Peter Angelos, MD, PhD, FACS

The case had been straightforward. My patient had primary hyperparathyroidism and her localization studies had shown a single parathyroid adenoma. In the operating room, with her under general anesthesia, I had found and removed the abnormal parathyroid gland. The intraoperative parathyroid hormone levels were being run outside the OR door. I was getting ready to close with my fellow when I happened to palpate the thyroid isthmus. There was a firm nodule right in the center of the isthmus. The thyroid looked fine, but the nodule was unmistakable.

This was a surprise. The patient had undergone an ultrasound in radiology the week before, and the study was notable for there being no thyroid nodules. We had performed our own ultrasound in the OR. We had confirmed the location of the parathyroid adenoma and saw no thyroid nodules. I was faced with the initial question of what to do with this incidental finding. Although I could not see the nodule, certainly by feel, it was suspicious, but it was also very small – several millimeters at most. One option was to simply ignore the finding – certainly a bad choice. I knew that the patient had come to the hospital with her sister and a close friend. They were both in the waiting room expecting my update as soon as we were finished. I could have discussed this unexpected finding with the sister and friend, but I felt certain that no one would object to me removing a small piece of thyroid when this added little or no risk. It seemed unnecessary to seek permission to do this small additional procedure.

We proceeded to resect the nodule within the thyroid gland, taking enough adjacent thyroid tissue that I never actually saw the nodule. Once it was removed, I faced another question: Should I send it for frozen section? This seemed to be an easy one to answer. If I was suspicious enough to remove it, I should also know what it is.

The frozen section report was called in a short time later. It was a 4-mm papillary thyroid cancer (PTC) that was within normal thyroid tissue. I had been expecting this possible result. Now I had more choices. I could talk with the family/friend in the waiting room and seek advice on what to do. Alternatively, I could simply say that the presence of PTC was enough of a reason to just take out the thyroid gland since I had not expected this finding and the negative preoperative ultrasound had certainly missed this small tumor (and there might even be others). Finally, I could simply close the patient based on the fact that a 4-mm PTC is of no real clinical significance. Certainly, if this small PTC had been removed with a thyroid lobe for other reasons, we would never go back to take out the rest of the thyroid gland.

As I considered these options, it seemed clear to me that if I went to talk with the family/friend with an unexpected diagnosis of cancer, it was very likely that the patient would wind up with a bigger operation than might be necessary. Ten or fifteen years ago, most surgeons would have removed the thyroid gland for almost any diagnosis of PTC so that patients could go on to receive radioactive iodine. However, today many patients with small incidental PTCs found on lobectomy are simply followed with surveillance ultrasounds because the risks of recurrence or spread are very low. It was clear that I had no basis to take out the whole thyroid gland for a small PTC that was already out. It also seemed unwise to ask what to do, when I felt certain that I knew what was best for the patient. Of course, the suggestion that “I knew what was best for the patient” is a very paternalistic thing to say. It suggests that the medical issues trump all others. It is also quite contrary to the movement of medical ethics in the last several decades that has emphasized shared decision making yet doing what is best for the patient is what surgical patients expect of their surgeons.

I decided to close the patient and then explain what I did and why I did it. She might have been angry with me that I had found a cancer and had not taken out her thyroid gland. However, I felt that the medical evidence supported a less-aggressive surgical approach. In addition, I could always take out her thyroid if she was too worried by the concept of surveillance but I could never put it back if I had removed it!

The patient was understandably surprised and concerned when talked to her. Her first response was one of concern about recurrence. She wanted to know how I knew that there was no more cancer in her thyroid gland. I explained that I actually could not know that, but based on the ultrasound, there was no evidence of any clinically significant thyroid cancer. Fortunately, she was ultimately relieved that the thyroid cancer had been found even though it raised concerns for the future that she had never considered previously.

Whenever surgeons operate on patients under general anesthesia, we are faced with the potential need to make decisions for our patients without the patient’s input. Sometimes it is appropriate to seek input from family when there are multiple good options. However, surgery requires surgeons to make many decisions on their patient’s behalf with no input from the patient – that is, surgeons are expected to act paternalistically in the OR. Rather than being detrimental to the ethical care of patients, such limited paternalism is sometimes the best that we can offer our patients and critical to our role as surgeon.

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.

The case had been straightforward. My patient had primary hyperparathyroidism and her localization studies had shown a single parathyroid adenoma. In the operating room, with her under general anesthesia, I had found and removed the abnormal parathyroid gland. The intraoperative parathyroid hormone levels were being run outside the OR door. I was getting ready to close with my fellow when I happened to palpate the thyroid isthmus. There was a firm nodule right in the center of the isthmus. The thyroid looked fine, but the nodule was unmistakable.

This was a surprise. The patient had undergone an ultrasound in radiology the week before, and the study was notable for there being no thyroid nodules. We had performed our own ultrasound in the OR. We had confirmed the location of the parathyroid adenoma and saw no thyroid nodules. I was faced with the initial question of what to do with this incidental finding. Although I could not see the nodule, certainly by feel, it was suspicious, but it was also very small – several millimeters at most. One option was to simply ignore the finding – certainly a bad choice. I knew that the patient had come to the hospital with her sister and a close friend. They were both in the waiting room expecting my update as soon as we were finished. I could have discussed this unexpected finding with the sister and friend, but I felt certain that no one would object to me removing a small piece of thyroid when this added little or no risk. It seemed unnecessary to seek permission to do this small additional procedure.

We proceeded to resect the nodule within the thyroid gland, taking enough adjacent thyroid tissue that I never actually saw the nodule. Once it was removed, I faced another question: Should I send it for frozen section? This seemed to be an easy one to answer. If I was suspicious enough to remove it, I should also know what it is.

The frozen section report was called in a short time later. It was a 4-mm papillary thyroid cancer (PTC) that was within normal thyroid tissue. I had been expecting this possible result. Now I had more choices. I could talk with the family/friend in the waiting room and seek advice on what to do. Alternatively, I could simply say that the presence of PTC was enough of a reason to just take out the thyroid gland since I had not expected this finding and the negative preoperative ultrasound had certainly missed this small tumor (and there might even be others). Finally, I could simply close the patient based on the fact that a 4-mm PTC is of no real clinical significance. Certainly, if this small PTC had been removed with a thyroid lobe for other reasons, we would never go back to take out the rest of the thyroid gland.

As I considered these options, it seemed clear to me that if I went to talk with the family/friend with an unexpected diagnosis of cancer, it was very likely that the patient would wind up with a bigger operation than might be necessary. Ten or fifteen years ago, most surgeons would have removed the thyroid gland for almost any diagnosis of PTC so that patients could go on to receive radioactive iodine. However, today many patients with small incidental PTCs found on lobectomy are simply followed with surveillance ultrasounds because the risks of recurrence or spread are very low. It was clear that I had no basis to take out the whole thyroid gland for a small PTC that was already out. It also seemed unwise to ask what to do, when I felt certain that I knew what was best for the patient. Of course, the suggestion that “I knew what was best for the patient” is a very paternalistic thing to say. It suggests that the medical issues trump all others. It is also quite contrary to the movement of medical ethics in the last several decades that has emphasized shared decision making yet doing what is best for the patient is what surgical patients expect of their surgeons.

