Excessive prescribing of pain medications after surgery has contributed to the epidemic of opioid misuse and diversion in the United States. Pain specialists may be particularly well situated to address these issues. We describe an attempt to reverse the trend at an orthopedic surgical hospital by implementing a peri-operative assessment and treatment service which minimizes preoperative opioid use, when necessary implements addiction treatment, and encourages early tapering from opioids.

Historians have found it difficult to give a general account of the early medical use of X‐rays in medicine. While the rays were hailed by some as a miracle technology, their early medical application was patchy, often remaining subsidiary to traditional methods of diagnosis and treatment, and was of disputed value. In this essay, I argue that the selective appropriation of the new technology needs to be understood within the wider medical practice of the period. The argument is developed around (...) the case of orthopedic surgery in Germany, probably the first example in which doctors quickly made X‐rays indispensable as a medical tool. I show that value of X‐rays in this case was contingent upon an ongoing dispute, the theory and practice of surgical intervention, and the sociology of new surgical knowledge. (shrink)

Ransomware attacks on healthcare systems are becoming more prevalent globally. In May 2021, Waikato District Health Board in New Zealand was devastated by a major attack that crippled its information technology system. The Department of Orthopaedic Surgery faced a number of challenges to the way they delivered care including, patient assessment and investigations, the deferral of elective surgery, and communication and patient confidentiality. These issues are explored through the lens of the four key principles of medical ethics in (...) the hope that they will provide some guidance to future departments who may experience such attacks. (shrink)

Background Hip fracture repair surgery carries a certain mortality risk, yet evidence suggests that orthopedic surgeons often refrain from discussing this issue with patients prior to surgery. Aim This study aims to examine whether orthopedic surgeons raise the issue of one-year post-surgery mortality before hip fracture repair surgery and to explore factors influencing this decision. Method The study employs a cross-sectional design, administering validated digital questionnaires to 150 orthopedic surgeons. Results A minority of (...) orthopedic surgeons reported always informing patients about the risk of mortality in the year following hip fracture surgery. The main reasons for not discussing this risk were a desire to avoid frightening patients, time constraints, and concerns about undermining patient hope. Orthopedic surgeons reported a medium-high level of perceived self-efficacy, with higher self-efficacy associated with a reduced likelihood of discussing one-year mortality risk. Conversely, older age and holding a specialist status in orthopedic surgery were associated with an increased likelihood of discussing this risk with patients. Conclusions These findings suggest a need for interventions to address communication barriers and ensure consistent provision of essential information to patients undergoing hip fracture surgery. Additionally, they highlight the importance of considering individual factors such as self-efficacy, age, and expertise in designing strategies to improve patient-provider communication in orthopedic care settings. Trial registration : The study doesn`t report the results of a health care intervention. (shrink)

Advances in veterinary orthopaedics are assessed on their ability to improve the function and wellbeing of animal patients. And yet historically veterinarians have struggled to bridge the divide between an animal's physicality and its interior experience of its function in clinical settings. For much of the twentieth century, most practitioners were agnostic to the possibility of animal mentation and its implications for suffering. This attitude has changed as veterinarians adapted to technological innovations and the emergence of a clientele who claimed (...) to understand and relate to the subjective experiences of their animals. While visualising technologies and human analogies have shaped the nuts and bolts of veterinary orthopaedic practices, an emerging awareness of the inability of radiographic images to apprehend or correlate to a patient's experience of their function reliably has required veterinarians to place a greater emphasis on the owner's knowledge of the "selves" inhabiting their animals. Rather than simply basing clinical judgments on the "look" of their patients, the indeterminacy in the connection between form and function has compelled veterinarians to put questions regarding particular human-animal relationships near the centre of their practices, not least in orthopaedic surgery. (shrink)

Dynamic stability of the knee and weakness of the extensor muscles are considered to be the most important functional limitations after anterior cruciate ligament injury, probably due to changes at the central level of motor control rather than at the peripheral level. Despite general technological advances, fewer contraindicative surgical procedures, and extensive postoperative rehabilitation, up to 65% of patients fail to return to their preinjury level of sports, and only half were able to return to competitive sport. Later, it becomes (...) clear that current rehabilitation after knee surgery is not sufficient to address the functional limitations after ACL reconstruction even years after surgery. Therefore, new therapeutic tools targeting the central neural system, i.e., the higher centers of motor control, should be investigated and integrated into current rehabilitation practice. To improve motor performance when overt movement cannot be fully performed, several techniques have been developed to increase physical and mental activation without the need to perform overt movements. Among the most popular cognitive techniques used to increase physical performance are motor imagery and action observation practices. This review, which examines the available evidence, presents the underlying mechanisms of the efficacy of cognitive interventions and provides guidelines for their use at home. (shrink)

