PurposeAdolescents develop their decision-making ability as they transition from childhood to adulthood. Participation in their medical care should be encouraged through obtaining assent, as recommended by the American Academy of Pediatrics (AAP). In this research, we aim to define the current knowledge of AAP recommendations and surgeon practices regarding assent for elective reconstructive procedures.MethodsAn anonymous electronic survey was distributed to North American paediatric surgeons and fellows through the American Pediatric Surgical Association (n=1353).ResultsIn total, 220 surgeons and trainees responded (16.3%). (...) Fifty per cent of the surgeons who are familiar with the concept of assent had received formal training; 12% of the respondents had not heard of assent before the survey. Forty-seven per cent were aware of the 2016 AAP policy statement regarding assent in paediatric patients. Eighty-nine per cent always include adolescents as part of the consent discussion. Seventy-seven per cent solicit an expression of willingness to accept the proposed care from the patient. The majority (74%) of the surgeons perceived patient cooperation/understanding as the biggest barrier to obtaining assent. Over half of the respondents would consider proceeding with elective surgery despite the adolescent patient’s refusal. Reasons cited for proceeding with elective surgery include surgeons’ perception of medical necessity, perceptions of disease urgency, and lack of patient maturity.ConclusionPaediatric surgeons largely acknowledge the importance of assent, but variably practice the principles of obtaining assent from adolescent patients undergoing elective reconstructive procedures. Fewer surgeons are explicitly aware of formal policy statements or received formal training. Additional surgeon education and institutional policies are warranted to maximise inclusion of adolescents in their medical care. (shrink)

“Every surgeon carries within himself a small cemetery where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation of his failures” René Leriche,...

Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk–to–benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient’s co–morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients (...) have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83–year–old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform. I was the resident in the endocrine surgery clinic the day that Ms. M came in. Given my background in bioethics, the attending physician told me about the patient’s history beforehand and asked for advice on how to approach the clinical encounter. I then accompanied him into her room to talk with her and her husband. (shrink)

Surgical training has traditionally involved a lengthy apprenticeship to a series of master surgeons, who teach medical students and residents the techniques of surgery while allowing them to work on patients in the operating room. This article examines surgical training as a structured environment that prepares students for the embodied lessons taught by a surgeon. It argues that even the most seemingly mechanical of surgical techniques contains social lessons when taught by a surgeon within the rich environment of (...) the operating room. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

The aim of this paper is to evaluate the claim that the disclosure of surgeons' performance data could lead to the practice of defensive medicine. I argue that disclosure could actually encourage surgeons to practice a new form of defensive medicine, one that has not hitherto been noted. I explore a possible way of avoiding this problem.

Aim To examine the hypothesis that knowledge about physician-assisted suicide (PAS) and euthanasia is associated with a more restrictive attitude towards PAS. Design A questionnaire about attitudes towards PAS, including prioritisation of arguments pro and contra, was sent to Swedish veterinary surgeons. The results were compared with those from similar surveys of attitudes among the general public and physicians. Participants All veterinary surgeons who were members of the Swedish Veterinary Association and had provided an email address (n=2421). Main outcome measures (...) Similarities or differences in response pattern between veterinary surgeons, physicians and the general public. Results The response pattern among veterinary surgeons and the general public was almost similar in all relevant aspects. Of the veterinarians 75% (95% CI 72% to 78%) were in favour of PAS, compared with 73% (95% CI 69% to 77%) among the general public. Only 10% (95% CI 5% to 15%) of the veterinary surgeons were against PAS, compared with 12% (95% CI 5% to 19%) among the general public. Finally, 15% (95% CI 10% to 21%) of veterinarians were undecided, compared with 15% (95% CI 8% to 22%) among the general public. Physicians had a more restrictive attitude to PAS than the general public. Conclusions Since veterinary surgeons have frequent practical experience of euthanasia in animals, they do have knowledge about what euthanasia really is. Veterinary surgeons and the general public had an almost similar response pattern. Accordingly it seems difficult to maintain that knowledge about euthanasia is unambiguously associated with a restrictive attitude towards PAS. (shrink)

In this article, I respond to Alan Henderson’s critique of the quality of care argument for surgeon report cards. I discuss some significant US and UK studies demonstrating that surgeon report cards improve clinical outcomes. I also indicate that surgeon report cards are in any case supported by other important ethical arguments, such as arguments from surgeons’ professional accountability obligations, and from patients’ entitlements to be informed about the risks of surgery upon them.

