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The Ethics of Surgery

Conflicts and Controversies

Edited by Robert M. Sade,M.D.

Surgical ethics was only recently recognized as a subdivision of biomedical ethics; few other books specifically address this field.
Most of the articles in the book are debates, a format that emphasizes the wide range of controversies that characterize contemporary biomedical ethics.
Most of the authors of the papers are surgeons, giving a real-world cast to the discussions and arguments; the exchanges are enriched by an admixture of lawyers, sociologists, philosophers and others with expertise in ethics.

The Ethics of Surgery

Conflicts and Controversies

Edited by Robert M. Sade,M.D.

Description

According to popular belief, technical skill is far more important for surgeons than thoughtful deliberation. Nothing could be further from the truth. Although surgeons must sometimes make decisions rapidly on the basis of incomplete evidence and must respond to unexpected catastrophes in the operating room rapidly, those events are intermittent - most of the time surgeons deliberate on diagnostic problems and thoughtfully manage postoperative care, which is often intellectually challenging.
The relationship of surgeons with their patients is, in a real sense, far more intimate and trusting than that of any other professional, a claim that is supported by the fact that patients surrender their bodies to their surgeons in a state of total helplessness and vulnerability when they undergo anesthesia. Because of that responsibility, no other professional group has a greater sense of dedication to the welfare of their patients than surgeons.
Surgical culture is deeply steeped in ethics, and surgeons confront and resolve ethical dilemmas as much or more than most other professionals, although they often may not recognize the situations they resolve are problems in ethics - they are just part of the daily routine. This book is a compendium of articles from the recent surgical literature that address ethical issues chosen by surgeons because they are controversial and pertinent to the practice of surgery. The reader will not find a great deal of sophisticated dissection of fine philosophical distinctions in these discussions of ethical conflicts and controversies in surgery. Instead, they will discover differing viewpoints from thoughtful essayists, mostly surgeons, whose feet are firmly in contact with the ground and who have extensive experience in the real world of surgery, medicine, and law.

The Ethics of Surgery

Conflicts and Controversies

Edited by Robert M. Sade,M.D.