Developments in biomedical science continue to transform our understanding of concepts such as health and disease. The creation of this expertise has also had a substantive role in changing the veterinary approach to animal diseases. Traditionally, companion animal veterinarians modelled their practices on developments in the diagnosis and treatment of human patients. As science and technology have realigned the boundaries between normalcy, intra-species variation and pathology in particular domains of expertise such as orthopaedic surgery, these patterns of knowledge translation (...) have changed. Not so long ago, treatments for the rupture of the cruciate ligament in human and canine patients were based on pathoanatomical comparison and designed to reestablish the stability of the joint by the functional restoration of ligament anatomy. Recently, a radically different characterization of the canine injury—with a corresponding alternative intervention—has been proposed within the field of veterinary orthopaedics. It views the normal anatomy of the canine knee as being in some way inherently pathogenic and proposes the surgical creation of an idealized structure as a remedy to dysfunction and disease. The veterinary focus on an ideal of patient performance, rather than a specific pathology, is now influencing how orthopaedists choose to approach analogous human injuries. In this article, I chart the history of canine ‘cruciate disease’ therapies as a means to map some of the epistemic assumptions, interplays of idealized and analogical reasoning and patterns of knowledge translation central to the biomedicalization of the science and practice of orthopaedic surgery. (shrink)

Russia did not participate in the bourgeois revolution, the revolution occurred in Russia after the Tsar absolute doctrine, dictatorship, terrorism, superstition and personal police state. Stalinist Marxism beyond recognition, damaged Marx's own image. Impoverishment of the proletariat of Marx and Engels theory, crisis theory has been declared invalid, the Marxist dialectics is still valid is that the theory of contradiction. Contradictions of capitalism can be accurately understood as the general alienation, self-alienation. Inherited estate will determine the natural rights of free (...) face of communism. Straight orthopedic surgery is the most urgent task of socialism, and humane socialism contains the highest human rights as straight. Marxism is not is not a utopia, but a concrete utopia. Russia did not join in the bourgeois revolution, and there appeared absolutely Tsarism, autarchy, terror, individual superstition and police country after its revolution. Stalinism made the Marxism distorted beyond recognition and destroyed the figures of Marx himself. The theory of Proletarian poverty and the theory of crisis of Marx and Engles' were declared invalid, while its dialectic, that is Contradiction, is still valid. The contradiction of Capital can be understood precisely as Total-alienation and Self-alienation. Inheriting natural rights will decide the freedom face of Communism. Orthopaedic surgery of upright way is the most urgent mission of Socialism, and human Socialism contains the upright way as the highest human rights. Marxism is not non-Utopia, but concrete Utopia. (shrink)

Obtaining adequate informed consent from trauma patients is challenging and time-consuming. Healthcare providers must communicate complicated medical information to enable patients to make informed decisions. This study aimed to explore the challenges of obtaining valid consent and methods of improving the quality of the informed consent process for surgical procedures in trauma patients. We conducted a systematic review of relevant English-language full-text original articles retrieved from PubMed that had experimental or observational study design and involved adult trauma patients. Studies involving (...) informed consent in clinical or research trials were excluded. Titles and abstracts of searched articles were reviewed and relevant data were extracted with a structured form. Results were synthesized with a narrative approach. A total of 2044 articles were identified in the initial search. Only eight studies were included in the review for narrative synthesis. Six studies involved orthopedic surgeries, one involved nasal bone surgeries, and one involved trauma-related limb debridement. Only one study was conducted in an emergency department. Information recall was poor for trauma patients. Risk recall and comprehension were greater when written or video information was provided than when information was provided only verbally. Patient satisfaction was also greater when both written and verbal information were provided than when verbal information alone was provided; patients who received video information were more satisfied than patients who received written or verbal information. Many articles have been published on the subject of informed consent, but very few of these have focused on trauma patients. More empirical evidence is needed to support the success of informed consent for trauma patients in the emergency department, especially within the necessarily very limited time frame. To improve the informed consent process for trauma patients, developing a structured and standardized informed consent process may be necessary and achievable; its effectiveness would require evaluation. Adequately educating and training healthcare providers to deliver structured, comprehensive information to trauma patients is crucial. Institutions should give top priority to ensuring patient-centered health care and improved quality of care for trauma patients. (shrink)

