a slim reed to rely on. Using this historical example, this paper aims to describe how procedures that are not guided by an ethical framework are capable of immense harm and offers perioperative considerations that ought to supplement the “ACS Statement of Principles in Surgery.” Specifically, it addresses three fundamental components of modern surgery that have the potential to cause unintended harm: 1) sterile positioning and preparation methods; 2) the development of and reliance on muscle memory; and 3) the use of anesthesia during procedures.
Preparation and Positioning
Most people believe that an operation begins with the first incision. For the surgeon, this may be true. For the patient, however, the automatic and unvaried sequence of events that comprise the operation begins immediately after entering the OR. The patient is first asked to identify himself and the operation that he will be having. Staff then ask him to lie down on the operating table, which marks his final conscious act before being anesthetized, paralyzed, and intubated. Even after having observed this process numerous times, I am still struck by the diverging interpretations of these events by the patient and the OR staff. The patient always perceives this experience as special or unique, because, for the patient, it is. But for the OR staff, it is as routine as sitting down at one’s desk and turning on the computer screen first thing in the morning.
As a medical student on my cardiac-surgery rotation, I began my tasks as soon as the patient was anesthetized. I removed the blankets and the hospital gown from their body. I peeled off their socks. I placed and secured a Foley tube catheter in the urethra to drain the bladder. Then, I used an electric razor to shave the chest, armpits, groins, and legs, occasionally stopping to lift clumps of free hair with a thick roll of silk tape. Once done, I scrubbed the body with sponges soaked in cold, soapy water. I dried off the patient with sterile towels and then placed sterile drapes across him or her from head to toe. At this point, the surgeon would step in to feel for the relevant bony anatomical landmarks and use a marker to outline the points of incision. The process of transforming an awake, speaking patient into a ventilator-dependent, sterile body with ink markings on it takes about an hour on average. All this happens prior to first incision. For most of that hour, the patient is unconscious and uncovered.
In the OR, the sterile field is sacred. The act of removing clothes, shaving, scrubbing, and draping the patient seems ethical, lifesaving in its purpose. In surgery, these are necessary steps to prevent infection, but the actions are not always benign, and this noble context is not something that we can take for granted. Similar acts, although with a completely different purpose, formed a series of initiatory humiliations for newly arrived prisoners at Auschwitz and other concentration camps by the Schutzstaffel (SS), the Nazi paramilitary organization. In their scheme, the act of cleansing the prisoners’ bodies carried darker connotations One of their victims, Marianne F., described the experience of undressing completely in front of the SS prior to entering the shower or “sauna,” having all of her bodily hair shaved, and lastly being tattooed with a number2. Everyone underwent the same process regardless of their age, sex, or desired degree of modesty, rendered equal in the process of becoming nothing. In his book, “Auschwitz: A Doctor’s Eyewitness Account”, Miklos Nyiszli, a prisoner at Auschwitz and himself a doctor who was eventually forced to work with the infamous Dr. Josef Mengele, recalls entering a room labeled “Baths & Disinfection,” where he was undressed, washed, rubbed with noxious chemicals, and tattooed. In a moment of solemn awareness, he writes that “Dr. Miklos Nyiszli had ceased to exist, [and had now become] merely KZ prisoner Number A-8450.”3.
This history reminds us that the acts of removing clothing, washing hair, and labelling the human body cannot only sterilize but also dehumanize. In surgery most of these steps cannot be modified, as they are necessary to prevent infection. However, by consciously acknowledging the patient’s perspective—the deep vulnerability of the experience— surgeons and other OR staff can preserve their patients’ dignity and modesty. Empathy can elevate these acts beyond debasement and toward healing.
“Muscle memory”
By the second week of my cardiac-surgery rotation, certain tasks had become a part of my muscle memory. Movements that were once slow and purposeful became efficient and swift, which one could argue is the general aim of surgical education. But there was also an unintended side effect: the more I performed my tasks from muscle memory, the less mindful I became of the bigger picture, which, in this case, was the patient’s story. On some days, I simply walked into the OR when it was time for me to do my part and, like a technician, left once I had completed my tasks. I shaved and washed bodies without knowing the patients’ names. Through these encounters, I grew increasingly competent and confident in my skill. I could not, however, have explained why an operation was necessary for a particular patient or who the patient was, because I had never met him or her. A procedure had become the mere carrying out of a mechanical process.
Admittedly, it is in the best interests of patients that surgeons hone their technical skills. At times, the surgeon’s performance in a challenging operation may depend on their ability to quiet their own emotional, ethical, or other considerations. However, there is a critical distinction between consciously using muscle memories to serve well-thought-out purposes and mindlessly applying them in any setting. The former is an important attribute of any skilled surgeon. The latter can mark the beginning of a dangerous slippery slope, one which leads physicians to devolve into technicians who do not consider the ethical implications of their work.
Auschwitz offers one of the more extreme examples. Many physicians who worked there developed a tendency to focus compulsively on individual topics or technical aspects (das rein Fachliche or the “the purely technical”), helping them to avoid thinking about the morality of their actions. As the psychiatrist and medical historian Robert Lifton has written, technically talented people who “believed themselves to be experts […] pressed forward and engaged themselves” with the technical aspects of how to best run the crematoria4. They began to question how the gas chambers could accommodate more bodies or kill people at a faster rate. One doctor wanted to figure out how to effectively ignite piles of corpses, remarking, “[y]ou can
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