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The Right Choice? A New Chapter
As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.
Over the last 7 years, I have been flattered by the comments from fellow surgeons who report that they actually read the column. I have always said that I wrote this column with the expectation that no one would actually read them. I have to confess that this is not completely true. As I wrote each column, I did so as though I was writing them for my father to read. My father, S. Peter Angelos, MD, FACS, was a general surgeon who spent his entire career practicing in the town of Plattsburgh, N.Y., where he grew up. My father’s practice was very different from mine. I work at an urban academic medical center where I have a very narrow subspecialty practice in endocrine surgery. My father had a small-town community practice of “bread and butter” general surgery. Yet, when he and I would talk about patients, the commonality of the relationship between a surgeon and a patient transcended these differences. I realize that in many ways, I wrote this column as a way of organizing my own thoughts and then presenting them to my father in the hopes that he would find them of some value.
For several years, I would send drafts of my column to my parents, and both my father and mother would read them and give me suggestions. Many of the earlier columns were changed for the better by their comments. In recent years, my father’s health declined and he was no longer able to give me comments. Nevertheless, I continued to compose them as though writing for him. Approximately 6 weeks ago, my father passed away. It has been sad for my mother and my entire family. We all realized that it was the end of one chapter of our lives and the start of a new one without my father.
I find the concept of “beginning a new chapter” to be an important one for surgeons to reflect upon. There are certain events, such as the death of a parent, that force us to think about the end of one phase of life and the beginning of another phase. However, the division of one’s experience into phases or chapters, is somewhat arbitrary. This past summer I became a patient and had surgery myself for the first time. I cannot help but think of that operation as the start of a new chapter for me. I am convinced that although all patients may not reflect upon surgery in the same way that I did, nevertheless, an operation is a dramatic event that most people remember for a long time. In this context, many people will see their interactions with their surgeon and their operation as the end of one chapter and the beginning of a new one.
In this context, it is critical for surgeons to be fully cognizant of the great impact that we may have on our patient’s internal narratives of their lives. When we operate on someone, we run the risk of that person’s functional status changing forever. We may be the means by which our patient is cured of cancer or suffers a debilitating complication. As surgeons, we therefore, occupy a potentially significant role in the trajectory of our patients’ lives. I believe that the relationship between a surgeon and a patient is distinctive and central in the narrative that so many patients create about their lives. It is essential that surgeons continue to appreciate the value of the quality of that relationship with our patients and the impact—potentially positive or negative—that it can have upon our patients.
Throughout medicine, in general, and in surgery in particular, one cannot go a week without hearing about the problem of burnout. Although there is no single cure for burnout, I do believe that paying attention to the ethical dimension of our interactions with our patients and the impact that surgery can have on their lives will go a long way to reducing the risks of burnout among surgeons.
In an era in which we are often pushed to increase RVUs at the expense of spending time with individual patients, we must not forget how significant our relationships with our patients can be. I believe that attention to this relationship will be beneficial to patients and also to us as we help our patients start new chapters in their lives.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.
Over the last 7 years, I have been flattered by the comments from fellow surgeons who report that they actually read the column. I have always said that I wrote this column with the expectation that no one would actually read them. I have to confess that this is not completely true. As I wrote each column, I did so as though I was writing them for my father to read. My father, S. Peter Angelos, MD, FACS, was a general surgeon who spent his entire career practicing in the town of Plattsburgh, N.Y., where he grew up. My father’s practice was very different from mine. I work at an urban academic medical center where I have a very narrow subspecialty practice in endocrine surgery. My father had a small-town community practice of “bread and butter” general surgery. Yet, when he and I would talk about patients, the commonality of the relationship between a surgeon and a patient transcended these differences. I realize that in many ways, I wrote this column as a way of organizing my own thoughts and then presenting them to my father in the hopes that he would find them of some value.
For several years, I would send drafts of my column to my parents, and both my father and mother would read them and give me suggestions. Many of the earlier columns were changed for the better by their comments. In recent years, my father’s health declined and he was no longer able to give me comments. Nevertheless, I continued to compose them as though writing for him. Approximately 6 weeks ago, my father passed away. It has been sad for my mother and my entire family. We all realized that it was the end of one chapter of our lives and the start of a new one without my father.
