Peter Angelos, MD, PhD, FACS

As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.

His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.

This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.

This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.

However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.

We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.

Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.

Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.

His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.

This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.

This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.

However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.

We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.

Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.

Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.

His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.

This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.

This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.

However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.

We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.

Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.

Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.¹ Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.

Reference

1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.

On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.

I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.

In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.

Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.

The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”

Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.

Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.

Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As I sit down to write this column, I reflect on the news that my mentor and friend, Norman W. Thompson, M.D, FACS, passed away yesterday. I had the good fortune to spend 1 year as an endocrine surgery fellow with Dr. Thompson at the University of Michigan in 1995-96. That year was certainly the most significant of my training in terms of defining my professional life as an endocrine surgeon. However, as I think back on my time with Dr. Thompson, I am struck by how much more I learned from him than how to take out a thyroid or a parathyroid or manage multiple endocrine neoplasia.

Dr. Thompson was an excellent technical surgeon, and he would have had a tremendous career helping thousands of patients if that was all that he had done. However, he was much more than an excellent technician. He was also a great doctor. In order for a surgeon to be a great doctor, it is necessary to be technically excellent, but that alone is not sufficient. I believe that what makes a surgeon a great doctor is the combination of technical mastery with outstanding interpersonal skills and ethically sound clinical judgment. Dr. Thompson had all of that, and he was exceptionally kind.

Kindness is not a word that we commonly use in describing surgeons today. In an era of surgeons being pressured to see more patients and generate more RVUs [relative value units], it is unusual to hear kindness mentioned as an essential attribute of a great surgeon. However, Dr. Thompson’s kindness was immediately apparent to all who spent time with him. He treated each patient as a unique individual. In addition, he treated his trainees and his colleagues in Ann Arbor and around the world with respect and incredible humility. He was generous with his time and was always approachable no matter how inexperienced the surgeon asking him a question. Dr. Thompson was kind to all of us and made us feel that he valued spending time with us.

What does kindness have to do with a column that traditionally focuses on ethical issues in the practice of surgery? Although acting with kindness is not the same as acting in an ethical manner, I believe that there is more overlap of the terms than we often imagine. The kind surgeon is the one who treats people – whether they are patients or colleagues – as though they matter. The ethical surgeon respects the patient’s wishes and acts to benefit the patient as much as possible in all circumstances. I am certain that I have met ethical surgeons who were not kind, but I have met very few kind surgeons who are not ethical.

As someone who has spent significant time and energy in the last 19 years as a surgery faculty member trying to teach ethics, I am also struck by a clear truth. Actions always speak louder than words. It may be valuable to talk about the ethical principles that may come to play in a particularly difficult surgical case. Defining the competing interests and assessing the patient’s wishes are important components of the ethical practice of surgery. However, no amount of discussion of these issues can substitute for the value of behavior. Treating patients and colleagues with kindness and respect is modeling the behaviors of an ethical surgeon – perhaps learned from a wise and thoughtful mentor.

Dr. Thompson was an excellent role model for me and so many others in how he treated patients and everyone around him. As I see patients and perform surgery, I still hear myself saying many of the same things that he said many years ago. His genuine expressions of optimism before difficult operations, honesty in communicating, and sadness when things did not go well were tremendous examples to me of how a great doctor treats those around him. These lessons that I learned from Dr. Thompson have influenced my practice significantly, and I am grateful for the opportunity to try to model them on a daily basis.

Although I remain convinced that formal curricula in ethics and professionalism remain important in the education of today’s surgeons, it is valuable to remember the impact that the behaviors of those we respect have on us. Perhaps we surgeons more than other physicians are molded by the people who train us, but there is no question that the ethical behaviors of our teachers and mentors will have a greater impact than any lecture or manuscript. I want to acknowledge and commemorate the kindness and ethical behaviors that Dr. Thompson modeled daily for all who were fortunate enough to work with him.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As I sit down to write this column, I reflect on the news that my mentor and friend, Norman W. Thompson, M.D, FACS, passed away yesterday. I had the good fortune to spend 1 year as an endocrine surgery fellow with Dr. Thompson at the University of Michigan in 1995-96. That year was certainly the most significant of my training in terms of defining my professional life as an endocrine surgeon. However, as I think back on my time with Dr. Thompson, I am struck by how much more I learned from him than how to take out a thyroid or a parathyroid or manage multiple endocrine neoplasia.

