The Right Choice?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

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

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

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

The traditional Surgical Morbidity and Mortality Conference that I remember so well from my residency days has changed. Not everything has changed, however. Usually the most senior resident involved still presents the case along with a discussion of the operation performed and the complication. There is invariably a discussion of the central question, “What should have been done differently?” Residents still occasionally get nervous before presenting a case as I did years ago, and there is still the occasional disagreement over how a surgical issue was handled. But there are subtle differences notable in the M&M discussions of today.

Rather than focusing on who did something wrong, there is today more often a focus on the “systems issues” in the case. In other words, if a pneumothorax was missed after a central line placement, the discussion today is much more commonly focused on the systems that should have been in place to ensure that such an abnormality was noted and acted upon. In years past, the focus was squarely on identifying which resident shirked his or her responsibility to review the film.

This current “blame-free” environment is the hallmark of a “learning organization” that aims to use the review process to improve performance. Mistakes are viewed as opportunities for learning and improving the system. And the nonpunitive analysis goes a long way toward improving morale among the residents and certainly encourages teamwork and identification of mechanisms to avoid errors within a hospital or service. These are all good things. But I worry that perhaps there is a tendency to go too far with avoiding individual responsibility.

Sometimes it is easy to talk about things “just happening” in large medical systems of today. Many surgeons are accustomed to dictating operative reports in the passive voice. For example, I find myself routinely stating, “the patient was prepped and draped,” “an incision was made,” and “exposure was obtained.” All these statements suggest that things happened and, perhaps “mistakes were made,” but there is little attribution to a specific actor. Unfortunately, it can be easy to also talk about patient care in a similarly abstract manner in which it is hard to identify who did what to whom.

The central question, I believe, is whether this new focus on the system and the team is ultimately better for patient care. We do want all members of the operating room team, for example, to feel responsible for speaking up when something does not seem right. We want every person involved in a patient’s care to feel comfortable with stopping an incorrect intervention. Surgeons, in particular, should not be upset by having the medical student question which side of the patient is being operated upon. Hierarchy should never stand in the way of speaking up to avoid an error being made. Nevertheless, we must not completely eliminate the sense of personal responsibility that each individual caregiver should feel toward ensuring the well-being of the patient.

In 1937, Chicago surgeon Max Thorek, M.D., wrote a pioneering book entitled, Surgical Errors and Safeguards. Dr. Thorek wrote, “While it is human to err, it is inhuman not to try, if possible, to protect those who entrust their lives into our hands from avoidable failures and danger.” I believe that this philosophy continues to be embodied in the Surgical M&M conference.

One of the central components of the M&M discussion has not changed. After all of the discussion about systems and corporate responsibility, I believe that the most common statement that I have heard from the treating surgeon is, “My error was that I should have done ... ” Although some observers might see this ascription of the individual role of the surgeon to be anachronistic, I believe that it captures the reality of the situation that even though patients are operated upon by teams, it is most commonly an individual relationship with a specific surgeon that has prompted the patient to go ahead with the surgery. We must not lose sight of the importance of that individual relationship and the responsibility that the individual surgeon has in influencing patient choice. In many ways, although the tenor of the Surgical M&M conference has changed the old question of “What could I have done differently?” remains of central importance to ensuring that surgeons take responsibility for their patients’ well-being.

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

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

The case being presented at Surgical Morbidity and Mortality Conference was all too familiar to many of the surgeons in the auditorium. After extensive discussions with the surgeon, an elderly man had undergone a risky operation. Although the operation had gone well, the patient had several setbacks in the first 48 hours requiring a second trip to the operating room. The patient was back in the surgical ICU fully ventilated on minimal pressors less than 24 hours after leaving the operating room the second time when the patient’s two sons and a daughter approached the surgeon to talk about the plan moving forward.

