Transcript The Ethic of Surgery Professional Obligations of Surgeons Surgical Competence Martin McKneally University of Toronto Dept.

The Ethic of Surgery
Professional Obligations of Surgeons
Surgical Competence
Martin McKneally
University of Toronto
Dept. of Surgery & Joint Centre for Bioethics
Principles of Surgery
April 27, 2010
Case 1
• Dr. Innovatore is performing a new
minimally invasive procedure. Tension
rises in the operating room as he
struggles with the technical aspects of
the operation. The operating team
becomes increasingly concerned that
Dr. Innovatore is unable to complete the
procedure.
Question 1
• What should the resident do to resolve
the moral quandary of participating in
Dr. Innovatore’s operation when he is
not meeting the standard of
competence?
Question 2
• What is the standard of competence to
which Dr. Innovatore should be held?
Question 3
• Is Dr. Innovatore behaving unethically?
Ethic
• Values, principles and beliefs that
guide the behaviour of a specified
group
• “What we should do”
• Codes of conduct
Ethic of Surgery
Trustworthiness:
Competence
Commitment
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 in the right way
Technical Skill - sufficient to perform the surgical
intervention
- minimum of risk
- high probability of benefit
Question 4
• Do residents bear moral and legal
responsibility for the outcome of
operations in which they participate?
• In other words, are they surgeons, or
are they students?
Graded Responsibility
• Resident (adj.) a resident surgeon
resides in the hospital to provide on
site care & emergency treatment
• Residents are responsible for the
procedures performed at their level
of proficiency
Graded Responsibility in Operative Surgery
U of T Dept of Surgery
What do patients think about you?
Case 1 continues
• Dr. Innovatore is performing a new minimally
invasive procedure. Tension rises as he
struggles with the technical aspects of the
operation.
• The team becomes increasingly concerned
that Dr. Innovatore is unable to complete the
procedure, and that he may be operating
under the influence of alcohol, a problem that
has troubled him in the past.
Question 5
• How should deficiencies in competence
related to alcohol, chemical
dependency, or illness (stress,
depression…) be managed?
Case 1 continues
• As Dr. Innovatore ages, his judgment
seems to be failing. The team feels he
tends to perform unnecessary surgery,
perhaps to maintain his income…
• He has become dependent on
residents to complete the more
challenging components of his
operations….
Question 6
How should deficiencies in
competence related to age
be managed?
Departmental policy
Review by SIC
Report to trustees
Surgeon in chief
responsible and accountable to the
community through the hospital trustees
for the safety of the operating room and
the competence of surgeons on the staff.
Hospital trustees
accountable to the community for the
safety of health care at their institution;
obliged to verify the competence of
practitioners under their supervision or
employment.
Question 7
Are residents competent to operate
independently?
Residents are morally and legally
responsible for the outcomes of the
interventions that are deemed by
their supervisors to be appropriate
to their level of training.
Graded Responsibility
Residents are expected to be able to
operate as independent specialists
at the completion of their training.
Staff surgeons are expected to
supervise the independent operative
experience of residents according to
their level of proficiency.
Graded Responsibility in Operative Surgery
U of T Dept of Surgery
Question 8
• How can I justify performing an
operation when there is a surgeon
available who is more experienced or
skilled than I am?
Competence is a threshold attribute
drive, fly, operate
Expertise is a graduated attribute
Natural limits determine appropriate
distribution of expertise:
distance, volume, resources
Most patients rely on trust.
Trust: Reliance on others’
competence and willingness to
look after rather than harm things
one cares about.
Annette Baier
Trust provides an alternative to
vigilance and rational calculation
of risks, benefits, and
alternatives.
Annette Baier
Contemplation before surgery
Joe Wilder, MD
Department of Surgery website:
www.surg.med.utoronto.ca
RCPSC ethics curriculum in surgery:
http://rcpsc.medical.org/ethics/surgery/index.php
[email protected]
Surgical ethics
Certification of ethics education
Acknowledgements
Paintings by Robert Pope and Joe Wilder
Deborah McKneally, The Ravine
Research and Education Centre