I find the concept of “beginning a new chapter” to be an important one for surgeons to reflect upon. There are certain events, such as the death of a parent, that force us to think about the end of one phase of life and the beginning of another phase. However, the division of one’s experience into phases or chapters, is somewhat arbitrary. This past summer I became a patient and had surgery myself for the first time. I cannot help but think of that operation as the start of a new chapter for me. I am convinced that although all patients may not reflect upon surgery in the same way that I did, nevertheless, an operation is a dramatic event that most people remember for a long time. In this context, many people will see their interactions with their surgeon and their operation as the end of one chapter and the beginning of a new one.
In this context, it is critical for surgeons to be fully cognizant of the great impact that we may have on our patient’s internal narratives of their lives. When we operate on someone, we run the risk of that person’s functional status changing forever. We may be the means by which our patient is cured of cancer or suffers a debilitating complication. As surgeons, we therefore, occupy a potentially significant role in the trajectory of our patients’ lives. I believe that the relationship between a surgeon and a patient is distinctive and central in the narrative that so many patients create about their lives. It is essential that surgeons continue to appreciate the value of the quality of that relationship with our patients and the impact—potentially positive or negative—that it can have upon our patients.
Throughout medicine, in general, and in surgery in particular, one cannot go a week without hearing about the problem of burnout. Although there is no single cure for burnout, I do believe that paying attention to the ethical dimension of our interactions with our patients and the impact that surgery can have on their lives will go a long way to reducing the risks of burnout among surgeons.
In an era in which we are often pushed to increase RVUs at the expense of spending time with individual patients, we must not forget how significant our relationships with our patients can be. I believe that attention to this relationship will be beneficial to patients and also to us as we help our patients start new chapters in their lives.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
As I write this last installment of “The Right Choice?” for ACS Surgery News, a number of different emotions are going through my mind all at the same time. I am surprised at how quickly the time has passed since I wrote my first surgical ethics column for SN in 2011. In the 33 columns that I have written since then, I have tried to focus on aspects of surgical practice that emphasize the ethical dimension. I have tried to write columns that would be of interest to practicing surgeons in any setting and not only to academic surgeons that practice in urban environments such as I practice in. This is the last column and thus the end of a chapter of my life and the beginning of a new one.
Over the last 7 years, I have been flattered by the comments from fellow surgeons who report that they actually read the column. I have always said that I wrote this column with the expectation that no one would actually read them. I have to confess that this is not completely true. As I wrote each column, I did so as though I was writing them for my father to read. My father, S. Peter Angelos, MD, FACS, was a general surgeon who spent his entire career practicing in the town of Plattsburgh, N.Y., where he grew up. My father’s practice was very different from mine. I work at an urban academic medical center where I have a very narrow subspecialty practice in endocrine surgery. My father had a small-town community practice of “bread and butter” general surgery. Yet, when he and I would talk about patients, the commonality of the relationship between a surgeon and a patient transcended these differences. I realize that in many ways, I wrote this column as a way of organizing my own thoughts and then presenting them to my father in the hopes that he would find them of some value.
For several years, I would send drafts of my column to my parents, and both my father and mother would read them and give me suggestions. Many of the earlier columns were changed for the better by their comments. In recent years, my father’s health declined and he was no longer able to give me comments. Nevertheless, I continued to compose them as though writing for him. Approximately 6 weeks ago, my father passed away. It has been sad for my mother and my entire family. We all realized that it was the end of one chapter of our lives and the start of a new one without my father.
I find the concept of “beginning a new chapter” to be an important one for surgeons to reflect upon. There are certain events, such as the death of a parent, that force us to think about the end of one phase of life and the beginning of another phase. However, the division of one’s experience into phases or chapters, is somewhat arbitrary. This past summer I became a patient and had surgery myself for the first time. I cannot help but think of that operation as the start of a new chapter for me. I am convinced that although all patients may not reflect upon surgery in the same way that I did, nevertheless, an operation is a dramatic event that most people remember for a long time. In this context, many people will see their interactions with their surgeon and their operation as the end of one chapter and the beginning of a new one.
In this context, it is critical for surgeons to be fully cognizant of the great impact that we may have on our patient’s internal narratives of their lives. When we operate on someone, we run the risk of that person’s functional status changing forever. We may be the means by which our patient is cured of cancer or suffers a debilitating complication. As surgeons, we therefore, occupy a potentially significant role in the trajectory of our patients’ lives. I believe that the relationship between a surgeon and a patient is distinctive and central in the narrative that so many patients create about their lives. It is essential that surgeons continue to appreciate the value of the quality of that relationship with our patients and the impact—potentially positive or negative—that it can have upon our patients.