This was not a surprising turn of events since the patient’s wife had died several years earlier and he was in close contact with his children. They all lived in the area and had been present in the waiting room during both of his trips to the operating room. In accordance with the accepted standards for surrogate decision making, since the patient was not able to make decisions for himself, the appropriate surrogates were the two sons and a daughter. What was surprising to the surgeon was that now, less than 24 hours after leaving the operating room, the children were unanimous in their request that the patient’s life-supporting measures be stopped. Although there was no written advance directive, all the children felt strongly that their father would not have been wanted to be kept alive through “artificial means.”

This request created a series of quandaries for the attending surgeon. First, the surgeon felt that the patient had fully understood the small risks of complications and he had wanted to proceed with the operation despite understanding these risks. Second, the surgeon fully believed that the patient had a good chance for a complete recovery after surgery despite the complication. Based on the belief that the current requirement for intubation and ventilation was a temporary one, the surgeon felt that to withdraw support of the patient for a reversible problem so soon after surgery would be evidence of her not respecting the patient’s specifically stated wishes that he wanted to have surgery and recover from it.

The ensuing M&M discussion focused on a series of important questions. Had the patient fully understood the risks of the operation? His surgeon felt that he had, and she believed that the patient would not have wanted her to “give up” so soon after the operation. Someone asked whether the surgeon should have been willing to perform a high-risk operation on an elderly patient without having had the sons and daughter present to participate in the preoperative discussions. Such a scenario might have avoided the circumstance of the surgeon having a different understanding of the patient’s wishes than was currently being expressed by the sons and daughter. However, the logistics of requiring a competent adult patient who is living independently to bring his sons and daughter to the consultation before the surgeon was willing to operate seemed problematic.

It became clear that from the surgeon’s point of view (as well as from the majority of us at the M&M conference) that when the patient agreed to have the operation, he was not only agreeing to the surgery but also to the necessary perioperative care to allow him to recover. On the other hand, the family (who were now the appropriate surrogate decision makers) believed that the operation was over and all further treatments were open to discussion and should be evaluated based on what they believed their father’s wishes would have been.

What should be done when the surgeon’s responsibility to respect what she believes the patient’s wishes were are in conflict with the surrogate decision makers? Unfortunately, there is no clear answer to this question. The closer in time one is to the operation, the more the patient’s initial decision to proceed with surgery seemingly should hold sway. The further away from the operation, the more the family members’ interpretation of the patient’s wishes should guide decisions about treatments.

The surgeon in this case seemed to have reached an excellent compromise with the family. Based on the belief that the need for intubation and ventilation was short term, the surgeon convinced the family to allow aggressive treatment for 48 hours. She had expressed to the family that she felt she had a responsibility to their father to try to get him safely through this early part of the recovery. After the 48-hour time-limited trial, the surgeon and the family would meet again to discuss his status. If there had been improvements, then the same aggressive treatments would be continued in the hopes that the patient would soon be able to make his own decisions. Alternatively, if there was not improvement over the next 2 days, the surgeon agreed that further interventions would all be reassessed in accordance with what the family believed would have been their father’s wishes.

Although the patient ultimately did not recover, the surgeon felt that she had lived up to her responsibility to respect her patient’s decision to have surgery, while not completely ignoring the family’s wishes. The family also felt that the surgeon had been respectful of their own interpretation of their father’s goals and values. Sometimes in the ethical care of surgical patients, there is not a right and a wrong answer, but a series of compromises that we all hope will lead to the best outcome for our patients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."

Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?

Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.

At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.

Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.

For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.

As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice

In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."

I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.

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

In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."

Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?

Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.

At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.

Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.

For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.

As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice

In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."

I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.

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

In July 2011, I first had the opportunity to write a column on ethics for ACS Surgery News. That article, "Responding to Family/Patient Requests," explored possible responses to the family members’ requests to "do everything" for a critically ill patient. The article was published under the tag line, "The Right Choice."

