An increasing number of HIV-infected patients require surgical care. Many surgeons, regardless of their venue of practice, would prefer not to treat HIV-infected patients.1 The reasons for this attitude differ from individual to individual but include the fear of contracting an incurable fatal illness, a desire to avoid interaction with homosexuals and intravenous drug users, and fears that occupationally acquired HIV infection would result in restriction of clinical privileges and loss of income.2,3 At the same time, many individuals, (...) institutions, and professional organizations have affirmed the obligation of all healthcare workers, including surgeons, to care for patients without regard to their HIV status.4-6 This article explores the nature of this obligation from the perspective of a clinical surgeon working in an inner city hospital. (shrink)

Ten nurses at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The main theme in the narratives was being close to and moved by the suffering of patients and relatives. The nurses' responsibility for patients and relatives was expressed as a commitment to act, and they needed to ask (...) themselves whether their responsibility had been fulfilled, that nothing had been left undone, overlooked or neglected, before they could leave the unit. When there was confirmation by the patients, relatives, colleagues and themselves that the needs of patients and relatives had been attended to in a morally and professionally satisfying manner, this increased the nurses' confidence and satisfaction in their work, and their strength to live with the burden of being in ethically difficult situations. (shrink)

Although the field of surgical ethics focuses primarily on informed consent, surgical decision‐making, and research ethics, some surgeons have started to consider ethical questions regarding justice and solidarity with poor and minoritized populations. To date, those calling for social justice in surgical care have emphasized increased diversity within the ranks of the surgical profession. This article, in contrast, foregrounds the agency of those most affected by injustice by bringing to bear an ethic of accompaniment. The (...) ethic of accompaniment is born from a theological tradition that has motivated work to improve health outcomes in those at the margins through its emphasis on listening, solidarity against systemic drivers of disease, and proximity to individuals and communities. Through a review of surgical ethics and exploration of a central patient case, we argue for applying an ethic of accompaniment to the care of surgical patients and their communities. (shrink)

Informed consent in medical practice is essential and a global standard that should be sought at all the times doctors interact with patients. Its intensity would vary depending on the invasiveness and risks associated with the anticipated treatment. To our knowledge there has not been any systematic review of consent practices to document best practices and identify areas that need improvement in our setting. The objective of the study was to evaluate the informed consent practices of surgeons at University teaching (...) Hospitals in a low resource setting. (shrink)

Physicians, registered nurses (RNs) and enrolled nurses (ENs) engaged in geriatric (n = 49) and surgical (n = 59) care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs (n = 40) gave 78, the RNs (n = 38) 55 and the physicians (n = 30) 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were (...) female; there were no differences in gender in the form and content of the moral reasoning disclosed in either morally difficult care episodes or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

The purpose of this study was to determine the opinions and expectations of patients and nurses about privacy during a hospital admission for surgery. The study explored what enables and maintains privacy from the perspective of Turkish surgical patients and nurses. The study included 102 adult patients having surgery and 47 nurses caring for them. Data were collected via semistructured questionnaire by face-to-face interviews. The results showed that patients were mostly satisfied by the respect shown to their privacy by (...) the nurses but were less confident of the confidentiality of their personal data. It was found that patients have expectations regarding nursing approaches and attitudes about acknowledging and respecting patient autonomy and confidentiality. It is remarkable that while nurses focused on the physical dimension of privacy, patients focused on informational and psychosocial dimensions of privacy, as well as its physical dimension. (shrink)

Background and aim: Surgical intensive care nurses should have ethical sensitivity allowing them to identify ethical issues in order that they can recognize them and make the right decisions. This descriptive study was conducted with the aim of evaluating the ethical sensitivity of surgical intensive care nurses. Materials and methods: The research was carried out with the participation of 160 nurses in six Turkish hospitals, four state, one university, and one private. The data were collected using (...) the “Nurse Description Form” developed by the researcher and the “Ethical Sensitivity Questionnaire.” The percent, mean, standard deviation, median, minimum and maximum values, significance test for the difference between two means, variance analysis, Mann–Whitney U test, and Kruskal–Wallis Variance Analysis test were used to evaluate the data. Ethical considerations: Ethical commission permission and the corporate permission of the hospitals were received before conducting the research. Results: It was determined that the ethical sensitivities of surgical intensive care nurses were moderate based on the Ethical Sensitivity Questionnaire total score and subdimension score averages. A statistical difference was determined between the Ethical Sensitivity Questionnaire total score of surgical intensive care nurses and the institution where they worked, the period of working in the occupation, and the period of working in the intensive care unit (p < 0.05). Conclusion: Based on the results of the research, the organization of training and studies devoted to the elimination of ethical sensitivity differences between institutions and workers is suggested. (shrink)

The ideal moral standard for surgical informed‐consent calls upon surgeons to carry out a disclosure dialogue with patients so they have as full as possible an understanding of the procedure before they sign the informed‐consent form. This study is the first to empirically explore patient preferences regarding disclosure dialogue. Twelve Israelis who underwent life‐saving surgeries participated in a narrative study. Three themes emerged from the analysis: objectification of patients, anxiety provoking processes and information, and lack of information that was (...) essential for patients. Findings contribute to existing debates among surgeons regarding the scope and importance of some disclosure components. Analysis led to our formulation of an augmented subjective model of information disclosure that participants prefer, which extends beyond the immediate present of the surgery to the period after discharge, and until return to routine. Surgeons should be aware of patient preferences in disclosure, and gaps between perceptions of surgeons, and preferences and needs of patients. (shrink)