Throughout medicine, in general, and in surgery in particular, one cannot go a week without hearing about the problem of burnout. Although there is no single cure for burnout, I do believe that paying attention to the ethical dimension of our interactions with our patients and the impact that surgery can have on their lives will go a long way to reducing the risks of burnout among surgeons.
In an era in which we are often pushed to increase RVUs at the expense of spending time with individual patients, we must not forget how significant our relationships with our patients can be. I believe that attention to this relationship will be beneficial to patients and also to us as we help our patients start new chapters in their lives.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Communication and consent
We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.
His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.
This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.
This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.
However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.
We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.
Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.
Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.
His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.
This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.
This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.
However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.
We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.
Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.
Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
We knew that the case would be a difficult one. The patient was a man in his mid-40s who had several serious chronic conditions and was on high-dose steroids. He had been operated on 10 days earlier by one of my partners for a bowel obstruction and had required a resection of a small portion of the terminal ileum. Unfortunately, on the day after surgery, it became obvious that the patient needed a reexploration for bleeding. He had developed clear evidence of a significant anastomotic leak and had to be taken emergently back to the operating room.
His condition had been worsening during the day. We had booked the case in the OR but had been put off by a trauma emergency and a neurosurgical emergency. During the 3 hours of waiting to take him to the OR, the patient’s sister and mother came to the hospital and were now waiting with him in the preop area. I was on my way up to see him when my resident called. Despite the patient having signed an operative consent form a few hours earlier when we booked the case, he was now “declining” an operation. I was surprised. This man had undergone several operations in the last few years and two in the last 2 weeks. I arrived to find the patient stating that he did not want surgery. Lying in bed, he was adamant that he should not have surgery. The surgical resident who had spoken with the patient several times over the last few hours was also surprised. The patient’s family members were yelling that, of course, he wanted surgery and why would he change his mind.
This is a difficult situation since one of the central tenets of the ethical practice of surgery is to allow patients to make decisions about their own care. The right to make autonomous choices even extends to circumstances in which patients make what we might consider “bad” decisions. As long as the patient has the capacity to make an autonomous choice, he or she should have that choice respected.
This patient, who just a few hours ago had agreed to surgery, now seemed to have changed his mind. Although it can be frustrating, we do allow patients to change their minds. On the one hand, this was a straightforward case. The patient was refusing a potentially life-saving operation. Such a situation is never pleasant for a surgeon, but as long as the patient understands the risks, we respect such choices.
However, my resident made an astute observation. She pointed out that, when asked why he now did not want surgery, he replied that “this is all a movie – it’s not really happening.” The patient appeared to be oriented to person and place, but nevertheless, his reasoning seemed to have been altered. It appeared that this patient was no longer making sense because his underlying medical condition had deteriorated. We considered whether he was becoming septic and that this change in medical condition had rendered him unable to make an informed decision. My resident, who had discussed the operation with the patient several times, stated that the patient’s decision making seemed very different than even an hour ago. His family members agreed, stating that, up until a few minutes before, he was in favor of surgery. They pleaded with us to just take him into the operating room.
We considered our options. We could delay surgery and consult psychiatry to ask them to assess his competency. However, on a weekend night, this would likely take several hours. We considered the option of waiting in the preop area for the patient’s medical condition to further worsen. If he became overtly septic and lost consciousness, then we could readily turn to the family members – his surrogate decision makers – and ask them to consent to the procedure. Although this “by the book” approach might take away any worry that we were overriding an autonomous patient’s choice, we knew that it would unnecessarily expose him to greater operative risks. This option was not in his best interest and therefore not much of an option.
Ultimately, the surgical resident, the attending anesthesiologist, the family, and I decided that his decision to not have surgery at this moment was not consistent with his prior decisions, and he could provide no reason for changing his mind. We brought the patient into the operating room and explored him. He did have a large anastomotic leak with a large volume of enteric contents in the peritoneal cavity. He survived the operation and, not unexpectedly, required a long postoperative stay in the hospital. Once he was a few days out, I inquired about whether he was glad that he had surgery. He was quick to state his confidence that it had been the right choice for him. He did not even remember having ever refused the surgery.
