstructions in dogs, justifying their use as essential for advancing surgical knowledge.

As a surgical chief resident, I helped pioneer laparoscopic techniques, using pigs to develop skills foundational to modern minimally invasive surgery. Finally, teaching Advanced Trauma Life Support® (ATLS®) courses, I witnessed the use of dogs to train physicians for surgical procedures in critical scenarios.

Each stage of my career involved the use of animals to advance medical progress. However, reflecting on these experiences has deepened my ethical considerations.

Moral Standing of Nonhuman Animals

Exploring the moral status of animals through a deontological lens offers a perspective distinct from the traditionally utilitarian approach. Unlike rational beings who form a “moral community,” animals lack autonomy and the cognitive ability to be held morally responsible for their actions. However, this reality does not exclude them from being moral subjects.¹

The idea that the moral status of an animal is inherently less important than that of a human has been challenged, as the Cambridge Declaration on Consciousness in 2012 formally acknowledged that nonhuman animals possess the neurological substrates necessary for consciousness.^2,3 This point of view challenges traditional Kantian perspectives while criticizing the reliance on cost-benefit analyses and the aggregation of pleasure and pain. Under utilitarian reasoning, painful or fatal experiments on animals are justifiable if they maximize overall happiness or minimize human suffering.

Some argue that animal suffering carries less moral weight because it may be less intense than human suffering, which is attributed to the absence of reflective capacities. However, this assumption is not universally valid; animals may experience more acute suffering due to their inability to contextualize or rationalize their pain.⁴

Ethical guidelines can be traced to the World Organization for Animal Health’s guiding principles, developed in 1965, which describe society’s expectations for the conditions animals should experience when under human control. Guidelines from the American Psychological Association and the ACS⁵ emphasize the need for animal use to be scientifically justified, humane, and minimized whenever possible. Both frameworks advocate alternatives, such as simulation, whenever feasible.

Use of Nonhuman Animals for Surgical Skills Development

LTT is intended to address gaps in clinical practice, focusing on acquisition of technical skills rather than theoretical knowledge. LTT prioritizes revisiting and refining techniques rather than initial skills learning, with experts designing and regularly evaluating curricula.

In a systematic review, Swain and colleagues identified four themes in the literature about LTT: realism and fidelity, urgency and decision-making, psychological engagement, and self-efficacy.⁶ With a proper understanding of the Dreyfus model of clinical problem-solving skills acquisition,⁷ these themes underscore the value learners derive from LTT and provide a frame for ethical reflection on its necessity in various educational contexts.

Jerry’s ethical framework for analyzing the use of live nonhuman animals in surgical skills development (see Figure above) integrates the four educational themes identified by Swain et al.—recreating the experience, decision-making under urgent conditions, and the trainee’s psychological engagement, while emphasizing the role of self-efficacy in surgical training. Self-efficacy, the personal assessment of how well one can complete a task, is central to determining the trainee’s readiness and ability to perform surgical procedures.

The Dreyfus model of clinical problem-solving acquisition provides a structured methodology for evaluating proficiency in surgical skills, offering an objective measure to determine whether live animal use is ethically justifiable. This model balances educational value with ethical responsibility by aligning these themes with a structured competency-based framework that nonhuman animal use is only employed when it demonstrably enhances self-sufficiency and decision-making under real-world conditions.

LTT in Preclinical Medical Education

Preclinical medical education is enhanced by recreating the experience through training fidelity and real-world case scenarios, which help students understand the basics of surgical procedures and promote psychological engagement. However, the emotional impact of working with live animals can be profound, ranging from initial stress to ethical discomfort. These experiences may foster empathy, but do not necessarily contribute to long-term skill retention or moral practice.

One common justification, the benefits argument, states that such practices are acceptable because the advantages to humans outweigh the harm to animals. However, the benefits can be overstated.

At the same time, surgical skills proficiency in nonhuman animal models has been proven unreliable in translating proficiency, safety, and effectiveness in human patients.⁸ This lack of reliability questions the epistemic value of using animals in such practices. Without clear and consistent benefits, the moral justification for the continued use of nonhuman animals in this context is insufficient, necessitating a shift toward alternative, humane methods.

Teaching Surgical Skills to Nonsurgical Specialists

For nonsurgical specialists who may encounter trauma scenarios, LTT provides a valuable opportunity to recreate realistic clinical experiences. High-fidelity training models help these professionals understand the urgency and complexity of managing bleeding and other critical conditions, preparing them for high-stakes situations.

Understanding the dynamics of hemorrhage emphasizes the importance of rapid decision-making and procedural efficiency. LTT allows nonsurgical specialists to practice these skills under realistic conditions, enabling them to respond effectively in emergency scenarios. However, these scenarios are often infrequent, limiting the long-term applicability of learned skills.

The emotional intensity of LTT can heighten awareness and engagement, fostering a deeper understanding of trauma care, particularly for those who will be providing care in a combat setting.^6,9 While participants may experience a temporary boost in self-efficacy, this confidence can wane without regular practice of these skills.

