Should the spectacle of surgery be sold to the highest bidder?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d237 (Published 26 January 2011) Cite this as: BMJ 2011;342:d237
- Simon Chapman, professor of public health, University of Sydney
Recently my band, the Original Faux Pas, donated its services to a cancer fundraising event. The event was a huge success, raising more than $A50 000 (£30 000; €37 000; $US50 000), with about 260 people digging deep for auctioned items donated by local businesses. Among the items was the opportunity for two to attend an operation being performed by a neurosurgeon.
Bidding was spirited as the auctioneer barked out the virtues of this exclusive opportunity, and the winning bidders paid something like $A1600, presumably to watch someone having brain surgery. I once bid for an opportunity to have dinner with a senior politician so I could get in his ear. For good causes sports stars often offer games of golf or tennis, and musicians give backstage passes. But somehow this seemed rather different. Two medical members of my band pulled perplexed faces as the item appeared between autographed football jumpers.
In the 19th century surgeons performed their tasks in rooms where limited seats were available for the public to watch. But many things have changed since then, not least the emergence of bioethics as a discipline that is relevant to every branch of medicine. Let’s assume that in tapping the value of his prominence to help in funding cancer research the surgeon had obtained full clearance from his hospital ethics committee to have paying strangers sit in on his operations. This clearance could be conditional only on the observed patient giving full consent. But here, important considerations would arise for any ethics committee.
A person about to have brain surgery will often be desperate and vulnerable, fearful that the operation may fail. Imagine yourself in such a circumstance and having your surgeon say, “Oh, by the way, would you be willing to allow a couple of people who’ve paid big money to raise funds for cancer research to sit in and watch what happens to you?” Plainly, in offering the opportunity the surgeon and any ethics committee who supported him think that no coercion would be involved, that any patient would be absolutely free to say no.
But vulnerable patients are in very different circumstances from those of patients who consent to take part in a study where personal questions might be asked by researchers whom they have never met before and will probably never see again and who are offering them nothing in return. Here, a surgeon whose skills may literally mean the difference between life and death invites a seriously ill patient to think twice about turning down that surgeon’s request.
An obvious parallel is with reality television surgery programmes, such as Channel Nine’s RPA, which shows the everyday work at the Royal Prince Alfred Hospital in Sydney. Instead of two paying customers witnessing the travails of surgery in the operating theatre, hundreds of thousands of faceless viewers witness patients’ journeys, their indignities, hopes, and anxieties—and sometimes their last days of life. Viewers can talk to anyone they like about it, however they like. All the patients filmed in RPA fully consent to participate. So what’s the difference?
One critical difference is that, at any time after the RPA filming and before the segment is broadcast, if any of those who gave consent chose to withdraw it the segment would not be shown. If a patient who consented died, their relatives may well wish not to have the world witness their grief. But with paying spectators at an operation the witnessing will have taken place and could not be withdrawn. Two strangers will have been temporarily admitted as paying spectators.
What guarantees are there that winning bidders would not pass on full descriptions of what they saw to enthralled dinner party guests? What if interesting biographical details slipped out about the patient? Unlike hospital staff, paying guests are not subject to the same ethical requirements of confidentiality. It would be unimaginable that the spectators would be allowed to film what they saw, because of the potential for gross invasion of privacy. So what is it about merely watching that makes it all right?
Medical ethics recognises that some things can never be done with patients, regardless of any question of consent. Health professionals and teachers cannot have sex with their patients or students, even if they might consent, because of the understanding that the imbalance of power between patient and doctor or teacher and pupil rules out the possibility of a mutually consenting arrangement.
The surgeon was doing a noble thing by trying to contribute to cancer research. But should his patients really be put in a position to have to surrender their privacy? In important respects the same concerns about undue influence also apply to RPA and other reality medical programmes. Patients should be told that the deal between the hospital and the RPA programme provides much needed dollars to the hospital, to enable it to continue to do important things.
Cite this as: BMJ 2011;342:d237