Background: It is stated that high ethical sensitivity positively affects the quality of nursing care. However, the relationship between nursing care quality and ethical sensitivity has not been clearly demonstrated in researches. Aim: This study was carried out to determine the relationship between surgical nurses’ care behaviors and their ethical sensitivity. Method: The sample of this cross-sectional, descriptive-correlational study consists of 308 nurses who worked at the surgical departments in four Turkish hospitals. The data were (...) collected using the “Nurse Description Form” developed by the researcher, “Caring Behaviours Inventory-24” and “Ethical Sensitivity Questionnaire.” Data were evaluated by the Mann Whitney U test, Kruskal Wallis one-way analysis of variance and Spearman correlation analysis. Ethical considerations: The study was approved by the ethics committee. Verbal and written consent was received from the nurses. Results: It was found in the study that nurses’ Caring Behaviours Inventory-24 total score median was 5.25 (4.83–5.58), nurses’ perception level of caring quality was high, median of Ethical Sensitivity Questionnaire total score was 89.00 (75.00–101.00) and nurses’ ethical sensitivity was moderate. A negative significant relation was found between nurses’ Caring Behaviours Inventory-24 total score and Ethical Sensitivity Questionnaire total score (r = -0.162; p = 0.009). A negative relation was also detected between nurses’ working period at the current clinic and providing benefit (r = -0.147; p = 0.012), holistic approach (r = -0.139; p = 0.018) and orientation (r = -0.175; p = 0.003) scores of Ethical Sensitivity Questionnaire sub-scales. Conclusion: Nurses’ perception levels of caring quality were high and their ethical sensitivity levels were moderate. It was found out that nurses’ ethical sensitivity increased together with their perception of caring quality, and as their working period at the current clinic increased, the ethical sensitivity also increased in terms of the sub-scales of providing benefit, holistic approach, and orientation. The factors that adversely affect the quality of nursing care and ethical sensitivity should be examined and attempts should be made to improve the working environment. (shrink)

Background: Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy—a responsibility to support the patient’s best interest; surgeons have a sense of agency—a responsibility to keep the patient alive. Objectives: The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as “advocates” and “agents,” and (2) apply (...) these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Research design: Articles, books, and professional documents were explored to obtain descriptions of nurses’ and surgeons’ responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Findings: Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient’s outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. Discussion: These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other’s responsibilities. Conclusion: Interventions that improve understanding of each profession’s responsibilities may be helpful to reduce intra-team conflict in the intensive care unit. (shrink)

The nature and limits of the physician's professional responsibilities constitute core topics in clinical ethics. These responsibilities originate in the physician's professional role, which was first examined in the modern English-language literature of medical ethics by two eighteenth-century British physician-ethicists, John Gregory and Thomas Percival. The papers in this annual clinical ethics number of the Journal explore the physician's professional responsibilities in the areas of surgical ethics, matters of conscience, and managed care.

Surgical Informed Consent has long been recognized as an important component of modern medicine. The ultimate goals of SIC are to improve clients’ understanding of the intended procedure, increase client satisfaction, maintain trust between clients and health providers, and ultimately minimize litigation issues related to surgical procedures. The purpose of the current study is to assess the comprehensiveness of the SIC process for women undergoing obstetric and gynecologic surgeries. A hospital-based cross-sectional study was undertaken at Hawassa University Comprehensive (...) Specialized Hospital in November and December, 2016. A total of 230 women who underwent obstetric and/or gynecologic surgeries were interviewed immediately after their hospital discharge to assess their experience of the SIC process. Thirteen components of SIC were used based on international recommendations, including the Royal College of Surgeon’s standards of informed consent practices for surgical procedures. Descriptive summaries are presented in tables and figures. Forty percent of respondents were aged between 25 and 29 years. Nearly a quarter had no formal education. More than half of respondents had undergone an emergency surgical procedure. Only 18.4% of respondents reported that the surgeon performing the operation had offered SIC, while 36.6% of respondents could not recall who had offered SIC. All except one respondent provided written consent to undergo a surgical procedure. However, 8.3% of respondents received SIC service while already on the operation table for their procedure. Only 73.9% of respondents were informed about the availability of alternative treatment options. Additionally, a majority of respondents were not informed about the type of anesthesia to be used and related complications. Only 54.2% of respondents reported that they had been offered at least six of the 13 SIC components used by the investigators. There is gap in the provision of comprehensive and standardized pre-operative counseling for obstetric and gynecologic surgeries in the study hospital. This has a detrimental effect on the overall quality of care clients receive, specifically in terms of client expectations and information needs. (shrink)

The practice of surgery requires consideration of a number of specific aspects of clinical medical ethics that are different from those most influential in other areas of medical care. The nature of surgical care alters the sense of responsibility that surgeons feel for their actions and also alters the relationship between surgeons and patients. Because surgical care requires patients to place such great trust in their surgeons, surgical informed consent must emphasize the importance of (...) that trust. Surgeons must use innovative means to solve individual patient problems even if the result is a novel operation. Surgical procedures may be altered due to the unexpected findings in the operating room and therefore surgeons must have considered how to respond in such situations. The future of surgical practice will inevitably lead to increasing ethical concerns in maintaining the ethical dimension of surgery, in allowing autonomy for trainees while maintaining patients’ safety, and in balancing surgical risks of prophylactic surgery with the genetic predisposition to develop cancer. (shrink)

