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
All rapid responses
I agree with the concerns with the issue of informed consent and that
this is not the only issue being debated on
Having dealt with patients and producers of at least 2 different
primetime TV medical programs in Australia on occasions in the last 5
years I do have concerns about how some of these programs have been made.
Some of the initial introduction of the TV producers is made by the
treating doctors to make it look legitimate though often many consultants
does not appear to be fully aware of the implications of involving a
commercial entity to what is effectively a private contractual
relationship between a doctor and the patient.
The issue that the TV programme will be in a public dormain is rarely
fully explored by the producers in their dicussion with the patients to
get their consent. In fact for practical reasons, the actual process of
getting consent from the patient is delayed long after the initial day of
admission, say on the day of injury, such that there would have been hours
of footage of the initial consultation at the emergency department (when
the patient is drugged up on narcotics) and several operations performed.
I dont know whether the TV station destroy the footage if the patient
ultimately refused consent or just kept in cold storage for the future.
In terms of capacity to consent, while theoretically "if anyone can
consent for surgery then they should be good for consent for TV access as
well", we often forget that most of the consent for procedure between
doctors and patients is mostly influenced by the patient's trust and
goodwill with the doctors, whereas the consent with the TV station is a a
true commercial contract which the TV station will take their entitement
to the fullest within the contract once it is signed. Patients do not
realise that until they have a dispute with the TV station.
And then there is the issue of practicality and patient care, getting
a film crew in operating theatre will involve at least 2 extra persons in
the enclosed area and the surgical team have to watch them closely to
ensure infection control is not breached (no matter how experienced thay
are at this, especially with all that camera and sound equipment). We all
know that we should limit number of unnecessary staff in theatre during a
total joint replacement to reduce microbal load, so are the TV crew
Lastly, if someone can buy into a seat at the operating theatre, then
similarly patients can request their (non-paying) partner or children or
their pets to be present in the theatre during the operation; they (except
the pets) would have more vested interest in the successful outcome of the
surgery than some spectators who paid to be rubbing sterile shoulders with
While I support the idea of demystifying the medical miracle, I do
not see a circus as part of the solution
Competing interests: I am learning to be an orthopaedic surgeon
Christopher Ryan's key point is that the ethical test of whether it
is fine for paying spectators to enter the normally private relationship
between doctor and patient rests on the adequacy and comprehensiveness of
the information given to patients before they consent.
He describes consent for treatment, films that will be screened only
to other doctors and medical students, and reality TV medical
"infotainment" as examples where informed consent can and has taken
If being adequately informed is the main thing that matters here,
many possibilities could open up for others to observe the doctor-patient
relationship and the practices, emotions and trust that should be integral
to it. Doctors wanting to open up the list of suitable spectators in their
consulting rooms and theatres in order to advance a good cause might
reconsider inviting cashed-up salespeople from pharmaceutical companies
keen to gather vital information on expressed patient concerns, attitudes
to treatment and potential anxieties about everyday problems that might be
medicalised. Why not also invite artists and photographers wanting to
capture the looks of sick and worried people, and authors looking to note
down authentic dialogue for their novel or movie script?
And what information should a surgeon have to give patients about
those who successfully bid to watch them? What assurances can be given to
the patients about these strangers' willingness to respect the
confidentiality of what they witnessed, given that such assurances could
hardly be policed and that breaches could not attract any professional
disciplinary action as occurs with medical and allied staff. Should the
patients be given character references about the observers?
Imagine if GPs routinely displayed silent auction notices in their
waiting rooms inviting patients or anyone off the street to bid to sit in
on their consultations and examinations of other (consenting) patients in
order to raise money for various good causes. To get sufficient
interest, it's unlikely that offering the opportunity to witness a
prescription renewal or a blood pressure reading would attract much
interest. But what about genital, rectal or breast examinations? We
might object that these are qualitatively different and involve inviolable
breaches of privacy. But a few patients may well consent -- supposedly
the key issue here - if the money was going to a good cause. So why not?
And should the size of the bids be relevant to the ethical
considerations? Would $10 be enough to praise this fund raising
initiative if no higher bids were received? $50? Or does it only become
justifiable when you can attract the sort of big money that someone like a
prominent neurosurgeon can pull? What is the minimum price for pushing
the boundaries of the privacy of the doctor-patient relationship?
When patients attend a doctor or a health care facility, unless it is
in emergency circumstances or in parts of the world where privacy is a
luxury accorded only to the rich, the expectation is that during
consultation or treatment, one should be attended to only by those
providing medical care and their support staff. The presence of trainee
doctors and nurses is also consistent with such expectations. Having
enough money to satisfy one's curiosity or other personal motive about
medical matters hardly seems relevant.
Competing interests: SC is the author of the article being commented on.
The idea of monetizing the spectacle of medicine raises some
intriguing possibilities, and could offset some of the rising costs of
TV broadcasts of actual Emergency Departments, operating rooms,
childbirth, etc. could compete with their counterparts from TV's fictional
dramas. Of course, the patients would share in the profits, in return for
Eventually the military will also come to embrace the marketplace,
putting out for bid exclusive rights tobattle-field reporting. Isn't it
the current religion, to let the free market set all policies?
Competing interests: No competing interests
The presence of the power imbalance in the doctor-patient
relationship does not extinguish a patient's capacity to weigh the pros
and cons of a particular course of action. In his ethical critique of a
surgeon's efforts to raise money for cancer research by auctioning off an
opportunity to watch him operate, Simon Chapman appears to assume that it
Chapman worries that patients about to have brain surgery won't be
able to consent to having ticketed observers in theatre because they "will
be desperate and vulnerable". However, patients consent to all manner of
things in these circumstances. Most obviously they are asked to consent to
the surgery itself. Similarly, though, they will often be asked to consent
to participate in a research project, from which they are unlikely to
directly benefit. Also, as Chapman himself points out, it is not uncommon
for patients to have their operations filmed for teaching purposes or even
reality show entertainment.
The issue of concern here is not whether or not these patients are
capable of consenting. The issue is whether patients know what they are
consenting to and whether they feel coerced into accepting. The answers to
these questions will always lie in the details around the request.
Chapman's envisaged consent process - "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?" - is obviously
unethical. Equally obviously though, it is a strawman. Proper consent to
this process would involve a long discussion of exactly what is
envisioned, including any risks to the patient's privacy. The surgeon
would need to ensure that patients genuinely understood that they were
free to refuse to participate, that a refusal would not prejudice their
treatment and would not jeopardise research funds.
A properly informed patient would be quite able to consent, and it
seems most, but not all patients, are happy to participate.
1. Robothem J. Knives out over sale of ringside surgery seats. Sydney
Morning Herald 2011 (28 January). Available at URL:
Competing interests: No competing interests
Reading the Views & reviews "Should the spectacle of surgery be
sold to the highest bidder?" by S Chapman (BMJ 2011 342:d237;
doi:10.1136/bmj.d237) reminded me that, whenever anybody remarks that a
soccer player is paid scandalously more than, say, a brain or heart
surgeon, I tend to reply that this obvious injustice will be amended the
day a stadium full of people will pay to watch the surgeon operating. I
see now it's going to happen ...
Competing interests: No competing interests