This article considers aspects of a development aid that provides medical support to strengthen pediatric orthopedics in Rwanda. We present part of the Afriquia foundation work, a nonprofit foundation from Poland involved in supporting the medical sector in Rwanda as a sign of global solidarity and the human right to health. The main foundation's activity is the treatment of orthopedic problems among Rwandan citizens. We present a case study of two children under the care of the Afiquia foundation. 11‐year‐old (...) Seraphine treated due to the consequences of right tibia osteomyelitis and 11‐year‐old Lavi suffering from osteogenesis imperfecta. Both children were treated surgically in Poland due to Rwanda's lack of treatment possibilities. After the applied treatment, Seraphine walks correctly without crutches and can attend school and thrive among her peers. Lavi has not sustained any fragility fracture since the surgery in Poland. He is healthy and constantly ongoing his rehabilitation including gait training. The described cases initiated development aid in Rwanda, supplying hospitals with orthopedic implants and training medical staff. The growing number of humanitarian crises across the globe and the people affected requires increasing organizations involved in providing relief. The emphasis should be on global education, aiming to make the recipients reflect and prepare them to face humanitarian crises. (shrink)

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to his face (...) and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and “get in his way,” causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper-extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Experiences of an Obese PatientChristine R. BrassIn the middle of an annual pelvic exam, the gynecologist said to me, “You should apply to be on ‘The Biggest Loser.’” I was too stunned and embarrassed to mutter anything more than a [End Page 88] comment that I didn’t think that, being quite introverted, I was a good candidate for a reality TV show. She argued with me about that. I (...) felt blindsided, intensely vulnerable, and dumbstruck—completely unable to respond—and later, when the shock wore off, incandescent with impotent rage.Four years later, I still don’t have words to adequately describe my outrage at this comment. It was only the second time I’d see this medical professional. The first time was the previous year, when she had been filling in for my regular doctor who was on maternity leave. At neither appointment did this physician ask me any questions about my lifestyle, whether or not I saw a primary care physician, or even if I had any concerns that day. She was very brisk, efficient and did not engage in conversation. Such a statement coming from a health care provider, who did not seek to understand or gather more information, surprised and dismayed me.Other incidents where physicians’ statements were not helpful:• Pediatrician: “Well, my wife has had great success with Weight Watchers.”—I was age 12, about 5’5 and weighted about 145 lbs. at that time. If you look at photos of me at the time, you would see I was not overweight.• Orthopedic Surgeon: “If you want her to look better, make her lose weight.”—This was directed to my mother. I was 19, weighed about 200 lbs., and in his office as per his directions to come back in seven years to see if the surgery he had done on my neck needed more attention.• Internist: “How did you get all those stretch marks?”—I was age 24, weighed approximately 220 lbs., and had lost and gained 50 or so pounds several times as a teenager and in college.• Gynecologist: “Lose weight and your periods will be regular.”—I was age 27, weighed 227 lbs. and my periods, which started at age 15, had never been regular.• Another Orthopedic Surgeon: “You don’t have to worry about osteoporosis; everything you do is a weight–bearing exercise.”—I was age 42 and weighed 300 lbs. This was after follow up surgery to remove pins from a broken ankle that had healed and I had asked about whether or not I should have a bone density test.Coming from a genetic heritage of predominately tall, large–boned people, I was tall and proportionally large compared to other girls my age until high school, when the others caught up. I was told I had to “watch my weight” by family members from my pre–teen years. Enforced dieting ensued, with little result because I wasn’t fat. I did not begin to be overweight until my junior and senior years of high school. I was 5’7” when I graduated from high school and weighed 187. By the time I graduated from college, I was no taller but 50 lbs. heavier. Now, nearing my 40th high school reunion, I am 120 lbs heavier than that. During the intervening years, I have done Weight Watchers®, TOPS®, medically–supervised programs (group and individual), and other popular diets, with periodic but temporary success, and hypnosis and aversion therapy, with no success at all.Over the years, I have been insulted, verbally abused, even bullied, because of my weight. I have been treated as though I am invisible, worthless, and stupid—a pariah. As a result, I have felt invisible, worthless, and stupid, even though I know I am none of those things. I have experienced and been treated for clinical depression. The descent into depression began in my late teen years, which was the time when I started gaining excess weight.In 2004, under medical supervision, I lost 70 lbs. over four–month period. I was delighted to finally lose a substantial amount of weight and feel physical lighter. My diabetes medications were significantly reduced, and... (shrink)