I decided to close the patient and then explain what I did and why I did it. She might have been angry with me that I had found a cancer and had not taken out her thyroid gland. However, I felt that the medical evidence supported a less-aggressive surgical approach. In addition, I could always take out her thyroid if she was too worried by the concept of surveillance but I could never put it back if I had removed it!

The patient was understandably surprised and concerned when talked to her. Her first response was one of concern about recurrence. She wanted to know how I knew that there was no more cancer in her thyroid gland. I explained that I actually could not know that, but based on the ultrasound, there was no evidence of any clinically significant thyroid cancer. Fortunately, she was ultimately relieved that the thyroid cancer had been found even though it raised concerns for the future that she had never considered previously.

Whenever surgeons operate on patients under general anesthesia, we are faced with the potential need to make decisions for our patients without the patient’s input. Sometimes it is appropriate to seek input from family when there are multiple good options. However, surgery requires surgeons to make many decisions on their patient’s behalf with no input from the patient – that is, surgeons are expected to act paternalistically in the OR. Rather than being detrimental to the ethical care of patients, such limited paternalism is sometimes the best that we can offer our patients and critical to our role as surgeon.

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.

The case had been straightforward. My patient had primary hyperparathyroidism and her localization studies had shown a single parathyroid adenoma. In the operating room, with her under general anesthesia, I had found and removed the abnormal parathyroid gland. The intraoperative parathyroid hormone levels were being run outside the OR door. I was getting ready to close with my fellow when I happened to palpate the thyroid isthmus. There was a firm nodule right in the center of the isthmus. The thyroid looked fine, but the nodule was unmistakable.

This was a surprise. The patient had undergone an ultrasound in radiology the week before, and the study was notable for there being no thyroid nodules. We had performed our own ultrasound in the OR. We had confirmed the location of the parathyroid adenoma and saw no thyroid nodules. I was faced with the initial question of what to do with this incidental finding. Although I could not see the nodule, certainly by feel, it was suspicious, but it was also very small – several millimeters at most. One option was to simply ignore the finding – certainly a bad choice. I knew that the patient had come to the hospital with her sister and a close friend. They were both in the waiting room expecting my update as soon as we were finished. I could have discussed this unexpected finding with the sister and friend, but I felt certain that no one would object to me removing a small piece of thyroid when this added little or no risk. It seemed unnecessary to seek permission to do this small additional procedure.

We proceeded to resect the nodule within the thyroid gland, taking enough adjacent thyroid tissue that I never actually saw the nodule. Once it was removed, I faced another question: Should I send it for frozen section? This seemed to be an easy one to answer. If I was suspicious enough to remove it, I should also know what it is.

The frozen section report was called in a short time later. It was a 4-mm papillary thyroid cancer (PTC) that was within normal thyroid tissue. I had been expecting this possible result. Now I had more choices. I could talk with the family/friend in the waiting room and seek advice on what to do. Alternatively, I could simply say that the presence of PTC was enough of a reason to just take out the thyroid gland since I had not expected this finding and the negative preoperative ultrasound had certainly missed this small tumor (and there might even be others). Finally, I could simply close the patient based on the fact that a 4-mm PTC is of no real clinical significance. Certainly, if this small PTC had been removed with a thyroid lobe for other reasons, we would never go back to take out the rest of the thyroid gland.

As I considered these options, it seemed clear to me that if I went to talk with the family/friend with an unexpected diagnosis of cancer, it was very likely that the patient would wind up with a bigger operation than might be necessary. Ten or fifteen years ago, most surgeons would have removed the thyroid gland for almost any diagnosis of PTC so that patients could go on to receive radioactive iodine. However, today many patients with small incidental PTCs found on lobectomy are simply followed with surveillance ultrasounds because the risks of recurrence or spread are very low. It was clear that I had no basis to take out the whole thyroid gland for a small PTC that was already out. It also seemed unwise to ask what to do, when I felt certain that I knew what was best for the patient. Of course, the suggestion that “I knew what was best for the patient” is a very paternalistic thing to say. It suggests that the medical issues trump all others. It is also quite contrary to the movement of medical ethics in the last several decades that has emphasized shared decision making yet doing what is best for the patient is what surgical patients expect of their surgeons.

I decided to close the patient and then explain what I did and why I did it. She might have been angry with me that I had found a cancer and had not taken out her thyroid gland. However, I felt that the medical evidence supported a less-aggressive surgical approach. In addition, I could always take out her thyroid if she was too worried by the concept of surveillance but I could never put it back if I had removed it!

The patient was understandably surprised and concerned when talked to her. Her first response was one of concern about recurrence. She wanted to know how I knew that there was no more cancer in her thyroid gland. I explained that I actually could not know that, but based on the ultrasound, there was no evidence of any clinically significant thyroid cancer. Fortunately, she was ultimately relieved that the thyroid cancer had been found even though it raised concerns for the future that she had never considered previously.

Whenever surgeons operate on patients under general anesthesia, we are faced with the potential need to make decisions for our patients without the patient’s input. Sometimes it is appropriate to seek input from family when there are multiple good options. However, surgery requires surgeons to make many decisions on their patient’s behalf with no input from the patient – that is, surgeons are expected to act paternalistically in the OR. Rather than being detrimental to the ethical care of patients, such limited paternalism is sometimes the best that we can offer our patients and critical to our role as surgeon.

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.

At a recent surgical Morbidity and Mortality Conference, we discussed a tragic case of an elderly gentleman who had been explored for a gastric outlet obstruction. He was found to have a widely metastatic malignancy of unknown primary that was clearly unresectable. Biopsies were taken, a bypass was performed to alleviate the obstruction, and the patient was closed. The surgeon subsequently discussed the findings with the patient and his family. They were understandably upset after getting the news, but plans were made for follow-up and possible treatment when the final pathology was back. During several days in the hospital, the patient seemed to be in good spirits and was seen regularly, encouraging his family not to worry. However, on the day of discharge, the patient went home and committed suicide.

This case raised a series of important questions at the Morbidity and Mortality (M&M) Conference. Had the patient shown signs of depression? Should he have been evaluated by psychiatry? Did the surgical team miss any signs of his impending actions? In the tradition of M&M Conferences, the discussion focused on the question, "What would you have done differently?"

One issue repeatedly raised in the discussions at conference given the patient’s response was whether he should have been told his diagnosis. Such a consideration is a radical idea today when no physician would argue against telling a patient a diagnosis of cancer. But this consensus of full disclosure is relatively new in the medical profession. In 1961, 88% of physicians surveyed at Michael Reese Hospital in Chicago stated that their general policy was not to disclose a cancer diagnosis to the patient (JAMA 1961;175:1120-8). Certainly, this view among physicians has changed dramatically in recent decades. By 1979, the same survey at the same hospital revealed that 98% of physicians said that they tell patients that when the diagnosis is cancer (JAMA 1979;241:897-900).

In the medical profession, a diagnosis is no longer seen as information that can be withheld from a patient. The idea of respecting the patient as a person means that the patient must have the information necessary to make decisions about his or her future.

In this context, the recent New York Times article entitled "When Doctors Need to Lie" (Feb. 22, 2014) is provocative. Dr. Sandeep Jauhar suggests that sometimes there are situations in which doctors need to exercise a form of paternalism and lie to patients for their own benefit. Dr. Jauhar described a case in which he informed the family of a young patient of the true diagnosis, but only gradually and gently told the young man of his true condition.

