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Char S, Prager K, Dugdale L, Fischkoff K. Surgeon Perspectives on Daily Presentation of Ethical Dilemmas: A Qualitative Study. J Am Coll Surg 2023; 237:751-761. [PMID: 37427844 DOI: 10.1097/xcs.0000000000000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Surgeons encounter and navigate a unique set of ethical dilemmas. The American College of Surgeons (ACS) previously identified 6 core ethical issues central to the practice of surgery, but there have been no reports of the true range and complexity of ethical dilemmas encountered by surgeons in their daily practice. Qualitative research is well positioned to address this question. STUDY DESIGN We conducted in-depth interviews with attending surgeons across multiple surgical subspecialties at a large, urban, academic medical center asking them to describe the most common ethical dilemmas they encounter in day-to-day practice. Interviews were recorded, transcribed, and coded according to a grounded theory, inductive approach. RESULTS Thirty attending surgeons were interviewed, representing twelve different general surgery subspecialties. The majority of dilemmas identified pertained to 4 of the 6 ACS identified core ethical issues: professional obligations, competition of interests, truth telling, and end-of-life care. No participants described dilemmas relating to the themes of confidentiality or surrogate decision-making. Approximately one-third of participants identified ethical issues not well characterized by the ACS core principles, most often relating to the pressure to provide care that is not medically indicated. There was strong support for a formalized surgical ethics curriculum. CONCLUSIONS Although the ACS-defined core ethical issues in surgery appropriately captured many ethical dilemmas identified by participants, surgeons described several scenarios not well characterized by these themes. A dedicated surgical ethics curriculum may help to better equip surgeons to navigate the ethical dilemmas they are likely to face in practice.
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Affiliation(s)
- Steven Char
- From the Department of Surgery, Division of General Surgery (Chan, Fischkoff), Columbia University Medical Center, New York, NY
| | - Kenneth Prager
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (Prager), Columbia University Medical Center, New York, NY
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
| | - Lydia Dugdale
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
- Department of Medicine, Division of General Medicine (Dugdale), Columbia University Medical Center, New York, NY
| | - Katherine Fischkoff
- From the Department of Surgery, Division of General Surgery (Chan, Fischkoff), Columbia University Medical Center, New York, NY
- Department of Medicine, Center for Clinical Medical Ethics (Prager, Dugdale, Fischkoff), Columbia University Medical Center, New York, NY
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Boggi U. Laparoscopic duodenum-preserving total pancreatic head resection for pancreatic tumors: the difficult balance among overtreatment, ideal treatment, and undertreatment. Langenbecks Arch Surg 2022; 407:3859-3861. [DOI: 10.1007/s00423-022-02512-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/08/2022] [Indexed: 12/07/2022]
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Hogikyan ND, Kana LA, Shuman AG, Firn JI. Patient perceptions of trust formation in the surgeon-patient relationship: A thematic analysis. PATIENT EDUCATION AND COUNSELING 2021; 104:2338-2343. [PMID: 33583655 DOI: 10.1016/j.pec.2021.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 01/22/2021] [Accepted: 02/03/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Trust is crucial to the success of any personal or professional relationship. Literature on trust in the surgeon-patient relationship has been largely explored through quantitative methodologies, primarily examining why trust may or may not exist. We aimed to qualitatively elucidate the mechanisms of how trust develops between otolaryngologists and their patients. METHODS Patients were recruited by surgery scheduling staff following an outpatient visit where a decision had been made to proceed with surgery at a tertiary academic medical center. We used qualitative realist thematic analysis of phone interviews to explore participants' (n = 17) perceptions and conceptualization of trust formation within the surgeon-patient relationship. RESULTS Thematic analysis revealed three themes regarding trust formation in the surgeon-patient relationship: 1) Trust Across Various Contexts; 2) Impact of Prior Knowledge; and 3) Interpersonal Connection during the Clinical Encounter. CONCLUSION An interpersonal surgeon-patient connection is crucial to the formation of trust. Trust is also influenced by surgeon and institutional reputation and witnessed surgeon interactions with the healthcare team. PRACTICE IMPLICATIONS Patients perceive trust in a surgeon as carrying unique importance. To optimize conditions for trust development in this context, surgical care paradigms should promote meaningful preoperative interpersonal surgeon-patient relationships and positive surgeon and institutional reputations.