Although this case raised many concerns for all of us involved in the patient’s care, one overriding lesson that came through to me. Informed consent should not be viewed as a solitary event, but a conversation. This patient had expressed his desire to have surgery multiple times to my surgical resident and to his family. Even though we should never take the position that patients cannot change their minds, we should carefully question those choices that are inconsistent with the prior discussions that have been undertaken. Good communication skills – including listening to the patient, understanding the patient’s reasoning, and reflecting on the entire conversation – are essential in obtaining informed consent.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Right Choice? Modifiable risk factors and surgical decision making
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the July 26, 2018, issue of the New England Journal of Medicine, Ira L. Leeds, MD, David T. Efron, MD, FACS, and Lisa S. Lehmann, MD, raise the important issue of how to proceed when a patient has an indication for surgery and wants the surgery, but the patient has modifiable risk factors that make the likelihood of surgical complications high.1 Specifically, the authors describe a 45-year-old woman with morbid obesity and chronic opioid dependency who presented with a large incisional hernia. The patient suffers from debilitating pain and nausea that has been attributed to her hernia. She is homebound and is seeking a third opinion on repair of the hernia. She has smoked for 30 years and continues to do so after prior unsuccessful attempts to quit. She has been turned down previously by two surgeons who reportedly felt she was too high risk. Application of an all-procedure risk calculator has shown a 38% higher than average risk of a complication with an expected length of stay 80% longer than average.
I commend the authors for raising this set of issues for consideration. As surgeons, we routinely make decisions about what operations we recommend to patients based on the risks of the operation. However, we also allow significant latitude for patients to make individual decisions about assuming greater or lesser risks. If the patient’s surgical risks could be reduced by her stopping smoking and losing weight, should the surgeon insist upon those things being done before being willing to operate on the patient? The answer to this question depends on the perspective that one takes in viewing this case. If the surgeon’s relationship with the patient is primary and the potential benefit of surgery is clearly present, then one could view the considerations of lower public ranking and added costs to society as irrelevant. However, if a surgeon views his or her role as not only advocating for their patient, but also being a steward of societal resources, then the added resources necessary to get this patient safely through the operation are critically important to consider.
In order to come to a decision for this individual patient, the authors argue in favor of greater patient education of the surgical risk so the patient can appreciate the importance of modifying the risky behaviors prior to surgery. This concept of shared decision making with patients is certainly important and should be encouraged in any surgeon-patient interaction around a possible surgical intervention. The authors also note the importance of ensuring an alignment of values between the patient and the surgeon in why the operation might be undertaken. These suggestions are excellent and undoubtedly would lead to better relationships between surgeons and patients and also likely better decisions about when to operate.
My primary concern with the authors’ suggestions occurs when the authors encourage surgical professional societies to “develop consistent practice guidelines without partiality to any particular patient.” The authors make the claim that, in a complex case in which it is difficult to decide what is best for the patient, we would benefit from having more guidelines about what modifiable risk factors should preclude surgery.
I worry that the appeal to guidelines is too often an appeal to ignore the individual aspects of a patient’s condition and the impact that the condition has on a patient’s life. Rather than saying, “What we need is more guidelines,” I would much prefer we emphasize the need for more communication between surgeons and patients about the risks of surgery and the implications of recovery on the patient’s quality of life. Although there is nothing detrimental to gathering data about the impact of modifiable risks on surgical outcomes, I am concerned that guidelines may become viewed as parameters of “good” patient care. We all know that no guideline can account for all the individual values and goals a patient may have and, thus, we ought not use guidelines to shield us from the complex individual decision making that as surgeons we should engage in with each of our patients.
Reference
1. Leeds IL et al. Surgical gatekeeping – modifiable risk factors and ethical decision making. N Engl J Med. 2018 Jul 26. doi:10.1056/NEJMms1802079.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Right Choice? Mixed feelings about a recent informed consent court decision
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
On June 20, 2017, the Supreme Court of Pennsylvania ruled on a case that may have significant implications for surgical informed consent.
Although the legal complexities of the case might be interesting to some, what got my attention was the question of whether a surgeon can delegate the informed consent discussion with a patient to someone else.
