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.