Ethical and Legal Issues in Modern Surgery

The following sections are included:

• Contents
• Preface
• List of Authors

What might an average patient consider to be the ethical issues in surgery? Does a patient even consider that the surgeon might not behave ethically and if not what does an average patient think are the motivations and principles that a surgeon is governed by?

Since the mid twentieth century, the doctrine of informed consent has become the most important tenet of medical ethics worldwide. This chapter provides a systematic critical overview of the doctrine. By means of a structural-contextual analysis, it shows that there is a gap between what the doctrine appears to do and what it actually does. This gap requires us to reassess its social role, history, and morality.

Maintaining confidentiality and respecting a patient's right to privacy are core duties or obligations of healthcare professionals. Long before modern law, Hippocrates cautioned that whatever one heard in the course of medical practice must “never be spread abroad” [1], the expectation being that doctors would not speak publicly about what they learned privately in attending to their patients. Such a prescription may be found in many cultures throughout the world. Islamic religious teaching and law have also long been protective of patient privacy [2]. Maintaining patient confidentiality is considered the “highest virtue of a Muslim physician” [3]. Buddhism similarly recognizes a patient's right to privacy and confidentiality [4]…

The following sections are included:

• Introduction
• The Distribution of Healthcare Resources
• Ethical Considerations of Resource Allocation
• Legal Aspects of Resource Allocation, with Special Reference to the UK
• Conclusion
• References

The following sections are included:

• Introduction
• Why Do We Need RECs?
• What is the Mechanism for Ethical Review?
• What are the Ethical Factors that RECs Look at?
• What “Tools” Do RECs Use in Considering Ethical Issues?
• Does REC Scrutiny Ensure Ethical Research?
• Conclusions
• Acknowledgements
• References

The following sections are included:

• Introduction
• The Law of Negligence
• Defences
• Cross-Border Jurisdiction
• Medical Malpractice
• References

The following sections are included:

• Introduction
• Learning through Operating
• The European Working Time Directive (EWTD)
• Academic Surgery
• Surgical Training Abroad
• Conclusions
• References

While it may appear on first impression that the practices of medicine and policing have little in common, this perception is wholly deceptive; they are both inextricably linked by a number of professional obligations and responsibilities. These include:

• Both professions are service-oriented — that is they offer a valuable public service.
• They are both first responders in emergencies and other crises.
• Doctors and police officers have to make fast time decisions in challenging and rapidly changing situations.
• Policing and medicine have points of reference towards the satisfaction of fundamental needs in health and justice.
• Practitioners deal with matters and make decisions of significant importance to the welfare of individuals which may have great benefits or cause severe harm.
• Medicine and policing have specialist knowledge and expertise that enables them to fulfil their role in ways that untrained members of the public cannot. Therefore the public seek the services of medicine and policing to intervene and assist them in situations that they have neither the knowledge or expertise to be able to do so for themselves.
• The professions are characterised by a high degree of autonomy and discretion.

The following sections are included:

• Consent for Anaesthesia
• Special Circumstances
• Maternal Fetal Conflicts and the Role of the Anaesthetist
• Anaesthesia for Jehovah's Witness Patients
• Anaesthesia for Patients with “Do Not Attempt Resuscitation” Decisions
• References

The traditional practice of neurosurgery is fraught with questions and issues that have ethical and legal implications, for example, is it appropriate to withdraw life-sustaining treatment from a patient who has sustained a severe irreversible head injury leading to brain death or persistent vegetative state? Who should be the decision-maker for the patient? Should the ventilator be removed from a quadriplegic patient who has sustained a high cervical spinal cord injury, has no chance of significant recovery, and asks to die? Because a central nervous system disease may alter the decision- making capacity of those afflicted, who makes the decision for the incapacitated patient and how? Those issues, often involving neurosurgical patients, were discussed, debated, and written about during the latter part of the twentieth century in the medical ethics literature, by court decisions and by institutional ethics committees. Although still sometimes contentious, those questions are not as unique as they once were and society seems to have come to terms with an approach for most. Because surgery on the nervous system is inherently a risky business, neurosurgeons are frequently the subject of medical-legal action as defendants in medical malpractice actions or as expert witnesses in court opining on standard of care in malpractice litigation. Neurosurgical societies have crafted codes of ethics as guidelines for their members who testify in medical malpractice cases, for example, the American Association of Neurological Surgeons [1] and the World Federation of Neurosurgical Societies together with the European Association of Neurosurgical Societies [2]. Future advances in technology and disease understanding will likely lead to unforeseen treatments for neurological maladies. Lipsman and Bernstein predict the ethical challenges in the field of neurosurgery of the future: “As technology continues to advance, the onus will be on the practicing neurosurgeon to justify the application of novel technology to new and evolving patient populations” [3]. These “new and evolving patient populations” will likely include those with movement disorders, some with neuropsychiatric conditions (for example, obsessive compulsive disorder, depression, alcoholism, drug addiction, and severe obesity), those with chronic pain, possibly those who are “normal” but seek neuroenhancement through surgical means, those who are paralyzed and seek to walk, and the blind who seek to see via brain-machine interface implants.

The following sections are included:

• Historical Perspective
• Coverage of Ethical Issues in Cardiothoracic Surgery in Literature
• Principles of Ethics
• Informed Consent
• Coronary Revascularization: Evidence-based Practice versus Informed Consent
• Ethics of Innovation in Cardiothoracic Surgery
• The Ethics of Publication of Cardiothoracic Surgical Outcomes
• Withdrawing Life-sustaining Treatments
• Ethical Issues in Heart and Lung Transplantation
• Stem Cell and Cloning Research
• Conclusions
• References

The following sections are included:

• Introduction
• Religion and Fertility Control
• The Ethics of Abortion and Sterilisation
• Legal Aspects
• References

The following sections are included:

• Introduction
• Respect for Patient Autonomy and Informed Consent
• Beneficence
• Non-maleficence
• The Field of Plastic and Reconstructive Surgery
• Training of the Plastic Surgeon
• Marketing, Media, and Plastic Surgery
• Innovative Research and New Technologies in Plastic Surgery
• Conclusion
• References

Transplant medicine is a huge ethical minefield. Virtually each and every one of its evolving aspects was at some point subject to a heated controversy. For more than five decades now it has challenged our conceptions of identity, personhood, autonomy, death, and the body. It has even called into question our time-honoured relations of solidarity, altruism, and love. And yet nothing in this field is philosophically challenging in itself. The only thing that accounts for its conceptual and ethical flammability is the enormous bearing it has on some of the most sensitive interests of so many social stakeholders…

The following sections are included:

• Introduction
• Composite Tissue Allograft: Science Fact
• Best Interests: Balancing Benefits and Risks
• Respecting Autonomy, Consent, and Personal Identity
• In the Public Interest?
• Conclusion
• Post-script: Science Future?
• Acknowledgements
• References

The following sections are included:

• Introduction: Why Trauma Medicine?
• Informed Consent and Capacity
• Research Ethics in Emergency Contexts
• Organ Donation
• Confidentiality and Mandatory Reporting
• Triage
• Concluding Remarks
• References

The following sections are included:

• Index