A few weeks later, the patient had a phone conversation with Dr. Tom’s physician assistant (PA) who answered several additional questions Ms. Shinal had about the surgery. Approximately one month later, the patient met with the same PA and had a preoperative history and physical examination and the informed consent form was signed.
About 2 weeks after that, the patient had an open craniotomy with total resection of the tumor. Unfortunately, the procedure was complicated by bleeding that resulted in stroke, brain injury, and partial blindness. Ms. Shinal and her husband sued Dr. Toms for malpractice, and included in the suit was a claim that Dr. Toms failed to obtain informed consent from Ms. Shinal.
At the original trial, the jury was instructed by the judge to consider information given to Ms. Shinal both by Dr. Toms and his PA as included in the informed consent process. The jury found in favor of Dr. Toms and the patient then appealed to the Pennsylvania Superior Court which upheld the decision. The case was then appealed to the Pennsylvania Supreme Court, which specifically addressed the issue of whether the informed consent discussion must be performed by the surgeon or can be delegated to others.
Several groups, including the American Medical Association, filed briefs in the case supporting Dr. Tom’s claim that the information that is conveyed in the informed consent process is what is important rather than exactly who provides that information to the patient. For many, this case seemed to be relatively straightforward. The surgeon had discussed the operation with the patient, she had agreed, and then in several additional conversations with the surgeon’s PA, the patient’s additional questions had been answered and the patient had willingly signed the informed consent document.
However, in a surprise to many, the Pennsylvania Supreme Court decision stated that “a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patients’ informed consent. Informed consent requires direct communication between physician and patient and contemplates a back-and-forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient’s informed consent belongs solely to the physician.” Based on this finding, the case was sent back to the trial court for a new trial.
Although legal scholars may debate the legal basis of this opinion and the ramifications for future cases, I am more interested in the ethical issues that it raises. Although, in recent decades, I have become increasingly accustomed to the idea of medical care by teams, there is something almost nostalgic about this decision. It suggests to me that at least four of the seven Pennsylvania Supreme Court justices believe that there is something so special about surgical informed consent that it must involve a direct conversation between the patient and the surgeon.
This view seems ever more foreign in an environment in which we increasingly talk about processes of care and systems errors rather than individual relationships and individual responsibility. Although the supremely hierarchical concept of the surgeon as the “captain of the ship” has largely been replaced by the team approach, it is nevertheless true that, in an elective case, the patient would not be in the operating room but for the relationship and trust that the patient has in the surgeon.
As I contemplate this court case, I see how it may add to the challenges of providing surgical care to patients and how it may further the delays to see some surgeons. However, it also reemphasizes for me that informed consent for surgery is less about the information that is transferred to the patient and much more about the relationship in which a patient places his or her trust in the surgeon. The emphasis that this court ruling places on the direct relationship between a surgeon and a patient is a refreshing reminder of the personal responsibility that surgeons have for their patients’ outcomes.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The right choice? Surgery “offered” or “recommended”?
The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.
When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.
The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?
These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.
There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.
Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.
When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.
The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?
These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.
There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.
Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The story was not unusual for a late-night surgical consultation request by the emergency department. The patient was a 32-year-old man who had presented to the emergency room with crampy abdominal pain. He initially had felt distended, but – during the 3 hours since his presentation to the hospital – the pain and distention had resolved. A CT of the abdomen and pelvis was obtained shortly after the patient arrived in the emergency department. The study showed some dilated small bowel along with a worrisome spiral pattern of the mesentery that suggested a midgut volvulus. The finding was surprising to the surgical resident examining the patient given that the patient now had a soft and nontender abdomen on exam. The white blood cell count was not elevated, and the electrolyte levels were all normal.
When presented with this recommendation, the patient declined the recommended surgery. He stated that he felt fine and that this would be a bad time to have an operation and miss work. The patient ultimately left the hospital only to present 5 days later with peritonitis. When he was emergently explored on the second admission, he was found to have a significant amount of gangrenous small bowel that required resection.
The case was presented at the M and M (morbidity and mortality) conference the following week. When asked about the prior hospital admission, the resident reported that the patient had been “offered surgery,” and in the context of “shared decision making,” the patient had chosen to go home. This characterization of the interactions with the patient raised concern among several of the attending surgeons present. Was the patient only “offered” surgery, or was he strongly recommended to have surgery to avoid potentially risking his life? Was the patient’s refusal to have surgery despite the risks actually a case of “shared decision making”?