Fundamento. La historia de la Neurocirugía en el territorio está estrechamente relacionada con la de otras especialidades como la Cirugía General y la Ortopedia. Tiene sus primeras referencias establecidas en la etapa colonial en el Hospital General, documentadas en el Boletín del Colegio Médico de Camagüey. Objetivo es resaltar la importancia que tuvieron el Hospital General y el Colegio Médico de Camagüey con su boletín en la historia de la Neurocirugía y la Ortopedia. Método. Es una investigación histórica que se (...) basa en la revisión documental y utiliza el submétodo cronológico para establecer el orden de los hechos que se describen. Desarrollo. El Hospital General a partir de su reconstrucción a finales del siglo XIX, se convirtió en el principal centro médico quirúrgico de la provincia en la época colonial. Muchos de los resultados de la actividad asistencial y científica de sus médicos apareció publicada en el Boletín del Colegio Médico de Camagüey, prestigiosa revista científica que se encargó de divulgar los resultados de la medicina camagüeyana y donde aparecen artículos que evidencian cómo cirujanos generales realizaron las primeras intervenciones neuroquirúrgicas y ortopédicas. Conclusiones. Se consideran al Hospital General y al Colegio Médico de Camagüey y su boletín, como elementos indispensables al escribir la historiografía de la Neurocirugía y la Ortopedia en el territorio. Ground: the history of Neurosurgery in this place is closely linked to other specialties like General Surgery and Orthopedics. The first documented references went back to the colonial period in the General Hospital, documented in the bulletin of the medical college in Camagüey. The objective is to highlight the importance of the General Hospital and the medical college and its bulletin in the history of Neurosurgery and Orthopedics in Camagüey. Methods: This a historical investigation that was carried out taking documented revision and using chronologic sub method to establish the order of the facts that have been described. Development: Since the reconstruction of the General hospital at the end of the XIX century, it became the main medical_ surgical center in the province during the colonial period. Many of the scientific results and medical activities were published in the bulletin of the medical college, which became a well-known scientific magazine that was in charge of publishing the medical success in Camagüey. There are articles to prove that general surgeons performed the first neurosurgical and orthopedic interventions. Conclusions: The General hospital, the medical college and its bulletin are considered crucial elements to describe the history of Neurosurgery and Orthopedics in the territory. (shrink)

More than one single professional group deals with therapeutic manipulations of the spine and the joints. Osteopaths, Chiropractors, Naprapaths, Physical Therapists (and a contingent Physicians) all share this interest. Each profession is also very clear about where its bulk of knowledge stems from. The disciplines that are reckoned as the oldest are from the USA. A number of “inventors” are to be found, all without a formal university degree in Medicine. Andrew Taylor Still (1828–1917) came up with his system of (...) Osteopathy in 1874. Daniel D. Palmer (1845–1913), the man behind Chiropractic, founded his system in 1894, and Palmer’s colleague and former student, Oakley Smith (1880–1967), developed Naprapathy in 1906/1907. Physical Therapists working with what is called Orthopaedic Manual Physical Therapy are on the other hand not claiming American ancestry, nor do their body of knowledge and clinical skills originate from outside the medical profession. It is an offspring of Orthopaedic Medicine (OM) which was an invention by Physicians. Date and place of birth is said to be 1929 in England. This article turns the above-mentioned chronology on its head. It will show that Orthopaedic Medicine likely is the oldest system. It will also unearth OM’s sturdy roots in a strong but forgotten, and even hidden, discourse of Mechanical Medicine found in 19th century Europe, which was ruled by Physical Therapists. Why “we” do not know about this “history” is analysed and explained from a variety of perspectives. (shrink)

This study elucidates the nursing of undernourished patients as experienced by eight registered clinical nurses and five nursing assistants by using content analysis. The participants' narratives describe the inner perspective of caring for undernourished patients, known in Sweden as `the thin ones'. Categories identified were: frustration in nursing, joy in nursing and that undernourishment is taboo. The taboo was narrated as feelings of guilt and shame. Frustration in nursing could be seen as feeling stressed, exposed, lonely, powerless, helpless, and being (...) torn between demands and needs. Joy in nursing was experienced when creating a trusting relationship, promoting pleasure in the meal situation and working with respect for each individual's life-style and context of life. Understanding staff members' views is important when implementing guidelines as well as in the teaching situation in order to identify where staff stand with regard to knowledge and attitudes. (shrink)

1894 erwarb das Germanische Nationalmuseum in Nürnberg ein Instrument, welches einem Beinharnisch ähnlich sieht. Über seitliche Gewinde konnten damit steife Beine gebeugt oder gestreckt werden. Dem Ätzdekor nach zu urteilen stammt es aus der Kunstkammer Kurfürst Augusts von Sachsen (1526–1586). Ein Vergleich mit zeitgenössischen Beinharnischen legt nahe, dass die Beinschiene bereits ursprünglich als orthopädisches Instrument hergestellt wurde. Sie komplettierte die Sammlung chirurgischer Instrumente des sächsischen Regenten in Dresden. Vermutlich war der Plattenharnisch in vielen Eigenschaften eine technologische Bedingung für derartige Orthesen (...) und Prothesen. (shrink)