Background: Informed consent involves patients being informed, in detail, of information relating to diagnosis, treatment, care and prognosis that relates to him or her. It also involves the patient explicitly demonstrating an understanding of the information and a decision to accept or decline the intervention. Nurses in particular experience problems regarding informed consent. Research question and design: This descriptive study was designed to determine nurse knowledge and practices regarding their roles and responsibilities for informed consent in Turkey. The research (...) was performed using 92 nurses who work at the surgical clinics. Data collection form was prepared by the researchers with assistance from the literature, and the data were evaluated by the SPSS 12.0 data analysis program. Ethical consideration: This study was approved by the Medicine and Health Sciences Research and Ethics Committee of the university. Written consent was received from the nurses. Findings: Among the nurses who participated in this study, 39.1% indicated that they were responsible for obtaining informed consent. It was also found that 90.2% of the nurses informed patients before providing nursing interventions and 32.6% of the nurses obtained consent from patients, and 90.0% of the nurses who indicated that they obtain patient consent only obtain verbal consent. Among all of the nurses, 21.7% agreed that informed consent needs to be obtained in order to protect the medical staff legally. Discussion: It is argued that a lack of official procedures at hospitals regarding informed consent and insufficient information being provided to healthcare providers has caused problems regarding informed consent. Conclusion: The nurses in this study lacked information regarding their role in obtaining informed consent from patients and they often performed incomplete and/or incorrect practices within the framework of their required role. It is believed that an increased level of education along with the creation of official policies and procedures would contribute towards solving these problems. (shrink)

This is the first textbook of surgical ethics. It is a practical, clinically comprehenive, well-organized guide to ethical issues in surgical practice, research, and education written by leading figures in surgery and bioethics. The authors cover the surgeon-patient relationship, the full range of surgical patients, surgical education and research, and surgery and managed care. Their chapters are not abstract discussions of ethical principles; rather, they connect directly with the everyday concerns of practicing surgeons.

Surgical innovation promises improvements in healthcare, but it also raises ethical issues including risks of harm to patients, conflicts of interest and increased injustice in access to health care. In this article, we focus on risks of injustice, and use a case study of robotic prostatectomy to identify features of surgical innovation that risk introducing or exacerbating injustices. Interpreting justice as encompassing matters of both efficiency and equity, we first examine questions relating to government decisions about whether (...) to publicly fund access to innovative treatments. Here the case of robotic prostatectomy exemplifies the difficulty of accommodating healthcare priorities such as improving the health of marginalized groups. It also illustrates challenges with estimating the likely long-term costs and benefits of a new intervention, the difficulty of comparing outcomes of an innovative treatment to those of established treatments, and the further complexity associated with patient and surgeon preferences. Once the decision has been made to fund a new procedure, separate issues of justice arise at the level of providing care to individual patients. Here, the case of robotic prostatectomy exemplifies how features of surgical innovation, such as surgeon learning curves and the need for an adequate volume of cases at a treatment centre, can exacerbate injustices associated with treatment cost and the logistics of travelling for treatment. Drawing on our analysis, we conclude by making a number of recommendations for the just introduction of surgical innovations. (shrink)

The encounter between a patient and her surgeon is unique for several reasons. The surgeon inflicts pain upon a patient for the patient’s own good. An operative intervention is irreducibly personal, such that the decisions about and performance of operations are inseparable from the idiosyncrasies of the individual surgeon. Furthermore, there is a chasm of knowledge between the patient and surgeon that is difficult to cross. Hence, training in the discipline of surgery includes the inculcation of certain virtues and practices (...) to safeguard against abuses of this relationship and to make sure that the best interests of the patient are prioritized. The stories in this issue are evidence that in contemporary practice this is not quite enough, as surgeons reflect on instances they felt were ethically challenging. Common themes include the difficulty in communicating surgical uncertainty, patient–surgeon relationships, ethical issues in surgical training, and the impact of the technological imperative on caring for dying patients. (shrink)

There seems no good reason for doctors to work in secret. Individual users of healthcare and the community in general, which ultimately bears the cost, are perfectly entitled to know how their health services and health providers are performing. The promulgation of surgical report cards has been hailed by some as a liberating step in the right direction. This paper seeks to analyse, from a clinician’s perspective, the evolution and limitations of report cards. Ultimately, the importance of report cards (...) will not be their immediate utility, which is minimal, but as a first step in a much wider and far more important debate about how we meaningfully measure the quality of health services and providers (including managers and bureaucrats), the likely cost of such an enterprise, how much we are willing and able to pay and how we reconcile the competing needs of information versus clinical and preventive care when all are competing for the same and inadequate pool of resources. (shrink)