Since that first article, I have had the opportunity to write 12 additional columns on different ethical issues in the care of surgical patients. The issues have ranged from considerations of informed consent and disclosure of information to the challenges of innovative techniques and scarce resources. Each of these columns has continued to be under the heading "The Right Choice." As I considered what to write about this month, I reviewed my previous articles and I was struck by a worrisome possibility. In the challenging surgical cases presented, is the suggestion that I know "the right choice" actually wrong?

Medical ethics has increasingly become an important topic in medical schools and the clinical care of patients since the late 1970s. Although the medical and surgical care of patients has always had an ethical dimension, it has only been in the last several decades that the ethical issues have been separately identified and analyzed. As the acceptance of surgeons making decisions about what is "best" for their patients has shifted to increasing respect for the patient as an autonomous decision maker, we have seen the importance of understanding patient preferences increase.

At the same time, as medical and surgical care has improved, we now have more options to prolong patients’ lives even when the quality of those lives may be dramatically diminished. These factors have led to the increased consideration of ethical dimensions of decisions that we must help our patients make.

Although many authors have suggested ways to proceed with the ethical analysis of cases, few methods have been as widely adopted as that suggested by Albert Jonsen, Mark Siegler, and William Winslade in their influential book, "Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine," 7th edition (New York: Lange Clinical Science/McGraw Hill, 2010). These authors suggest that the analysis of a case should include attention to four sets of issues: medical indications, patient preferences, quality of life, and contextual features. By analyzing these issues for a difficult case, we are often able to see where the underlying principles of beneficence, nonmaleficence, respect for patient autonomy, and justice may be at odds.

For example, in the case that I discussed in the July 2011 issue, about the 80-year-old woman with extensive gangrenous bowel, a central concern was whether the surgical decision making should be altered by the family member’s request to "do everything you can." In this case, I suggested that requests from surrogate decision makers must be tempered by the realities of the case and the importance of not harming a patient by providing burdensome care that has minimal chance of success.

As I reread that prior article, I am struck by the fact that I suggest a way of thinking about the case and a series of considerations that are important. However, I am not comfortable saying that I have identified the single correct course of action. I believe that although ethical analysis of cases has tremendous value for doctors and patients, there is rarely one right answer. There may be several wrong answers, and there may be several acceptable answers, but there is rarely a single right choice. My goal in these columns that I wrote in the past and hope to write in the future is to raise awareness of the ethical dimensions of the case, to suggest important considerations, and perhaps even to identify some of the ethical principles that may be relevant. But I do not believe that I can identify "the right choice

In the very first edition of "Clinical Ethics" published in 1982, Jonsen, Siegler, and Winslade wrote in the preface, "We do not merely discuss or analyze the ethical problems; we offer counsel about decisions. Lest this be thought presumptuous, we do not consider our counsel the single and final answer. We offer it in the tradition of medical consultation: The consultant may bring to the practitioner’s view of the case not only broader information but another perspective."

I have tried to provide this type of information and perspective in the ACS Surgery News ethics columns and in view of the difficulty of determining the single right answer to many challenging cases, future columns will be found under the new heading, "The Right Choice?" By adding the critical question mark, I hope that readers will be reminded of the need for ongoing discussion of the challenging ethical questions that arise in the care of surgical patients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.

This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?

Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.

In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.

Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.

Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?

The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.

How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.

Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.

Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.

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

In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.

This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?

Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.

In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.

Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.

Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?

The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.

How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.

Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.

Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.

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

In a recent issue of JAMA Surgery, Dr. Jacqueline M. Garonzik-Wang and colleagues presented the results of an important study of missing surgical consent forms at Johns Hopkins Hospital. The authors tallied the absence of a surgical consent form in a patient’s medical record and the resulting delays and other impacts on the surgical services. The authors also surveyed nurses, surgical residents, and surgical faculty regarding their satisfaction with the informed consent process. The results of the study show that cases are often delayed and surgical residents are often pulled away from other activities (e.g., educational conferences) to have new consent forms signed in the preoperative area. In addition, both faculty and residents had concerns about residents obtaining informed consent for major elective procedures.

