Surgical Ethics-Kannan.pptx.pptx

Slides on Surgical Ethics

1. Surgical Ethics Dr.Kamalakannan.K

2. Points to discuss Define Ethics - Modern Oath Surgical Ethics - Framework & its Virtues Ethical Issues & its Considerations Principles of Surgical Ethics Four Box Model Approach Patients Expectations Implications & Perspectives

3. Ethics means Character !!! (Ethics word dervied from greek word –Ethos) To put it formally - Ethics is the branch of philosophy that defines what is good for the individual and for society and establishes the nature of obligations, or duties, that people owe themselves and one another.

4. Ethics … Greek healers in the 4th Century B.C. drafted the Hippocratic Oath and pledged to – “prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone”

5. Medical Ethics may be traced to guidelines on the duty of physicians such as the Hippocratic Oath

6. Noble Profession Possessing outstanding qualities like eminence,dignity,commanding excellence of mind,character or high ideals or morals. “The very term Doctor demands Respect. The very term Surgeon demands Greatness.

7. Percival Thomas (1849) Medical Ethics Helsinki meet - Declaration of Geneva “Nuremberg Code” The International Code of Medical Ethics in 1948

8. Surgical Ethics - Prior to 400 B.C Ayurvedic Surgical Practices is like “Guru - Sishiya tradition” Helped to design principles in surgical academics and ethics

9. Surgery The practice of surgery is based on the technical capabilities of the surgeon (techne), their knowledge (episteme) and their capacity of judgment (phronesis). Surgeons face situations that call into question moral choices and face ethical difficulties in their daily practice. In fact, innovation is increasing, and as operations become more complex and the risks become greater, the tools necessary to approach an ethically challenging surgical case become more important.

10. Surgical Ethics - Framework for Surgeons/Patients/Society Surgical ethics can be distinguished from other medical ethics fields because of its unique characteristics and goals. Ethics lie at the core of professionalism: a proficient surgeon is considered to be not only competent to perform the art and science of surgery as traditionally understood, but also to be ethically and morally reliable.

11. Virtue in Surgical Ethics Ethics is an essential discipline in the practice of surgery. Represents your best understanding of moral responsibility. Evolves as reasoned reflection on clinical experience. Role of the Surgeon is to act as the patient’s fiduciary (person to whom property or power is entrusted for the benefit of another).

12. Virtue in Surgical Ethics … Ethical study investigates what should be our character and conduct. Morality is subject to re-examination and improvement. Ideas of justice and fairness require critical assessment and improvement. Ethical argument should maintain relevance and integrity.

13. Ethical Issues in Surgery Surgical decision-making can be viewed as a two-part process. Firstly, there is the ‘is it possible to treat’ or ‘how to treat’ aspect, which is a matter of knowledge and technique (i.e. surgical science).This is translated into an evidence-based practice. Secondly, the ‘why treat’ or ‘what should be done’ issues, which are a matter of surgical ethics and should be based on moral philosophy.

14. Ethical Considerations - New Techniques/Technology • How is the safety of a new technology or technique ensured? • What is the timing and process by which a new technology or technique is implemented at a hospital? • How are patients informed before undergoing a new technology or technique? • How are surgeons trained and credentialed in a new technology or technique? • How are the outcomes of a new technology or technique tracked and evaluated? • How are the responsibilities to individual patients and society at large balanced?

15. The paramount responsibility of physicians when caring for patients is to the patients, placing their interests ahead of all other interests, personal and professional . One of the fundamental principles of medical ethics is respect for the right of individuals to make decisions about what will happen to their own bodies and to act upon those decisions; this is known as the principle of respect for patient's autonomy. The manifestation of this principle in the practice of medicine is informed consent, which comprises three essential elements: the preconditions for decision-making (capacity to make decisions and voluntariness), the provision of information (disclosure of relevant facts and recommendations) and consent (including both the decision itself and authorization for others to act on the patient's decision) .

16. Respect for Autonomy Patients should be treated as autonomous agents. This means recognizing the individual's capacity for self-determination,their ability to make independent decisions and authentic choices based on personal values and beliefs. Patients with diminished autonomy are entitled to protection. Autonomy does not mean that a patient has the right to obtain any treatment he or she wishes or requests if this particular treatment is not medically indicated. Autonomy can only be exercised after having obtained full and appropriate information as well as having understood it. The decision has to be taken without any undue coercion or pressure.