OBJECTIVES: This article presents an original definition of surgical innovation and a practical tool for identifying planned innovations. These will support the responsible introduction of surgical innovations. BACKGROUND: Frameworks developed for the safer introduction of surgical innovations rely upon identifying cases of innovation; oversight cannot occur unless innovations are identified. However, there is no consensus among surgeons about which interventions they consider innovative; existing definitions are vague and impractical. METHODS: Using conceptual analysis, this article synthesizes findings from (...) relevant literature, and from qualitative research with surgeons, to develop an original definition of surgical innovation and a tool for prospectively identifying planned surgical innovations. The tool has been developed in light of feedback from health care professionals, surgeons, and policy makers. RESULTS: This definition of innovation distinguishes between variations, introduction of established interventions, and innovations in surgical techniques or use of devices. It can be applied easily and consistently, is sensitive to the key features of innovation, is prospective, and focuses on features relevant to safety and evaluation. The accompanying tool is deliberately broad so that appropriate supports may, if necessary, be provided each time that a surgeon does something "new". CONCLUSIONS: The definition presented in this article overcomes a number of practical challenges. The definition and tool will be of value in supporting responsible surgical innovation, in particular, through the prospective identification of planned innovations. (shrink)

Medicine—and specifically surgery and surgical ethics—have long been part of the history of science. Surgical ethics play a pivotal role in ensuring successful outcomes and maintaining the highest standards of patient care. It includes the ethics of surgeons, the responsibility of surgeons, surgical errors, and the competence of a surgeon. Many works have been written about surgery, including during Iran’s Safavid period (1501 to 1736)—a period in which a surgeon needed to have a set of moral (...) principles in addition to practical surgical skills. One of the most valuable is Dhakhīrıh Kāmılıh, written by military surgeon Hakim Mohammad in the sixteenth and seventeenth centuries. In this work, Ḥakim Muhāmmad dedicates a chapter specifically to the topic of surgical ethics, aiming to provide moral and legal recommendations for surgeons in addition to explaining surgical techniques and methods. Some of these recommendations include improving surgical skills through observation and practical training, paying attention to hygiene to prevent the spread of infection, and giving patients hope for recovery. Dhakhīrıh Kāmılıh is a landmark text in the history of surgical ethics. (shrink)

Surgeons have an ethical obligation to ensure all patients, regardless of their personal characteristics, receive the same quality of care. Established surgeons also have an obligation to ensure equal treatment for their peers and for those who would like to join the field. The commitment to ethical hiring and working standards entails making certain all individuals have the same opportunities free from discriminatory practices. The world of business has long realized the positive implications of having a diverse and inclusive (...) workforce. Studies have shown a positive correlation between increased racial and gender diversity and company performance. Diversity can lead to an increase in knowledge by sharing ideas with individuals who come from different life experiences and breakdown cultural barriers. We have already begun to see the impact of ignoring the importance of diversity within healthcare, including surgery. Healthcare disparities are defined by the NIH as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups.” Healthcare disparities persist despite decades acknowledging their existence, and they are pernicious and prevalent in surgery. One proposed method to help reduce or eliminate healthcare disparities is to increase the diversity of the workforce treating the patients, which would in turn reduce potential bias the patients face in the healthcare setting. Implicit bias can play a key role in interactions with patients and colleagues and needs to be explored on an individual basis. Cultural competence training can also provide surgeons the ability to effectively communicate with not only a diverse population of patients but also a diverse surgical workforce. All surgeons regardless of their role can have a positive impact on diversity as it relates to patient care and the surgical workforce. (shrink)

John McMillan's detailed ethical analysis concerning the use of surgical castration of sex offenders in the Czech Republic and Germany is mainly devoted to considerations of coercion.1 This is not surprising. When castration is offered as an option to offenders and, at the same time, constitutes the only means by which these offenders are likely to be released from prison, it is reasonable—and close to the heart of modern medical ethics—to consider whether the offer involves some kind of coercion. (...) However, despite McMillan's seemingly careful consideration of this question, it appears to us that the matter is more complicated than his approach to it suggests.The first thing that adds to the complexity of the discussion concerns the alternative for sex offenders who do not accept the offer of castration. As mentioned, it is likely that these offenders will be kept in prison. McMillan even underlines that they may be detained ‘indefinitely’. And the response report of the European Committee for the Prevention of Torture and Inhumane or Degrading Treatment or Punishment to the Czech Government also emphasises—as part of the Czech Criminal Code—the possibility of ‘security detention’ that will last for as long as required for ‘the protection of society’.2 Suppose, …. (shrink)

Patients and surgeons participate in shared decision making when they make healthcare decisions together, taking into account the patient’s goals, values, and preferences. Surgical treatment is pursued when the potential benefits outweigh the risks, the burdens of treatment are acceptable, and no other alternatives are more appropriate for meeting the patient’s goals of care. Acute care surgical problems require shared decision making, often with constraining factors that include the time-sensitive and life-threatening nature of acute surgical (...) disease, absence of a patient’s decision-making capacity, and lack of a preexisting relationship between the patient and surgeon. These factors may create ethical challenges for acute care surgeons who care for these patients. (shrink)