_Background:_ Weight-related stigma is reported frequently by higher body-weight patients in healthcare settings. Bariatric surgery triggers profound weight loss. This weight loss may therefore alleviate patients' experiences of weight-related stigma within healthcare settings. In non-clinical settings, weight-related stigma is associated with weight-inducing eating patterns. Dietary adherence is a major challenge after bariatric surgery. _Objectives:_ (1) Evaluate the relationship between weight-related stigma and post-surgical dietary adherence; (2) understand if weight loss reduces weight-related stigma, thereby improving post-surgical dietary adherence; and (...) (3) explore provider and patient perspectives on adherence and stigma in healthcare settings. _Design:_ This mixed methods study contrasts survey responses from 300 postoperative bariatric patients with ethnographic data based on interviews with 35 patients and extensive multi-year participant-observation within a clinic setting. The survey measured experiences of weight-related stigma, including from healthcare professionals, on the Interpersonal Sources of Weight Stigma scale and internalized stigma based on the Weight Bias Internalization Scale. Dietary adherence measures included patient self-reports, non-disordered eating patterns reported on the Disordered Eating after Bariatric Surgery scale, and food frequencies. Regression was used to assess the relationships among post-surgical stigma, dietary adherence, and weight loss. Qualitative analyses consisted of thematic analysis. _Results:_ The quantitative data show that internalized stigma and general experiences of weight-related stigma predict worse dietary adherence, even after weight is lost. The qualitative data show patients did not generally recognize this connection, and health professionals explained it as poor patient compliance. _Conclusion:_ Reducing perceptions of weight-related stigma in healthcare settings and weight bias internalization could enhance dietary adherence, regardless of time since patient's weight-loss surgery. (shrink)

Surgical innovation involves practices, such as new devices, technologies, procedures, or applications, which are novel and untested. Although innovative practices are believed to offer an improvement on the standard surgical approach, they may prove to be inefficacious or even dangerous. This article considers how surgeons considering innovation should reason in the conditions of uncertainty that characterize innovative surgery. What attitude to the unknown risks of innovative surgery should they take? The answer to this question involves value judgments about (...) the acceptability of risk taking when satisfactory scientific information is not available. This question has been confronted in legal contexts, where risk aversion in the form of the precautionary principle has become increasingly influential as a regulatory response to innovative technologies that pose uncertain future hazards. This article considers whether it is appropriate to apply a precautionary approach when making decisions about innovative surgery. (shrink)

Innovative surgery raises four kinds of ethical challenges: potential harms to patients; compromised informed consent; unfair allocation of healthcare resources; and conflicts of interest. Lack of adequate data on innovations and lack of regulatory oversight contribute to these ethical challenges. In this paper these issues and the extent to which problems may be resolved by better evidence-gathering and more comprehensive regulation are explored. It is suggested that some ethical issues will be more resistant to resolution than others, owing to (...) special features of both surgery and innovation. (shrink)

The market for cosmetic surgery tourism is growing with an increase in people travelling abroad for cosmetic surgery. While the reasons for seeking cosmetic surgery abroad may vary the most common reason is financial, but does cheaper surgery abroad carry greater risks? We explore the risks of poorly regulated cosmetic surgery to society generally before discussing how harm might be magnified in the context of cosmetic tourism, where the demand for cheaper surgery drives the (...) market and makes surgery accessible for increasing numbers of people. This contributes to the normalisation of surgical enhancement, creating unhealthy cultural pressure to undergo invasive and risky procedures in the name of beauty. In addressing the harms of poorly regulated surgery, a number of organisations purport to provide a register of safe and ethical plastic surgeons, yet this arguably achieves little and in the absence of improved regulation the risks are likely to grow as the global market expands to meet demand. While the evidence suggests that global regulation is needed, the paper concludes that since a global regulatory response is unlikely, more robust domestic regulation may be the best approach. While domestic regulation may increase the drive towards foreign providers it may also have a symbolic effect which will reduce this drive by making people more aware of the dangers of surgery, both to society and individual physical wellbeing. (shrink)

In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with (...) the doctor's ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large. (shrink)

In this article, we explore the relation between bodies and selves evident in the narratives surrounding aesthetic surgery. In much feminist work on aesthetic surgery, such narratives have been discussed in terms of the normalising consequences of the objectifying, homogenising, cosmetic gaze. These discussions stress the ways in which we model our bodies, under the gaze of others, in order to conform to social norms. Such an objectified body is contrasted with the subjective body; the body-for-the-self. In this (...) article, however, we wish to make sense of the narratives surrounding such surgery by invoking the expressive body, which fits on neither side of this binary. We wish to explore how the modification of the body’s anatomical features (physiology) is taken to be a modification of its expressive possibilities, and therefore a modification of possibilities for inter-subjective relations with others. It is such expressive possibilities that, we suggest, underlie decisions to undergo surgical procedures. The possibility of modification of the expressive possibilities of the body, by the modification of its anatomical features, rests on the social imaginaries attached to anatomical features. In the context of such imaginaries, individual decisions to undergo or promote surgery can be both intelligible and potentially empowering. However, the social consequences of such acts are an increasing normalisation of the ‘body under the knife’ and an intolerance of bodily difference. This, we suggest, can only be changed by a re-visioning of bodily imaginaries so that expressive possibilities can be experienced across bodies with a range of physiological features. (shrink)