Dr. Thompson was an excellent technical surgeon, and he would have had a tremendous career helping thousands of patients if that was all that he had done. However, he was much more than an excellent technician. He was also a great doctor. In order for a surgeon to be a great doctor, it is necessary to be technically excellent, but that alone is not sufficient. I believe that what makes a surgeon a great doctor is the combination of technical mastery with outstanding interpersonal skills and ethically sound clinical judgment. Dr. Thompson had all of that, and he was exceptionally kind.

Kindness is not a word that we commonly use in describing surgeons today. In an era of surgeons being pressured to see more patients and generate more RVUs [relative value units], it is unusual to hear kindness mentioned as an essential attribute of a great surgeon. However, Dr. Thompson’s kindness was immediately apparent to all who spent time with him. He treated each patient as a unique individual. In addition, he treated his trainees and his colleagues in Ann Arbor and around the world with respect and incredible humility. He was generous with his time and was always approachable no matter how inexperienced the surgeon asking him a question. Dr. Thompson was kind to all of us and made us feel that he valued spending time with us.

What does kindness have to do with a column that traditionally focuses on ethical issues in the practice of surgery? Although acting with kindness is not the same as acting in an ethical manner, I believe that there is more overlap of the terms than we often imagine. The kind surgeon is the one who treats people – whether they are patients or colleagues – as though they matter. The ethical surgeon respects the patient’s wishes and acts to benefit the patient as much as possible in all circumstances. I am certain that I have met ethical surgeons who were not kind, but I have met very few kind surgeons who are not ethical.

As someone who has spent significant time and energy in the last 19 years as a surgery faculty member trying to teach ethics, I am also struck by a clear truth. Actions always speak louder than words. It may be valuable to talk about the ethical principles that may come to play in a particularly difficult surgical case. Defining the competing interests and assessing the patient’s wishes are important components of the ethical practice of surgery. However, no amount of discussion of these issues can substitute for the value of behavior. Treating patients and colleagues with kindness and respect is modeling the behaviors of an ethical surgeon – perhaps learned from a wise and thoughtful mentor.

Dr. Thompson was an excellent role model for me and so many others in how he treated patients and everyone around him. As I see patients and perform surgery, I still hear myself saying many of the same things that he said many years ago. His genuine expressions of optimism before difficult operations, honesty in communicating, and sadness when things did not go well were tremendous examples to me of how a great doctor treats those around him. These lessons that I learned from Dr. Thompson have influenced my practice significantly, and I am grateful for the opportunity to try to model them on a daily basis.

Although I remain convinced that formal curricula in ethics and professionalism remain important in the education of today’s surgeons, it is valuable to remember the impact that the behaviors of those we respect have on us. Perhaps we surgeons more than other physicians are molded by the people who train us, but there is no question that the ethical behaviors of our teachers and mentors will have a greater impact than any lecture or manuscript. I want to acknowledge and commemorate the kindness and ethical behaviors that Dr. Thompson modeled daily for all who were fortunate enough to work with him.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

As I sit down to write this column, I reflect on the news that my mentor and friend, Norman W. Thompson, M.D, FACS, passed away yesterday. I had the good fortune to spend 1 year as an endocrine surgery fellow with Dr. Thompson at the University of Michigan in 1995-96. That year was certainly the most significant of my training in terms of defining my professional life as an endocrine surgeon. However, as I think back on my time with Dr. Thompson, I am struck by how much more I learned from him than how to take out a thyroid or a parathyroid or manage multiple endocrine neoplasia.

Dr. Thompson was an excellent technical surgeon, and he would have had a tremendous career helping thousands of patients if that was all that he had done. However, he was much more than an excellent technician. He was also a great doctor. In order for a surgeon to be a great doctor, it is necessary to be technically excellent, but that alone is not sufficient. I believe that what makes a surgeon a great doctor is the combination of technical mastery with outstanding interpersonal skills and ethically sound clinical judgment. Dr. Thompson had all of that, and he was exceptionally kind.

Kindness is not a word that we commonly use in describing surgeons today. In an era of surgeons being pressured to see more patients and generate more RVUs [relative value units], it is unusual to hear kindness mentioned as an essential attribute of a great surgeon. However, Dr. Thompson’s kindness was immediately apparent to all who spent time with him. He treated each patient as a unique individual. In addition, he treated his trainees and his colleagues in Ann Arbor and around the world with respect and incredible humility. He was generous with his time and was always approachable no matter how inexperienced the surgeon asking him a question. Dr. Thompson was kind to all of us and made us feel that he valued spending time with us.

What does kindness have to do with a column that traditionally focuses on ethical issues in the practice of surgery? Although acting with kindness is not the same as acting in an ethical manner, I believe that there is more overlap of the terms than we often imagine. The kind surgeon is the one who treats people – whether they are patients or colleagues – as though they matter. The ethical surgeon respects the patient’s wishes and acts to benefit the patient as much as possible in all circumstances. I am certain that I have met ethical surgeons who were not kind, but I have met very few kind surgeons who are not ethical.