Informing the elderly gentleman of his diagnosis may well have triggered his suicide. If the patient had not known that he had unresectable cancer, he could well still be alive. Nevertheless, no one at the M&M conference thought that lying about the diagnosis could be justified. Knowing the diagnosis is the fundamental basis for a patient to project a future existence. The ability to make the best medical and nonmedical decisions is dependent on having valid information. Without truthful information, the decisions made are uninformed and no better than guesses. It is not the physician’s role to guess the reaction of a patient to a diagnosis or project a future circumstance that may result from the patient learning the truth.

While the outcome of the transmission of knowledge to the patient may at times be unfortunate, the ethical implications of not telling patients the truth are potentially even more unfortunate. How can a surgeon establish a relationship of trust while also lying to a patient or withholding important information? Even though the choice made by this particular patient was tragic, to have lied to him is contrary to the physician’s role. Truth is the basis of trust, and trust in turn must be the basis of the relationship between doctor and patient.

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.

At a recent surgical Morbidity and Mortality Conference, we discussed a tragic case of an elderly gentleman who had been explored for a gastric outlet obstruction. He was found to have a widely metastatic malignancy of unknown primary that was clearly unresectable. Biopsies were taken, a bypass was performed to alleviate the obstruction, and the patient was closed. The surgeon subsequently discussed the findings with the patient and his family. They were understandably upset after getting the news, but plans were made for follow-up and possible treatment when the final pathology was back. During several days in the hospital, the patient seemed to be in good spirits and was seen regularly, encouraging his family not to worry. However, on the day of discharge, the patient went home and committed suicide.

This case raised a series of important questions at the Morbidity and Mortality (M&M) Conference. Had the patient shown signs of depression? Should he have been evaluated by psychiatry? Did the surgical team miss any signs of his impending actions? In the tradition of M&M Conferences, the discussion focused on the question, "What would you have done differently?"

One issue repeatedly raised in the discussions at conference given the patient’s response was whether he should have been told his diagnosis. Such a consideration is a radical idea today when no physician would argue against telling a patient a diagnosis of cancer. But this consensus of full disclosure is relatively new in the medical profession. In 1961, 88% of physicians surveyed at Michael Reese Hospital in Chicago stated that their general policy was not to disclose a cancer diagnosis to the patient (JAMA 1961;175:1120-8). Certainly, this view among physicians has changed dramatically in recent decades. By 1979, the same survey at the same hospital revealed that 98% of physicians said that they tell patients that when the diagnosis is cancer (JAMA 1979;241:897-900).

In the medical profession, a diagnosis is no longer seen as information that can be withheld from a patient. The idea of respecting the patient as a person means that the patient must have the information necessary to make decisions about his or her future.

In this context, the recent New York Times article entitled "When Doctors Need to Lie" (Feb. 22, 2014) is provocative. Dr. Sandeep Jauhar suggests that sometimes there are situations in which doctors need to exercise a form of paternalism and lie to patients for their own benefit. Dr. Jauhar described a case in which he informed the family of a young patient of the true diagnosis, but only gradually and gently told the young man of his true condition.

Informing the elderly gentleman of his diagnosis may well have triggered his suicide. If the patient had not known that he had unresectable cancer, he could well still be alive. Nevertheless, no one at the M&M conference thought that lying about the diagnosis could be justified. Knowing the diagnosis is the fundamental basis for a patient to project a future existence. The ability to make the best medical and nonmedical decisions is dependent on having valid information. Without truthful information, the decisions made are uninformed and no better than guesses. It is not the physician’s role to guess the reaction of a patient to a diagnosis or project a future circumstance that may result from the patient learning the truth.

While the outcome of the transmission of knowledge to the patient may at times be unfortunate, the ethical implications of not telling patients the truth are potentially even more unfortunate. How can a surgeon establish a relationship of trust while also lying to a patient or withholding important information? Even though the choice made by this particular patient was tragic, to have lied to him is contrary to the physician’s role. Truth is the basis of trust, and trust in turn must be the basis of the relationship between doctor and patient.

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.

At a recent surgical Morbidity and Mortality Conference, we discussed a tragic case of an elderly gentleman who had been explored for a gastric outlet obstruction. He was found to have a widely metastatic malignancy of unknown primary that was clearly unresectable. Biopsies were taken, a bypass was performed to alleviate the obstruction, and the patient was closed. The surgeon subsequently discussed the findings with the patient and his family. They were understandably upset after getting the news, but plans were made for follow-up and possible treatment when the final pathology was back. During several days in the hospital, the patient seemed to be in good spirits and was seen regularly, encouraging his family not to worry. However, on the day of discharge, the patient went home and committed suicide.

This case raised a series of important questions at the Morbidity and Mortality (M&M) Conference. Had the patient shown signs of depression? Should he have been evaluated by psychiatry? Did the surgical team miss any signs of his impending actions? In the tradition of M&M Conferences, the discussion focused on the question, "What would you have done differently?"

One issue repeatedly raised in the discussions at conference given the patient’s response was whether he should have been told his diagnosis. Such a consideration is a radical idea today when no physician would argue against telling a patient a diagnosis of cancer. But this consensus of full disclosure is relatively new in the medical profession. In 1961, 88% of physicians surveyed at Michael Reese Hospital in Chicago stated that their general policy was not to disclose a cancer diagnosis to the patient (JAMA 1961;175:1120-8). Certainly, this view among physicians has changed dramatically in recent decades. By 1979, the same survey at the same hospital revealed that 98% of physicians said that they tell patients that when the diagnosis is cancer (JAMA 1979;241:897-900).

In the medical profession, a diagnosis is no longer seen as information that can be withheld from a patient. The idea of respecting the patient as a person means that the patient must have the information necessary to make decisions about his or her future.

In this context, the recent New York Times article entitled "When Doctors Need to Lie" (Feb. 22, 2014) is provocative. Dr. Sandeep Jauhar suggests that sometimes there are situations in which doctors need to exercise a form of paternalism and lie to patients for their own benefit. Dr. Jauhar described a case in which he informed the family of a young patient of the true diagnosis, but only gradually and gently told the young man of his true condition.

Informing the elderly gentleman of his diagnosis may well have triggered his suicide. If the patient had not known that he had unresectable cancer, he could well still be alive. Nevertheless, no one at the M&M conference thought that lying about the diagnosis could be justified. Knowing the diagnosis is the fundamental basis for a patient to project a future existence. The ability to make the best medical and nonmedical decisions is dependent on having valid information. Without truthful information, the decisions made are uninformed and no better than guesses. It is not the physician’s role to guess the reaction of a patient to a diagnosis or project a future circumstance that may result from the patient learning the truth.

While the outcome of the transmission of knowledge to the patient may at times be unfortunate, the ethical implications of not telling patients the truth are potentially even more unfortunate. How can a surgeon establish a relationship of trust while also lying to a patient or withholding important information? Even though the choice made by this particular patient was tragic, to have lied to him is contrary to the physician’s role. Truth is the basis of trust, and trust in turn must be the basis of the relationship between doctor and patient.

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.

Recently, a medical student assigned to my service spent a day in the outpatient office seeing patients with me. After seeing two consecutive patients who needed thyroidectomies, this student commented on the differences in how I obtained informed consent for thyroidectomy from the two patients. Why, she asked, had I spent relatively little time emphasizing the risks of the operation with one patient and so much more time discussing risks with the second patient?