Contributors
Preface
Introduction
Robert M. Sade, MD
SECTION 1: THE PROBLEM OF SURGICAL ETHICS
Chapter 1: Ethics Gap in Surgery
Robert M. Sade, MD, Timothy H. Williams, MD, David J. Perlman, MA, Cynthia L. Haney, JD, and Martha R. Stroud, MS
Chapter 2: Ethics in Cardiothoracic Surgery: A Survey of Surgeons' Views
Thomas A. D'Amico, MD, Martin F. McKneally, MD, and Robert M. Sade, MD
SECTION 2: PROFESSIONAL INTEGRITY
Chapter 3: Deceiving Insurance Companies: New Expression of an Ancient Tradition
Robert M. Sade, MD
Chapter 4: Hepatitis C Virus-Infected Resident: End of Residency, End of Career?
Carolyn M. Dresler, MD, MPA, Michael S. Kent, MD, Richard I. Whyte, MD, MBA, Robert M. Sade, MD
Chapter 5: Must Surgeons Tell Mitral Valve Repair Candidates About a New Percutaneous Repair Device That Is Only Available Elsewhere?
Eric R. Skipper, MD, Kevin D. Accola, MD, and Robert M. Sade, MD
Chapter 6: The Surgeon's Work in Transition: Should Surgeons Spend More Time Outside the Hospital?
Jamie Dickey, PhD, Ross M. Ungerleider, MD, Joseph S. Coselli, MD, Lori D. Conklin, MD, Robert M. Sade, MD
Chapter 7: Should Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent?
Charles A. Czeisler, PhD, MD, Carlos A. Pellegrini, MD, and Robert M. Sade, MD
Chapter 8: Are Thoracic Surgeons Ethically Obligated to Serve as Expert Witnesses for the Plaintiff?
Donald C. Watson, Jr, MD, Francis Robicsek, MD, PhD, Robert M. Sade, MD
SECTION 3: RELATIONSHIPS WITH PATIENTS - AUTONOMY AND CONSENT
Chapter 9: Should a Jehovah's Witness Patient Who Faces Imminent Exsanguination Be Transfused?
Keith S. Naunheim, MD, Charles R. Bridges, MD, ScD, and Robert M. Sade, MD
Chapter 10: No Heroic Measures: How Soon Is Too Soon to Stop?
Thomas A. D'Amico, MD, Mark J. Krasna, MD, Diane M. Krasna, CRNA, Robert M. Sade, MD
Chapter 11. Should Surgical Errors Always Be Disclosed to the Patient?
Constantine Mavroudis, MD, Constantine D. Mavroudis, MD, Keith S. Naunheim, MD, and Robert M. Sade, MD
Chapter 12: Another Surgeon's Error: Must You Tell the Patient?
Susan D. Moffatt-Bruce, MD, PhD, Chadrick E. Denlinger, MD, Robert M. Sade, MD
Chapter 13. Impending Loss of Insurance Coverage is an Indication to Proceed With Complex, Expensive Surgery
Anthony L. Estrera, MD , Sharon Ikonomidis, PhD, John S. Ikonomidis, MD, Robert M. Sade, MD
Chapter 14: Ethical Obligation of Surgeons to Noncompliant Patients: Can a Surgeon Refuse to Operate on an Intravenous Drug-Abusing Patient With Recurrent Aortic Valve Prosthesis Infection?
J. Michael DiMaio, MD, Tomas A. Salerno, MD, Ron Bernstein, JD, Katia Araujo, PsyD, Marco Ricci, MD, Robert M. Sade, MD
SECTION 4: INNOVATION AND USES OF TECHNOLOGY
Chapter 15: Surgical Innovation: Too Risky to Remain Unregulated?
Haavi Morreim, PhD,, Michael J. Mack, MD, Robert M. Sade, MD
Chapter 16: Who Should Adopt Robotic Surgery, and When?
Jessica K. Smyth, MD, Karen E. Deveney, MD, Robert M. Sade, MD
Chapter 17: Should Access to Transcatheter Aortic Valve Replacement Be Limited to High-Volume Surgical Centers?
Joseph E. Bavaria, MD, Philip Green, MD, Gregg F. Rosner, MD, Martin B. Leon, MD, Allan Schwartz, MD, Robert M. Sade, MD
Chapter 18: Should the Use of Transcatheter Aortic Valve Implantation be Rationed?
John E. Mayer, Jr, MD, Grayson H. Wheatley III, MD, Robert M. Sade, MD
SECTION 5: ORGAN DONATION AND TRANSPLANTATION
Chapter 19: Heart Donation Without the Dead Donor Rule
Franklin G. Miller, PhD, Robert M. Sade, MD
Chapter 20: Saving Lives Is More Important Than Abstract Moral Concerns: Financial Incentives Should Be Used to Increase Organ Donation
Benjamin Hippen, MD, Lainie Friedman Ross, MD, Robert M. Sade, MD
Chapter 21: Prisoners on Death Row Should Be Accepted as Organ Donors
Shu S. Lin, MD, PhD, Lauren Rich, RN, BSN, Jay D. Pal, MD, PhD, Robert M. Sade, MD
SECTION 6: CONFLICTS OF INTEREST IN SURGERY
Chapter 22: Politely Refuse the Pen and Note Pad: Gifts From Industry to Physicians Harm Patients
Kenneth V. Iserson, MD, MBA, Robert James Cerfolio, MD, Robert M. Sade, MD
Chapter 23: Should the Financial Link Between Industry and Physician Consultants Be Severed?
Stephen J. Immelt, JD, Vincent A. Gaudiani, MD, Robert M. Sade, MD
Chapter 24: Full Disclosure-Should Presentations and Publications Include Dollar Amounts and Duration of Surgeon-Industry Relationships?
J. Peter Murphy, MD and Robert M. Sade, MD
SECTION 7: ETHICAL ISSUES IN HEALTH CARE POLICY
Chapter 25: Medical Ethics Collides With Public Policy: LVAD for a Patient With Leukemia
Patrick M. McCarthy, MD,, Richard D. Lamm, LLB, CPA, Robert M. Sade, MD
Chapter 26: Should Coronary Artery Bypass Grafting Be Regionalized?
Brahmajee K. Nallamothu, MD, MPH, Kim A. Eagle, MD, Victor A. Ferraris, MD, PhD, Robert M. Sade, MD
Chapter 27: A Clash of Rights: Should Smoking Tobacco Products in Public Places be Legally Banned?
Carolyn Dresler, MD, MPA, Mark J. Cherry, PhD, Robert M. Sade, MD
Chapter 28: Should a Medical Center Deny Employment to a Physician Because He Smokes Tobacco Products?
James W. Jones, MD, PhD. MHA, William M. Novick, MD, Robert M. Sade, MD

The Ethics of Surgery

Conflicts and Controversies

Edited by Robert M. Sade,M.D.

