Ethics In General Surgery Notes

Ethics In General Surgery

Competency Of General Surgery 

Describe the principles of ethics as it pertains to general surgery.

Ethics In General Surgery Introduction

• Ethics in surgery is not something new. It has existed since ancient times. It existed during Hippocrates (460–c.370 BC) period also.
• During Hippocrates period, physicians were told to follow strict discipline, professionalism, and rigorous practice. Generally, they are advised to not harm people and if possible, help.
• Some code of conduct and morals existed even in ancient kingdom ruled by kings all over the world.
• We should know that surgery may cure a patient of his disease or surgery may save his life but surgery can also cause disfigurement, disability or even result in more problems due to complications.

Read And Learn More: Basic Principles Of Surgery Notes

Ethics In General Surgery Definition:

• Ethics is the discipline concerned with what is morally good and bad, or right and wrong. Surgery always deals with action and it is related to the body. Thus it is more relevant today because the field of medicine has developed rapidly.
• There is wide range of investigations available and many of them are costly also. Developments in surgery have been rapid with advent of new technologies.
• These add quality to life and at the same time, a kind of glamour and sophistication to surgery itself. A treating surgeon often needs to decide how much he should disclose about the nature of the disease to the patient or his relatives.
• He may also be in a dilemma as to what investigation to order, and how long and to what extent should he provide

treatment, for example, how many days to prolong life of a patient who is terminally ill and has advanced malignancy. This chapter discusses in brief ethics pertaining to general surgery.

Principles Of Ethics

The four main ethical principles are:

1. Beneficence,
2. Non-maleficence,
3. Autonomy and
4. Justice.

Some alteration of these are not uncommon depending upon the location, hospital practices and considering religion and race.

• The first two can be traced back to the time of Hippocrates “to help and do no harm”, while the latter two evolved later. Let us look at each one of them with examples.

Principles Of Ethics Beneficence:

• This means, as surgeons, we have an obligation to treat patients who are suffering, possibly due to pain or any wounds, to relieve them of the pain or any such symptom.
• What will you do if a patient presents to you with a bleeding ulcer? Irrespective of the paying capacity of the patient, his race or religion, it is our duty to stop that bleeding, make him comfortable and then proceed to do what needs to be done.

Principles Of Ethics Non-maleficence:

• One should not practice evil or do harm, often stated in Latin as Primum non nocere. This means surgeons also have an obligation not to harm the patient.
• Even though no surgeon would intentionally harm any patient, his surgery or investigations ordered also should not cause harm.
• For example, a patient with metastatic stage 4 disease of carcinoma rectum with secondaries in the liver and ascites presented with intestinal obstruction.
• The patient had a past history of myocardial infarction 2 months prior and was on medications. The surgeon decided to do colostomy to relieve obstruction.
• However, the patient died in the postoperative period due to leakage of ascitic fluid from incision site, sepsis, and cardiac failure.
• There was an expert available in the hospital who could have done stenting to relieve obstruction. The surgeon did not inform him nor did he take his suggestions.
• The surgeon can be held responsible for causing harm to the patient when he could have managed the situation without surgery.

Principles Of Ethics Autonomy:

• Every adult human being in sound mind has a right to decide what shall be done with his own body. He or she has a right to know what disease he/she is having.
• The surgeon should give all the information about the disease, treatment plans, and complications.
• Without this information, trust never develops between patient and the doctor. He has the right to give consent for treatment or refuse treatment even after the facts have been explained. However, if the patient is unconscious, mentally disabled, is an infant or a child, he/she will not be able to take decisions.
• A patient with hypotension and shock with altered sensorium due to gas gangrene has a risk of loss of limb and loss of life.
• He may not be in a position to understand. In such situations, the details, pros, and cons must be explained to the relatives, and proceed with amputation/debridement after getting the consent from patient’s legal representative.
• However, if the surgeon feels that a few hours of resuscitation can improve his mental status, he can wait for a few hours till he regains normal mental status and get consent from the patient.
• Informed consent: Informed consent is a process of taking consent from the patient/legal guardian for

