Effect of responsibility, patient trust, and managing innovation unique in surgical ethics

Peter Angelos, MD, PhD, FACS
Peter Angelos, MD, PhD, FACS

“Is surgery a purely technical discipline? I think the answer is no. I think technical mastery is necessary for surgeons, but it is not sufficient,” said Peter Angelos, MD, PhD, FACS, in his opening remarks at Wednesday’s John J. Conley Ethics and Philosophy Lecture, What’s Different about Surgical Ethics and Why Does It Matter?

Dr. Angelos, the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics, University of Chicago, IL, discussed how the advent of surgical ethics challenges the notion that being a successful surgeon requires little more than mechanical skill. He explained other concepts that affect modern surgeons, including responsibility and how surgeons view responsibility, the surgeon-patient relationship and surgical informed consent based on trust, and the challenges of surgical innovation.

“Responsibility is one of those things that I would say almost defines surgeons,” said Dr. Angelos, suggesting that surgeons feel a different level of internal and external responsibility compared to internists. A surgeon manually heals a patient through personal ability, which can lead to a different response from patients or families if a medical treatment doesn’t go to plan. He referred to an observation by sociologist Charles Bosk, PhD, who noted that internists are often asked “What happened?” in the event of a patient death, while surgeons are asked “What did you do?”

That level of accountability is reflected in the surgeon-patient relationship, which requires a unique trust, Dr. Angelos said. The core function of a surgeon is to cause harm in order to ultimately heal. In any other context, the actions of a surgeon would be unethical and illegal, but by developing the trust of a patient, they become accepted. Contrary to the belief that surgeons don’t need to have a rapport with patients, “If I’m not good at communicating with patients and developing a relationship in a very short period of time, I’m not going to be doing very much surgery,” Dr. Angelos said.

That patients are willing to leave their lives in the hands of surgeons only comes through a sincere trust, which is grown through receiving informed consent, according to Dr. Angelos. However, there is more to informed consent than providing the risks, benefits, and alternatives to patients—especially since much of that information is often forgotten by patients shortly after they hear it. “I would say that patient trust transcends problem with memory, and I think it is trust that is the basis of informed consent,” said Dr. Angelos, noting that patients who are willing to face the risk of harm for the possibility of benefit are implicitly placing trust in their surgeons.

“Surgeons are not only allowed, but truly expected to creatively solve their patients’ problems with no oversight about what we do in the operating room,” Dr. Angelos said. This leaves surgeons with a singular flexibility in the medical world, but that same flexibility creates ethical issues in determining whether a new surgical technique constitutes an advance and should be adopted on a broader scale. Dr. Angelos reviewed several approaches to thyroid surgery where the only differences were cosmetic and said that the option that is chosen is largely based on how much a patient values the aesthetic outcomes of an operation. And while a patient’s values must be taken into account when choosing the approach to an operation, “the professionalism of surgeons is necessary to ensure that what is new is not automatically assumed to be improved,” he said.

The challenge in surgery is to be the “complete surgeon,” who is technically excellent but who also thinks about the patient in the context of their values and their surgical goals, said Dr. Angelos, echoing the theme of Clinical Congress 2017. “The new question for surgeons is, ‘What should be done for this patient?’ And what we should be doing is always a question of ethics.”

Dr. Angelos delivered the John J. Conley Ethics and Philosophy Lecture in place of Peter A. Ubel, MD, who originally was scheduled to speak on Empowerment Failure: How Physician Communication Breakdowns Undermine Patient Autonomy.