Background Quality nursing care and ethical responses to patient pain and suffering are very important in the preoperative period. However, few studies have addressed these variables. Objective This study aimed to examine the relationship between compassionate care and preoperative anxiety from the perspective of hospitalized patients. Methods The current study was a cross-sectional descriptive one. The participants were selected using convenience sampling. The data were collected using a demographic questionnaire, Burnell Compassionate Care Tool, and Amsterdam Preoperative Anxiety (...) and Information Scale (APAIS). The collected data were analyzed with SPSS software (version 22) through descriptive and inferential statistics at a significance level of 0.05 ( p <.05). Participants and setting This study was conducted on 704 candidates for surgery in the internal and surgical wards of a large teaching hospital located in the south of Iran from December 2022 to March 2023. Ethical considerations The protocol for this study was reviewed and approved by the University Ethics Committee. Findings The patients’ average age was 36.61 ± 13.07. The average preoperative anxiety and need for information scores were 13.80 ± 2.66 and 7.44 ± 1.47, respectively. The average score of importance was 3.03 ± 0.19, and the average score of the extent of compassionate care provision was 1.22 ± 0.15. There was a significant relationship between preoperative anxiety with importance and the extent of compassionate care provision (r = 0.68, p <.001), r = −0.72, p <.001, respectively). A comparison of the demographic characteristics, need for information, importance, and provision of compassionate care showed that the extent of compassionate care provision had the greatest contribution in explaining preoperative anxiety (β = 0.50; p <.001). Conclusion Even though patients’ preoperative anxiety was high and providing compassionate care in the preoperative period had a great role in relieving their anxiety, many participants appear to have received little compassionate care. To this end, nursing managers should pay attention to the quality of compassionate care in the preoperative stage. Besides, healthcare staff should receive the necessary training in compassionate nursing care. (shrink)

The management of children born with trisomy 18 is controversial, and both providers and parents often have differing opinions. Many parents choose to terminate the pregnancy while others go forward, making decisions based on their beliefs, understanding, and physician recommendations. Physicians are similarly divided regarding treatment of these children, as some feel that aggressive treatments are futile while others defer to the parents' wishes.Interrupted aortic arch with ventricular septal defect in children with trisomy 18 presents an ethical dilemma that highlights (...) the kinds of controversies in medical decision making facing physicians on a daily basis. Repair of interrupted aortic arch with ventricular septal defect poses a high risk to newborns with or without trisomy 18. Therefore, the option for surgery should be treated as with any routine informed consent process. Parents should be counseled about the risks, benefits, alternatives, and the likelihood of success both short and long term and be should offered a choice between surgery and palliative care. (shrink)

It is obvious that every inventor should be rewarded for the intellectual effort, and at the same time be encouraged to successively improve his or her discovery and to work on subsequent innovations. Patents also ensure that patent owners are officially protected against intellectual piracy, but protection of intellectual property may be difficult to accomplish. Nevertheless, it all comes down to this basic question: Does a contradiction exist between medical ethics and the “Medical and Surgical Procedure Patents” system? It (...) may well turn out that medical-procedure patents can have a negative influence on the standard of medical care. Medical-method patents may also interfere with the physician-patient relationship. At present, physicians do not question the usefulness of patent protection for medicines, biotechnology, equipment and devices, but they strongly oppose it for surgical procedures. (shrink)

Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas (...) in discussions of innovation, that we categorised alliteratively under the themes of “purpose”, “place”, “process”, “product” and “person”. These conceptual areas are used in varying—sometimes contradictory—ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term “innovation” carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term “innovation” from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery. (shrink)

Background Informed consent is a process in which a healthcare provider obtains permission from an individual prior to surgery. Patient satisfaction with the informed consent process is one of the main indicators of healthcare service quality. This study aimed to assess patient satisfaction with surgical informed consent at Jimma Medical Center, Ethiopia, in 2020. Methods A facility-based cross-sectional study was conducted from April 1 to June 30, 2020, at Jimma Medical Center. Face-to-face interviews were conducted using structured questionnaires. A (...) systematic sampling technique was used to select the study participants. The collected data were coded, entered into Epi data version 3.1, and analyzed using SPSS version 25. Bivariate and multivariate regression analyses were performed to determine the association between patient satisfaction and socio-demographic and facility-related factors. In multivariate regression, predictors with a P-value of < 0.05 were considered statistically significant. Results Totally 372 study participants were interviewed with a response rate of 97.8%. Nearly two-fifths (43%) of patients were satisfied with surgical informed consent. Living in an urban area (AOR: 2.279, 95% CI 1.257–4.131), having current referred history (AOR: 1.856, 95% CI 1.033–3.337), consent form version (AOR: 2.076, 95% CI 1.143–3.773), time spent on the provision of informed consent (AOR: 5.227, 95% CI 2.499–10.936) and having better patient-health providers relationship (AOR: 5.419, 95% CI 3.103–9.464) predictors were positively associated with patient satisfaction. Conclusion Patient satisfaction with the surgical informed consent process was relatively low. Therefore, Health care professionals need to emphasize a way of delivering informed consent, patients' needs and obey a standard informed consent to improve patient satisfaction. (shrink)

The themes that emerge from these rich narratives by surgeons are familiar ones in the experiences of diverse health care providers. Questions about and difficulties with communication and with informed consent are common and troubling. Uncertainty was also a prevalent theme in these stories, uncertainty about the right thing to do or say and about how to treat the patients and families the surgeons wrote about. Uncertainty is a reality in medicine, and it is often said that medicine is (...) an art, not just a science. Although in medicine it is uncommon to find a situation so black and white that the course of action is obvious, this may be less true in surgery. Surgeons are prototypically confident in their recommendations. Yet, these surgeons poignantly describe uncertainty. Sometimes the uncertainty leads to careful reflection, taking a stand, or changing practice, and sometimes it lead to moral distress. (shrink)