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Affiliation(s)
- Norman D Hogikyan
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA; Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI, 48109, USA.
| | - Lulia A Kana
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA
| | - Andrew G Shuman
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA; Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI, 48109, USA
| | - Janice I Firn
- University of Michigan Medical School, 1301 Catherine St., Ann Arbor, MI, 48109, USA; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI, 48109, USA; Department of Learning Health Sciences, University of Michigan Medical School, 1111 E. Catherine St. Ann Arbor, MI, 48109, USA
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Caruso Brown AE. The Last Bastion of Paternalism? A Reflection on Proceduralism, Power, and Privilege. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021322173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mohan C, Sonntag E, Ehlers M, Akerman J, Hayon S, Figler B, Coward RM. Challenging Ethical Scenarios in the Surgical Treatment of Erectile Dysfunction: A Survey of High-Volume Penile Prosthesis Surgeons. Urology 2020; 148:166-172. [PMID: 33285211 DOI: 10.1016/j.urology.2020.10.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate how surgeons approach ethically challenging scenarios that arise in penile prosthesis surgery and identify patient-related factors that impact their approach. METHODS A survey was distributed to the Society for Urologic Prosthetic Surgeons membership consisting of 6 ethically challenging scenarios: an HIV+ patient, a patient with cognitive disability, a registered sex offender, a nonverbal patient, a litigious patient, and an uncontrolled diabetic patient whose insurance will lapse soon. Additional clinical information was provided to assess how the likelihood to offer surgery might change. The primary outcome was the likelihood of offering surgery in each scenario. RESULTS The response rate was 15.6% (n = 29). When compared to the baseline patient, respondents had a lower likelihood of offering surgery in all scenarios except the HIV+ patient, with the lowest likelihood of offering surgery to a sex offender (P < .01). Within each scenario, factors associated with an increased odds of offering surgery included knowledge that a patient with Down Syndrome is high functioning (odds ratio [OR] 5.0, confidence interval [CI]: 1.4-17.8), that a prior sex offender is currently married (OR 16.5, CI:3.5-99.8), that a litigious patient sued a surgeon for a retained sponge (OR 6.3, CI:1.7-24.3), and that a nonverbal patient had expressed prior interest in penile prosthesis surgery (OR 4.5, CI: 1.3-16.2). CONCLUSION Ethical principles, including respect for autonomy, nonmaleficence, beneficence, and justice, are appropriately applied by urological prosthetic surgeons when ethical challenges arise. While the likelihood of offering penile prosthesis surgery is decreased with most ethical dilemmas, specific clinical factors often augment decision-making.
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Affiliation(s)
- Charan Mohan
- The Smith Institute for Urology, New Hyde Park, NY
| | - Elizabeth Sonntag
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark Ehlers
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Jason Akerman
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Solomon Hayon
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Brad Figler
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - R Matthew Coward
- Department of Urology, University of North Carolina, Chapel Hill, NC; UNC Fertility, Raleigh, NC.
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Cardenas D. Surgical ethics: a framework for surgeons, patients, and society. Rev Col Bras Cir 2020; 47:e20202519. [DOI: 10.1590/0100-6991e-20202519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/01/2020] [Indexed: 11/22/2022] Open
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DiRisio AC, Muskens IS, Cote DJ, Babu M, Gormley WB, Smith TR, Moojen WA, Broekman ML. Oversight and Ethical Regulation of Conflicts of Interest in Neurosurgery in the United States. Neurosurgery 2019; 84:305-312. [PMID: 29850841 DOI: 10.1093/neuros/nyy227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 05/02/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Developmental incentives are fundamental to surgical progress, yet financial and professional incentives inherently create conflicts of interest (COI). Understanding how to manage COI held by neurosurgeons, industry, hospitals, and journal editors, without thwarting progress and innovation is critical. OBJECTIVE To present an overview of COI associated with innovation in neurosurgery, and review ways to manage these in an ethically sound manner. METHODS A review of the literature was performed to assess conflicts of interest that affect neurosurgical innovation, and review ways to manage COI of various parties while adhering to ethical standards. RESULTS COI are inherent to collaboration and innovation, and are therefore an unavoidable component of neurosurgery. The lack of a clear distinction between clinical practice and innovation, ability to use devices off-label, and unstandardized disclosure requirements create inconsistencies in the way that conflicts of interest are handled. Additionally, lack of requirements to compare innovation to the standard of care and inherent bias that affects study design and interpretation can have profound effects on the medical literature. Conflicts of interest can have both direct and downstream effects on neurosurgical practice, and it is possible to manage them while improving the quality of research and innovation. CONCLUSION Conflicts of interest are inherent to surgical innovation, and can be handled in an ethically sound manner. Neurosurgeons, device companies, hospitals, and medical journals can take steps to proactively confront bias and ensure patient autonomy and safety. These steps can preserve public trust and ultimately improve evidence-based neurosurgical practice.
