The Right Choice?

The right choice? Surgical ethics and the history of surgery


In the almost 30 years since I started surgical residency, the attention to ethical issues in surgery has dramatically changed. Although surgeons still faced ethical dilemmas decades ago, there was little specific attention paid to highlighting these ethical issues in the past. Today, for many reasons, specific attention to the ethical issues in the care of surgical patients is a widespread phenomenon. We see articles in surgical journals about ethical issues and it is commonplace to find sessions devoted to various surgical ethics topics at many surgical society meetings. The American College of Surgeons is even publishing a textbook of surgical ethics in the upcoming months.

This contemporary attention to ethics in surgery seems to be a recent phenomenon. One of my senior colleagues, in commenting on how much more specific attention we pay to ethical issues today, once jokingly stated that he had trained in surgery “before there was ethics.” Although we laughed at the idea that there was a time before ethics, my own experience and my discussions with many retired surgeons, including my father, have led me to believe that things are very different today than several decades ago. I thought that although there were certainly ethically challenging cases in the past that demanded surgeons to make tough choices, such cases I thought were unlikely to be called out as ethics cases.

Dr. Peter Angelos, 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
Dr. Peter Angelos
In this context, I was very surprised by recently coming across the publication of an address by Sir William Stokes, M.Ch., in 1894, titled, “The Ethics of Operative Surgery.” According to the publication, the address was originally printed in the Dublin Journal of Medical Sciences in November of 1894. Dr. Stokes was an influential surgeon whose titles included “Surgeon-in-Ordinary” to her Majesty Queen Victoria and Past President of the Royal College of Surgeons and of the Pathological Society of Ireland.

According to the short publication, the address was given to the Meath Hospital and County Dublin Infirmary at the “opening of the session” on Monday, Oct. 8, 1894. Dr. Stokes’ words on that date seem to have been addressed primarily to medical students, but many of the topics he touched upon resonate with ongoing ethical issues in the care of patients today.

When addressing the innovative ideas of antisepsis, Dr. Stokes wrote: “…it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles which should always guide us in our operative work have, at times, I think, been neglected, and operations undertaken that, in the present state of our knowledge, have, I fear, overleaped the pale of legitimate surgery.” In these sentences, Dr. Stokes is addressing the worry that overconfident surgeons might recommend operations that may put their patients at significant risk. Here, he is addressing an issue that remains problematic today as surgeons must often temper their enthusiasm for an innovative operation in the context of the potential complications that the patient will be put at risk for.

Later, Dr. Stokes goes on to use the term “surgical ethics” for perhaps the first time in the surgical literature when he writes: “A consideration of surgical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths. The question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty, as the result of such interference must end in weal or woe, satisfaction or regret to the patient as to the operator.” Although the language is somewhat different, Dr. Stokes is challenging surgeons to address a central question in the care of every patient with cancer:

Do the risks of the operation outweigh the potential benefits to the patient?

Although this question is central to all surgical decision making, Dr. Stokes’ specific attention to this question in relation to cancer surgery is a reflection of the understanding, even in the 1890s, that cancers most frequently led to death with or without aggressive surgical intervention. Although patients commonly are willing to put themselves at significant risk for even a small chance of benefit when the alternative is death, surgeons must carefully weigh risks and benefits when deciding when to offer surgery to such vulnerable patients.

The words of Sir William Stokes seem strangely modern in their emphasis on surgeon judgment. The question of “what should we offer to our patient?” is one that apparently is not new. The overarching question of whether the risks outweigh the benefits of innovative operations or challenging cancer procedures are as relevant to surgeons today as they were to a thoughtful surgeon in 1894. The questions that Dr. Stokes raised could have been lifted directly from the M & M discussion at any number of surgical departments today. This early work in surgical ethics should remind us of the importance of carefully considering when we should offer risky surgery to vulnerable patients who often believe that surgery is their only option for cure.

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

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