These questions are but a few of the many that can arise when language is used indiscriminately. Although, in the contemporary era of “patient-centered decision making,” it is common to think about every recommendation as an offer of alternative therapies, I worry that describing the interaction in this fashion is potentially misleading. Patients should not be offered potentially life-saving treatments – those treatments should be strongly recommended. Certainly, we must accept that patients can refuse even the most strongly recommended treatments, but a patient’s refusal to follow a strong recommendation for surgery should not be characterized as shared decision making. “Shared decision making” suggests that there are medically acceptable choices that the physician has offered the patient, from which the patient can make a choice based on his or her preferences and values. The case above is not shared decision making but one of respecting the patient’s autonomous choices even if we do not agree with the choices made.
There are undoubtedly situations in which there is a choice among reasonable medical options. When there is a such a choice to be made, as surgeons, we should help our patients understand the options so that they can make a decision that best fits with their values and goals. However, when the only choice is whether to have the recommended surgery or decline it, we have now moved beyond shared decision making. In that circumstance, we should strongly recommend what we believe is the better option while still respecting the autonomy of patients to decline our recommendation.
Shared decision making often is viewed as the pinnacle of ethical practice – that is, involving patients in the decisions to be made about their own health. Although I agree that we do want to educate our patients and encourage them to make what we consider safe medical decisions, when we recommend a safe choice and the patient declines it, we are no longer talking about shared decision making. In such circumstances, we are in the realm of respecting patients’ choices even when we disagree with those choices. Our responsibility as surgeons is to recommend what we think is safe but respect their choices whether we agree or not. We should do more than simply offer surgery when it is potentially life threatening not to have it.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The right choice? Surgical ethics and the history of surgery
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.
This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.
According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.
When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.
Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:
Do the risks of the operation outweigh the potential benefits to the patient?
Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.
The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Conflicts and the ethical practice of surgery
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Once a month in my department, we focus on a case with challenging ethical considerations for part of the discussion at the M & M conference.
Earlier this week, my colleagues and I heard about an unfortunate 87-year-old man, who had been living independently when he developed a partial bowel obstruction. His wife had died over 10 years earlier and, although he lived alone, he had two sons and a daughter who lived close to him and regularly looked in on him and helped him to keep up his small home.
The ethical challenge presented at M & M was the difficulty of determining what was the “best” treatment for this patient and how that decision was reached. The surgical team explained to the patient and his family that there were two broad possibilities for his treatment: definitive resection of the primary tumor or palliative options. In order for him to have a colon resection, the cardiologists felt that he would need coronary artery bypass grafting before surgery. To pursue this course of treatment, they wanted him to have a diverting colostomy before the heart surgery. Then, after a period of recovery from the heart surgery, he could have a colon resection with takedown of the colostomy.
Alternatively, the palliative option of a colonic stent followed by external beam radiation to the lesion was offered. The surgical team tried to present the options in an evenhanded manner so as not to paint either option as being significantly worse. However, even with a definitive resection, the surgeons did not believe that they could cure the patient and they explained this to him and his family.
The patient seemed to have the capacity to make the choice and, although he had originally wanted “everything” done, when he was transferred to our hospital and when presented with these choices, he stated that the palliative option seemed better for him. He told the surgical team that he did not want to have heart surgery, and he did not want to risk dying with a colostomy.
At the end of the family meeting, the surgical team felt that the patient had made a reasonable decision, and they were comfortable with his choice. However, the following day, the patient’s daughter called demanding another meeting with the surgical team. She had been at the family meeting the prior day and stated that, in her opinion, the surgical team had “pushed” the patient to accept the palliative option and that she was not certain that he really had the capacity to make decisions for himself.
During the subsequent meeting with the family, the daughter was the primary spokesperson, but the two sons also seemed in agreement with her assessment that the patient lacked capacity. She stated that the patient was transferred to our medical center in order to allow him to get the treatments that he needed, and now, in her opinion, the surgical team was not pursuing the “best” treatment. She was upset and repeatedly expressed this sentiment.
The surgery team was understandably concerned with this turn of events. They had undertaken their evaluation with constant reassessment of the likely impact of the treatment options on the patient’s quality of life. They had tried to explain the options fully to the patient and involved his family in the discussion. In short, the surgical team had done their best to pursue high-quality ethical care by utilizing shared decision making. Despite spending significant time with the patient and his family, there was now conflict. The patient wanted to pursue a course of treatment that the surgical team felt was appropriate, but the family disagreed and wanted to make the decisions for the patient and pursue a more aggressive approach.