LTT may extend human lifespans by facilitating medical advancements. However, this type of training inflicts severe suffering on animals. The idea of “saving lives” is context-dependent—combat—and does not universally justify moral transgressions, mainly when they involve unnecessary harm. Indeed, the ACS phased out the use of animal models in ATLS courses in the early 2000s,⁶ replacing them with simulation models that are more anatomically realistic, cost less, and allow trainees to repeat surgical skills until proficiency.¹⁰ However, although these alternative models collectively meet standards in military trauma training, only animal models and advanced manikins enable advanced skill proficiency.⁹

Training Surgeons

Some surgical interventions are inherently complex and heavily reliant on the surgeon’s evolving technical proficiency—expert and master levels. Achieving consistent quality care typically necessitates extensive training and experience—a process known as the “learning curve.” Controlling this variability in surgical training is inherently difficult. Moreover, the learning curve phase is frequently marked by an increased likelihood of errors, which can significantly skew outcome data and may compromise the procedure’s reliability.¹¹

LTT provides realistic experiences for trainees who will be managing complex surgical scenarios. The dynamic nature of live tissues, including bleeding and coagulation, mirrors real-life conditions, enabling trainees to refine their techniques under pressure and helping them become proficient before applying the skills to human patients. The urgency of managing hemorrhage reinforces critical decision-making and procedural skills essential for surgical practice. However, according to a 2020 meta-analysis, virtual reality (VR) improves efficiency and quality in trainees’ surgical practice with reduced error rates and improved tissue handling.¹²

The use of VR surgical simulators as a training tool has increased rapidly over the past few years. Several studies demonstrate that prior training in basic psychomotor skills such as hand-eye coordination, depth perception, and knot-tying with VR simulators improves resident performance in the operating room. Despite a noticeable boost in trainees’ self-sufficiency in laparoscopic techniques and hemostasis management following LTT, their overall opinions about the training showed no significant change before and after the lab session.

Using nonhuman animals in surgical training has historically played a significant role in medical education, but it raises serious ethical concerns. As medical practices and ethical frameworks evolve, the justification for LTT diminishes, especially considering the suffering inflicted on animals. While LTT offers transient benefits, such as improved technical skills and self-efficacy, these do not outweigh the ethical consequences.

Swain’s thematic framework, combined with Dreyfus’s model of skill acquisition, provides a structured approach to evaluating LTT. For preclinical education, LTT enhances the training experience but offers limited lasting benefits, leaving students at the advanced beginner stage. Thus, LTT is both ethically and educationally unjustifiable.

For nonsurgical specialists, LTT is valuable for simulating high-stakes scenarios but often can be replaced with high-fidelity simulations, with an exception for precombat training. In advanced surgical training, LTT’s dynamic realism justifies its use at proficient and expert levels. Alternative methods like simulation offer ethical, practical solutions, reducing reliance on animal use.

Disclaimer

The thoughts and opinions expressed in this column are solely those of the author and do not necessarily reflect those of the ACS.

Dr. Ricardo Gonzalez-Fisher, a surgical oncologist, is a lecturer in the Department of Health Professions at Metropolitan State University of Denver in Colorado.

References

1. Gruen L, Monsó S. The moral status of animals. In: Zalta EN, Nodelman U, eds. The Stanford Encyclopedia of Philosophy. Fall 2024 ed. Stanford University; 2024. Available at: https://plato.stanford.edu/archives/fall2024/entries/moral-animal. Accessed December 25, 2024.
2. Birch J, Schnell AK, Clayton NS. Dimensions of animal consciousness. Trends Cogn Sci. 2020;24(10):789-801.
3. Low P. The Cambridge Declaration on Consciousness. Proceedings of the Francis Crick Memorial Conference, Churchill College, Cambridge University; July 7, 2012:1-2.
4. Korsgaard CM. Medical research on animals and the question of moral standing: A comparison between Kantian and utilitarian accounts on moral standing of non-human animals. Harvard Center for Bioethics News. January 1, 2020. Available at: https://bioethics.hms.harvard.edu/journal/animal-moral-standing. Accessed December 25, 2024.
5. American College of Surgeons. Statement on the Use of Animals in Research, Education, and Teaching. October 1, 2002. Available at: https://www.facs.org/about-acs/statements/use-of-animals-in-research-education-and-teaching. Accessed December 25, 2024.
6. Swain CS, Cohen HML, Helgesson G, Rickard RF, Karlgren K. A systematic review of live animal use as a simulation modality (“live tissue training”) in the emergency management of trauma. J Surg Educ. 2023;80(9):1320-1339.
7. Peña A. The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective. Med Educ Online. 2010;15:10.3402/meo.v15i0.4846. Published June 14, 2010.
8. Ruan Y, Robinson NB, Khan FM, et al. The translation of surgical animal models to human clinical research: A cross-sectional study. Int J Surg. 2020;77:25-29.
9. Galloway DS. Alternatives to the use of live animals in military medical trauma training. Thesis. U.S. Army Command and General Staff College; 2000. Available at: https://apps.dtic.mil/sti/citations/ADA383824. Accessed December 26, 2024.
10. Gala SG, Crandall ML. Global collaboration to modernize advanced trauma life support training. J Surg Educ. 2019;76(2):487-496.
11. Andreoletti M, Bina F. A defense of surgical procedures regulation. Theor Med Bioeth. 2022;43:155-168.
12. Portelli M, Bianco SF, Bezzina T, Abela JE. Virtual reality training compared with apprenticeship training in laparoscopic surgery: A meta-analysis. Ann R Coll Surg Engl. 2020;102(9):672-684.