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Affiliation(s)
- Aislyn C DiRisio
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ivo S Muskens
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands
| | - David J Cote
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maya Babu
- Department of Neuro-surgery, Mayo Clinic, Rochester, Minnesota
| | - William B Gormley
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wouter A Moojen
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands.,Department of Neuro-surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marike L Broekman
- Computational Neurosciences Out-comes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
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Ethical Issues Encountered During the Medical Student Surgical Clerkship. J Surg Res 2019; 244:272-277. [PMID: 31302325 DOI: 10.1016/j.jss.2019.06.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Data regarding ethical issues encountered by medical students during the surgical clerkship are sparse. Identification of such issues facilitates development of an ethics curriculum that ensures student preparation for issues most frequently encountered on the surgical rotation. To better understand these issues, we performed content analysis of reflections written by medical students about ethical issues encountered during their surgical clerkship. MATERIALS AND METHODS All medical students on the surgical clerkship at a university hospital from 4/2017 to 6/2018 submitted a written reflection regarding an ethical issue encountered during the clerkship. Two investigators performed content analysis of each reflection. References to ethical principles (beneficence, nonmaleficence, justice, autonomy) were tabulated. Ethical issues were classified into main categories and subcategories, based on a modified version of a previously published taxonomy. RESULTS 134 reflections underwent content analysis. Nonmaleficence was the most frequently mentioned ethical principle. 411 specific ethical issues were identified. Ethical issues were distributed across ten main categories: decision-making (28%), communication among health care team members (14%), justice (12%), communication between providers, patients, and families (9%), issues in the operating room (9%), informed consent (9%), professionalism (5%), supervision/student-specific issues (5%), documentation (1%), and miscellaneous/other (8%). We identified two ethical issues infrequently discussed in previous reports: delivery of efficient yet high-quality care and poor communication between services/consultants. CONCLUSIONS Students encounter diverse ethical issues during their surgical clerkships. Ethical and contextual considerations related to these issues should be incorporated into a preclinical/clinical surgical ethics curriculum to prepare students to understand and engage the challenges they face during the clerkship.
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Wancata LM, Hinshaw DB. Rethinking autonomy: decision making between patient and surgeon in advanced illnesses. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:77. [PMID: 27004224 DOI: 10.3978/j.issn.2305-5839.2016.01.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon's autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons' autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients' outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient's and surgeon's autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient's goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time.
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Affiliation(s)
- Lauren M Wancata
- 1 Department of Surgery, University of Michigan, Ann Arbor, MI, USA ; 2 Department of Internal Medicine, Hospice and Palliative Medicine, University of Michigan Geriatrics Center, Ann Arbor, MI, USA ; 3 Palliative Care Program, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Daniel B Hinshaw
- 1 Department of Surgery, University of Michigan, Ann Arbor, MI, USA ; 2 Department of Internal Medicine, Hospice and Palliative Medicine, University of Michigan Geriatrics Center, Ann Arbor, MI, USA ; 3 Palliative Care Program, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
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Nanda A, Murray R. Neurosurgeons as Healers. Neurosurgery 2015; 62 Suppl 1:129-32. [DOI: 10.1227/neu.0000000000000820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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The ethics of "primo non nocere", professional responsibility and shared decision making in high-stakes neurosurgery. Acta Neurochir (Wien) 2015; 157:807-9. [PMID: 25749842 DOI: 10.1007/s00701-015-2384-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
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