For many physicians, especially the residents who were actively involved in caring for this patient, this outcome – namely, significant conflict with the family and the family feeling that the patient should not be allowed to make his own decisions – seemed to be exactly what the careful attention to the ethical dimension of surgical practice tries to avoid.
Even though most of us try to avoid conflicts with patients and their families, optimal ethical practice does not always result in a consensus of opinions and that lack of conflict. As physicians, we can try to follow all of the ethical guidelines of extensive communication and shared decision making, yet we may still wind up with unhappy patients and families.
The goal of ethical practice should not be to avoid conflicts, but, rather, to treat patients in the manner that helps them to achieve what they value most.
In this present case, what could the surgical team do moving forward? Sometimes conflicts can be solved with additional information. A psychiatry consultation might be helpful to gain an opinion on whether the patient has the capacity to make decisions. Additionally, an ethics consultation might be valuable to gain an outside view to help the family understand the potential merits of a palliative approach. Although this case raises ethical concerns for the surgical team, the conflicts that resulted ought not be seen as a failure of the discussions surrounding the patient’s goals for his treatment.
Most of us prefer to avoid conflicts with patients and their families, but our ultimate goal in the ethical practice of surgery cannot be consensus. Rather, it should be to do the best we can to provide care that helps the patient achieve his or her goals. Unfortunately, we may do everything possible to provide high quality ethical care to patients and conflict still result. However, we cannot use resulting conflict as a reason to avoid the many discussions needed to communicate the options accurately to our patients and their families.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The right choice? Surgeons, confidence, and humility
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. In order to do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have been because they were unable to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to have confidence and surgeons actually need to be confident in order to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach it authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. In order to do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have been because they were unable to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to have confidence and surgeons actually need to be confident in order to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach it authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess and requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. In order to do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have been because they were unable to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to have confidence and surgeons actually need to be confident in order to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach it authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Right Choice? Surgeons, confidence, and humility
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
It started as an offhand comment. The patient had been on the medicine service for over a week before developing acute appendicitis with an abscess requiring an emergency open appendectomy. He was a 68-year-old man who had longstanding medical issues that had given him many opportunities to interact with physicians in the prior few years.
On the second morning after surgery, a new team of surgical residents was rounding on him. The chief resident led the group of residents and students into the patient’s room and introduced himself as being part of the surgical team. The patient smiled and stated that he knew this was a group of surgeons. When asked why, the patient reported that he could always tell when surgeons enter the room. “You enter with an air of bravado and arrogance that the medical doctors do not exude.” The surgical residents commented on this fact to me later when I rounded on the patient, and it prompted discussion of the potential positives and negatives of confidence in surgical practice.
Most successful surgeons express a level of confidence in their abilities which often exceeds that of many other physicians. Such observations have led to the joke that “surgeons are often wrong, but never in doubt.” The question is whether the expression of confidence in one’s abilities as a surgeon is a requirement of a surgeon or simply a common characteristic for many people who choose to go into the field of surgery.
There is no doubt in my mind that in order to be willing to put a patient through an operation, surgeons must be confident in their skills. Surgery never achieves its benefit for patients without first causing the patient some harm. Any operation requires that the surgeon impose a violent act on the patient that, in any other context, would be illegal. To do such things to patients, surgeons must have a high degree of confidence.
Patients also appreciate a confident surgeon. Over the years, I have known many technically excellent surgeons who have never been as busy as they might have because of their inability to express confidence to their patients. The opposite, however, is also true. There are surgeons who become so overconfident in their abilities that they become reckless in recommending high-risk operations to patients.
Given that patients expect their surgeons to be confident and surgeons actually need to be confident to be successful, it might be surprising that the important attribute of self-confidence does not more frequently spill over into overbearing arrogance. Perhaps the most important temporizing of surgeon overconfidence is the unfortunate inevitable consequence of surgery that complications happen to even the best surgeons. We all know that the central question of the M & M conference is, “What could you have done differently?” Whether this question is answered publicly or only in the mind of the surgeon, the contemplation of the decisions made, and their consequences, is essential for each surgeon to consider in the face of every complication.
