Surgery is rich with bioethical considerations because it is a universally dramatic and intrusive field. Stripped of everything from personal belongings to consciousness itself, even the thickest-skinned person becomes vulnerable on the way to the operating table. In the ensuing hours, while the patient is under anesthesia, both the miraculous and the tragic hang in the balance. The surgeon carefully resects diseased tissue, after which they suture the healthy tissue’s bleeding edges back together. This cycle of destruction and reconstruction repeats itself until finally the blade is removed and the skin is sealed. The patient awakens to a body that has been irreversibly altered, for better or worse. It is literally a life-altering experience.
In this light, the operating room (OR) is far from sterile. It has tremendous potential to become the frontier for novel and creative ethical developments, including possible failings. Aware of these dangers, the American College of Surgeons issued its “Statement of Principles Underlying Perioperative Responsibility” in 1996, then an updated version in 2016. This document outlines topics such as informed consent, disclosure of therapeutic options and errors, conflicts of interest, and follow-up care1. While the document explicitly warns to, “[b]e sensitive and respectful of patients, understanding their vulnerability during the perioperative period,” there is a paucity of other literature that deals with matters taking place inside the OR. Partly this is due to the macabre subject matter. Although people readily discuss clinical issues, such as informed consent and admitting errors, they are more squeamish about evaluating the minutiae of surgical ethics. The media also skews and limits the public perception of the OR—the surgeon with his or her imperturbable gaze, constantly performing heroic, brilliant maneuvers as blood pools from invisible or unreachable sources. This simplified portrayal often stands in the way of understanding just how behaviorally complex and dynamic the OR can be.
Moreover, the OR is an autonomous and private space. It requires strict access privileges to enter. The only non-staff person in the room, the patient, is often under anesthesia. To protect the patient’s right to health privacy, no photo, video, or narration of the case may leave the room. And even if these were to be released, the layperson lacks the specialized knowledge to understand them. Lastly, and perhaps most importantly, instructors teach and students accept the rituals and routines of surgery at face value without scrutiny or reformulation. Even some of the more invasive or distasteful aspects of surgery may be justified as being necessary for success.
Why do we need a strong perioperative code-of-ethics? Of course, as with any field in medicine, it is in the interest of improving patient care. But what is unique about surgery is that it is procedure-driven, and no procedure is inherently ethical or unethical. Rather, the true value of a procedure relies entirely on what meaning or purpose caregivers ascribe to it. It can be elevated into a healing art or transformed into a tool of humiliation, of harm. One need not look far back in history to find examples. In the weeks prior to starting my rotations in cardiac surgery as a fourth-year medical student, I stood at the entrance of the Auschwitz Memorial as a fellow with the Fellowship at Auschwitz for the Study of Professional Ethics (FASPE). We learned about how doctors and other professionals were shielded from outside interference. We walked along the train tracks that are the symbol of deportation of over a million Jews, but also Poles, Roma and Sinti, prisoners of war, the handicapped or homosexuals, and others. Here, they were subjected to countless dehumanizing procedures, some of which, though they originated outside the camps for use in medical treatments, were used by the Nazis as tools of genocide.
Of course, there are significant differences between the actions in Auschwitz and those that take place in a contemporary operating room. I do not mean to suggest an equivalency between the two. Most clearly, the goal of surgery is to cure, not kill. Still, the historical example of the Holocaust spurs us to think about how procedures undertaken without an ethical framework can cause harm. Modern surgery relies on the ethical ideal that surgeons “do no harm,” but that is
Surgery is rich with bioethical considerations because it is a universally dramatic and intrusive field. Stripped of everything from personal belongings to consciousness itself, even the thickest-skinned person becomes vulnerable on the way to the operating table. In the ensuing hours, while the patient is under anesthesia, both the miraculous and the tragic hang in the balance. The surgeon carefully resects diseased tissue, after which they suture the healthy tissue’s bleeding edges back together. This cycle of destruction and reconstruction repeats itself until finally the blade is removed and the skin is sealed. The patient awakens to a body that has been irreversibly altered, for better or worse. It is literally a life-altering experience.
In this light, the operating room (OR) is far from sterile. It has tremendous potential to become the frontier for novel and creative ethical developments, including possible failings. Aware of these dangers, the American College of Surgeons issued its “Statement of Principles Underlying Perioperative Responsibility” in 1996, then an updated version in 2016. This document outlines topics such as informed consent, disclosure of therapeutic options and errors, conflicts of interest, and follow-up care1. While the document explicitly warns to, “[b]e sensitive and respectful of patients, understanding their vulnerability during the perioperative period,” there is a paucity of other literature that deals with matters taking place inside the OR. Partly this is due to the macabre subject matter. Although people readily discuss clinical issues, such as informed consent and admitting errors, they are more squeamish about evaluating the minutiae of surgical ethics. The media also skews and limits the public perception of the OR—the surgeon with his or her imperturbable gaze, constantly performing heroic, brilliant maneuvers as blood pools from invisible or unreachable sources. This simplified portrayal often stands in the way of understanding just how behaviorally complex and dynamic the OR can be.
Moreover, the OR is an autonomous and private space. It requires strict access privileges to enter. The only non-staff person in the room, the patient, is often under anesthesia. To protect the patient’s right to health privacy, no photo, video, or narration of the case may leave the room. And even if these were to be released, the layperson lacks the specialized knowledge to understand them. Lastly, and perhaps most importantly, instructors teach and students accept the rituals and routines of surgery at face value without scrutiny or reformulation. Even some of the more invasive or distasteful aspects of surgery may be justified as being necessary for success.
Why do we need a strong perioperative code-of-ethics? Of course, as with any field in medicine, it is in the interest of improving patient care. But what is unique about surgery is that it is procedure-driven, and no procedure is inherently ethical or unethical. Rather, the true value of a procedure relies entirely on what meaning or purpose caregivers ascribe to it. It can be elevated into a healing art or transformed into a tool of humiliation, of harm. One need not look far back in history to find examples. In the weeks prior to starting my rotations in cardiac surgery as a fourth-year medical student, I stood at the entrance of the Auschwitz Memorial as a fellow with the Fellowship at Auschwitz for the Study of Professional Ethics (FASPE). We learned about how doctors and other professionals were shielded from outside interference. We walked along the train tracks that are the symbol of deportation of over a million Jews, but also Poles, Roma and Sinti, prisoners of war, the handicapped or homosexuals, and others. Here, they were subjected to countless dehumanizing procedures, some of which, though they originated outside the camps for use in medical treatments, were used by the Nazis as tools of genocide.
Of course, there are significant differences between the actions in Auschwitz and those that take place in a contemporary operating room. I do not mean to suggest an equivalency between the two. Most clearly, the goal of surgery is to cure, not kill. Still, the historical example of the Holocaust spurs us to think about how procedures undertaken without an ethical framework can cause harm. Modern surgery relies on the ethical ideal that surgeons “do no harm,” but that is