Robert M. Sade, M.D., Timothy Williams, M.D.,

David Perlman, Cynthia Haney, J.D., and Martha Stroud, M.S.

Charleston, South Carolina

A survey of the surgical compared with the medical literature (12 surgical, 15 medical journals) showed that discussions of bioethical issues occurs much-less frequently in the surgical (17 of 2,645 articles, 0.6%) than in the medical (307 of 11,239 articles, 2.7%) literature (1). The reasons for this ethics gap are unclear, but several possibilities have been suggested (2).

1) Surgeons may ascribe less importance to ethical considerations than internists do, so talk about them less. 2) The traditional beneficence model of medical ethics (doing what is best for the patient), a fundamental surgical principle, sometimes conflicts with the contemporary autonomy model (patient self-determination, which may include rejecting medically indicated treatment). For this reason, surgeons may feel alienated from contemporary bioethical discourse. 3) There is evidence that surgeons are more authoritarian than other physicians, perhaps because of their professional training and the nature of surgical practice. If this is true, surgeons may understand the very meaning of ethics differently from others. 4) Ethical principles are so deeply ingrained in surgeons through training and practice that discussion of the principles may seem redundant. One surgical educator has explained the ethics gap in this way: The difference between surgeons and internists is that surgeons practice ethics, while internists mainly talk about it (3)!

We have undertaken a pilot study in the form of a survey of our academic medical center faculty. We solicited their views of ethical and legal options available to the surgeon in each of two cases of surrogate decision-making. The standard for ethical acceptability was derived from published guidelines of five medical organizations (none could be found from primarily surgical organizations). Although the outcome for any particular legal challenge is not predictable, we solicited legal opinion regarding which of the options would be legally prudent or imprudent on grounds of liability risk. Case 1 was that of a young woman with severe brain injury with potential for only minimal recovery at best, whose parents want to withdraw feeding, based on comments made by their daughter in the past. Case 2 was that of a newborn infant with hypoplastic left heart syndrome and Down Syndrome whose parents want prostaglandin discontinued.

Four options for responses by the surgeon were provided. The three ethically acceptable and legally prudent options in each case were to accede to the parents’ wishes, to withdraw from the case and transfer the care of the patient to another physician, and to seek a court order to continue life support. The fourth option was the only one that was ethically unacceptable and legally imprudent: continue treatment despite objection by the surrogate decision-maker.

Of 407 faculty physicians, 133 (33%) responded. Responses were grouped into groups of surgeons (including all surgical specialties), internists (including all medical specialties), pediatricians, and others (e.g., pathologists, radiologists). For interspecialty comparisons, only the surgeons, internists, and pediatricians had sufficient numbers for statistical evaluation. The response rates for those groups were: surgeons 31/74 (42%), 51/173 internists(29 %), and pediatricians 18/44 (41%).

Surprisingly often, faculty mistakenly believed the ethically unacceptable option to be acceptable (case 1, 88/132, 67%; case 2, 57/132, 42%). Although every commentator on ethical standard holds that mental disability should not be grounds for making treatment decisions, 44 (33%) of our faculty would have made a different treatment decision if Down Syndrome had not been present in Case 1.

Surgeons did not choose any ethical option more or less often than other physicians. We attempted to find in our data evidence for or against the several rationales for the ethics gap cited above. If surgeons ascribe less importance to ethical considerations than internists do, or feel alienated from contemporary biomedical discourse, they should have responded to the survey less frequently than others, but the response rate was the same. If surgeons understand the meaning of ethics differently from others because they are more authoritarian than other physicians, then they should have given more authoritarian responses (treat over parents’ objections or seek court order to treat) than other physicians. In fact, authoritarian responses were ranked the first choice more often by pediatricians (50%) than by surgeons (11%) or internists (22%) (p<0.05). If ethical principles are so deeply ingrained in surgeons that their discussion may seem redundant, there should be less variability in the responses of surgeons than of others. Agreement among surgeons, however, was no greater than within other specialty groups.

Among the general faculty, the only legally imprudent response, treat over objections of parents, was believed to be acceptable by 73% in case 1 and by 39% in case 2. It is legally imprudent to treat children with Down Syndrome differently from other children, yet 33% of our faculty would have treated Case 2 differently if Down Syndrome had not been present.

Surgeons (19/31, 62%), however, were significantly (p<0.05) more likely than internists (18/51, 35%) or pediatricians (4/18, 22%) to believe, mistakenly, that operating on the baby without parental consent was legally acceptable.

Many varieties of ethical problems confront surgeons in their daily practices, including issues of confidentiality, truthful disclosure, resource allocation, and the like. We chose to limit this pilot study to a single type of ethical issue, surrogate decision-making, because we have observed large differences and vehemently held positions in this area.

The survey provides interesting insights into the way our faculty understands ethical and legal issues in surrogate decision-making. Our faculty often chose ethically unacceptable or legally imprudent treatment options. Their choices were often authoritarian in orientation. Their choices in the case of a newborn with hypoplastic left heart syndrome were often unacceptably influenced by the presence of Down Syndrome.

Our main objective, however, was in elucidating the reasons for the ethics gap. The facts are clear: the surgical literature contains a relative dearth of ethics discussion, and surgical societies publish few ethical guidelines. Among the several published speculations attempting to explain the ethics gap, none was confirmed by our limited survey. Within the limits of our study, surgeons appear to consider ethical deliberation to be as important as do other specialists; their decision-making is no more authoritarian than others; they seem not to be alienated from ethical discourse; and their views are no more uniform than those of others.

Our data does not explain the ethics gap. Interpreting these results is difficult, though, because of the small population we studied, the relatively low response rate (33%) of our faculty, and the narrowness of the issues posed by our cases. Broader studies are needed, because it is important that we understand the reasons for the gap. Surgeons’ strong ethic of personal responsibility for patients’ welfare should be transmitted to young trainees; this is a goal best achieved by discussing and writing about ethics. Moreover, the results of our analysis of the legal aspects of the survey suggest not only that physicians have important lapses in their understanding of legal obligations, but also that a significant gap may also exist between surgeons and other physicians in understanding health law.