Surgical advances can provide great benefits to patients but can come at a cost. The successes are often matched by failures that cause harm to patients. The risks of surgery create a strong ethical imperative for research to establish the safety and efficacy of new treatments. Surgical research is, however, challenging for a number of reasons including the lack of a clear boundary between variations in practice, innovation and research, its irreversible nature, the difficulty of performing placebo-controlled randomised (...) trials, confounding factors such as surgeon learning curves and conflicts of interest. In this chapter the ethical issues raised by surgical innovation are explored with the use of a case study based on the uptake of vaginal mesh to treat vaginal prolapse to highlight these issues (Sects. 12.1 and 12.2). In Sect. 12.3 the argument for the value of a structured approach to introducing innovations, such as that developed by the IDEAL Collaboration, which clarifies both ethical and methodological issues at each stage of research is proposed. This chapter recognises that ethical challenges extend beyond adequate ethical evaluation of the innovation in the care of individual patients to include broader issues such as justice in access to any new interventions. (shrink)

The practice of surgical trainees operating in developing countries is gaining interest in the medical community. Although there has been little analysis about the ethical impact of these electives, there has been some concerns raised over the possible exploitation of trainees and their patients. An ethical review of this practice shows that care needs to be taken to prevent harm. Inexperienced surgeons learning surgical skills in developing countries engender greater risk of violating basic ethical principles. Advanced (...) class='Hi'>surgical trainees who have already achieved surgical competence are best qualified to satisfy these ethical issues. All training programs need to develop a structured ethical review for international electives to protect their trainees and their patients from harm. (shrink)

The aim of this article was to obtain an understanding of what is experienced as human dignity by nurses in surgical practice. In order to obtain experiences from practice, the critical incident technique was chosen. A total of 11 nurses from surgical practice wrote 49 stories about positive and negative incidents. The text was analysed using hermeneutical text interpretation. The findings revealed patient dignity in terms of preserved dignity, that is, healthcare professionals paid attention to the patient. Nurses (...) experienced preserved dignity when healthcare professionals allowed the patient to tell their story, allowed themselves to get close to the patient and in turn received the patient’s trust. Violated dignity included circumstances when the nurses were forced to see what they did not want to see. Nurses experienced violated dignity when healthcare professionals behaved rudely towards the patient, acted as if he or she was invisible or humiliated the patient at the end of life. (shrink)

Some transgender and nonbinary people undergo phalloplasty and/or metoidioplasty as part of their medical transition process. Across surgical disciplines, a variety of resources are used to assist patients who are preparing for surgeries, including educational materials, workshops, peer support, and lifestyle changes. For gender-affirming surgeries, patients undergoing assessments to discern whether they are ready to undergo the surgery, and to assist them in achieving preparedness when needed. Little research investigates what resources are useful in helping patients to feel prepared (...) to undergo phalloplasty or metoidioplasty, and how assessments and resources can promote patient autonomy in the process. Respect for patient autonomy is one of the central tenets of ethical healthcare, yet historically, scholarship related to pre-surgical assessments for gender-affirming surgery has focused determining the ideal surgical candidate rather than respecting patient autonomy and ascertaining individual patient needs. This study sought to fill this gap by utilizing data from PROGRESS (Patient-Reported Outcomes of Genital Reconstruction and Experiences of Surgical Satisfaction), a cross-sectional, community-based survey of trans and nonbinary adults from the United States of America and Canada who had undergone one or more of these surgeries. Results revealed most participants (86%, n = 186) felt prepared to undergo surgery, though the majority of our sample (53%, n = 105) did not find referral letter assessments to be helpful. Peer support such as online resources/blogs were rated as highly useful, along with surgical consults. In a multivariable logistic regression, higher perceived preparedness was associated with identifying as queer (inclusive of gay, bi and pansexual compared to being straight), and feeling that one’s assessment process was useful (as opposed to not useful). Type of assessment was not significantly associated with preparedness; therefore, what is most useful when preparing for surgery may vary across individuals. Healthcare professionals who interact with preparing patients should develop new or utilize existing resources to assist patients in identifying their preparation needs and achieving preparedness. Our data supports assessments that center surgical care planning rather than assessing level of gender dysphoria. Future longitudinal research could further refine which assessment processes are most effective in helping patients who are preparing for these surgeries. Assessments should ensure that patients are appropriately prepared to undergo and recover from surgery through a robust process of informed consent. (shrink)

The allocation of critical care resources and triaging patients garnered a great deal of attention during the COVID-19 pandemic, but there is a paucity of guidance regarding the ethical aspects of resource allocation and patient prioritization in ‘normal’ circumstances for Canadian healthcare systems. One context where allocation and prioritization decisions are required are surgical waitlists, which have been globally exacerbated due to the COVID-19 pandemic. In this paper, we detail the process used to develop an ethics framework to (...) support prioritization for elective surgery at The Hospital for Sick Children, Toronto, a tertiary pediatric hospital. Our goal was to provide guidance for the more value-laden aspects of prioritization, particularly when clinical urgency alone is insufficient to dictate priority. With this goal in mind, we worked to capture familial, relational, and equity considerations. As part of our institution’s concerted efforts to ethically and effectively address our surgical backlog, an ethics working group was formed comprising clinicians from surgery, anesthesiology, intensive care, a hospital bioethicist, a parent advisor, and an academic bioethics researcher. A reflective equilibrium process was used to develop an ethics framework. To this end, the same methodology was used to create a support for patient prioritization that identifies clinically and morally relevant factors for prioritization among medically similar surgical cases, with a substantive goal being to identify and redress health inequities in surgical prioritization, inasmuch as this is possible. While further steps are needed to validate several aspects of the framework, our research suggests that an ethics framework grounded in the practical realities of hospital operations provides consistency, transparency, and needed support for decisions that are often left to individual clinicians, as well as an opportunity to reflect upon the presence of health inequities in all domains of healthcare delivery. (shrink)

