Transcript How ethics guides us to face errors and patients harmed by

Surgical Ethics:
Relationships with Patients,
the Profession, and Society
Martin McKneally
University of Toronto
Dept. of Surgery
Joint Centre fo Bioethics
Foundations of Surgery
September 25, 2012
“Dr. McKneally, this is Jerry Wilson of
the FBI. Can you answer some
questions for me?”
“What kind of ethics education or
training is given to surgeons?”
The Moon/Realyvasquez case
“Doctors accused of performing
unnecessary heart surgeries at Redding
Medical Center agree to pay millions to
settle fraud allegations and accept
restrictions on their medical practice”
U.S. Department of Justice, 2005
Plan of talk
What’s an Ethic?
Teaching Ethics
The Ethic of Surgery
Obligations
to patients
to the team
to society
Ethics….What’s an Ethic?
• A set of values, principles, and beliefs,
standards of conduct
• Guides the behaviour of a specified group –
journalists, lawyers, mafiosi, monks,
physicians, surgeons.
• “What we should do” – codes of conduct
Ethics
should
Policy
Law
usually
must
Ethics
censure
Policy
disapproval
Law
fines/prison
Contemplation before surgery
Joe Wilder, MD
“Thou Shalt Teach Bioethics”
RCPSC 1995
Ethical Issues Taught Formally:
Consent, end-of-life, disclosure, surgical
competence, surgical decision-making, COI,
resource allocation, research/innovation
Ethical Challenges Not in Formal Curriculum:
Intra- and inter-professional conflict, lack of
experience, training issues, perceived
unethical staff behaviour
Ethic of Surgery
Trustworthiness:
Competence
Commitment
Trustworthiness
We are trusted to live up to our obligations
Professional: competence, commitment
Fiduciary: what is best for the patient
Team: integrity, coworker care
Societal: community need for surgical care
Surgical Competence
Knowledge
- timely and appropriate
Judgment
- balanced
- attentive to the particular needs and
circumstances of the individual patient
- the right operation for the right
patient at the right time
Technical Skill - sufficient to perform the surgical
intervention
- minimum of risk
- high probability of benefit
Commitment
Personal responsibility –
uniquely intensified
Constancy –
warrior energy
Fiduciary Obligation
Put patients’ interests above all
others, including the physicians
Trustworthy care
competence, commitment
Respect
dignitary rights
privacy, confidentiality
Confidentiality
Patients and the profession
expect physicians not to
disclose private information
learned in the course of care
Team Obligations
Maintaining the integrity of
the team
Coworker care: attention to
the needs and concerns of
team members
Societal Obligations
Implicit contract with society
Duty to treat
Explicit contract
with individual patient
emergency care
public agencies
Challenges – AIDS, SARS, Avian flu,
COI, hypocompetent surgical care,
suboptimal ‘system of care’
Societal Obligations of Surgeons
Effective subsystems of care
Trauma system
Cardiac Care Network
Cancer Care Ontario
CritiCall
Societal Obligations of Surgeons
Developing subsystems
“Coaching teams”
Coach Alan Hudson
Critical care – Tom Stewart
General surgery – Ori Rotstein, Andy Smith,
Bernie Langer, Richard Reznick
Orthopaedics – Alan Gross
Summary: Ethic of Surgery
Trustworthiness:
Competence
Commitment
Obligations:
Patients
Team
Society
[email protected]
Cell: 416.918.5032
Ethical Issues Taught Formally:
Consent, end-of-life, disclosure, surgical
competence, surgical decision-making, COI,
resource allocation, research/innovation
Ethical Challenges Not in Formal Curriculum:
Intra- and inter-professional conflict, lack of
experience, training issues, perceived
unethical staff behaviour
RCPSC Bioethics Curriculum: Surgery
• Consent:
Capacity, Disclosure, Surrogates
• Professional Conduct:
Duty to treat, Confidentiality
• Conflict of Interest
• Surgical Competence
• End of Life
• Truth Telling
• Resource Allocation
• Research Ethics
Circumstance
Ethics
Culture
should
Religion
Politics
Policy
Law
usually
must