Surgical Ethics:

Relationships with Patients,

the Profession, and Society

Martin McKneally
University of Toronto
Dept. of Surgery & Joint Centre for Bioethics

Principles of Surgery
October 5, 2010
“Dr. McKneally, this is Jerry Wilson of
the FBI. Can you answer some
questions for me?”

“What kind of ethics education or

training is given to surgeons?”

The Moon/Realyvasquez case

“Doctors accused of performing
unnecessary heart surgeries at Redding
Medical Center agree to pay millions to
settle fraud allegations and accept
restrictions on their medical practice”

U.S. Department of Justice, 2005

 Plan of talk
What’s an Ethic?
Teaching Ethics
The Ethic of Surgery
Obligations
to patients
to the team
to society
 Ethics….What’s an Ethic?
• A set of values, principles, and beliefs,
standards of conduct

• Guides the behaviour of a specified group –

journalists, lawyers, mafiosi, monks,
physicians, surgeons.

• “What we should do” – codes of conduct

 Ethics
should

Policy Law
usually must
 Ethics
censure

Policy Law
disapproval fines/prison
Contemplation before surgery
Joe Wilder, MD
“Thou Shalt Teach Bioethics”

RCPSC 1995
Ethical Issues Taught Formally:
Consent, end-of-life, disclosure, surgical
competence, surgical decision-making, COI,
resource allocation, research/innovation

Ethical Challenges Not in Formal Curriculum:

Intra- and inter-professional conflict, lack of
experience, training issues, perceived
unethical staff behaviour
Ethic of Surgery

Trustworthiness:
Competence
Commitment
 Trustworthiness
We are trusted to live up to our obligations

Professional: competence, commitment

Fiduciary: what is best for the patient
Team: integrity, coworker care
Societal: community need for surgical care
 Surgical Competence
Knowledge - timely and appropriate

Judgment - balanced
- attentive to the particular needs and
circumstances of the individual patient
- the right operation for the right
patient at the right time

Technical Skill - sufficient to perform the surgical

intervention
- minimum of risk
- high probability of benefit
Commitment

Personal responsibility –
uniquely intensified

Constancy –
warrior energy
 Fiduciary Obligation
Put patients’ interests above all
others, including the physicians

Trustworthy care
competence, commitment
Respect
dignitary rights
privacy, confidentiality
 Confidentiality

Patients and the profession

expect physicians not to
disclose private information
learned in the course of care
 Team Obligations
Maintaining the integrity of
the team

Coworker care: attention to

the needs and concerns of
team members
 Societal Obligations
Implicit contract with society
Duty to treat
Explicit contract
with individual patient
emergency care
public agencies
Challenges – AIDS, SARS, Avian flu,
COI, hypocompetent surgical care
Societal Obligations of Surgeons

Effective subsystems of care

Trauma system
Cardiac Care Network
Cancer Care Ontario
CritiCall
Societal Obligations of Surgeons
Developing subsystems

“Coaching teams”
Coach Alan Hudson

Critical care – Tom Stewart

General surgery – Ori Rotstein, Andy Smith,
Bernie Langer
Orthopaedics – Alan Gross
Summary: Ethic of Surgery
Trustworthiness:
Competence
Commitment

Obligations:
Patients
Team
Society
Ethical Issues Taught Formally:
Consent, end-of-life, disclosure, surgical
competence, surgical decision-making, COI,
resource allocation, research/innovation

Ethical Challenges Not in Formal Curriculum:

Intra- and inter-professional conflict, lack of
experience, training issues, perceived
unethical staff behaviour
RCPSC Bioethics Curriculum: Surgery

• Consent:
Capacity, Disclosure, Surrogates
• Professional Conduct:
Duty to treat, Confidentiality
• Conflict of Interest
• Surgical Competence
• End of Life
• Truth Telling
• Resource Allocation
• Research Ethics
Circumstance
Culture Ethics
should

Religion
Politics Policy Law
usually must