A thirty-year-old single mother with recurrent, metastatic, treatment-refractory cancer presents to the emergency room with severe difficulty breathing due to an obstructive tumor in her neck, compounded by progressive disease in her lungs and a new pulmonary embolism. She cannot be safely intubated and would require an emergent awake tracheotomy. Even if the airway can be successfully secured surgically, the likelihood that she will be able to be weaned from mechanical ventilation is very low. The surgeon, a young mother (...) too, appreciates the patient's desire for more time with her toddler. But the surgeon knows the significant risk of surgery, the massive responsibility she would accept in trying to get the patient through it, and the emotional toll of an intraoperative death on surgical staff. And she can imagine the second-guessing that will come during the inevitable morbidity and mortality conference if the patient should die in the perioperative window. Yet the surgeon does not want to take the “easy” way out; after all, critically ill patients undergo aggressive resuscitation all the time. What should she do? (shrink)

Background Informed consent is perhaps more relevant to surgical specialties than to other clinical disciplines. Fundamental to this concept is the provision of relevant information for the patient to make an informed choice about a surgical intervention. The opinions of surgeons in Nigeria about informed consent in their practice were surveyed. Methods A cross-sectional survey of surgeons in Nigeria was undertaken in 2004/5 using self-administered semistructured questionnaires. Results There were 102 respondents, 85.3% of whom were men and 58.8% were aged (...) 31–40 years. 43.1% were consultants and 54.0% were surgical trainees. 27.4% were in surgical subspecialties, 26.5% in general surgery and 21.6% were obstetricians and gynaecologists. 54.9% agreed that sufficient information is not provided to patients while obtaining their consent for surgical procedures. They listed medicolegal reasons, informing patients about benefits, risks and alternatives and hospital policy as some reasons for obtaining consent for surgical procedures. When patients decline to give consent for surgery, 84.3% of them thought that poor communication between surgeons and patients may be contributory. They identified taking a course in bioethics during surgical training and compulsory communication skills course as some ways to improve communication between surgeons and patients. Conclusion Most Nigerian surgeons seemed to have a good knowledge of the informed consent requirements and process but fall short in practice. There is a need to improve the surgeon–patient relationship in line with modern exigencies to provide interactive environments for fruitful patient communication and involvement. (shrink)

Volume 19, Issue 6, June 2019, Page 34-36.

Alisdair MacIntyre argues that the virtues necessary for good work are everywhere and always embodied by particular communities of practice. As a general surgeon, MacIntyre’s work has deeply influenced my own understanding of the practice of good surgery. The task of this essay is to describe how the guild of surgeons functions as a more-or-less coherent tradition of moral enquiry, embodying and transmitting the virtues necessary for the practice of good surgery. Beginning with an example of surgeons engaged in (...) a process of moral discernment, I describe how the practice of surgery depends on the cultivation of a certain kind of practical wisdom (phronesis) that effectively orders the techniques of surgery toward particular notions of human flourishing within the limits of what is possible with the particular body on which the surgeon operates. I then argue that one reason why surgeons train in an apprenticeship model of "residency" is to cultivate not only the technical skill but also the practical wisdom to perform good surgery. I conclude by noting that the surgical profession is enduring necessary, but unprecedented, changes in the way it practices and transmits its art; and without deliberate and sustained attention to the character formation of surgeons, the profession runs the risk of creating excellent technicians who are nonetheless ill-equipped to practice wise and good surgery. (shrink)

Surgeons are commonly evaluated with respect to outcomes and adherence to rules and regulations, rather than a true holistic examination of the character of the surgeon in question. We sought to examine the character failings of surgeons who faced fitness to practice enquiries under the Medical Practitioner Tribunal Service in the UK. In particular, we examined the absence of virtue as perceived through the lens of Aristotelian ethics using thematic analysis of tribunal hearing transcripts from 2016 to 2020. We (...) identified three overarching themes that are explored in depth: ‘the god complex’, ‘reputation over integrity’ and ‘wounded pride’. We hope to use this as the foundation for a re-examination of the place of phronesis in postgraduate surgical education, which we argue should be perceived as an exercise in character development and reformation rather than the simplistic teaching of skills to standardised outcomes. (shrink)

This paper argues that the provision of effective informed consent by surgical patients requires the disclosure of material information about the comparative clinical performance of available surgeons. We develop a new ethical argument for the conclusion that comparative information about surgeons' performance - surgeons' report cards - should be provided to patients, a conclusion that has already been supported by legal and economic arguments. We consider some recent institutional and legal developments in this area, and we respond to some common (...) objections to the use of report cards on the clinical performance of surgeons. (shrink)

The attitudes of patients' to consent have changed over the years, but there has been little systematic study of the attitudes of anaesthetists and surgeons in this process. We aimed to describe observations made on the attitudes of medical professionals working in the UK to issues surrounding informed consent.