Principles Of Ethics Informed Consent

• Firstly, the patient should be made comfortable during counselling and he should be able to comprehend what is being explained.
• The doctor must explain about the condition of the patient and the type of treatment planned, in the presence of a witness.
• This must be explained in the patient’s own language, taking the help of a translator as necessary. The patient’s understanding improves with the use of simple diagrams to explain.
• A written informed consent must be taken either from the patient or legal representative if the patient cannot sign or is minor.
• The form must have details of the patient, procedure, expected complications, date, and time of taking consent.
• The patient, the doctor, and the witness must sign the consent form acknowledging the explanation and giving consent to the procedure.
• Only the procedure documented in the consent form should be performed. If another lesion is encountered as a surprise finding during surgery, it should not be excised. Example: During cholecystectomy, the surgeon finds a 5 cm cyst in the liver.
• It was asymptomatic. If prior consent is not taken, it should not be removed. undergoing any procedure after the procedure is explained in detail to the patient in his own language or a language that he understands.

Informed Consent In Emergency Situations:

• Example: A patient is unconscious due to head injury following road traffic accident but has life-threatening bleeding from a ruptured spleen.
• In this situation, the treating surgeon should apply the first two ethical principles: Beneficence and non-maleficence, and operate. Who can give consent in this situation? The patient’s legal representative (spouse, son, guardian, etc.) can give consent.
• On some occasions, no relative is present and the patient is brought in by police personnel. In this situation, the Medical Superintendent of the hospital can give his consent to do surgery in order to stop the haemorrhage by splenectomy/ splenorrhaphy.

Principles Of Ethics Truth-telling:

• A valuable bond develops between the patient and the doctor when the truth has been conveyed to the patient. For example, the patient has gallstone disease with symptoms.
• The surgeon must not only explain to the patient about the disease and the need for surgery but also the type of surgery, complications, and difficulties that can be expected in the given patient.
• Any other alternate treatment options available as per guidelines issued by the speciality societies—such as Association of Surgeons of India or American Society of Surgeons, etc. must also be mentioned.
• For example, laparoscopic cholecystectomy is the surgery of choice but laparoscopic facilities are not available in a rural set-up, the patient must be informed about advantages of the laparoscopic procedure, non-availability of those facilities in that rural set-up, and the facilities available at a nearby place.
• In a few countries including India, when a patient is diagnosed to have cancer or some serious disease, the son or daughters often request that the treating doctors not reveal the facts about the disease or chances of survival to the patient directly.
• Culturally, this is acceptable in a society where a senior member takes the decision. However, legally this is not.
• To get around the problem, the patient can be asked whether it is acceptable to him, if further treatment plans are discussed with his son, daughter or brother, who will take decisions on his behalf. This is acceptable, if the patient agrees to it.

Principles Of Ethics Confidentiality:

• Surgeons must not discuss the disease or patient condition to anyone without permission from the patient. However, other health care professionals who may be required to treat such patients for various medical reasons or for scientific studies, can be informed.
• Such situations are also implied that the patient has been told about this. However, when there is any doubt regarding presence of communicable diseases such as HIV or hepatitis B, or even COVID infections, one must inform people who are connected with the patient to protect others from acquiring infection from the patient.

Principles Of Ethics Justice:

• It is a fair, equitable, and appropriate treatment of persons. Several issues govern this. It depends upon hospital resources and the time we give each patient.
• Is it the same for patients with and without insurance, paying and nonpaying patients? Another example is when a physician prescribes an expensive drug, it may benefit him and there may be another drug which is equally good and cheap but does not benefit him.

Life And Death

• As of now, euthanasia, intentional killing of a person, is rejected as unlawful malpractice. The patient may be terminally ill but conscious and well-oriented.
• The use of analgesic medications to the point of causing death may be considered as an intention to kill. Here, the surgeon or palliative medicine experts may have to prove their innocence.
• Patients who are brain-dead or have seriously damaged brain, once certified by concerned specia lists, are taken off ventilatory support and are allowed to die.
• However, the patient’s family or relatives have to be briefed about his condition and have to be informed that the decision is taken by a group of specialists.