Background: Informed consent goes beyond signing a form; it is a process of providing necessary information, helping patients make an informed decision, and actively participate in their treatment. Aim/objective: This study aimed to assess the quality of obtaining surgical informed consent in hospitals affiliated with Tehran University of Medical Sciences. Research design/participants/context: In a cross-sectional, descriptive-analytical study, 300 patients were chosen through stratified sampling from seven hospitals affiliated with Tehran University of Medical Sciences. Data were collected using a questionnaire (...) developed by the researchers and analyzed using descriptive and analytical statistics on SPSS software. Ethical considerations: Ethical approval of this study was granted by Tehran University of Medical Sciences research ethics committee. Written informed consent for participation was obtained. The participants were reassured that their information will be used anonymously and their answers will not affect their treatment and care. Findings: The mean score of quality of acquisition of informed consent was 17.13 out of 35, indicating that the quality falls in the inappropriate category. The results indicate that 48% of the signatories do not even read the form before signing it. Among the 52% who did read the consent form, 61.3% mentioned varying degrees of incomprehensibility of the consent form and 94.2% mentioned the presence of incomprehensible technical, medical and legal vocabulary. Only 12% and 18% of respondents reported that they were not in hurry and they had no fear or anxiety, respectively, when signing the form. The quality of obtaining informed consent was higher in women, younger patients, patients with higher education, and those who had special surgeries. Discussion: This study shows a poor practice in obtaining surgical informed consent in Iran. It seems necessary to consider fundamental changes in the process of acquiring consent based on the temporal and local conditions of the patients. (shrink)

Surgical patient safety remains a concern worldwide as, despite World Health Organization recommendations and implementation of its Surgical Safety Checklist, adverse events continue to occur. The aim of this qualitative study was to explore the views and experiences of perioperative nurses regarding the factors that impact surgical patient safety. Data were collected through five focus groups involving a total of 50 perioperative nurses recruited from four public hospitals in Spain. Content analysis of the focus groups yielded four (...) main themes: personal qualities of the perioperative nurse, the surgical environment, safety culture, and perioperative nursing care plans. One of the main findings concerned barriers to the exercise of leadership by nurses, especially regarding completion of the Surgical Safety Checklist. Some of the key factors that impacted the ability of perioperative nurses to fulfil their duties and ensure patient safety were the stress associated with working in the operating room, time pressures, and ineffective communication in the multidisciplinary team. Targeting these aspects through training initiatives could contribute to the professional development of perioperative nurses and reduce the incidence of adverse events by enhancing the surgical safety culture. (shrink)

BackgroundAn analysis of the position statements of secular US medical and surgical professional societies on physician-assisted suicide (PAS) and euthanasia have not been published recently. Available statements were evaluated for position, content, and sentiment.MethodsIn order to create a comprehensive list of secular medical and surgical societies, the results of a systematic search using Google were cross-referenced with a list of societies that have a seat on the American Medical Association House of Delegates. Societies with position statements were identified. (...) These statements were divided into 5 categories: opposed to PAS and/or euthanasia, studied neutrality, supportive, acknowledgement without statement, and no statement. Linguistic analysis was performed using RapidMinder in order to determine word frequency and sentiment respective to individual statements. To ensure accuracy, only statements with word counts > 100 were analyzed. A 2-tailed independentttest was used to test for variance among sentiment scores of opposing and studied neutrality statements.ResultsOf 150 societies, only 12 (8%) have position statements on PAS and euthanasia: 11 for PAS (5 opposing and 4 studied neutrality) and 9 for euthanasia (6 opposing and 2 studied neutrality). Although the most popular words used in opposing and studied neutrality statements are similar, notable exceptions exist (suicide,medicine, andtreatmentappear frequently in opposing statements, but not in studied neutrality statements, whereaspsychologists,law, andindividualsappear frequently in studied neutrality statements, but not in opposing statements). Sentiment scores for opposing and studied neutrality statements do not differ (mean, 0.094 vs. 0.104;P = 0.90).ConclusionsFew US medical and surgical societies have position statements on PAS and euthanasia. Among them, opposing and studied neutrality statements share similar linguistic sentiment. Opposing and studied neutrality statements have clear differences, but share recommendations. Both opposing and studied neutrality statements cite potential risks of PAS legalization and suggest that good palliative care might diminish a patient’s desire for PAS. (shrink)

Little is known about health care professionals’ perceptions regarding what it means to treat patients and families with respect and dignity in the intensive care unit (ICU) setting. To address this gap, we conducted nine focus groups with different types of health care professionals (attending physicians, residents/fellows, nurses, social workers, pastoral care, etc.) working in either a medical or surgical ICU within the same academic health system. We identified three major thematic domains, namely, intrapersonal (attitudes (...) and beliefs), interpersonal (behaviors), and system (contextual) factors that influence treatment with respect and dignity. Participants suggested strategies for improving treatment of patients and families in the ICU with respect and dignity, as well as the related need for enhancing respect among the multidisciplinary team of clinicians. Implementing these strategies will require innovative educational interventions and leadership. Future research should focus on the design and evaluation of such interventions on the quality of care. (shrink)

