The Right Choice?

It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.

A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.

Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.

When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.

Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.

I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?

The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.

Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.

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.

It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.

A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.

Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.

When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.

Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.

I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?

The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.

Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.

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.

It goes without saying that good surgical care is based on honesty in informed consent. The ethical basis of telling patients about their conditions and what needs to be done is central to what surgeons do. In this context, a request not to tell a patient a diagnosis is always jarring to me. One of the ethical principles that medicine has most fully embraced in the last few decades has been respect for patient autonomy. This principle is very much in opposition with the previous practice of paternalism in the prior era of medical care in which "the doctor knows best" and doctors made decisions for their patients. As a practicing surgeon today, I feel that there is very little that I know that I cannot disclose to my patient. However, occasionally cases challenge our underlying assumptions.

A few years ago, I saw an 11-year-old girl with a recent diagnosis of papillary thyroid cancer. Before I even saw her, the parents had called my office to be sure that I did not tell her the diagnosis of cancer. I found this request to be troubling. How could I discuss the operation with this child without telling her that she had cancer? Her parents assured me that she knew that she had a thyroid nodule and that on the basis of the biopsy, that she would need a thyroidectomy. The only thing that had not been explained to the child was the diagnosis of thyroid cancer.

Despite my initial concern with this request, in pediatrics, the parents are the decision makers for the child, so that there was no legal reason why the patient needed to be told that she had cancer. Nevertheless, the ethical imperative to include the diagnosis of cancer in the discussion about surgery weighed on me. Despite my initial opposition to being put in the position of not telling the patient of her diagnosis, I decided that I could do nothing more at that point. I hoped to convince the parents to let me share the diagnosis with their daughter at a later time.

When I met my patient, I found her to be a quiet and calm girl who seemed to me to be mature beyond her years. I proceeded to explain the risks of thyroidectomy to the patient and her parents. She seemed to take it all in and asked good questions about the operation and the recovery. She wanted to know how long before she could get back to school and sports. At the end of the consultation, the patient’s mother asked her to wait with her younger sister and her grandmother in the waiting room for a few minutes while the parents spoke to me alone.

Once she had left, the parents expressed their appreciation that I had not told her she had cancer. I told them how impressed I was with her poise and maturity and that although I did not agree with their decision not to tell her the diagnosis, I would certainly go along with it based on the assumption that they knew what would be in her best interests better than I. They seemed relieved that I was willing to go along with their decision. I realized at that point that the ethical arguments in favor of telling the patient of her diagnosis would likely be unconvincing for the parents, so I decided to focus instead on the practical problems with nondisclosure.

I asked the parents to consider that the operative schedule would include the diagnosis of thyroid cancer and that everyone seeing her in the hospital (doctors, nurses, etc.) would know her diagnosis. For all of these reasons, there would be a high likelihood that at some point during her hospital stay, someone would slip, and she would learn of the diagnosis in an uncontrolled manner from someone other than her parents or her doctor. In addition, I suggested that she would likely figure it out anyway even if no one told her. Finally, I asked them to consider the next few years. If they did not tell her the diagnosis of cancer now, at what point would they choose to do so? Certainly, at the point that she turned 18 years old, she would need to know the diagnosis, but would the parents want to hide it from her that long, even if they could?

The parents seemed to have not thought of all of these issues and answered that they fully wanted to tell her, but they were concerned about doing so when they, themselves, were still so upset by the diagnosis. They explained that they planned to tell her when they felt more in control of their own emotions.

Two weeks later, on the morning of surgery, the parents told me how they had explained the diagnosis to their daughter and that she had then explained it to her younger sister. It was clear to me that the assurance that the parents had given to the patient had allowed her to be calm and positive when talking with her younger sister. It is unknown how things might have worked out had the parents not told the patient of her diagnosis when they did, but it was clear to me that the fact that the parents had been able to control some aspects of how the patient learned of her diagnosis had helped them to feel better about a difficult situation. In addition, the patient seemed to be reassured by having explained things to her sister. Although I continue to assume that disclosure is always the best approach, there may be cases, such as this one, in which the timing of the disclosure might allow for a good outcome.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

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.

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

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.

Obtaining informed consent for surgery is one of the most common tasks surgeons perform. Ensuring that a patient has the capacity to make a decision and then explaining the indications, risks, and alternatives to the surgery is something that surgeons do hundreds of times a year. Although the process is routine, it reflects the importance of respecting patients’ autonomy in making informed decisions about their health care. Informed consent has been an accepted practice in American surgery for decades, but questions about the process can arise and elicit varied responses among surgeons.