Examples

• A patient with cirrhosis of liver with encephalopathy is slowly recovering but has a massive variceal bleeding. The patient is not consenting for banding therapy when explained by the doctors.
• If the varices are not banded, he may die or have serious consequences but the patient does not consent. How does one proceed in this situation? Beneficence and autonomy have conflicts. If you follow the rules of autonomy, you should not proceed.
• If you follow the rules of beneficence, you should proceed with banding. Now look at his mental status. He is a bit drowsy and has encephalopathy.
• He is not capable of understanding what the doctors are explaining. So now beneficence takes precedence. The specialist should go ahead with banding after explaining the procedure, advantages, and risks involved to the patient’s relatives.
• A 65-year-old retired banker was diagnosed to have a 6 cm tumor in the liver, a hepatocellular carcinoma, and a big and suspicious nodule in the lung probably metastasis. He was advised to undergo surgery for the liver tumor followed by other modalities of treatment including chemotherapy and removal of lung lesion, etc.
• The patient said he does not want to undergo surgery as he is scared that he may die of complications and that he would resort to alternative medicines. What should be done now? It is his autonomy, he has taken this decision in spite of knowing about the disease and probable survival.
• So, we should not force him to undergo surgery. However, if he comes with pain/discomfort/any other complications later, it is our duty to give him the best palliation. We can also suggest that he seek a second opinion.
• Jehovah’s Witness patients refuse blood transfusion even when they know that their life could be in danger. This group is a sect of Christianity. Here autonomy comes into the picture, not justice.
• A 70-year-old man undergoes total gastrectomy followed by esophagojejunostomy for carcinoma stomach. He was a smoker with COPD, diabetes, also had myocardial infarction a few months back, and was on treatment. He developed multiorgan failure on day 6 due to pneumonia and deteriorated very fast.
• He was intubated and he went into coma by day 14 and no improvement was seen till day 21. How to proceed in such cases? This is the time to discuss patient’s condition with his family and explain to them about his condition, whether his lung condition is reversible, take them into confidence, and discontinue the treatment.
• A 75-year-old lady was brought with bleeding per rectum of 8 months duration and jaundice of 1 month duration. It was treated as hemorrhoids for a few months. Rectal examination, biopsy, and later MRI revealed advanced carcinoma rectum infiltrating the anal sphincter. She also had multiple metastasis in both lobes of liver.
• Relatives of many patients insist that diagnosis should not be told to the patient. How do we proceed? Call the patient and ask her whether her disease and best plan of action can be explained to her son/representative and whether she would consent for that.
• A 35-year-old lady underwent hysterectomy for excessive bleeding. She was discharged after 5 days. However, she returned after 4 weeks with abdominal pain, distension and high-grade fever.
• CECT scan revealed foreign body—a left-over mop in the peritoneal cavity. The patient underwent exploration and the mop was removed. She did well and was discharged. What should the surgeon tell the patient? He has to tell the truth.
• That mop was left behind by mistake. One can also apologise to the patient. The expenses of the second operation or surgeon’s fees can also be waived off by the hospital authorities and some amount of compensation can be given to the patient.
• Here is a situation of harm caused to the patient inadvertently by not following certain guidelines/check lists to prevent them.
• During COVID-19, an 85-year-old, otherwise fit patient in Nagpur whose saturation was 60%, who required an oxygen bed told the doctors in the hospital to give that oxygen bed to a 35-year-old patient who was also having 60% saturation since there was only one oxygen bed available.
• It was a great sacrifice. However, if you face this situation in real life in emergency department, what should be your decision? Decision cannot be based on wealth of the patient, influence from the authorities or influence

from politicians. A 35-year-old patient has a longer life. He may be the only bread-earning member of his family.

• He may have the responsibility of looking after his parents. So, he has a definite edge over the 85-year-old man/woman. So, this is fair decision and justice to resuscitate the 35-year-old man.
• An advanced case of liver cell failure, portal hypertension, uncontrolled ascites, with large obstructed ulcerated irreducible hernia with sepsis for surgery—surgery was done to relieve pain, fungation and ulceration—only as palliation. All the details about the risks were explained to the patient.
• Surgery was done after consent was obtained. He died on the 3rd postoperative day of sepsis, hypotension and shock.

Ethics In General Surgery Conclusions

If you follow guidelines of ABCDEFG of doctor–patient relationship which is given in Chapter 1 and principles of ethics given in this chapter, it is a great service to humanity. You will give your best to your patients. You will also uphold the virtues and values of medical education and ethics.