In order to understand why there appeared to be such a dramatic difference between the discussions with the two patients, it is helpful to understand the different indications for surgery. The first patient had recently been diagnosed with a 2.3-cm papillary thyroid cancer. I had explained that the first step in the treatment was to remove the thyroid, and I detailed the risks to the recurrent laryngeal nerves and the parathyroid glands.

The second patient had been treated for Graves’ disease for the last 3 years. She had many cycles of hyper- and hypothyroidism and had now decided that she needed definitive treatment. Although she had discussed the option of radioactive iodine with her endocrinologist, she had a significant fear of radiation and also was hoping to become pregnant in the next several months. I had discussed the risks of thyroidectomy with this patient. However, even though the risk I quoted of having a complication from the thyroidectomy was just the same as in the first case, I deliberately spent more time discussing the ramifications of the complications and the alternatives with the second patient.

My student was initially perplexed by this description. As she correctly stated, if the risks are the same for the same operation between the two patients, why emphasize the risks so much more for the second patient, compared with the first?

To most surgeons, the reason for this difference is clear. The first patient needed to know the risks, but there were few options to total thyroidectomy as the initial step in the treatment. The second patient had the clear option of getting radioactive iodine instead of surgery. Although the risks of the surgical procedure are the same with the two operations, I felt that the second patient needed to clearly understand the alternative to surgery and to fully consider the implications of the potential complications should one occur in her case.

As I think back over this interchange with my student, it is clear that the informed consent discussion for any operation cannot be fully standardized for every patient. Even if the risks remain the same, the indications for surgery are different and, of course, the patients are different.

More than 30 years ago, Dr. C. Rollins Hanlon, then executive director of the American College of Surgeons wrote, "Both ethics and surgery are inexact disciplines, in definition, practice, and in relation to one another." The more years I have been in practice, the more I am convinced of the truth of these words. Although my two patients both needed the same operation, it was important for me to emphasize the choices that the second patient had. In so doing, I felt it was essential to ensure that in evaluating the choices, the patient fully understood the implications of the risks. Although the patient with thyroid cancer had the same risks of the procedure, she did not have a good alternative choice to surgery. The difference between these two patients, and in how I altered my discussions of the proposed thyroidectomy, reveal the personal dimension of informed consent that goes beyond a simple statement of risks.

In obtaining informed consent from my patients, I should be providing them with much more than "just the facts." Patients can (and often do) obtain the data about the risks of surgical procedures from the Internet prior to seeing me. I believe that I should be giving them something more than they could obtain from reading about the risks of a procedure. I should provide them with a context in which to consider the risks, relative to their particular condition. Even small risks may be very significant if there are alternatives that have no risks. In contrast, patients often quickly agree to high-risk operations when there is no good nonoperative alternative. As surgeons, we must be cognizant of the critical personal dimension of the informed consent process and thereby be sure to put the discussion of risks in the appropriate context to help our patients make good decisions.

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.

Recently, a medical student assigned to my service spent a day in the outpatient office seeing patients with me. After seeing two consecutive patients who needed thyroidectomies, this student commented on the differences in how I obtained informed consent for thyroidectomy from the two patients. Why, she asked, had I spent relatively little time emphasizing the risks of the operation with one patient and so much more time discussing risks with the second patient?

In order to understand why there appeared to be such a dramatic difference between the discussions with the two patients, it is helpful to understand the different indications for surgery. The first patient had recently been diagnosed with a 2.3-cm papillary thyroid cancer. I had explained that the first step in the treatment was to remove the thyroid, and I detailed the risks to the recurrent laryngeal nerves and the parathyroid glands.

The second patient had been treated for Graves’ disease for the last 3 years. She had many cycles of hyper- and hypothyroidism and had now decided that she needed definitive treatment. Although she had discussed the option of radioactive iodine with her endocrinologist, she had a significant fear of radiation and also was hoping to become pregnant in the next several months. I had discussed the risks of thyroidectomy with this patient. However, even though the risk I quoted of having a complication from the thyroidectomy was just the same as in the first case, I deliberately spent more time discussing the ramifications of the complications and the alternatives with the second patient.

My student was initially perplexed by this description. As she correctly stated, if the risks are the same for the same operation between the two patients, why emphasize the risks so much more for the second patient, compared with the first?

To most surgeons, the reason for this difference is clear. The first patient needed to know the risks, but there were few options to total thyroidectomy as the initial step in the treatment. The second patient had the clear option of getting radioactive iodine instead of surgery. Although the risks of the surgical procedure are the same with the two operations, I felt that the second patient needed to clearly understand the alternative to surgery and to fully consider the implications of the potential complications should one occur in her case.

As I think back over this interchange with my student, it is clear that the informed consent discussion for any operation cannot be fully standardized for every patient. Even if the risks remain the same, the indications for surgery are different and, of course, the patients are different.

More than 30 years ago, Dr. C. Rollins Hanlon, then executive director of the American College of Surgeons wrote, "Both ethics and surgery are inexact disciplines, in definition, practice, and in relation to one another." The more years I have been in practice, the more I am convinced of the truth of these words. Although my two patients both needed the same operation, it was important for me to emphasize the choices that the second patient had. In so doing, I felt it was essential to ensure that in evaluating the choices, the patient fully understood the implications of the risks. Although the patient with thyroid cancer had the same risks of the procedure, she did not have a good alternative choice to surgery. The difference between these two patients, and in how I altered my discussions of the proposed thyroidectomy, reveal the personal dimension of informed consent that goes beyond a simple statement of risks.

In obtaining informed consent from my patients, I should be providing them with much more than "just the facts." Patients can (and often do) obtain the data about the risks of surgical procedures from the Internet prior to seeing me. I believe that I should be giving them something more than they could obtain from reading about the risks of a procedure. I should provide them with a context in which to consider the risks, relative to their particular condition. Even small risks may be very significant if there are alternatives that have no risks. In contrast, patients often quickly agree to high-risk operations when there is no good nonoperative alternative. As surgeons, we must be cognizant of the critical personal dimension of the informed consent process and thereby be sure to put the discussion of risks in the appropriate context to help our patients make good decisions.

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.

Recently, a medical student assigned to my service spent a day in the outpatient office seeing patients with me. After seeing two consecutive patients who needed thyroidectomies, this student commented on the differences in how I obtained informed consent for thyroidectomy from the two patients. Why, she asked, had I spent relatively little time emphasizing the risks of the operation with one patient and so much more time discussing risks with the second patient?

In order to understand why there appeared to be such a dramatic difference between the discussions with the two patients, it is helpful to understand the different indications for surgery. The first patient had recently been diagnosed with a 2.3-cm papillary thyroid cancer. I had explained that the first step in the treatment was to remove the thyroid, and I detailed the risks to the recurrent laryngeal nerves and the parathyroid glands.

The second patient had been treated for Graves’ disease for the last 3 years. She had many cycles of hyper- and hypothyroidism and had now decided that she needed definitive treatment. Although she had discussed the option of radioactive iodine with her endocrinologist, she had a significant fear of radiation and also was hoping to become pregnant in the next several months. I had discussed the risks of thyroidectomy with this patient. However, even though the risk I quoted of having a complication from the thyroidectomy was just the same as in the first case, I deliberately spent more time discussing the ramifications of the complications and the alternatives with the second patient.

My student was initially perplexed by this description. As she correctly stated, if the risks are the same for the same operation between the two patients, why emphasize the risks so much more for the second patient, compared with the first?