Twelve narratives written by surgeons on ethical decision-making are analyzed in this commentary. Several major themes in their narratives are discussed: the preponderance of end-of-life issues; the struggle to be inclusively empathetic, even under emotionally alienating circumstances; social justice; and the disagreement among colleagues about how to deal with patients in situations of medical uncertainty. The commentary not only discusses the areas of stress that the surgeons identify in their accounts. It also highlights phenomena and themes that are missing from (...) them, and calls for more work to be done gathering stories from surgeons to explore and explain the “gaps” in this narrative collection. (shrink)

Gender, most feminists agree, isn’t a fact about people in the same way that height or hair color is. Genders are constructed within and are part of a power system circulating through all of society that sets standards for men’s and women’s identities and places men’s interests above women’s. The system is bad for all of us, but especially for women, genderqueer people, and men of color. Here, I want to point out ways in which it’s bad for our health. (...) I’ll start with abortion, as laws recently passed in a number of states have restricted women’s access to the point where it’s nearly nonexistent. (shrink)

A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians (...) to treat emergencies. (shrink)

Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as ‘completely’ or ‘mostly’ unethical. Participants were also asked to rank-order the value of (...) five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as theleastvaluable (even less valuable than an anecdote) and 35.7.% viewing it as themostvaluable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects. (shrink)

This paper argues that a major contribution to women’s under-representation and the gender pay gap in surgery is the interaction and aggregation of many small wrongs, or as they have come to be called in the literature, microinequities. Further, the paper argues that existing strategies do not adequately address the problems faced by women surgeons and cannot do so without an understanding of those wrongs as microinequities. Insights from the literature on ethics and microinequities are thought to be able to (...) inform new strategies.1 The study identifies four different kinds of gender bias: workplace discrimination, epistemic injustice, stereotyped roles and objectification. The different kinds of gender bias interact with one another and add up in ways that pose serious setbacks to the careers of women surgeons. In addition to being small wrongs, microinequities share other features. They are cumulative; they interact with one other; they are often invisible; and they are implicit or unintended. My comments are going to focus on the response to microinequities, …. (shrink)

BackgroundThe attitudes of patients' to consent have changed over the years, but there has been little systematic study of the attitudes of anaesthetists and surgeons in this process. We aimed to describe observations made on the attitudes of medical professionals working in the UK to issues surrounding informed consent.MethodA questionnaire made up of 35 statements addressing the process of consent for anaesthesia and surgery was distributed to randomly selected anaesthetists and surgeons in Queen's Medical Centre, Royal Sussex County Hospital and (...) Eastbourne District General Hospital during 2007. Participants were asked to what extent they agreed with statements regarding consent.ResultsOf 234 questionnaires distributed, 63% were returned. Of the respondents 79% agreed that the main purpose of the consent process is to respect patient autonomy. While 55% of the examined cohort agreed that the consent process maybe inappropriate as patients do not usually remember all the information given to them. Furthermore, 84% of the participants agreed that what the procedure aims to achieve should be explained to the patient during the consent process. While of the participants, over 70% agreed that major risks of incidence greater than 1/100 should be disclosed to the patient as part of the consent process.ConclusionsThe majority of respondents appear to hold attitudes in standing with current guidelines on informed consent however there was still a significant minority who held more paternalistic views to the consent process bringing into question the need for further training in the area. (shrink)