In 2008 the Human Fertilisation and Embryology Act amendments made deliberately choosing to bring disability into the world, using assisted reproduction, a criminal offence. This paper considers whether the legal prohibition above, should influence other policy areas concerning the welfare of future children such as new possibilities presented by foetal surgery and in utero gene therapy. If we have legal duties to avoid disability in one context should this influence our avoidance of disability in this other context? This paper (...) investigates whether the State might have a stake in wider promotion of practices to reduce the degree of disability in foetuses that will come to exist. Not selecting for disability does not affect the welfare of any future individual, whereas treating in utero abnormalities can optimize the eventual child’s welfare; antenatal interventions stand to improve clinical outcomes and welfare should that specific child be born. I explore why the State may want to intervene in the antenatal setting and to what extent, if at all; the State should implement these technologies. I argue that if the State is justified in intervening to outlaw the choosing to create disabled lives using assisted reproductive techniques, it is also justified in putting pressure on prospective parents to accept therapies in utero to help their child be born less disabled. However, I qualify this with the argument that the State is not justified in using force or the criminal law in this situation during pregnancy. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

Since the late 1980s, intersex adults and activists have critiqued the clinical recommendations defined in the 1950s to treat children born with ‘ambiguous genitalia’ with normalising medicine. While their struggles continue, in particular to halt the practice of genital surgery in early infancy, some European surgeons travel to African countries to transfer standards of care that have become highly controversial in the North, including in the medical community. Simple disapproval of these tours as ‘surgical safaris’ forecloses the possibility of (...) analysing more complex situations in which the so-called transfer of competence involves surgeons who promote ‘less cutting and more talking’. Such is the case – and the interest – of the surgical missions in West Africa in which I conducted recent fieldwork, accompanying a team of paediatric surgeons from a European university hospital collaborating with a renowned international NGO. This article analyses the ways in which a variation of sex development called hypospadias is framed and managed in this context through what I call a surgical script for hypospadias. I examine the conditions of (im-)possibility for Northern surgeons to operationalise, and sometimes revise, this script at the missions (but also closer to home). I discuss what the surgeons do in practice to reflect critically on the normative work of the surgical script for hypospadias as a social script on morphological ideals of sex, gender and reproductive heterosexuality. I consider in what sense genital surgery can be said to (re-)construct ‘normal’-looking genitalia, but also, fundamentally, the very idea of genitalia. (shrink)

Debate continues about the ethics of sham surgery controls. The most powerful argument for sham surgery controls is that rigorous experiments are needed to demonstrate safety and efficacy of surgical procedures. Without such experiments, there is danger of adopting worthless procedures in clinical practice. Opponents of sham surgery controls argue that sham surgery constitutes unacceptable violation of the rights of research subjects. Recent philosophical discussion has used two thought experiments—the transplant case and the trolley problem—to explore (...) the circumstances under which individuals may be harmed to benefit a larger group. The transplant case is felt to exemplify circumstances that forbid harming some to benefit a larger group while the trolley problem exemplifies circumstances that permit harming some to benefit others. I argue that sham surgery controls satisfy criteria derived from the trolley problem and are morally permissible. (shrink)

COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical, practical and medical dilemmas. Adapting to crisis conditions requires a rethink of traditional best practices in surgical management, delving into an area of unknown risk profiles. Key challenging areas include cancelling elective operations, modifying procedures to adapt local services and updating the consenting process. We aim to provide an ethical rationale to support change in practice and guide future decision-making. Using the four principles (...) approach as a structure, Medline was searched for existing ethical frameworks aimed at resolving conflicting moral duties. Where insufficient data were available, best guidance was sought from educational institutions: National Health Service England and The Royal College of Surgeons. Multiple papers presenting high-quality, reasoned, ethical theory and practice guidance were collected. Using this as a basis to assess current practice, multiple requirements were generated to ensure preservation of ethical integrity when making management decisions. Careful consideration of ethical principles must guide production of local guidance ensuring consistent patient selection thus preserving equality as well as quality of clinical services. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. As such, the need for surgery must be sufficiently pressing to proceed with conventional or non-conventional operative management; otherwise, delaying intervention is justified. For delayed operations, it is our duty to quantify the long-term impact on patients’ outcome within the constraints of pandemic management and its long-term outlook. (shrink)