Much as the public should want surgeons to be confident, but not too confident, they should also want their surgeons to take complications seriously, but not too seriously. It is helpful for a surgeon to think about making a different choice in the future. But it would not be helpful if, in the face of a bad outcome, a surgeon decides that he or she can no longer perform surgery.
This balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications, is challenging to teach to surgical residents and fellows. Part of the challenge is that often surgical faculty do not verbalize the challenges that we face in this realm. The perfect combination of confidence and humility is something that few of us have identified in our own lives, let alone are prepared to teach authoritatively to others. Nevertheless, teaching the next generation of surgeons to recognize the tension between confidence and humility is worthwhile. And like their elders, they may well discover that achieving the right balance is a lifelong pursuit.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The Problem of ‘Is’ and ‘Ought’ for Surgeons
Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.
I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.
In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.
Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.
The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”
Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.
Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.
I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.
In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.
Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.
The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”
Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.
Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
Many years ago during medical school, I took time out to pursue graduate studies in philosophy. At that time, I took a number of courses that explored various approaches to the philosophical questions of morality and ethics. My ultimate goal, even back then, was to focus on ethical issues in the practice of medicine.
I often found the philosophical discussions from the “giants” in philosophy were not always easy to apply to everyday problems. After completing my graduate studies in philosophy and nearing the end of medical school, I found that I was drawn to surgery. Not surprisingly, many surgical faculty that I interviewed with for my residency saw little application of my philosophy studies to the practice of surgery. Although I felt confident that ethics was central to the practice of surgery, I let pass the general suggestions from many senior surgeons that surgery and philosophical analysis have little in common.
In recent years, however, I have increasingly seen an area of overlap that I believe will be central to the future of surgery. The options for the treatment of critically ill surgical patients across all areas of surgery have increased dramatically. Just in the area of cardiovascular disease, patients with failing hearts have the option of mechanical assist devices. Patients with multiple comorbidities and vascular problems can have numerous endovascular procedures done that years ago would have been unthinkable. Consider a patient with a ventricular assist device on a ventilator who is being dialyzed. Such a patient may be supported for weeks or months beyond what was possible just a few decades ago.
Whereas our surgical forefathers were constantly asking the question, “What can be done for this patient?” those caring for critically ill patients today must repeatedly ask, “What should we do for this patient?” Years ago, the statement, “there is nothing more that we can offer” was much more commonly heard than it is today. The critical question for today – “What should be done?” – is often more challenging and nuanced than “what can be done?” Whenever we ask “what should be done?” we must take into account the values of the patient and weigh the possible outcomes and the inherent risks of the possible interventions with the patient’s goals.
The current necessity to answer “what should be done?” has several striking parallels with the classical philosophical problem of “is” and “ought.” Over the centuries, many philosophers have considered whether we can derive an “ought” from an “is.” In other words, just because one can show that something is the case in the world, it does not automatically follow that it ought to be that way. David Hume, the Scottish philosopher (1711-1776), famously argued that there is a tremendous difference between statements about what is and statements about what ought to be. In particular, Hume argued that we cannot logically derive an “ought” from an “is.”
Despite the centuries that have passed since Hume’s days, I believe that his analysis has much to teach modern surgery. Just because we can undertake many interventions for our patients, it does not follow that we should undertake all of those interventions. A central aspect of what many of us refer to commonly as “surgical judgment” is deciding among the many possible interventions for a patient, what specific ones ought we offer. Although this entire discussion may seem theoretical (and possibly even arcane) to some surgeons, I firmly believe that one of the greatest challenges to the future of surgery is whether surgeons are willing to address the question of what should be done for every patient.
Excellent surgeons have traditionally been seen as having both technical mastery and sound judgment. In the current era in which surgeons are increasingly pushed to do more cases and maximize RVUs, multiple forces are encouraging surgeons to increasingly become pure technicians. Technicians can answer the question “what can be done?” However, “what should be done for this specific patient?” is a question that only a physician can answer. In the decades to come, we must ensure that surgeons continue to engage in the harder questions of “what should be done?” so that we do not forget that “is” and “ought” are different. The mastery of surgery involves not only the technical expertise that can be applied on behalf of a patient, but also the appreciation and understanding of the patient’s values so that surgeons can make recommendations about what should be done for their patients.
Dr. Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics; chief, endocrine surgery; and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.
