Ethics gap in surgery

Surgery should be routinely videoed

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as a duty to protect, arguing for professional and institutional duties, as distinguished for duties of rescueA professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of confidentiality. I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted-such that where consent and the technology are in place, routine videoing meets a duty of easy protection In other words, its use should be standard of care.

Ethical issues in cardiac surgery

While ethical behavior has always been part of cardiac surgical practice, ethical deliberation has only recently become an important component of cardiac surgical practice. Issues such as informed consent, conflict of interest and professional self-regulation, among many others, have increasingly attracted the attention of cardiac surgeons. This article covers several broad topics of interest to cardiac surgeons and cardiologists and discusses several other topics more briefly. There is much uncertainty regarding what the future holds for cardiac surgical practice, research and culture and we also discuss the background of ethical issues to serve as a platform for envisioning what is to come.

Ethics in cardiothoracic surgery: a survey of surgeons' views

BACKGROUND

Cardiothoracic surgeons are frequently confronted with complex ethical issues. Educational efforts to help surgeons navigate such issues have been undertaken in recent years, but their effectiveness is uncertain.

METHODS

A survey instrument exploring the effects of ethics educational sessions at annual meetings and publications in cardiothoracic surgery journals was sent electronically to cardiothoracic surgeons who belong to The Society of Thoracic Surgeons and the American Association for Thoracic Surgery.

RESULTS

Of 3,705 surgeons, 578 responded (15.6%). The majority of respondents practice in an academic setting (55%), attended at least two of the last five Society annual meetings (66%), and at least one of the last five Association annual meetings (68%). A majority of respondents agreed that their own practices would be improved (69%) and that cardiothoracic surgeons in general would benefit (83%) from better understanding of ethical issues. Respondents also believed that demonstration of an adequate understanding of ethical issues should be part of both American Board of Thoracic Surgery certification and maintenance of certification processes (61% and 60%, respectively). Among respondents who attended ethics presentations at annual meetings, only 4% believed that the sessions did not improve their understanding of complex ethical issues, and only 10% believed that the sessions did not affect their surgical practices.

CONCLUSIONS

The survey suggested that efforts toward ethics education for cardiothoracic surgeons might be both relevant and important; the results encourage continuation and further improvement of such efforts.

Hospitals? organizational variables and patients? perceptions of individualized nursing care in Finland

AIM

To examine the association between hospitals' organizational variables and patients' perceptions of individualized care.

BACKGROUND

There is lack of evidence related to the effects that the hospital environment has on patient perceptions of the individuality of care they receive.

METHODS

A cross-sectional design was used. The questionnaire survey data were obtained from 861 (response rate 82%) hospital patients and 35 (100%) nurse managers in Finland. Results An inverse relationship between the size of the hospital and ward and patients' perceptions of individualized care was found. Increased staffing or skill mix failed to predict a higher patient perception of individualized care, but primary nursing care delivery did.

CONCLUSIONS

Instead of increasing the amount of nursing staff, there is a need to improve the quality of the nurse-patient interactions to facilitate individualized care. The generalizability of the study is limited by the regional nature of the setting.

Action ethical dilemmas in surgery: an interview study of practicing surgeons

Background

The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice.

Methods

Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation.

Results

No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests.

Conclusion

The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable.

Patients' autonomy in surgical care: a comparison of nurses' perceptions in five European countries

BACKGROUND

This report forms part of the results of an international comparative study funded by the European Commission (1998-2001).

AIM

To describe and compare the maintenance of patients' autonomy on surgical wards, from the point of view of nursing staff, in five European countries (Finland, Spain, Greece, Germany and Scotland). Autonomy is defined in terms of information received and decision making by patients.

METHOD

The data were collected using a questionnaire specifically designed for use in this study. Responses (response rate 66%) were obtained from 1280 nurses working on surgical wards. Data analysis was based on descriptive statistics, t-tests, analysis of variance (ANOVA) with posthoc Tukey's HSD test and logistic regression.

RESULTS

There were clear between-country differences in nurses' perceptions, especially on a north-south axis (Finland and Scotland vs. Greece and Spain), regarding the extent to which the autonomy of surgical patients is supported by nursing staff. Training and ethics education, in particular, were associated with nurses' perceptions of the maintenance of patient autonomy in Finland and Greece.

CONCLUSION

Further research is needed to establish whether the results obtained are caused by differences in cultures, nursing practices or roles of health-care personnel or patients in different European countries.

Discussion of death and dying in surgical textbooks

BACKGROUND

Quality end-of-life care is an increasing concern for the public and the medical profession. Surgical textbooks could serve as an important educational and reference resource to improve this care.

METHODS

Four general surgical textbooks were scored for helpful information on death and dying for eight surgical diseases. For each disease, nine content domains related to care of the dying patient were evaluated. Three texts included a chapter on cancer that was evaluated separately.

RESULTS

Disease epidemiology, prognosis/prevention, progression, and medical interventions were generally well discussed in all textbooks. However, little helpful information was provided with regards to breaking bad news/advanced care planning, mode of death, treatment decision-making, effect on family/surgeon, and symptom management. Cancer chapters also addressed only a few of these concerns.

CONCLUSION

Death and the dying patient are sufficiently frequent in surgical practice that it would be appropriate to increase the amount of information provided.