In recent years, bariatric surgery has become an increasingly popular treatment of obesity. The amount of resources spent on this kind of surgery has led to a heated debate among health care professionals and the general public, as each procedure costs at minimum $14,500 and thousands of patients undergo surgery every year. So far, no substantial argument for or against giving this treatment a high priority has, however, been presented. In this article, I argue that regardless which (...) moral perspective we consider—greatest need, utility or personal responsibility—the conclusion is that we should give bariatric surgery a high priority when allocating scarce resources in health care. (shrink)

Sham surgery is a controversial and rarely used component of randomised clinical trials evaluating surgical interventions. The recent use of sham surgery in trials evaluating efficacy of intracerebral fetal tissue grafts in Parkinson’s disease has highlighted the ethical concerns associated with sham surgery controls. Macklin, and Dekkers and Boer argue vigorously against use of sham surgery controls. Macklin presents a broad argument against sham surgery controls while Dekkers and Boer present a narrower argument that sham (...) surgery is unnecessary in the specific setting of fetal tissue engraftment for Parkinson’s disease. I defend sham surgery controls against both these criticisms. Appropriate clinical trial design, sometimes including sham surgery, is needed to ensure that false positive trial results do not occur and endanger public safety. Results of a completed trial of fetal tissue grafting for Parkinson’s disease are used to illustrate the potential benefits of, and problems associated with, sham surgery controls. Sham surgery controls, however, should be employed only when absolutely necessary. I suggest criteria for appropriate use of sham surgery controls. (shrink)

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as aduty to protect,arguing for professional and institutional duties, as distinguished forduties of rescue.A professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of (...) confidentiality. I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted—such that where consent and the technology are in place, routine videoing meets aduty of easy protection. In other words, its use should be standard of care. (shrink)

BackgroundBariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open (...) and transparent decision making process.DiscussionA wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.SummaryPerforming bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents. (shrink)

Surgical clinical trials have seldom used a "sham" or placebo surgical procedure as a control, owing to ethical concerns. Recently, several ethical commentators have argued that sham surgery is either inherently or presumptively unethical. In this article I contend that these arguments are mistaken and that there are no sound ethical reasons for an absolute prohibition of sham surgery in clinical trials. Reflecting on three cases of sham surgery, especially on the recently reported results of a sham-controlled (...) trial of arthroscopic surgery for arthritis of the knee, I present an ethical analysis that focuses on the methodological rationale for use of sham surgery, risk-benefit assessment, and informed consent. (shrink)

Leading feminist scholars have been brought together for the first time in this comprehensive volume to reveal the complexity of feminist engagements with the exponentially growing cosmetic surgery phenomenon. Offering a diversity of theoretical, methodological and political approaches Cosmetic Surgery: A Feminist Primer presents not only the latest, cutting-edge research in this field but a challenging and unique approach to the issue that will be of key interest to researchers across the social sciences and humanities.

The popularity of surgical modifications of race-typical features among Asian women has generated debates on the ethical implications of the practice. Focusing on blepharoplasty as a representative racial surgery, this article frames the ethical discussion by viewing Asian cosmetic surgery as an example of medicalization, which can be interpreted in two forms: treatment versus enhancement. In the treatment form, medicalization occurs by considering cosmetic surgery as remedy for pathologized Asian features; the pathologization usually occurs in reference to (...) western features as the norm. In the enhancement form, medicalization occurs by using medical means to improve physical features to achieve a certain type of beauty or physical appearance. Each type of medicalization raises slightly different ethical concerns. The problem with treatment medicalization lies in the pathologization of Asian features, which is oppressive as it continues to reinforce racial norms of appearance and negative stereotypes. Enhancement medicalization is ethically problematic because cosmetic surgery tends to conflate beauty and health as medical goals of surgery, overemphasizing the value of appearance that can further displace women’s control over their own bodies. I conclude that in both forms of medicalization, cosmetic surgery seems to narrowly frame a complex psychosocial issue involving physical appearance as a matter that can be simply solved through surgical means. (shrink)

As our knowledge of the functional and pharmacological architecture of the nervous system increases, we are getting better at treating cognitive and affective disorders. Along with the ability to modify cognitive and affective systems in disease, we are also learning how to modify these systems in health. “Cosmetic neurology,” the practice of intervening to improve cognition and affect in healthy individuals, raises several ethical concerns. However, its advent seems inevitable. In this paper I examine this claim of inevitability by reviewing (...) the evolution of another medical practice, cosmetic surgery. Cosmetic surgery also enhances healthy people and, despite many critics, it is practiced widely. Can we expect the same of cosmetic neurology? The claim of inevitability poses a challenge for both physicians and bioethicists. How will physicians reconsider their professional role? Will bioethicists influence the shape of cosmetic neurology? But first, how did cosmetic surgery become common? (shrink)