Science is a force for good in the world--at least usually. But sometimes, when obsession gets the better of scientists, they twist a noble pursuit into something sinister. Under this spell, knowledge isn't everything, it's the only thing--no matter the cost. Bestselling author Sam Kean tells the true story of what happens when unfettered ambition pushes otherwise rational men and women to cross the line in the name of science, trampling ethical boundaries and often committing crimes in the process. The (...) Icepick Surgeon masterfully guides the reader across two thousand years of history, beginning with Cleopatra's dark deeds in ancient Egypt. The book reveals the origins of much of modern science in the transatlantic slave trade of the 1700s, as well as Thomas Edison's mercenary support of the electric chair and the warped logic of the spies who infiltrated the Manhattan Project. But the sins of science aren't all safely buried in the past. Many of them, Kean reminds us, still affect us today. We can draw direct lines from the medical abuses of Tuskegee and Nazi Germany to current vaccine hesitancy, and connect icepick lobotomies from the 1950s to the contemporary failings of mental-health care. Kean even takes us into the future, when advanced computers and genetic engineering could unleash whole new sways to do one another wrong. Unflinching, and exhilarating to the last page, The Icepick Surgeon fuses the drama of scientific discovery with the illicit thrill of a true-crime tale. With his trademark wit and precision, Kean shows that, while science has done more good than harm in the world, rogue scientists do exist, and when we sacrifice morals for progress, we often end up with neither. (shrink)

Como resultado de búsqueda y recuperación de información registrada en documentos de archivos, libros, revistas y otras fuentes, se confeccionó una obra de referencia, donde se registran pequeñas biografías de 19 camagüeyanos que se desempeñaron como médicos cirujanos, médicos y cirujanos romancistas en los siglos XVIII y XIX. Se dan a conocer los antecedentes que sirvieron de motivación a la realización del estudio y se explica el radio de acción, en el aspecto asistencial, de los que ostentaban estas categorías profesionales. (...) Los datos obtenidos a partir de las fuentes consultadas, fueron el punto de partida para la confección de un material que informa el quehacer de los profesionales de la salud de la región camagüeyana en esa época y que se espera sea de interés y utilidad a los interesados en el tema As a result of the search and collection of information registered in documents, books, magazines and other sources, a reference paper that presents the biographies of 19 Camagüeyan medical surgeons, doctors and surgeons that lived in the XVIII and XIX centuries was made. The antecedents that served as motivation to the realization of the study are made known and the action radius is explained, taking into account their role in medical assistance. This comprises all those that had the above-mentioned professional categories. The data obtained from the sources consulted, constituted the starting point for the making of a material that informs about Camagüeyan health professionals of that time. It is also expected that this scientific paper is of interest and utility for those interested in this topic. (shrink)

Trait emotional intelligence concerns people’s perceptions of their emotional functioning. Two studies investigated this construct in surgeons and comparison occupations. We hypothesized that trait EI profiles would differ both within surgical specialties as well as between them and other professions. Study 1 compared the trait EI profiles of four different surgical specialties. There were no significant differences amongst these specialties or between consultant surgeons and trainees in these specialties. Accordingly, the surgical data were combined into a single target sample that (...) was compared against samples of engineers, executives and senior managers, lawyers, junior military managers, nurses, and salespeople. Surgeons scored significantly higher on global trait EI than junior military managers, but lower than executives and senior managers, salespeople, and nurses. There were no significant differences vis-à-vis engineers or lawyers. A MANOVA confirmed a similar pattern of differences in the four trait EI factors. Global trait EI scores correlated strongly with single-question measures of job satisfaction and job performance in the surgical sample. These findings suggest that interventions to optimize the trait EI profiles of surgeons can be helpful in relation to job satisfaction, job performance, and overall psychological wellbeing. (shrink)

I establish two contrasting results: In his first career as surgeon, François Quesnay was antisemitic.Nothing allows to say that his economic system was antisemitic. Very few antisemitic remarks are found in the plethora of books and articles written by his pupils.

Volume 25, Issue 3, March 2025, Page 26-28.

Women are under-represented in surgery, especially in leadership and academic roles, and face a gender pay gap. There has been little work on the role of implicit biases in women’s under-representation in surgery. Nor has the impact of epistemic injustice, whereby stereotyping influences knowledge or credibility judgements, been explored. This article reports findings of a qualitative in-depth interview study with women surgeons that investigates gender biases in surgery, including subtle types of bias. The study was conducted with 46 women surgeons (...) and trainees of the Royal Australasian College of Surgeons. Maximum variance sampling strategies ensured a comprehensive set of perspectives. Data were analysed using iterative thematic analysis to document and classify forms of gender bias experienced by the participants, including implicit bias and epistemic injustice. It found four types of bias affecting women surgeons: (1) workplace factors such as access to parental leave and role models; (2) epistemic injustices—unfair assessments of women surgeons’ credibility by patients and colleagues; (3) stereotyped expectations that they will carry out more of surgery’s carework, such as meeting the emotional needs of patients and (4) objectification. Implicit biases arose in each category. Given that many of the biases identified in this study are small, are harmless on their own and are not necessarily under anyone’s conscious control, important questions arise regarding how they cause harm and how to address them. I draw on theoretical work on cumulative harm to answer these questions. (shrink)