Author Information

Edited by Robert M. Sade, M.D.

Robert M. Sade, MD, is Distinguished University Professor, Professor of Cardiothoracic Surgery and Director of the Institute of Human Values in Health Care at the Medical University of South Carolina, where he also is Director of the Clinical Research Ethics Program. At MUSC, he created the Section of Pediatric Cardiac Surgery in 1975 and has concentrated mainly on biomedical ethics for the last two decades. He has written several hundred articles, book chapters, and books on cardiothoracic surgery, medical education, biomedical ethics, and health policy.

Contributors:

Kevin D. Accola, MD: Florida Heart Institute, Cardiovascular Surgeons, PA, Orlando, Florida
Katia Araujo, PsyD: Jackson Memorial Hospital, Miami-Dade County Attorney's Office, Kaplan University, School of Criminal Justice, Miami, Florida
Joseph E. Bavaria, MD: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Ron Bernstein, JD: Miami-Dade County Attorney's Office, Kaplan University, School of Criminal Justice, Miami, Florida
Mark I. Block, MD: Thoracic Surgery, Memorial Hospital System, Hollywood, Florida
Charles R. Bridges, MD: Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania and the Pennsylvania Hospital, Philadelphia, Pennsylvania
Robert James Cerfolio, MD: Department of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
Mark J. Cherry, PhD: Department of Philosophy, St. Edward's University, Austin, Texas
Lori D. Conklin, MD: Department of Anesthesiology and Chief, Division of Vascular Anesthesia, University of Virginia, Charlottesville, Virginia
Joseph S. Coselli, MD: Texas Heart Institute, Baylor College of Medicine, Houston, Texas
Charles A. Czeisler, PhD, MD: Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
Thomas A. D'Amico, MD: Division of Thoracic Surgery, Duke University Medical Center, Duke University Health System, Durham, North Carolina
Karen E. Deveney, MD: Department of Surgery, Oregon Health and Science University, Portland, Oregon
Jamie Dickey (Ungerleider), MA, MSW-LCSW, PhD: Family & Community Medicine?Center for Integrative Medicine, Student Wellness Center, Wake Forest Baptist Health, Winston-Salem, North Carolina
J. Michael DiMaio, MD: Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
Carolyn M. Dresler, MD, MPA: Center for Tobacco Products, Food and Drug Administration, Rockville, Maryland
Kim A. Eagle, MD: University of Michigan Cardiovascular Center, Ann Arbor, Michigan
John W. C. Entwistle, MD, PhD: Departments of Cardiothoracic Surgery and Psychiatry, Drexel University College of Medicine, Philadelphia, Pennsylvania
Anthony L. Estrera, MD: Department of Cardiothoracic & Vascular Surgery, University of Texas Medical School, Houston, Houston, Texas
Victor A. Ferraris, MD, PhD: Division of Cardiovascular and Thoracic Surgery, Linda and Jack Gill Heart Institute, University of Kentucky Chandler Medical Center, Lexington, Kentucky
Vincent A. Gaudiani, MD: Pacific Coast Cardiac and Vascular Surgeons, California Pacific Medical Center Heart Institute, and Cardiac Surgery, Community Hospital of the Monterey Peninsula, Redwood City, California
Philip Green, MD: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
David E. Guinn, BFA, JD, MA, PhD: International Law and Human Rights, University at Albany, University at Albany, The State University of New York, Albany, New York, New York
Cynthia L. Haney, JD: Division of Legislative Counsel, American Medical Association, Washington, DC
Benjamin Hippen, MD: Metrolina Nephrology Associates and Carolinas Medical Center, Charlotte, North Carolina
John S. Ikonomidis, MD, PhD: Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
Sharon Ikonomidis, MS, PhD: Department of History, Humanities & Political Science, Trident Technical College, Charleston, South Carolina
Stephen J. Immelt, JD: Hogan Lovells, LLP, Baltimore, Maryland
Kenneth V. Iserson, MD, MBA: Arizona Bioethics Program, University of Arizona, Tucson, Arizona