Recently, an experienced colleague (Dr. S) called me to discuss a case that had been troubling him. A 68-year-old man had been referred to him for a surgical opinion after experiencing recurrent episodes of diverticulitis. He was a former insurance executive, now retired. He was married, but came without his wife to the appointment with Dr. S.

After completing the history and physical examination and reviewing the imaging, Dr. S recommended an elective sigmoid colon resection. He explained to the patient what was involved in the surgery and the expected recovery. According to Dr. S, the patient then stated, "I understand. When can we schedule it?" At this point, Dr. S stated that a few more things needed to be reviewed and began to discuss the potential risks of the surgery. The patient stopped him abruptly, saying that he knew that there were risks, but he preferred not to hear about them.

When Dr. S responded that it is always good to know the risks when deciding to have surgery, the patient stated, "Look, I trust my primary care doctor who sent me to see you. You seem like a good surgeon, and I have confidence in you. I don’t want to hear about the risks, because my hearing them won’t make them not happen and will only make me worry. I’ll sign anything that you want, but I don’t want you to tell me the risks."

Dr. S felt torn. He had always felt that the consent process was primarily about informing the patient of what could happen. Reviewing the potential risks would help the patient to become better informed in making the decision to have surgery. Dr. S felt that his patient’s desire not to be informed had short-circuited the process, and it now seemed incomplete.

Dr. S offered to call the patient’s wife to discuss the risks with her, but the patient said that would not be necessary since he was making his own decisions. Although there was no hostility in the patient’s remarks, Dr. S felt that he had pushed hard enough, so he obtained a signature on the consent form and documented in his note that he had offered to inform the patient of the risks but that the patient had refused to hear them.

In the 3 weeks between this office visit and the surgery, Dr. S related the case to a number of his surgical colleagues and received diametrically opposing views. One group of surgeons stated that as the surgeon, Dr. S had an ethical responsibility to ensure that his patient knew of the risks of the procedure. They felt strongly that unless Dr. S had reviewed these risks with the patient, the consent was not valid because "it was not truly informed." Another group of surgeons felt that the ethical responsibility was not to inform the patient, but rather to provide the opportunity for the patient to be informed. This second group felt that pushing the patient to hear information that he did not want to hear would actually be violating his autonomous choice not to be informed.

These opposing views of what to do in this case help to clarify what I believe is one of the central points of confusion about the informed consent process as it is currently used. Surgeons and patients alike often believe that the information transfer – that is, describing the risks of the surgery – is the central goal of the process. However, many studies have shown that patients do not actually remember much of what they are told by their surgeons. Specifically, few risks are remembered even on the same day that the surgeon has reviewed them and the consent form is signed. These data clearly suggest to me that the more important aspect of the informed consent process is the communication between the surgeon and the patient.

Communication suggests something more than providing a lecture to a patient. It suggests the importance of listening and responding to requests for more or less information. Given that the requirement for informed consent prior to surgery is grounded on the principle of respecting a patient’s autonomy, it seems clear that when a patient does not want to hear the information that a surgeon wants to convey, the surgeon must respect the patient’s choice not to be informed.

Although Dr. S had felt that something was missing in the consent process since it did not include "the usual discussion of risks," the patient’s choices had been respected and Dr. S had fully discharged his responsibilities in obtaining the patient’s informed consent.

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 recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

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

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

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

In recent years, the goal of controlling health care costs has become an important challenge. However, whenever cost control is raised in the context of an individual patient, the issue of who will be making those decisions becomes central and problematic.

One of the core principles of the ethical practice of medicine and surgery is beneficence, meaning that the doctor’s motivation in rendering medical care is to benefit the patient. Any discussion of economics and costs seems to potentially distract the doctor from the primary concern of benefiting his or her patients. Thus, when rationing decisions are made, it is generally felt that those decisions should be made systemwide and not by individual physicians with respect to the needs of specific patients.

Dr. Lisa Rosenbaum and Dr. Daniela Lamas recently suggested that medical education should do a much better job of teaching physicians to think about costs (N. Engl. J. Med. 2012;367:99-101). They acknowledged that there are potential problems associated with such an educational initiative, but the authors seem to conflate two different things: medical costs to an individual patient and medical costs to society as a whole.

With respect to medical costs to an individual patient, arguing that physicians should know how much the tests and treatments that they order will cost an individual patient is an easy position to justify. In fact, if prescribed medical tests and treatments will bankrupt the patient, that will have a significant impact on the patient’s well-being. In this context, the physician should be aware of such costs, and in fact should disclose those costs so that the patient can share in the decision making.