17. Informed Consent Informed consent plays a highly significant role in the patient-surgeon relationship. For patients waiting to undergo surgery, obtaining informed consent is the surgeon’s final step in the information process, and giving informed consent is an important decision that the patient must make freely and independently. For informed consent in surgery, the legal principle emphasizes that the patient is an independent adult who has the capacity and the competence to authorize that which is going to be done to their body and mind. Therefore, any operation that may infringe upon this principle is not only considered to be illegal and liable to result in lawsuits for unlawful injury caused to the patient, it is also ethically unacceptable.

18. Beneficence The principle of beneficence imposes an obligation to act for the benefit of the patient. Surgeons have to follow professional obligations and standards. Surgeons should provide appropriate surgical intervention in response to a medical indication and following the consent of the patient. Each decision must be taken on an individual level.

19. Nonmaleficence The principle of nonmaleficence imposes an obligation not to inflict harm on others. Surgery should minimize possible harm. Surgeons must assess the nature and scope of the risks and benefits. If the risks and burdens of a given surgery for a specific patient outweigh the potential benefits, then the surgeon has an obligation not to operate.

20. Justice The principle of justice refers to equal access to health care for all. Limited resources including the time surgeons and other health personnel and caregivers devote to their patients must be evenly distributed to achieve a true benefit for the patient. Resources should be distributed fairly without any discrimination. With regard to limited resources, there must be proper use of ethically appropriate and transparent criteria.

21. Four Box Model Approach

22. Patients Expectations Surgical ethics were defined by the English surgeon Miles Little in five categories within the moral domain of the surgical relationship: 1) Rescue 2) Proximity 3) Ordeal 4) Aftermath and 5) Presence

23. Patients Expectations… According to Pellegrini , the tenets of a modern competent surgeon include the following characteristics: 1) good clinical skills and appropriate surgical judgment; 2) good technical skills, including knowledge of and expertise in the performance of operations; 3) knowledge and practice of humanism, ethics, and solid moral values

24. Implications & Perspectives Surgical ethics are an essential component in contemporary surgical practice. The success of even the most technically skillful surgery requires an ethical approach . In fact, what makes a good surgeon is the balance of technical questions and surgical ethics reasoning. The acknowledgement of the importance of surgery ethics should have implications to patients, surgeons, and society

25. Implications & Perspectives - Surgeons Surgeons must stop being regarded as callous, tireless and invincible professionals. Surgeons should be skilled in the art and science of surgery and be trustworthy from an ethical and moral standpoint. Surgeons should rely upon their judgment and their values and beliefs to make ethical decisions, and if necessary, to take difficult decisions to an ethical consultation or committee

26. END OF LIFE -ISSUES In unusual circumstances (close to death) that no evidence shows that a specific treatment desired by the patient will provide any benefit from any perspective, the physician need not provide such treatment. If there are no treatment options ie the patient is brain dead and the family insists on treatment - If there is nothing that a physician can do , treatment MUST BE STOPPED. *Note - Updates must be in case sheet along with senior physician comment.

27. Research Surgeons have a subsidiary responsibility to improve operative techniques through research, to assure their patients that the care proposed is best. The administration of such regulation is through research ethics committees, and surgeons should not participate in research that has not been approved by such bodies.

28. Good Standards To optimise success in protecting life and health to an acceptable standard, surgeons must only offer specialised treatment in which they have been properly trained. To do so will entail sustained further education throughout a surgeon’s career in the wake of new surgical procedures. To do otherwise would be to place the interest of the surgeon above that of their patient, an imbalance that is never morally or professionally.

29. The greatness of Surgeon is measured beyond Qualification !!! Skill Academic Brilliance Intelligence Creativity Courage Perseverance Leadership Qualities Professionalism Ethical Practice Successful Surgeon

30. A good Surgeon knows how to Operate A better Surgeon knows when to Operate The best Surgeon knows when not to Operate

31. Righteousness & Wrongfulness

32. Few Takeaways The practice of surgery is based on the technical capabilities of the surgeon (techne), their knowledge (episteme) and their capacity of judgment (phronesis). The principlism and the four-box model approaches to clinical ethics could serve as a guide to the surgical ethics discussion. There are five categories of experience and relationships that are especially important in surgery-rescue, proximity, ordeal, aftermath and presence. Ethical reasoning should help surgeons to gives answers to the questions: What should be done? Has the right decision in this situation been made?

33. “The fundamental contract in surgery is an undertaking by one individual to cure another by operation, in the expectation of reward” J.Cook “The Delegation of Surgical Responsibility