BackgroundThe evaluation of the surgical readiness of patients plays an important role in clinical care. Preoperative readiness assessment is needed to identify the inadequacy among surgical patients, which provides guide for interventions to improve patients’ preoperative readiness. However, there is a paucity of high-level, quality tool that evaluate surgical readiness of patients in China. The purpose of this study is to translate the Preoperative Assessment of Readiness Tool into Chinese and determine the reliability and validity of (...) the Chinese version in the population of surgical patients.MethodsUsing a standard translation-backward method, the original English version of PART was translated into Chinese. A convenient sampling of 210 surgical patients was recruited from 6 hospitals in Zhejiang Province to test the psychometric properties of this scale including internal consistency, split-half reliability, content validity, structure validity, and floor/ceiling effect.ResultsA total of 194 patients completed questionnaires. The Chinese version of PART achieved Cronbach’s alphas 0.948 and McDonald’s omega coefficient 0.947, respectively, for the full scale. The estimated odd-even split-half reliability was 0.959. The scale-level content validity index was 0.867, and the items content validity index ranged from 0.83 to 1.0.The output of confirmatory factor analysis revealed a two-factor model with no floor/ceiling effect.ConclusionThe Chinese version of PART demonstrated acceptable reliability and validity among surgical patients. It can be used to evaluate patients’ preoperative preparation and help health professionals provide proper preoperative support. (shrink)

Background and Purpose: Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system. Participants and methods: A single-centre opinion survey (...) of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013. Ethical considerations: The project was approved by the board of the Lorraine University Diploma in Medical Ethics. Results: Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor’s family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient’s care. But more than 75% of respondents think that the advance patient’s consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France. Conclusion: The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families’ support. But they ask to require previously expressed patient’s consent and family’s approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Care of the terminal patient:Are we on the same page?Lauren WancataIn surgical training a “service” or care team consists of sick patients admitted to the hospital and the medical team caring for the patient. Each service consists of an attending physician, a chief resident, a senior resident and junior residents structured as a hierarchy. The chief was gone for the week. As a senior trainee I (...) would be the acting chief—a role I had assumed many times before this month. To prepare for the week of his absence, I read through each patient’s chart, and the chief and I discussed each patient—diagnosis, procedures, and plans.One was a 41–year–old male with cancer—he was young, but a patient like him was not uncommon at my institution. He originally came in through the emergency department with abdominal pain and difficulty with urination. His admitting medical team started the work–up for his symptoms—blood tests, a CAT scan, and consults to other physician services with specialized knowledge. He eventually underwent endoscopy with biopsies of his stomach and placement of stents into his ureter and kidney for his urinary issues. With return of the biopsies, he had a diagnosis—cancer. He required additional procedures, including the placement of stents into his bile ducts, as they, like his ureter, had become affected by the cancer. The next step was staging the cancer to determine his treatment options. Our surgical service was consulted for a diagnostic laparoscopy with washing—we would take a look inside his abdomen with a camera and obtain a fluid sample to be sent to the pathologist for review, the standard of care for this type of cancer. When the camera was placed nodules were seen—a sample of the nodules and the fluid were sent to a pathologist and determined to be positive for cancer: metastatic disease, stage IV. A special feeding tube was placed into his small intestine to aid in nutritional support, as he had already lost a significant amount of weight, and improving his nutrition would be imperative for any further treatments. Following this operation, oversight of his day–to–day care was taken on by our surgical service, and he had been under our care for a period of time before I rotated onto the service for the month.What was the plan for his care in the hospital, and what was his–long–term plan? His cancer could not be surgically removed due to the extent of its spread within his body. He had recently undergone another CAT scan due to an elevation in his white blood cell count (this elevation was a sign of possible infection) and a thoracentesis, a procedure to remove some of the fluid that was collecting around his lungs. Nephrologists (kidney specialist) had been consulted due to his declining kidney function. Throughout the days, his tube feeds, his source of nutrition, would often be turned off due to bloating and feeling full.Each morning, I rounded with our team, and we would see how he was doing. We would discuss how his night went, and make a plan for the day. He was a man of few words, but his wife was always at his bedside, to support him, listen to updates and keep tract of his progress. She had worked at the hospital and had seen a wide range of patients. She would ask about his kidney function, his tube feeds, and his labs. But, she never asked about his prognosis. I would leave his room each day with the unnerving feeling that the patient, family members and care team were not on the same page. Yes, we all wanted him to get better and to leave the hospital. [End Page 28] But, was he really going to get better? What defined better? Did the patient and his family really know the extent of his disease and his prognosis?Towards the end of my week as chief, I started to ask if they had any other questions. It had been a few weeks since his operation. Was there anything that they wanted to discuss or ask me about? At the... (shrink)

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly’. Indeed, we describe how the current clinical guidance on prioritisation (...) issued by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context. (shrink)

Training of resident physicians is essential for the care of future patients. While surgical trainee involvement is necessary, its disclosure to patients can often be omitted or underplayed by surgeons. The informed consent process and the underlying ethical principles make evident that patients should be informed of trainee involvement. In this review we explore the importance of disclosure, current themes in practice, and the optimal discussion for which we should strive.