Jeffrey P. Jacobs, MD: Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Heart Surgery, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida, Saint Petersburg and Tampa, Florida
Michael S. Kent, MD: Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Lev M. Khitin, MD: Vascular and Endovascular Interventions of New York, New York, New York
Diane M. Krasna, CRNA: Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
Mark J. Krasna, MD: Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
Richard D. Lamm, LLB, CPA: Institute for Public Policy Studies, University of Denver, Denver, Colorado; Former Governor of Colorado
Martin B. Leon, MD: Center for Interventional Vascular Therapy, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
Shu S. Lin, MD, PhD: Departments of Surgery, Immunology, and Pathology, and the Duke Lung Transplant Program, Duke University Medical Center, Durham, North Carolina
Michael J. Mack, MD: Cardiovascular Research and Cardiovascular Medicine, Heart Hospital Baylor Plano, Baylor Healthcare System, Baylor Plano, Plano, Texas
John E. Mayer, Jr, MD: Department of Cardiac Surgery, Children's Hospital Boston, and Harvard Medical School, Boston, Mass.
Constantine Mavroudis, MD: Congenital Heart Institute, Florida Hospital for Children, Orlando, Florida
Constantine D. Mavroudis, MD, MSC: Penn Surgery, Cardiac Surgery Direct Program, University of Pennsylvania, Philadelphia, Pennsylvania
Patrick M. McCarthy, MD: Division of Cardiothoracic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
Martin F. McKneally, MD, PhD: Toronto General Hospital, Department of Surgery and Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
Haavi Morreim, PhD: College of Medicine, University of Tennessee, Health Science Center, Memphis, Tennessee
J. Peter Murphy, MD: Department of Cardiovascular Surgery, Missouri Baptist Hospital, St. Louis, Missouri
Brahmajee K. Nallamothu, MD, MPH: Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
Keith S. Naunheim, MD: Division of Cardiothoracic Surgery, St. Louis University Health Sciences Center, St. Louis, Missouri
Jay D. Pal, MD, PhD: Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
Carlos A. Pellegrini, MD: Department of Surgery, University of Washington, Seattle, Washington
David J. Perlman, PhD: School of Nursing, Center for Bioethics, University of Pennsylvania, Philadelphia, Pennsylvania
Ralph J. Petrucci, EdD: Departments of Cardiothoracic Surgery and Psychiatry, Drexel University College of Medicine, Philadelphia, Pennsylvania
Marco Ricci, MD: Division of Cardiothoracic Surgery, University of New Mexico Health Science Center, Albuquerque, New Mexico
Lauren Rich, RN, BSN: Departments of Surgery, Immunology, and Pathology, and the Duke Lung Transplant Program, Duke University Medical Center, Durham, North Carolina
Francis Robicsek, MD, PhD: Department of Thoracic and Cardiovascular Surgery, Carolinas Heart Institute and Carolinas Medical Center, Charlotte, North Carolina
Gregg F. Rosner, MD: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
Lainie Friedman Ross: Departments of Pediatrics, Medicine, and Surgery, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
Tomas A. Salerno, MD: Department of Surgery and Division Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida
Allan Schwartz, MD: Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
Eric R. Skipper, MD: Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, North Carolina
Martha R. Stroud, MS: Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
Jessica K. Smyth, MD: Department of Otolaryngology, University of North Carolina, Chapel Hill, North Carolina
Donald C. Watson, Jr, MD: Pediatric Cardiovascular Surgery, Asheville, North Carolina
Grayson H. Wheatley III, MD: Department of Cardiovascular Surgery, Arizona Heart Institute, Phoenix, Ariz.
Richard I. Whyte, MD, MBA: Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Timothy H. Williams, MD: Cardiothoracic Surgery, St. Francis Hospital, Greenville, South Carolina
Ross M. Ungerleider, MD: Pediatric Cardiac Surgery, Brenner Children's Hospital, Wake Forest University Baptist Medical Center, Winston Salem, North Carolina