Ethical Issues in Colorectal Surgery
Ethics, at its most fundamental level, is a way to answer the question, “what should we do?” In this chapter, I define what “ethical dilemmas” are and discuss one approach for resolving them. I discuss informed consent, surrogate decision-making, futility
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Key Concepts • Ethics is a formal way of examining what one should do. • The four principles approach emerged from a common morality of health care. • A moral dilemma occurs when the moral intuitions of individuals disagree. • Informed consent is a process that is rooted in respect for patient autonomy. • Surrogate decision-making is necessary should a patient become incompetent. • Futility is a concept that is in evolution and should be based on a local definition. • Disparities in outcomes from colorectal operations vary based on race. • Financial conflicts of interest are a contemporary problem that has been addressed at the level of the federal government.
Introduction Ethics, at its most fundamental level, is a way to answer the question, “what should we do?” Since surgeons are, first and foremost, doers in the world, it seems apropos that ethics should be a part of our study. Surgeons have a unique relationship with humankind, and ethics is a way of exploring this relationship deeply. In this chapter, I will discuss what ethical problems in surgery are, and what a good, reasoned way to approach them might be. I will then discuss several twenty-first century issues in colorectal surgical ethics. This chapter should not be regarded as an exhaustive review, but rather a sampling of some of the most difficult problems faced by colorectal surgeons today.
The Ethical Dilemma Surgical practice is similar to the practice of all medicine, in that it is conducted against a background of historical ethical problems that have achieved a relatively stable solution. We do not think twice now, for example, about obtaining informed consent prior to operating on a patient or enrolling him or her in a clinical trial. Part of our reasons for doing this may have to do with the legal framework that surrounds us, but should that legal framework be stripped away, informed consent intuitively seems a good thing that we ought to do. The individual moral intuition that we each have seems to march in lock step in this regard—rarely does anyone bring up an ethical dispute with getting good informed consent. Occasionally, however, our moral intuitions disagree. What one surgeon views as “right,” another views as “wrong.” More commonly, the surgical team views one choice as right and the patient, or patient’s family, views the choice as wrong. The story of Jahi McMath is a recent example of such a disagreement. McMath was a 12-year-old girl who suffered an irreversible anoxic brain injury while undergoing a tonsillectomy for obstructive sleep apnea at a hospital in northern California in 2013. While she was pronounced dead by braindeath criteria by her physicians, her family protested, claiming that she was not, in fact, dead. The family obtained a restraining order against the hospital and physicians and was successful in transferring her body out of the hospital. She remains on ventilator and nutritional support to this day [1]. New ethical dilemmas arise against the relatively stable background of an ethical surgical practice for several
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