Crouching tiger, hidden surgeon

Cast your eye down the list of delegates at any course in medical ethics. You will find represented a wide range of specialties: the usual batch of general practitioners and anaesthetists, intensivists, psychiatrists, oncologists, junior doctors, and even the occasional radiologist and pathologist. Yet there is one species of doctor that is as rare as the Siberian tiger: the surgeon. I must confess that my eyes light up when I see a surgeon on the list, and I scan the room hoping to catch a glimpse of the rare animal. When I see one in the flesh, he (for it usually is) tends, surprisingly, to be shy, crouching towards the back of the classroom or lecture theatre. More often than not he is an older creature. Without his tools and instruments, without his mask, exposed and alone, the surgeon in the ethics course has ventured into a foreign habitat.

The Royal College of Surgeons offers an extensive menu of training courses, from the cheerful “drawing for surgeons” to the bone chilling course on the Ilizarov method. Although a course exists on legal issues in surgery, there is no course on surgical ethics. Several royal colleges, including those of the general practitioners, pathologists, obstetrics and gynaecology, paediatrics, and psychiatry, have established their own ethics committees. There is no such permanent committee for the surgeons.

Some of the surgical textbooks I consult on the library shelf have a few pages devoted to the law of consent, but ethics is notable by its absence. At surgical conferences oral presentations on the subject are rare. I was mightily surprised when, scanning the programme of the forthcoming 14th European Congress on Neurosurgery, the last of the 42 topics was “ethics in neurosurgery.” In my excitement I submitted an abstract in support of the brave surgeon who must have raised the idea to puzzled looks at a meeting of the scientific committee. As I was doing so, my wife, a neurosurgical trainee, commented that this particular session would not be overflowing with delegates. No matter. A soliloquy is better than silence.

Surgery is a field brimming with ethical issues: a patient refuses lifesaving surgery on religious grounds or is the victim of an intraoperative error; another has been harmed by a previous doctor but knows nothing of it or has a tumour that is operable but high risk; and yet another mistakenly believes that the operator will be a consultant. There is also the sometimes tenuous link between properly informed consent and that signature on the consent form.

Incise deeper and you will find the surgeon who wants to try a new technique, the surgeon who adds his or her name to publications for no other reason than hierarchy, who is “economical with the truth” with patients and family, whose hand is unsteady or whose judgment is impaired, whose tendency is to overtreat patients, or whose bedside manner borders on the discourteous. And what of the well intentioned but brash trainee who is unaware of his or her limits, the ethics regulating the proper relationship between the surgeon and the anaesthetist, or the ethics of operative scheduling and triaging, in ordinary times and in emergencies? And let us not forget the military surgeons, whose contributions to the art cannot be overestimated but whose ethical dilemmas are no less acute. The ethical issues are not visible on the radiologist’s scan, nor palpable deep in the recesses of the iliac fossae, nor graspable like a bowel clamp but are nevertheless there, as real and important as the potent gases of the anaesthetist.

Why there should be such a neglect of ethics training in surgery is unclear. I hope surgical readers will forgive me for suggesting the possibility of an irreverent attitude towards formal ethics education in surgery. Some of the older tigers may hold the attitude that junior surgeons learn ethics by copying their seniors and betters, that the ethics of surgery will enter the trainee like the absorbable sutures of the patient. Raanan Gillon, an emeritus professor of medical ethics, encountered such a type when he expressed his desire to study for a PhD as a junior doctor in the 1960s. His consultant replied, in an incredulous tone, “You can’t study medical ethics!” The main danger of the osmosis theory is that it can perpetuate bad habits, carefully developed over years of unethical conduct.

Another possibility, equally uncharitable, is that the decision makers in the surgical community, whose own training perhaps contained little ethics teaching, believe that there are few ethical issues in their specialty or that the issues are dealt with adequately in the Royal College of Surgeons’ helpful booklet Good Surgical Practice. Alternatively they may think that these ethical issues are handled perfectly well at present and there is no need for change. “Seek and ye shall find” is the obvious response.

Talk to surgical trainees in private and they will soon complain about publications and presentations. “What about something on ethics,” I usually suggest, “perhaps an audit or a case report on an ethically interesting case?” Their response is that this would be received by their colleagues as enthusiastically as the wrong instrument in an operation. If my observations reflect the wider reality, the surgical community would benefit from a closer examination of the ethical issues in surgery. A one day course in surgical ethics and law, the occasional session in conferences, the odd presentation at the weekly departmental meeting, and a word of encouragement at the mention of ethics. That is all. The rest will follow. Surgical ethics may not be very fashionable, but it is a central part of the practice of surgery. In 100 years’ time the Ilizarov method will be confined to the history books, but surgical ethics will endure.