To most surgeons, the reason for this difference is clear. The first patient needed to know the risks, but there were few options to total thyroidectomy as the initial step in the treatment. The second patient had the clear option of getting radioactive iodine instead of surgery. Although the risks of the surgical procedure are the same with the two operations, I felt that the second patient needed to clearly understand the alternative to surgery and to fully consider the implications of the potential complications should one occur in her case.

As I think back over this interchange with my student, it is clear that the informed consent discussion for any operation cannot be fully standardized for every patient. Even if the risks remain the same, the indications for surgery are different and, of course, the patients are different.

More than 30 years ago, Dr. C. Rollins Hanlon, then executive director of the American College of Surgeons wrote, "Both ethics and surgery are inexact disciplines, in definition, practice, and in relation to one another." The more years I have been in practice, the more I am convinced of the truth of these words. Although my two patients both needed the same operation, it was important for me to emphasize the choices that the second patient had. In so doing, I felt it was essential to ensure that in evaluating the choices, the patient fully understood the implications of the risks. Although the patient with thyroid cancer had the same risks of the procedure, she did not have a good alternative choice to surgery. The difference between these two patients, and in how I altered my discussions of the proposed thyroidectomy, reveal the personal dimension of informed consent that goes beyond a simple statement of risks.

In obtaining informed consent from my patients, I should be providing them with much more than "just the facts." Patients can (and often do) obtain the data about the risks of surgical procedures from the Internet prior to seeing me. I believe that I should be giving them something more than they could obtain from reading about the risks of a procedure. I should provide them with a context in which to consider the risks, relative to their particular condition. Even small risks may be very significant if there are alternatives that have no risks. In contrast, patients often quickly agree to high-risk operations when there is no good nonoperative alternative. As surgeons, we must be cognizant of the critical personal dimension of the informed consent process and thereby be sure to put the discussion of risks in the appropriate context to help our patients make good decisions.

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.

This morning I had the usual 7:30 a.m. elective surgical case scheduled. As I usually do, I went to see my patient at around 7 a.m. to review the procedure, answer any new questions that may have come up, and mark the incision site. My patient greeted me very cheerfully with the following questions, "How was your night? Did you sleep OK? Are you feeling good this morning? No arguments at home, I hope?" I readily answered, as I almost always do, when discussing things with patients in the preop area, that I am feeling good and ready for things to go well with the case.

I have been asked such questions many times over the years. However, for some reason the interchange with my patient this morning raised additional questions for me: Is it really acceptable for patients to ask such questions? Do I have an obligation to disclose such things? Do patients really want to know the answers or are they simply making nervous conversation?

In recent years, there have been a number of articles questioning whether surgeons should be required to disclose a lack of sleep to their elective surgical patients so that the patient can make a "truly informed" decision about what the risks of their surgery are. Thus far, there have been no such requirements at any hospital in the United States that I know of. But my patient’s questions raised a number of practical issues for me with such disclosure. We had already had a conversation in my office when I originally obtained consent for the procedure. I had carefully reviewed risks, benefits, and alternatives to the operation, and I had answered a list of the patient’s questions. Since I was actually the patient’s third opinion, it was clear that the patient already had significant background knowledge about the operation. The patient had signed the consent form before leaving my office.

At some point, before, during, or after my conversation with the patient, he had decided to trust me enough to allow me to do the operation. Subsequently, while home in the days prior to the surgery date, the patient had the opportunity to change his mind, but he actually came to the hospital on the morning of surgery. He had thus actively expressed his confidence in me by showing up for surgery. In this context, I believe that the patient’s questions were really a friendly way of expressing some degree of anxiety about the operation rather than an actual second guessing of my capacity to optimally perform the surgery. In this context, I believe that it is more important that I try to alleviate the patient’s concerns than that I give an expansive discourse on whatever stressful issues may be going on in my personal life.

Of particular importance is the issue of how much I have slept. I do not believe that I should discuss any concerns I may have with lack of sleep with my patient unless I have decided that I am not the best person to perform the surgery. I do not think that I would be doing my patient a service by, for example, saying that I didn’t sleep well and studies show that I might have altered judgment and asking the patient to sign a document that I have disclosed this fact. Such a disclosure seems to be designed to protect the surgeon and the institution rather than the patient.

However, if I believe that my lack of sleep, my personal stressors, or any other distraction will significantly hinder my ability to perform the operation safely, then I should not simply disclose these issues to the patient. Rather, I should explain why I should NOT be doing the surgery and either postpone the case or find someone else to do it if the patient requests this and if it is possible. Although some commentators have suggested that a sleep-deprived surgeon is the worst person to be able to assess his or her abilities to optimally perform an operation, I am convinced that we need to depend on the surgeon to make this assessment. Three central required components of professionalism are the exercise of self-regulation, the capacity to make decisions that are altruistic, and the discipline to abide by ethical standards. The issue of self-regulation is absolutely critical to the professionalism of any surgeon. The professionalism of the surgeon is the basis for patients trusting us to operate on them and make decisions in the operating room on their behalf. To mandate a separate disclosure to the patient about the amount of sleep the surgeon got the night before, or any other distracting issue, would be to cast doubt on the professionalism of the surgeon at the very time that patients most need to trust their surgeons.

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.

This morning I had the usual 7:30 a.m. elective surgical case scheduled. As I usually do, I went to see my patient at around 7 a.m. to review the procedure, answer any new questions that may have come up, and mark the incision site. My patient greeted me very cheerfully with the following questions, "How was your night? Did you sleep OK? Are you feeling good this morning? No arguments at home, I hope?" I readily answered, as I almost always do, when discussing things with patients in the preop area, that I am feeling good and ready for things to go well with the case.

I have been asked such questions many times over the years. However, for some reason the interchange with my patient this morning raised additional questions for me: Is it really acceptable for patients to ask such questions? Do I have an obligation to disclose such things? Do patients really want to know the answers or are they simply making nervous conversation?

In recent years, there have been a number of articles questioning whether surgeons should be required to disclose a lack of sleep to their elective surgical patients so that the patient can make a "truly informed" decision about what the risks of their surgery are. Thus far, there have been no such requirements at any hospital in the United States that I know of. But my patient’s questions raised a number of practical issues for me with such disclosure. We had already had a conversation in my office when I originally obtained consent for the procedure. I had carefully reviewed risks, benefits, and alternatives to the operation, and I had answered a list of the patient’s questions. Since I was actually the patient’s third opinion, it was clear that the patient already had significant background knowledge about the operation. The patient had signed the consent form before leaving my office.

At some point, before, during, or after my conversation with the patient, he had decided to trust me enough to allow me to do the operation. Subsequently, while home in the days prior to the surgery date, the patient had the opportunity to change his mind, but he actually came to the hospital on the morning of surgery. He had thus actively expressed his confidence in me by showing up for surgery. In this context, I believe that the patient’s questions were really a friendly way of expressing some degree of anxiety about the operation rather than an actual second guessing of my capacity to optimally perform the surgery. In this context, I believe that it is more important that I try to alleviate the patient’s concerns than that I give an expansive discourse on whatever stressful issues may be going on in my personal life.