This is undoubtedly an important study in that it casts light upon an important source of delays and dissatisfaction in the preoperative setting. However, are there additional lessons about informed consent that might be gleaned from this type of analysis?

Moving beyond the study itself, other important issues arise. Consider a patient who comes to the office for evaluation of a symptomatic hernia. Once the surgeon decides that the operation is indicated, the consent process requires a description of the indications (benefits), risks, and alternatives for the patient. Even though the surgeon may be convinced that the benefits of the operation outweigh the risks, the patient still needs to be convinced. Depending on the patient and the procedure being recommended, the time necessary to explain the above to the patient so that he or she is adequately informed and willing to sign the consent form will vary greatly.

In contemporary surgical practice, the determination of when the patient has been adequately informed is made by the patient. At the point that he or she is comfortable enough with the recommendation to proceed to an operation, the informed consent process has reached its conclusion. Only at this point, is the informed consent form even relevant to the discussion. The patient’s signature on the informed consent form is designed to signify the conclusion of the informed consent process.

Although we often mix the signature on the form with the process itself, they are, in fact, markedly different. The informed consent process is an ethical requirement; whereas the signature on the form is a legal requirement. The fact that these two requirements are different can readily be seen from the Mayo Clinic experience. For years, no informed consent forms were even used at the Mayo Clinic! The discussion of the indications, risks, and alternatives was documented in the surgeon’s notes and the fact that the patient showed up for the elective operation could be taken as the evidence of the adequacy of the informed consent process. Although this practice was acceptable to both surgeons and patients for years, the Clinic ultimately changed its practice in response to federal regulations that require the patient’s signature on an informed consent form.

Certainly, there is nothing inherently wrong with the practice of obtaining a signature from a patient on a consent form at the conclusion of the informed consent process. However, the current emphasis on the form itself has had a tendency for the process to be short changed in favor of getting the signature. The fact that both practicing surgeons and surgeons in training often slip into the habit of referring to the process solely by the form can frequently be seen. How often have we or our colleagues talked about "consenting the patient" when we really mean "obtaining informed consent from a patient"?

The Hopkins study serves to remind us that if we really take the process of obtaining informed consent from surgical patients as ethically important, we must be sure to give it the attention it deserves in our practice. If obtaining informed consent is central to the ethical practice of surgery, then why do we so often depend on the least experienced member of the surgical team to carry out this task right before surgery? Perhaps this practice does not reflect our devaluation of the informed consent process as much as a realization that if a patient scheduled for elective surgery has discussed the operation with the surgeon and has chosen to come to the hospital for the procedure, we can assume that the patient has already had a satisfactory consent process. In this context, the problem of the missing consent form is less an ethical issue than a clerical one that might be solved by eliminating the paper form and depending on technology for a solution.

How might a technological fix help in this situation? Among the possibilities would be to have paper forms signed in the attending surgeon’s office at the time of the informed consent discussion. The form could then be scanned into the electronic medical record. Such an approach should significantly reduce the numbers of missing forms since the electronic version cannot be misplaced. This approach will not, however, solve the problem of the missing consent form if the patient is undecided about surgery when he or she leaves the outpatient visit. In such cases, the patient may not be back to the office or hospital until the day of surgery.

Alternatively, all of the information on the standard informed consent form could be made electronic and after the discussion with the attending surgeon, the electronic version could be signed if the patient is amenable, or printed for the patient to take home if he or she is undecided. If the patient then decides to proceed with surgery, the patient could sign in to a secure website and electronically acknowledge (that is, sign) the electronic consent form. This electronic version could then be reviewed by the preoperative nurse and the patient on the day of surgery. As long as the informed consent process that is dependent on the relationship between the surgeon and patient remains intact, there is no reason why technology might not help us eliminate the problem of the missing consent form.

Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing consent forms in the preoperative area: A single-center assessment of the scope of the problem and its downstream effects. JAMA Surg. Published online July 10, 2013, E1-E4.

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