The much bigger problem for practicing surgeons is when it appears to be in the best interest of a patient to have five different tests, but such an approach would be very costly and therefore bad for the health system as a whole. We do still generally believe that individual surgeons should be patient advocates and ignore costs to the system if it will benefit their patient. How, then, can we maintain our position as patient advocates while remaining aware of the costs of the interventions that we are requesting for them?

One potential way out of this dilemma of either ignoring all cost information or ignoring individual patient benefit is to emphasize the ethical imperative to recommend efficient testing. Such an ethics of efficiency would not require any tradeoff of individual patient benefit for cost containment. Instead of ordering a battery of tests that might narrow down a diagnosis, surgical research should focus on ordering tests in the most efficient manner possible – that is, do not order a test if the result will not significantly alter the plan of care. This ethical imperative for efficiency is something that the American Board of Internal Medicine Foundation has advocated with its "Choosing Wisely" campaign, an initiative designed to eliminate expensive, non-beneficial tests and treatments.

Although I am convinced that eliminating "useless" tests is a good idea, often it is not easy to say what is "nonbeneficial" in a global sense. It is more realistic to answer that question for a specific patient with a specific problem. Therefore, research and education should increasingly focus on how to efficiently answer diagnostic questions so that optimal treatment can be recommended in the most cost-effective manner. To do this, physicians must first be knowledgeable about the costs of the tests and treatments they recommend for their patients. Second, surgeons and other specialists must pursue research that refines the specific order of tests in different patient scenarios so that meaningless or redundant tests are avoided.

Conventional wisdom has held that the more specialists there are, the more expensive health care will be. However, if the ethical imperative of efficiency were emphasized, the role of the specialist would be to optimize the efficient work-up of any condition, thereby eliminating redundancy and waste. Such a goal might be hard to reach throughout the field of medicine, but within surgery, surgical specialists should begin to undertake this challenge immediately so that future patients might have the opportunity to benefit from the highest quality of efficient care.

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

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

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

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

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

As a surgical resident over two decades ago, I often cringed when a faculty member would say, " When I was a resident," and launch into a story about how difficult things were "in the old days." Sometimes I was reminded of jokes about our forebears having to walk 5 miles to school every day uphill -- both ways!

I’m sure my residents have a similar reaction when I talk about how tough we had it compared with now. However, today’s residents have a much more difficult road than I ever had in terms of the choices they must make because of duty-hour limits.

In prior decades, the excellent resident was the one who always knew what was going on with his or her patients, and who came in early and stayed as late as necessary to get everything done. When I was a junior resident, the chief resident role models we all emulated were those who worked the hardest (i.e., the longest hours). I often felt that the willingness to work hard more clearly defined who succeed than intelligence, efficiency, or technical abilities. However, today’s surgical residents are constantly being challenged to make ethical choices that were unheard of in years gone by.

Recently, a midlevel surgical resident who I respect very much related the following case to me. At about 5 a.m. during his night of call he had admitted a 79-year-old man in septic shock with an acute abdomen to the surgical intensive care unit. The patient had required significant fluid resuscitation prior to safely going to the operating room for an exploratory laparotomy. The surgery was just beginning at 7 a.m. when the the attending asked the resident when his shift ended. The resident said he wanted to stay to do the case, but was conflicted by the fact that doing so would mean exceeding his work hour limit for the week. In addition, the program director had recently sent residents a notice saying that it was unacceptable to ignore the work hour limits. The resident felt that in order to stay to do the case, he would be required to lie on his work hour log.

This challenge of weighing what might be good for the individual resident against the potential harm to the program for work hour violations is a new ethical tension. The need to choose between continuity of care (which might be good for a patient and aid the resident’s education) and the requirement to sign out to other residents to maintain the accreditation of the residency program is a conflict that didn’t exist in previous decades.

It is unclear what the ideal role model should be for a surgical resident today. Simply spending more time taking care of patients than anyone else can no longer be considered as the optimal position for a surgical resident. However, many surgical faculty have not altered their concept of the ideal resident to meet the necessary time constraints that are required of residents. As a result, residents are often held to unreasonable standards based on prior concepts of how "great" residents used to act.

Today, surgical faculty and surgical residents must seek to define the new ideal role model for a surgical resident. This person should not have any less commitment to patients, but must have high levels of efficiency to complete the work within the allotted time. Even more important, a resident who cannot provide continuity of care must communicate well enough with other residents to ensure that high levels of surgical care will be possible throughout a patient’s hospitalization.

Surgical faculty must understand these new ethical challenges to help residents succeed and to formulate a new concept of what the ideal surgical resident role model looks like in the 21st century.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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