Of particular importance is the issue of how much I have slept. I do not believe that I should discuss any concerns I may have with lack of sleep with my patient unless I have decided that I am not the best person to perform the surgery. I do not think that I would be doing my patient a service by, for example, saying that I didn’t sleep well and studies show that I might have altered judgment and asking the patient to sign a document that I have disclosed this fact. Such a disclosure seems to be designed to protect the surgeon and the institution rather than the patient.

However, if I believe that my lack of sleep, my personal stressors, or any other distraction will significantly hinder my ability to perform the operation safely, then I should not simply disclose these issues to the patient. Rather, I should explain why I should NOT be doing the surgery and either postpone the case or find someone else to do it if the patient requests this and if it is possible. Although some commentators have suggested that a sleep-deprived surgeon is the worst person to be able to assess his or her abilities to optimally perform an operation, I am convinced that we need to depend on the surgeon to make this assessment. Three central required components of professionalism are the exercise of self-regulation, the capacity to make decisions that are altruistic, and the discipline to abide by ethical standards. The issue of self-regulation is absolutely critical to the professionalism of any surgeon. The professionalism of the surgeon is the basis for patients trusting us to operate on them and make decisions in the operating room on their behalf. To mandate a separate disclosure to the patient about the amount of sleep the surgeon got the night before, or any other distracting issue, would be to cast doubt on the professionalism of the surgeon at the very time that patients most need to trust their surgeons.

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.

This morning I had the usual 7:30 a.m. elective surgical case scheduled. As I usually do, I went to see my patient at around 7 a.m. to review the procedure, answer any new questions that may have come up, and mark the incision site. My patient greeted me very cheerfully with the following questions, "How was your night? Did you sleep OK? Are you feeling good this morning? No arguments at home, I hope?" I readily answered, as I almost always do, when discussing things with patients in the preop area, that I am feeling good and ready for things to go well with the case.

I have been asked such questions many times over the years. However, for some reason the interchange with my patient this morning raised additional questions for me: Is it really acceptable for patients to ask such questions? Do I have an obligation to disclose such things? Do patients really want to know the answers or are they simply making nervous conversation?

In recent years, there have been a number of articles questioning whether surgeons should be required to disclose a lack of sleep to their elective surgical patients so that the patient can make a "truly informed" decision about what the risks of their surgery are. Thus far, there have been no such requirements at any hospital in the United States that I know of. But my patient’s questions raised a number of practical issues for me with such disclosure. We had already had a conversation in my office when I originally obtained consent for the procedure. I had carefully reviewed risks, benefits, and alternatives to the operation, and I had answered a list of the patient’s questions. Since I was actually the patient’s third opinion, it was clear that the patient already had significant background knowledge about the operation. The patient had signed the consent form before leaving my office.

At some point, before, during, or after my conversation with the patient, he had decided to trust me enough to allow me to do the operation. Subsequently, while home in the days prior to the surgery date, the patient had the opportunity to change his mind, but he actually came to the hospital on the morning of surgery. He had thus actively expressed his confidence in me by showing up for surgery. In this context, I believe that the patient’s questions were really a friendly way of expressing some degree of anxiety about the operation rather than an actual second guessing of my capacity to optimally perform the surgery. In this context, I believe that it is more important that I try to alleviate the patient’s concerns than that I give an expansive discourse on whatever stressful issues may be going on in my personal life.

Of particular importance is the issue of how much I have slept. I do not believe that I should discuss any concerns I may have with lack of sleep with my patient unless I have decided that I am not the best person to perform the surgery. I do not think that I would be doing my patient a service by, for example, saying that I didn’t sleep well and studies show that I might have altered judgment and asking the patient to sign a document that I have disclosed this fact. Such a disclosure seems to be designed to protect the surgeon and the institution rather than the patient.

However, if I believe that my lack of sleep, my personal stressors, or any other distraction will significantly hinder my ability to perform the operation safely, then I should not simply disclose these issues to the patient. Rather, I should explain why I should NOT be doing the surgery and either postpone the case or find someone else to do it if the patient requests this and if it is possible. Although some commentators have suggested that a sleep-deprived surgeon is the worst person to be able to assess his or her abilities to optimally perform an operation, I am convinced that we need to depend on the surgeon to make this assessment. Three central required components of professionalism are the exercise of self-regulation, the capacity to make decisions that are altruistic, and the discipline to abide by ethical standards. The issue of self-regulation is absolutely critical to the professionalism of any surgeon. The professionalism of the surgeon is the basis for patients trusting us to operate on them and make decisions in the operating room on their behalf. To mandate a separate disclosure to the patient about the amount of sleep the surgeon got the night before, or any other distracting issue, would be to cast doubt on the professionalism of the surgeon at the very time that patients most need to trust their surgeons.

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.

Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

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.

Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

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.

Recently, I was invited to present surgical grand rounds on an ethics topic.  After the talk, a senior surgeon, now retired, who was in the audience confided to me that in all of his years of residency, he had never had a lecture on ethics.  This off-hand comment raised a question that demands consideration in the contemporary era of increasingly limited time available for teaching in surgical residencies.  Do we need ethics teaching in surgery residencies?

As someone who spent significant time in the last few years in ethics teaching activities, my reflex answer is “Yes.”  However, it is worthwhile to explore the reasons why, in the education of contemporary surgeons, it is important to focus dedicated attention on the ethical issues that arise in the practice of surgery.

Certainly, it is not true that ethics was previously unimportant in surgery.  In 1915 when the early organizers of the American College of Surgeons were first writing down the qualifications for membership, they emphasized the importance of ethics:  “The moral and ethical fitness of the candidates shall be determined by the reports of surgeons whose names are submitted by the candidate himself, and by such other reports and data as the Credentials Committee and the administration of the College may obtain.”[i]  Thus, the early founders of the College considered “ethical fitness” to be essential to their members.  Since there were clearly ethical and unethical ways to practice surgery, why has the focused emphasis on ethics teaching only occurred in recent decades?

I believe that there are three changes that have occurred in surgical care and surgical education that have led to the importance of this recent focus on ethics education in contemporary surgical training programs:  the limitations on work hours for surgical residents, the increasing shift to outpatient care, and the increasing number of options for surgical patients brought about by improvements in surgical technology. 

To begin with, surgical residents today spend significantly less time in the hospital every week than did surgical residents in years past.  Although one could debate the actual educational value the additional time that I and my surgical predecessors spent in the hospital, there is no question that the significant shortening of the amount of time that surgical residents spend with surgical faculty has resulted in fewer opportunities for learning through role modeling.  These many additional hours in the hospital for surgical residents in the past resulted in greater opportunities for residents to see how their faculty dealt with the challenges of managing ethically complex cases.  Although these interactions were not often thought of as “ethical role modeling” in prior years, there is no question that significant ethical teaching occurred in this informal curriculum.

Second, and closely related to the reduction in surgical resident work hours, has been the significant shift to outpatient surgical care.  This shift has meant that surgical residents whose time is focused on what happens in the hospital have even fewer opportunities to witness faculty engaging in many central aspects of the ethical care of surgical patients (e.g., obtaining informed consent for complex surgical procedures, communicating bad news to patients and families, or weighing risks and benefits of high risk elective surgical procedures).

