Surgeons as Mirrors of Common Life
Author: Harold Y. Vanderpool, PhD, ThM
Tex Heart Inst J. 2009; 36(5): 449–450.
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Surgeons in their operating theaters are a world removed from the lives of ordinary citizens. Away from the streets and buildings of urban and rural life, they perform operations in settings that are foreign and off-limits to the vast majority of citizens. This, however, should not mask the ways in which the values and ethics of surgery reflect the common values and ethical principles upon which societies rest. Viewing surgeons as mirrors of common life leads to an expanded understanding of the ethics of surgery, a straightforward description of “standard” surgical ethics, and the identification of a major dimension of surgical practice that has received virtually no ethical attention.
How a Values Analysis Expands Our Understanding of the Ethics of Surgery
A values analysis consists of understanding how all the dimensions and practices of human culture reflect various types of values and value judgments. Persons commonly, but falsely, assume that assertions and judgments about values are ethical assertions and judgments.1
While value judgments involve assertions that things and actions are good or bad, right or wrong, or something in between—and thus appear to pertain to ethics—many types of value judgments have little or nothing to do with ethics. Consider, for example:
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Practical or prudential value judgments: “That's the best medical device for this procedure.”
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Epistemic or educational value judgments: “You think you know too much.”
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And, as a subset within the universe of human values and valuing, there are ethical values and judgments: “Honesty is imperative.” Or, “First, do no harm.”
This analysis relates directly to the ethics of surgery. Surgical practice reflects all the above types of values. This gives us a beginning point for exploring the many ways that nonmoral values can undermine surgeons' moral duties to patients, medical trainees, and research subjects.
At the present time, economic values are the only category of values widely recognized as possibly interfering with surgeons' moral duties. The American Association for Thoracic Surgery and the Society of Thoracic Surgeons recently promulgated ethical standards whereby society members “must prescribe drugs, devices, and treatment solely on the basis of medical considerations and patients' preferences,” apart from any and all “direct or indirect financial inducements from industry.” 2
Without diminishing the power of economic conflicts of interest, the expanded analysis advanced here extends the term “conflicts of interest” to include conflicts between the moral values of surgeons and the entire range of human values and valuing—epistemic, aesthetic, practical, and so on.
The import of this analysis is far-reaching and deserves far more exploration.
“Standard” Surgical Ethics
The “standard” approach to surgical ethics regards surgery as a specialized expression of the general ethics of medicine.3 For 40 years, bioethicists have agreed that medical ethics is not some unique version of morality but is aligned with humanity's “common morality.” 4 This demystifies and de-complicates surgical ethics. The ethics of surgery should be regarded as expressions of the same moral truths and principles that hold sway in homes, factories, and farms across the fruited plain.
Like ordinary citizens, surgeons are called upon to display virtues of character (such as courage, honesty, trustworthiness) and to manifest actions predicated on respect for human dignity and autonomy, and on other fundamental moral principles. Putting these virtues and principles into action includes responsible and thorough-going harm–benefit analysis before surgery, truth-telling in diagnosis and in reporting the results of treatment, and upholding the implicit moral promises of the fiduciary relationship, whereby surgeons put patients' interests before self-interests.
Reliance upon these principles must not rest upon “gut” responses, but upon well-thought-out reflection and reasoning.3 Among the numerous special issues that continue to arise are justifications of surgical procedures near the end of life and the handling of surgical errors.
An Unexplored Dimension of Surgical Practice
This inquiry that takes its ethical cues from common life alerts us to a dynamic, but ethically neglected, dimension of life that surgeons share with notable groups of their fellow citizens: rescuing persons from the jaws of death.5 Like firefighters, police, and military personnel, many surgeons rescue persons from sudden life-and-death crises, personally experience the ordeals of those whom they rescue, and assume measures of responsibility for the aftermaths that follow.
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Invasions into regions of the human body where no one but a rescue surgeon would dare to go;
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Patients' surrender of self-awareness in the hope of being rescued and made whole; and
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A wide range of emotions among patients, from fear to profound gratitude.
This topic raises a host of questions. Should surgical education include a component that highlights the sequelae of rescue surgery for both patient and doctor? For the well-being of the patients who are rescued—and possibly for the surgeons—should postoperative communication between the 2 parties be further explored and defined? Should the postoperative schedule include a time for family members to query and possibly express their profound gratitude to the surgeon?
In regard to the 2nd and 3rd of these questions, it may be that what surgeons do postoperatively with patients and family members does not constitute a medical duty or a moral imperative. The presence of surgeons postoperatively may involve what ethicists call “acts of supererogation”—levels of beneficence that are admirable, noble, and profoundly ethical, but not morally mandated.
Surgeons are challenged to explore whether the dynamics of rescue surgery do or do not give rise to moral obligations.
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