As someone who has spent significant time and energy in the last 19 years as a surgery faculty member trying to teach ethics, I am also struck by a clear truth. Actions always speak louder than words. It may be valuable to talk about the ethical principles that may come to play in a particularly difficult surgical case. Defining the competing interests and assessing the patient’s wishes are important components of the ethical practice of surgery. However, no amount of discussion of these issues can substitute for the value of behavior. Treating patients and colleagues with kindness and respect is modeling the behaviors of an ethical surgeon – perhaps learned from a wise and thoughtful mentor.

Dr. Thompson was an excellent role model for me and so many others in how he treated patients and everyone around him. As I see patients and perform surgery, I still hear myself saying many of the same things that he said many years ago. His genuine expressions of optimism before difficult operations, honesty in communicating, and sadness when things did not go well were tremendous examples to me of how a great doctor treats those around him. These lessons that I learned from Dr. Thompson have influenced my practice significantly, and I am grateful for the opportunity to try to model them on a daily basis.

Although I remain convinced that formal curricula in ethics and professionalism remain important in the education of today’s surgeons, it is valuable to remember the impact that the behaviors of those we respect have on us. Perhaps we surgeons more than other physicians are molded by the people who train us, but there is no question that the ethical behaviors of our teachers and mentors will have a greater impact than any lecture or manuscript. I want to acknowledge and commemorate the kindness and ethical behaviors that Dr. Thompson modeled daily for all who were fortunate enough to work with him.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

When I was a resident, one of the surgery faculty who often performed big, high-risk operations liked to say, “If the patient can tolerate a haircut, he can tolerate an operation.” By this, he meant that there were not patients who were too sick for surgery if the operation was indicated. However, over the last 2 decades, I have seen a handful of patients for whom the risks of the operation far outweigh the potential benefits and for whom I have said I am not offering surgery as an option.

Recently, I had a chance to discuss troubling ethics cases with group of thoughtful surgical residents. They raised concerns over the common scenario of being consulted in the middle of the night on the critically ill patient in the intensive care unit for whom the risks of surgery are extremely high. These residents asked the question of whether it is ever acceptable for surgeons to simply refuse to take such patients to the operating room if the alternative to surgery is virtually certain death. The overriding concern among the residents was whether saying “no” to a request for operative intervention in a critically ill patient can ever be justified since the surgeon is essentially “playing God” by not offering the possibility of intervention.

There is no question that there can be very sick patients who have a poor prognosis and the decision is appropriately made to recommend surgery even though the risks are very high. I also believe that there are patients for whom the risks of surgery are so high, and the prospects for a good outcome are so low, that surgery should not be recommended. However, it is important to distinguish two different scenarios. In one scenario, the surgical consultant decides that surgery is an option, but then tries to convince the surrogate decision makers (usually the patient’s family) to decline surgery because of the very high risks. In the second scenario, the surgeon decides that the risks to the patient are so high that it would be wrong to even take the patient to the operating room.

In both scenarios, the patient does not get an operation and in the vast majority of such cases, the patient will die in a short period of time. The question remains whether it is better to give families a choice or not. I believe that posing the question in this manner is misleading and presents a false dichotomy.

Although the distinctions can be subtle, it is critical for the surgeon to decide whether each patient has a high enough chance for survival that the operation is medically justifiable. If the answer is “yes,” then the next question will be one for the surrogate decision makers to decide whether to consent to the surgery or not. Based on the importance of respecting the autonomous choices of patients or their surrogates, it is important that surgeons respect the choice not to have an operation even if one is being recommended. If the answer to the question of whether the operation is medically justifiable is “no,” to offer surgery to family and then try to convince them to decline it by overstating the risks is misleading. Although such a strategy would give the family a sense of control over the situation, it would also give the false impression that surgery is truly an option. To act this way would allow the surgeon the ability to avoid “playing God” since the family is “making the decision”. However, I believe that taking that decision away from families when there is not really a reasonable choice for surgery is a better way to eliminate their potential guilt. Not only is it ethically acceptable to decline to offer an operation to an extremely high-risk patient, I would argue that such behavior is actually the ethical responsibility of the surgeon. We should take on the burden of saying “no” when surgery should NOT be performed. Forcing such a decision on families in the name of respecting autonomy is to shirk our responsibility and something that we must avoid doing whenever possible.

Dr. Angelos is an ACS Fellow; the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.