This article deals with surgical practice as it is locally organized within the course of the operation; it focuses on the way in which surgical action shaping the body for the local purposes of the operation is organized in a timely, situated, interactive manner. In order to do that, I offer a systematic analysis of the instructions addressed by a chief surgeon to his assistant in the form of directives during a surgical operation, as well as of instructed actions (...) of the assistant following the directives of the surgeon. In this way, I aim to show how surgery is a methodic collaborative achievement, relying on finely tuned coordination between staff members. More generally, the article sketches a systematic and detailed analysis of instructions as situated accomplishments in time, and of instructed action as resulting from an embodied and indexical understanding of directives and requests as they are produced in time and in context. (shrink)

The foreskin in small boys causes much anxiety in our society. It develops during the second half of gestation, and in premature infants may appear relatively deficient. By term, however, it has grown and protruded to well beyond the glans penis. The inner layer of the foreskin is densely adherent to the surface of the glans and cannot be retracted until it is fully separated, which occurs during the first few years of life. Prior to that time the distal opening (...) of the foreskin is narrow, but because of its adherence there is no significant pocket under the skin to allow accumulation of urine or debris. Later in childhood, after the foreskin is fully separated, urine and dirt can accumulate between the foreskin and the glans, leading to infection and inflammation . With recurrent balanitis, and/or tearing of the delicate foreskin, phimosis or scarring may constrict the distal foreskin.Circumcision has a long history in ancient societies of the Middle East, and is likely to have arisen as an early public health measure for preventing recurrent balanitis, caused by sand accumulating under the foreskin. Circumcision is a major part of the ritual for such religions as Judaism, Christianity, and Islam, and it is probably no accident that all of these arose in the Middle East. By contrast, in religions arising outside the arid Middle East , there is no ritual circumcision. In aboriginal society in Australia, circumcision is practised also.The importance of preventing recurrent balanitis and secondary phimosis in arid, sandy regions was confirmed by the Australian army medical corps in two world wars. During both wars, Australian soldiers were stationed in North Africa and the Middle East, and the incidence of recurrent balanitis caused by sand under the foreskin reached “epidemic” proportions, leading to large numbers …. (shrink)

Surgeons share their challenges and dilemmas in making ethical decisions in these twelve personal stories. The three commentary articles draw out the lessons the stories address. The commentators come from diverse backgrounds including sociology, bioethics, nursing, and surgery.

The English Surgeon . 2008. Produced and directed by Geoffrey Smith. Eyeline Films and Bungalow Town Productions. English and Ukrainian, with English subtitles. 1 hour 33 minutes. http://www.theenglishsurgeon.com Content Type Journal Article DOI 10.1007/s11673-010-9225-7 Authors Rebecca L. Volpe, California Pacific Medical Center Clinical Ethics Fellow, Program in Medicine & Human Values 2395 Sacramento Street, 3rd floor San Francisco CA 94115 USA Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529 Journal Volume Volume 7 Journal Issue Volume 7, (...) Number 2. (shrink)

Hannah James makes a persuasive case for the use of donated bodies and body parts in surgical training, enabling high fidelity training, improved competency of surgeons and reduced risk of harm to patients from trainees ‘learning on the job’.1 She also identifies some pertinent ethical questions that arise from this practice that should be considered by training organisations, regulatory authorities and the trainees themselves. Many countries throughout the world have regulated programmes, governed by strict ethical principles, for donating bodies, usually (...) to academic institutions for the purposes of medical education.2 In the UK the Human Tissue Authority sets out guiding principles for institutions licensed to handle human tissue including donation of bodies for anatomical examination, education and research; consent, dignity, quality, and honesty and openness.3 The Nuffield Council on Bioethics, in its 2011 report, Human Bodies: donation for medicine and research, identified a number of relevant ethical values including autonomy, altruism, justice, dignity, reciprocity, maximising welfare, and honesty and respect.4 While this report did not focus specifically on donation of human tissue for education and training the principles identified are equally relevant in this context. In terms of maximising welfare whole body donation for education and training provides benefit to many patients over a relatively short time frame …. (shrink)