Perhaps most importantly, today there are more options for surgical therapies than ever before.  The central question for a surgeon in 1913 when the American College of Surgeons was formed was, “What can be done for this patient?”  Today, in caring for the most complex and critically ill patients, the question that is foremost for surgeons is often “What should be done?”  This question is not a purely surgical question, but also an ethical question.  Consider a patient who has developed multisystem organ failure after complications from surgery.  Because of the advances in critical care, such a patient might be able to be kept alive with technologies such as mechanical ventilation, augmented cardiac output with a ventricular assist device, and hemodialysis.  These therapies cannot be judged to be appropriate or not without thoughtful consideration of an individual patient’s overall goals and values.   In such a case, weighing values and probabilities for success or failure relative to a particular patient’s goals moves beyond purely scientific surgical decision making into the realm of ethics.

For all of these reasons, I believe that although surgeons have practiced in an ethical fashion for countless generations, the contemporary education of surgeons should include focused attention on ethics and the ethical implications of the surgical interventions that we recommend for our patients.  Some might argue that the ultimate goal of surgical education should be to fully integrate the ethical considerations into the surgical care rendered to patients.  However, there is so much surgical science to be learned in residency, that in order for consideration of the ethical implications to not be lost, I believe that there must be dedicated attention to ethics teaching. 

Although it is an artificial separation to think about distinguishing the ethical considerations from the surgical decision making for a particular patient, the separation is valuable to emphasize the differences between surgical science and surgical ethics.  The former is dependent on anatomy, physiology, and surgical technique; whereas the latter is dependent on relationships, communication, and patient values.  Although we can train surgical residents to be excellent technicians with a focus purely on surgical science, we can only educate great doctors who are also surgeons by expanding the discussions of optimal surgical care to include the considerations central to surgical ethics.

 [1] This important historical background is courtesy of David Nahrwold, MD.

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.

This morning while attending our department’s weekly Surgical Morbidity and Mortality conference, I was struck by how similar the case sounded to so many others that we have discussed in the past. An elderly patient with multiple comorbidities was found to have evidence of an acute abdomen. Unfortunately, the patient was intubated at the time of the surgical consultation, and it was unclear what his wishes would have been. Here was an apparent surgical problem in a very-high-risk patient.

The patient’s family, the medicine team, and the surgery team had several discussions and all agreed that the patient’s condition was very serious and that he would likely die without surgery. In addition, the surgical team felt that the chances for survival even with an exploratory laparotomy were extremely low. After much discussion, the decision was made to operate on the patient. He survived the operation only to have a gradual decline in his condition such that he developed multisystem organ failure. The resident presenting the case noted that eventually the surgical team was convinced that "further treatments were futile" and "after discussing the patient’s condition with the family, the decision was made to withdraw aggressive treatment." The patient was made comfortable and died a short time later.

As the discussion at the M&M conference showed, there were many surgeons present who felt that the outcome was expected and even a few who questioned whether the patient should even have had surgery. These are important issues, but what struck me most was the use of the term "futility" in reference to this patient’s care.

In recent years, there has been significant analysis within the medical ethics literature of the concept of futility. Futility in this context is difficult to define. Moreover, it appears some doctors determine a treatment to be futile as a means of pulling back control from the patient or surrogate who may be asking for a course of action. In other words, if we accept the importance of respecting patient autonomy and if patients/surrogates want a particular treatment, doctors often have difficulty saying "no" unless they define the treatment as futile. Since it is widely accepted that physicians need not offer futile treatments, defining a treatment as futile may be a way to limit the choices for patients/surrogates to consider or request.

In line with much of this literature, I have previously argued that we should "strike the term ["futility"] from our professional lexicon" (World J. Surg. 2009;33:1338-40). However, despite the chorus of suggestions that futility is a problematic concept when it comes to caring for patients, it continues to be used in discussions of actual patient care. I have concluded that it is impossible to eliminate the term "futility." In contrast, perhaps a better approach would be to realize that calling a certain set of treatments "futile" actually provides very little information to the people with whom we are talking. When we say a treatment would be an exercise in futility, we are really saying that in our best medical judgment the likelihood of success is very low. In addition, calling something futile suggests that a careful weighing of burdens and benefits of a particular treatment has been undertaken, and the doctor believes that the burdens so clearly outweigh the benefits that the treatment should not be offered to the patient. Therefore, rather than removing "futility" from our discussions with patients and each other, we should strive to realize how little the term actually conveys to our patients/surrogates.

When we use the term "futile" to describe a treatment, we are saying it just does not make sense in a specific case. The problem is that what a patient/surrogate considers to be the burdens and benefits might differ from what the medical team sees. For example, if an operation has virtually no chance of curing a patient, it might be considered futile. However, if the patient’s primary goal is palliation of certain symptoms for even a few days, then the operation should perhaps be viewed as "potentially beneficial" relative to a particular goal rather than "futile."

Surgeons should remember that the weighing of burdens and benefits requires more than medical knowledge. As such, every time the concept of "futility" is raised in the context of caring for a specific patient, the medical team should carefully explain to the patient/surrogate the benefits and burdens are that are being considered. Since it seems impossible for us to eliminate "futility" from our clinical discussions, let us instead use the term as a reminder to communicate the details and implications of a course of action. In this manner, a surgeon’s assessment of futility might prove an opportunity for further discussions rather than a statement of a definitive conclusion.

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

This morning while attending our department’s weekly Surgical Morbidity and Mortality conference, I was struck by how similar the case sounded to so many others that we have discussed in the past. An elderly patient with multiple comorbidities was found to have evidence of an acute abdomen. Unfortunately, the patient was intubated at the time of the surgical consultation, and it was unclear what his wishes would have been. Here was an apparent surgical problem in a very-high-risk patient.

The patient’s family, the medicine team, and the surgery team had several discussions and all agreed that the patient’s condition was very serious and that he would likely die without surgery. In addition, the surgical team felt that the chances for survival even with an exploratory laparotomy were extremely low. After much discussion, the decision was made to operate on the patient. He survived the operation only to have a gradual decline in his condition such that he developed multisystem organ failure. The resident presenting the case noted that eventually the surgical team was convinced that "further treatments were futile" and "after discussing the patient’s condition with the family, the decision was made to withdraw aggressive treatment." The patient was made comfortable and died a short time later.

As the discussion at the M&M conference showed, there were many surgeons present who felt that the outcome was expected and even a few who questioned whether the patient should even have had surgery. These are important issues, but what struck me most was the use of the term "futility" in reference to this patient’s care.

In recent years, there has been significant analysis within the medical ethics literature of the concept of futility. Futility in this context is difficult to define. Moreover, it appears some doctors determine a treatment to be futile as a means of pulling back control from the patient or surrogate who may be asking for a course of action. In other words, if we accept the importance of respecting patient autonomy and if patients/surrogates want a particular treatment, doctors often have difficulty saying "no" unless they define the treatment as futile. Since it is widely accepted that physicians need not offer futile treatments, defining a treatment as futile may be a way to limit the choices for patients/surrogates to consider or request.

In line with much of this literature, I have previously argued that we should "strike the term ["futility"] from our professional lexicon" (World J. Surg. 2009;33:1338-40). However, despite the chorus of suggestions that futility is a problematic concept when it comes to caring for patients, it continues to be used in discussions of actual patient care. I have concluded that it is impossible to eliminate the term "futility." In contrast, perhaps a better approach would be to realize that calling a certain set of treatments "futile" actually provides very little information to the people with whom we are talking. When we say a treatment would be an exercise in futility, we are really saying that in our best medical judgment the likelihood of success is very low. In addition, calling something futile suggests that a careful weighing of burdens and benefits of a particular treatment has been undertaken, and the doctor believes that the burdens so clearly outweigh the benefits that the treatment should not be offered to the patient. Therefore, rather than removing "futility" from our discussions with patients and each other, we should strive to realize how little the term actually conveys to our patients/surrogates.

