Ethics in surgery

AI and Ethics: A Systematic Review of the Ethical Considerations of Large Language Model Use in Surgery Research

INTRODUCTION

As large language models receive greater attention in medical research, the investigation of ethical considerations is warranted. This review aims to explore surgery literature to identify ethical concerns surrounding these artificial intelligence models and evaluate how autonomy, beneficence, nonmaleficence, and justice are represented within these ethical discussions to provide insights in order to guide further research and practice.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Five electronic databases were searched in October 2023. Eligible studies included surgery-related articles that focused on large language models and contained adequate ethical discussion. Study details, including specialty and ethical concerns, were collected.

RESULTS

The literature search yielded 1179 articles, with 53 meeting the inclusion criteria. Plastic surgery, orthopedic surgery, and neurosurgery were the most represented surgical specialties. Autonomy was the most explicitly cited ethical principle. The most frequently discussed ethical concern was accuracy (n = 45, 84.9%), followed by bias, patient confidentiality, and responsibility.

CONCLUSION

The ethical implications of using large language models in surgery are complex and evolving. The integration of these models into surgery necessitates continuous ethical discourse to ensure responsible and ethical use, balancing technological advancement with human dignity and safety.

Surgeon Perspectives on Daily Presentation of Ethical Dilemmas: A Qualitative Study

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.

Operating Ethically: A Review of Surgical Ethics in Pakistan and Recommendations for the Way Forward

Medical ethics underpin the moral framework that delineates the professional relationship between physicians and their patients and thereby is an integral part of making patient-centric healthcare decisions. The concept of ethics is deeply embedded in the field of surgery as surgeons confront a myriad of dilemmas as a part of their routine, whether it be in a preoperative or postoperative environment. The current review aims to describe the state of surgical ethics in Pakistan, with the intent of encouraging dialogues about the ethical considerations relevant to the field surgery that will identify actionable areas for improvement. While most surgeons are aware of the traditional principles of ethics and their practice, their surgical and clinical decisions may fall short of these standards because of time constraints and prevailing cultural and religious beliefs and taboos. The rigorous application of ethical principles in areas of patient-related communication, such as consenting, trainee education, palliative and end-of-life care, and surgical innovation and research, will have significant implications for patients, surgeons, and society. Our review has identified the lack of formal bioethics education and insufficient oversight and ethical regulations to be at the core of inadequate ethical practices in Pakistan and has highlighted actionable areas to be addressed in the future.

Unreasonable Expectations: A Call for Training and Educational Transparency in Gender-affirming Surgery

Although in most areas of practice, there is a reasonable expectation that doctors are sufficiently trained to offer care, this is not true in the case of gender-affirming procedures, which are not required learning in any surgical residency. At the current time, the field of gender surgery is too rapidly evolving, with available resources too scarce for fellowship or residency training to be a realistic requirement for offering these procedures, as the demand already outstrips the available workforce. However, patients are currently given too little information about surgeons' history with these procedures to provide truly informed consent. There is, as such, an ethical mandate to mold the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care.

Risk factors for difficult thyroidectomy and postoperative morbidity do not match: retrospective study from an endocrine surgery academic referral centre

Hyperthyroidism, goiter and thyroiditis have been associated with complex thyroidectomy. Difficult thyroidectomies may implicate longer operating times and higher complication rates, while literature on quantification and prediction of difficulty in thyroidectomy is scant. We aim at assessing the impact of preoperative and intraoperative factors on the technical difficulty of total thyroidectomy (TT) and on the incidence of postoperative complications. We conducted a retrospective study on 197 TT from 343 thyroidectomies performed with intraoperative neuromonitoring between October 2019 and June 2022 (excluding lobectomies, nodal dissection, extra-thyroidal procedures). Operating time (surrogate of TT difficulty), postoperative hypocalcaemia, recurrent laryngeal nerve palsy and postoperative bleeding were assessed in relation to pre- and intraoperative characteristics. Vocal fold palsy(VFP) was defined as recovering < 12 months postoperatively. There were 87 thyroid cancers and 110 multinodular goiters (21 hyperfunctioning, 51 mediastinal). Median operating time was 136 min (range 51-310). Within 17.4 months overall median follow-up we recorded two transient VFPs and 12% symptomatic transient hypocalcaemia. At univariable analysis male sex (p = 0.005), BMI (p < 0.001), thyroiditis (p < 0.05), hypervascular goiter (p = 0.003) and thyroid adhesions to surrounding anatomical structures (p < 0.001) were associated with longer operating time. At multivariable analysis male male sex (p = 0.01), obesity (p = 0.001) and thyroid adhesions (p = 0.008) were factors for prolonged operating time. Above-normal anti-thyroid peroxidase antibodies correlated to transient symptomatic hypocalcemia (p < 0.001). Risk factors for complex TT were identified and did not correlate with morbidity rates. Results from this study may help optimizing operating room schedule and inform case selection criteria for training programs in thyroid surgery. Further research is required to confirm these findings.

Ethical considerations in pediatric solid organ transplantation

Solid organ transplantation is now an accepted therapeutic modality for children and teenagers suffering from a wide variety of complex medical conditions. Unfortunately, patients continue to die while on the organ waiting list as there remains an imbalance between the number of recipients listed for transplantation and the number of donors available. The organ allocation process continues to generate ethical questions and debates. In this publication, we discuss some of the most frequently reported ethical matters in the field of pediatric solid organ transplantation.

Challenging Ethical Scenarios in the Surgical Treatment of Erectile Dysfunction: A Survey of High-Volume Penile Prosthesis Surgeons

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.

Practical Bioethics for the Humanitarian Surgeon: The Development, Implementation and Assessment of an Ethics Curriculum for Residents Participating in Humanitarian Missions

BACKGROUND

Humanitarian surgeons face many ethical challenges. Despite increasing resident participation during humanitarian activities, minimal literature exists describing premission ethics training.