Recently, there has been a shift in attitude among some feminists towards the practice of cosmetic surgery away from that of outright rejection. Kathy Davis, for instance, offers a guarded `defence' of the practice as a strategy that enables women to exercise a degree of control over their lives in circumstances where there are very few other opportunities for self-realization. Others, such as Kathryn Morgan, Anne Balsamo and Orlan, though highly critical of the current practice of cosmetic surgery, (...) go even further than Davis in advocating its redeployment as a tool to subvert the dominant patriarchal ideals of feminine beauty. In this article I critically appraise this `rehabilitation' of cosmetic surgery, arguing, in the case of Davis, that she leaves unchallenged the social structures of inequality responsible for women's dissatisfaction with their bodies. The proposal to use cosmetic surgery as a tool of political critique is equally problematic insofar as it shares with the cosmetic industry its instrumentalization of the body as mere matter, which is almost infinitely transformable, and also effaces the economic inequalities within which such body transformations occur. (shrink)

La historia de la Cirugía Pediátrica cubana está pendiente de ser documentada científicamente. Se estableció como objetivo definir las etapas de desarrollo de la especialidad en Cuba, para lo cual se hizo un análisis histórico y se identificó cuatro períodos fundamentales. Este artículo tiene una significación práctica puesto que permite conocer en qué momento se encuentra la especialidad para modelar el futuro de la misma. The history of Cuban pediatric surgery is pending of being scientifically documented. It was established (...) as an objective to define the stages of the development of the specialty in Cuba. For this purpose a historical analysis was carried out and four main periods were identified. This study has a practical importance because it allows knowing the stage in which the specialty is to model its future. (shrink)

The use of placebo controls in surgical research, or ‘sham surgery’ as it sometimes described, raises a number of ethical issues. Despite such issues, sham surgery is presently being employed, albeit very rarely, in surgical research. In this paper, the ethical implications of such control groups are discussed in the context of research into various conditions, including Parkinson's Disease and arthritis. Conflicting ethical considerations include: i) patients' best interests in relation to the harms and risks involved; ii) the (...) need for more rigorous methods in surgical research, and iii) the question of patient autonomy. Contextual features which may influence the ethical acceptability of a specific sham-controlled surgical trial are discussed. (shrink)

This article identifies a prevalent strand of feminist writing on beauty and aesthetic surgery and explores some of the contradictions and inconsistencies inscribed within it. In particular, we concentrate on three central feminist claims: that living in a misogynist culture produces aesthetic surgery as an issue predominantly concerning women; that pain - both physical and psychic - is a central conceptual frame through which aesthetic surgery should be viewed; and that aesthetic surgery is inherently a normalizing (...) technology. Engaging with these ‘myths’, we explore the tensions uncovered through a historical analysis of the practices of aesthetic surgery as well as the challenges to feminist claims offered by post-feminism. In particular we seek to destabilize the connection in feminist writing between beauty and passivity. We argue that through aesthetic references to denigrated black and working-class bodies, young women may mobilize aesthetic surgeries to reinscribe active sexuality on the feminine body. (shrink)

The question of racial identity in the process and outcome of aesthetic surgery is gaining increasing attention in bioethical discourse. This paper attempts an ethical examination of the racial identity issues involved in aesthetic surgery. Dominant moral values in Western culture are explored in the evaluation of aesthetic surgery. The paper argues that African values are yet to receive the universal attention they arguably deserve especially in the rethinking of values underlying aesthetic surgery as racial transformation. (...) Through a consideration of some moral-aesthetic values in the Yorùbá-African culture, this paper further re-evaluates the ethics of aesthetic surgery. The paper contends against the propagation of aesthetic surgery as a new form of bolstering racial divides and identity in the evolving cosmopolitan age. The position defended in the paper is that some values from Yorùbá-African culture are useful in the consideration of the ethics of aesthetic surgery and more importantly, in avoiding the racial identity bias embedded in aesthetic surgery. The paper concludes that if due consideration is perhaps given to some African moral-aesthetic values in the global aesthetic surgery industry, some of the evolving moral and racial complexities would be better mediated. (shrink)

The lack of access to gender-affirming surgery represents a significant unmet health care need within the transgender community, frequently resulting in depression and self-destructive behavior. While some transgender people may have access to gender reassignment surgery, an overwhelming majority cannot afford facial feminization surgery. The former may be covered as a “medical necessity,” but FFS is considered “cosmetic” and excluded from insurance coverage. This demarcation between “necessity” and “cosmetic” in transgender health care based on specific body parts (...) is in direct opposition to the scientific community’s understanding of gender dysphoria and professional guidelines for transgender health. GRS affects one’s ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one’s quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs. (shrink)