When we use the term "futile" to describe a treatment, we are saying it just does not make sense in a specific case. The problem is that what a patient/surrogate considers to be the burdens and benefits might differ from what the medical team sees. For example, if an operation has virtually no chance of curing a patient, it might be considered futile. However, if the patient’s primary goal is palliation of certain symptoms for even a few days, then the operation should perhaps be viewed as "potentially beneficial" relative to a particular goal rather than "futile."

Surgeons should remember that the weighing of burdens and benefits requires more than medical knowledge. As such, every time the concept of "futility" is raised in the context of caring for a specific patient, the medical team should carefully explain to the patient/surrogate the benefits and burdens are that are being considered. Since it seems impossible for us to eliminate "futility" from our clinical discussions, let us instead use the term as a reminder to communicate the details and implications of a course of action. In this manner, a surgeon’s assessment of futility might prove an opportunity for further discussions rather than a statement of a definitive conclusion.

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

This morning while attending our department’s weekly Surgical Morbidity and Mortality conference, I was struck by how similar the case sounded to so many others that we have discussed in the past. An elderly patient with multiple comorbidities was found to have evidence of an acute abdomen. Unfortunately, the patient was intubated at the time of the surgical consultation, and it was unclear what his wishes would have been. Here was an apparent surgical problem in a very-high-risk patient.

The patient’s family, the medicine team, and the surgery team had several discussions and all agreed that the patient’s condition was very serious and that he would likely die without surgery. In addition, the surgical team felt that the chances for survival even with an exploratory laparotomy were extremely low. After much discussion, the decision was made to operate on the patient. He survived the operation only to have a gradual decline in his condition such that he developed multisystem organ failure. The resident presenting the case noted that eventually the surgical team was convinced that "further treatments were futile" and "after discussing the patient’s condition with the family, the decision was made to withdraw aggressive treatment." The patient was made comfortable and died a short time later.

As the discussion at the M&M conference showed, there were many surgeons present who felt that the outcome was expected and even a few who questioned whether the patient should even have had surgery. These are important issues, but what struck me most was the use of the term "futility" in reference to this patient’s care.

In recent years, there has been significant analysis within the medical ethics literature of the concept of futility. Futility in this context is difficult to define. Moreover, it appears some doctors determine a treatment to be futile as a means of pulling back control from the patient or surrogate who may be asking for a course of action. In other words, if we accept the importance of respecting patient autonomy and if patients/surrogates want a particular treatment, doctors often have difficulty saying "no" unless they define the treatment as futile. Since it is widely accepted that physicians need not offer futile treatments, defining a treatment as futile may be a way to limit the choices for patients/surrogates to consider or request.

In line with much of this literature, I have previously argued that we should "strike the term ["futility"] from our professional lexicon" (World J. Surg. 2009;33:1338-40). However, despite the chorus of suggestions that futility is a problematic concept when it comes to caring for patients, it continues to be used in discussions of actual patient care. I have concluded that it is impossible to eliminate the term "futility." In contrast, perhaps a better approach would be to realize that calling a certain set of treatments "futile" actually provides very little information to the people with whom we are talking. When we say a treatment would be an exercise in futility, we are really saying that in our best medical judgment the likelihood of success is very low. In addition, calling something futile suggests that a careful weighing of burdens and benefits of a particular treatment has been undertaken, and the doctor believes that the burdens so clearly outweigh the benefits that the treatment should not be offered to the patient. Therefore, rather than removing "futility" from our discussions with patients and each other, we should strive to realize how little the term actually conveys to our patients/surrogates.

When we use the term "futile" to describe a treatment, we are saying it just does not make sense in a specific case. The problem is that what a patient/surrogate considers to be the burdens and benefits might differ from what the medical team sees. For example, if an operation has virtually no chance of curing a patient, it might be considered futile. However, if the patient’s primary goal is palliation of certain symptoms for even a few days, then the operation should perhaps be viewed as "potentially beneficial" relative to a particular goal rather than "futile."

Surgeons should remember that the weighing of burdens and benefits requires more than medical knowledge. As such, every time the concept of "futility" is raised in the context of caring for a specific patient, the medical team should carefully explain to the patient/surrogate the benefits and burdens are that are being considered. Since it seems impossible for us to eliminate "futility" from our clinical discussions, let us instead use the term as a reminder to communicate the details and implications of a course of action. In this manner, a surgeon’s assessment of futility might prove an opportunity for further discussions rather than a statement of a definitive conclusion.

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

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

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

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

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

The common scenario for the consent process is that when a patient has a medical condition requiring surgery, the surgeon explains the surgical risks. The patient might not want to have the operation, but once it is clear that the benefits outweigh the risks, the patient consents to the operation. This dynamic of the surgeon explaining what the patient needs and the patient considering that advice before agreeing to the operation is well accepted and firmly grounded on the principle of respect for patient autonomy. Unfortunately, in the current era of Internet marketing and the public’s fascination with the latest innovative technology, the traditional consent process is often dramatically altered.

Recently, a patient of mine requested a surgical procedure not commonly performed in the United States. The patient stated that she had read all about it on the Internet. When I asked what she had learned, my patient described the new surgical approach as an "innovative technique" that made use of the "latest technology" to allow the surgery to be performed in a "minimally invasive" fashion. When I pointed out that this approach was new and therefore less was known about it, she assured me that she likes to take on new challenges and she would be happy to be a pioneering patient for this innovative procedure.

In some ways, this scenario may sound ideal. A patient has actively explored the options to treat her disease and has found something appealing. Certainly education is good, and what could be better than a motivated patient taking an active role in her own health care decision making? Nevertheless, something made me uncomfortable. Perhaps it was the fact that the patient had misinterpreted the information that she had read and was requesting a procedure for which there was very little published safety data. Perhaps her enthusiasm for the operation took me by surprise. As I presented the risks, she seemed to disregard each and every one, having decided that this operation was "the best one" for her. Our traditional roles in the consent process had changed: The patient was pushing for an operation while the surgeon was wary of the unknown risks.

If a patient is already sold on a new procedure even before seeing a surgeon, then the surgeon has the ethical responsibility to ensure that risks are adequately considered. In this setting, the traditional emphasis on respecting the autonomous choices of patients may need to be tempered by the principle of nonmaleficence – that is, the physician’s responsibility to avoid bringing harm to the patient. I would never endorse a shift back to the old days of paternalism, when doctors made decisions for patients. However, we may be seeing the emergence of an era in which surgeons must exercise their professionalism by not offering patients everything that they might want.

The best surgeons are not always those who offer the latest high-tech, innovative procedures, but rather those who carefully explain why such an operation may not be appropriate. Surgeons have always had the ethical responsibility to apply their surgical skills to benefit their patients, and now they have the added challenge of trying to convince their patients that, despite marketing claims, a new operation may not be improved.

In trying to talk patients out of operations that they want, surgeons must ignore self-interest and, as objectively as possible, make thoughtful recommendations. As the public’s fascination with the "new," "high tech," and "innovative" procedures grows, the challenge will be to ignore the hype and make recommendations based on what is truly known about safety and efficacy.

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