METHODS

A systematic literature review was conducted to identify publications on humanitarian surgery. A 3-tiered review was performed assessing for ethical conflicts and guidelines. A Humanitarian Ethics Curriculum (HEC) was developed based on these findings and administered to residents prior to a humanitarian mission. Postmission essays were assigned to describe an ethical dilemma they encountered. The HEC's value was evaluated by identifying the ACGME core competencies represented in the essays.

RESULTS

49 eligible publications were identified. Several areas of consensus were found. Controversies identified included: trainee involvement, surgical innovation, and operating on patients with dismal prognosis. All residents stated that the HEC was vital. 61% of ethical dilemmas involved surgical patients. Core competencies emphasized included systems-based practice, patient care, professionalism, interpersonal/communication skills, and medical knowledge.

CONCLUSIONS

There is consensus regarding ethical principles that surgeons should follow during humanitarian activities. However, areas of controversy persist. Premission HEC should be administered to residents participating in humanitarian missions.

Ethical considerations in the use of Pernkopf's Atlas of Anatomy: A surgical case study

The use of Eduard Pernkopf's anatomic atlas presents ethical challenges for modern surgery concerning the use of data resulting from abusive scientific work. In the 1980s and 1990s, historic investigations revealed that Pernkopf was an active National Socialist (Nazi) functionary at the University of Vienna and that among the bodies depicted in the atlas were those of Nazi victims. Since then, discussions persist concerning the ethicality of the continued use of the atlas, because some surgeons still rely on information from this anatomic resource for procedural planning. The ethical implications relevant to the use of this atlas in the care of surgical patients have not been discussed in detail. Based on a recapitulation of the main arguments from the historic controversy surrounding the use of Pernkopf's atlas, this study presents an actual patient case to illustrate some of the ethical considerations relevant to the decision of whether to use the atlas in surgery. This investigation aims to provide a historic and ethical framework for questions concerning the use of the Pernkopf atlas in the management of anatomically complex and difficult surgical cases, with special attention to implications for medical ethics drawn from Jewish law.

Ethical aspects of a video-assisted thoracoscopic surgery practice

Thoracic surgery is a field encompassing many diverse operative techniques ranging from open surgeries involving thoracotomies and sternotomies to less invasive operations such as video-assisted thoracoscopic surgery (VATS), endoscopy, and bronchoscopy. The popularity and acceptance of VATS has been increasing over time. Ethical considerations must be used to navigate patient misconceptions of VATS surgery, creating an appropriate informed consent process, determining appropriate patients for VATS, training future thoracic surgeons in VATS, and advancing thoracic surgery innovation. Thoracic surgeons are the gateway to determine what operation and what technique is appropriate to offer to each patient. This requires strict adherence to ethical standards as well as self-regulation.

Morbidity and mortality after emergency lower extremity embolectomy

OBJECTIVE

Emergency lower extremity embolectomy is a common vascular surgical procedure that has poorly defined outcomes. Our goal was to define the perioperative morbidity for emergency embolectomy and develop a risk prediction model for perioperative mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried to identify patients undergoing emergency unilateral and lower extremity embolectomy. Patients with previous critical limb ischemia, bilateral embolectomy, nonemergency indication, and those undergoing concurrent bypass were excluded. Patient characteristics and postoperative morbidity and mortality were analyzed. Multivariate analysis for predictors of mortality was performed, and from this, a risk prediction model was developed to identify preoperative predictors of mortality.

RESULTS

There were 1749 patients (47.9% male) who met the inclusion criteria. The average age was 68.2 ± 14.8 years. Iliofemoral-popliteal embolectomy was performed in 1231 patients (70.4%), popliteal-tibioperoneal embolectomy in 303 (17.3%), and at both levels in 215 (12.3%). Fasciotomies were performed concurrently with embolectomy in 308 patients (17.6%). The 30-day postoperative mortality was 13.9%. Postoperative complications included myocardial infarction or cardiac arrest (4.7%), pulmonary complications (16.0%), and wound complications (8.2%). The rate of return to the operating room ≤30 days was 25.7%. Hospital length of stay was 9.8 ± 11.5 days, and the 30-day readmission rate was 16.3%. A perioperative mortality risk prediction model based on factors identified in multivariate analysis included age >70 years, male gender, functional dependence, history of chronic obstructive pulmonary disease, congestive heart failure, recent myocardial infarction/angina, chronic renal insufficiency, and steroid use. The model showed good discrimination (C = 0.769; 95% confidence interval, 0733-0.806) and calibrated well.

CONCLUSIONS

Emergency lower extremity embolectomy has high morbidity, mortality, and resource utilization. These data provide a benchmark for this complex patient population and may assist in risk stratifying patients, allowing for improved informed consent and goals of care at the time of presentation.

Prevention of chronic post-surgical pain: the importance of early identification of risk factors

Chronic post-surgical pain (CPSP) is currently an inevitable surgical complication. Despite the advances in surgical techniques and the development of new modalities for pain management, CPSP can affect 15-60% of all surgical patients. The development of chronic pain represents a burden to both the patient and to the community. In order to have a meaningful impact on this debilitating condition it is essential to identify those at risk. Early identification of patients at risk will help to reduce the percentage of patients who go on to develop CPSP. Unfortunately, evidence about any effective actions to reduce this condition is limited. This review will focus on providing context to the challenging problem of CPSP. The possible role of both the surgeon and anesthesiologist in reducing the incidence of this problem will be explored.

Identifying predictors of a difficult thyroidectomy

BACKGROUND

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

METHODS

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis.

RESULTS

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT.

CONCLUSIONS

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.