The purposes of surgery

Before any surgical procedure is undertaken, the surgeon must be clear in his or her mind regarding why the surgery is being undertaken. So also must the patient be clear. That is, the doctor and the patient must know what the surgery is trying to accomplish. And they must be in agreement regarding the ultimate goal. This comment is so fundamental that it may seem condescending even to say it. Of course the purpose, the desired outcome, must be clear. But frequently the surgeon is so involved in the technical aspects necessary to achieve the ultimate goal that the goal itself fades from view.

This chapter is intended to remind us all, but especially surgeons, that there is only one appropriate ultimate goal of surgery, specifically, restoration, maintenance, or enhancement of the health of the patient. Even patients themselves sometimes forget that. For example, they may want a drooping right upper lid lifted because they are dissatisfied with their appearance. But the dissatisfaction may have little to do with their actual appearance. The surgery that restores the right upper lid to its ‘proper’ position, then, no matter how perfect technically, may not help them at all, that is, may not restore, maintain, or enhance health. Patients with cataracts may be unhealthy because they are limited by the reduced vision. They feel incomplete, unhealthy. The strategy used to restore health in such a patient is to restore good vision. The mechanism by which this can be done is by removing the cataract and providing a tolerable refractive correction – such as an intraocular lens. The surgeon knows that merely removing the cataract will not make the patient happy. The problem is not the cataract, but the poor vision. But the patient does not know this. It is no wonder that, in years past, patients having had ‘successful’ intracapsular cata-

ract extractions were so often dissatisfied, whereas today patients whose hazy lenses have been replaced by clear intraocular lenses of the right strength to allow them to see without glasses are so often ecstatic following surgery.

The major purpose of this chapter is to consider how other purposes of surgery get layered onto the basic purpose, that of restoring, maintaining, or enhancing health. Specifically, surgery is also undertaken: (1) for the purpose of making a living for the surgeon; (2) to teach others how to perform surgery; (3) to discover new knowledge; (4) to allow the surgeon become famous; (5) to have fun;

(6) for the purpose of becoming rich; and (7) to achieve a specific goal, perhaps not directly related to improving the health of the patient.

1. Altruistic surgeons who perform surgery solely for the joy of helping people will not be able to help people for long unless they get some type of recompense that allows them to survive. It is entirely appropriate for the surgeon to expect and to receive some type of compensation from the person undergoing surgery, or from the society in which that person lives and that recognizes that a healthy, functioning populace is its best security. It is not appropriate, however, for surgeons to use patients’ vulnerability as a way of exploiting them for monetary gain. For care to be available, there must be caregivers and facilities, and these must be supported or else there will soon be no care. Someone has to pay. The person benefitting is the most appropriate person to pay. And the society benefitting is the next most appropriate source of funds to cover the inevitable costs of care. Individuals and societies need to consider how much they value health, and then provide the funds needed to ac-

complish that level. But surgeons need not be apologetic for wanting compensation for their work. Making a living is an appropriate purpose, but never the primary purpose. It is when placing the fee motivates the decision to undertake surgery that the surgeon is acting improperly.

2.Just as there would be no surgical care without surgeons, there would soon be none without teaching. But teaching takes time, and accordingly decreases the remuneration to the surgeon. Some schools or societies pay the teachers. Others think that teachers earn enough anyway and should teach for free. But more problematic is the effect on patients’ health. The problem is that no matter how carefully students are supervised, they cannot perform as well as master surgeons. They take longer, do not react as knowledgeably, and make more mistakes. The good teacher knows that the students must be allowed to proceed on their own, and will only intervene when concerned that the ‘mistake’ just made, or about to be made, will have a significant harmful effect on the patient. But sometimes the teacher errs, and the problem becomes a significant one for the patient. Student cases take longer, and the longer the case, the greater the likelihood of infection. The chance of infection is so low, however, that there is no measurable increase in the rate of infection with student-performed surgery. But, and here is the issue, there is an unavoidable conflict of purposes: (a) helping the patient undergoing surgery to obtain as good a result as possible; and (b) helping society by ensuring that there will be well-trained surgeons in the future. The two purposes are not mutually exclusive, but they are not the same. Some training programs are particularly sought out by students because they know that the program gives its students great leeway, that they will make more mistakes, but, in so doing, will learn more than they would in a program where complications are fewer. Without having seen a complication, it is difficult to know how to recognize the premonitory sign that led up to it, and, when recognized, can prevent it from developing. Students are correct in believing that they will end up as better surgeons when they train in a program where they ‘get to do everything’!

The moral is: teaching is a proper purpose of performing surgery. However, the primary purpose is the well-being of the patient undergoing surgery. Not to make that clear to the student being taught conveys the message that the patient is ‘teaching material’, thereby devaluing the patient, and vitiating the basic principle underlying great medical care, which is that every person is deserving of the best care that can be provided within the context in which the care is given.

3.A third purpose of surgery is the discovery of new knowledge. Without some attempt to improve

the cognitive knowledge about what makes patients do well or poorly with surgical procedures, and without an effort to improve the procedural skill involved in the technique of surgery, the methodology of surgery would either not improve at all, or improve only slowly. The consequence of that lack of improvement would be a lack of improvement for both individual patients and society as well. A person who develops a mature cataract becomes incapacitated. Not only can such affected individuals not support themselves, but also they cannot support society. The cost in terms of individual suffering and societal difficulty from cataract has, throughout history, been immense. We have overcome that suffering and difficulty to a large extent by developing surgical methods that remove the cataract with a morbidity of less than 5%, and restore a vision that is far better than that prior to the cataract extraction in well over 90%, and better than the vision before the cataract developed in a significant percentage. Clearly, these methods have made a major contribution to the welfare of individuals and society. What was required for cataract surgery to become so dramatically successful? The answer, of course, is the discovery of new knowledge.

Advancement in surgical knowledge has its costs. When Harvey Cushing, at Yale, first started to remove pituitary tumors, the first 30 or so patients on whom he performed the surgery died from it. The first ten patients in whom Harold Ridley inserted the first intraocular lenses did not have a result that was as good as was readily available with intracapsular cataract extraction with use of a contact lens. But the comparison between these two events deserves careful consideration. There was no alternative treatment for a pituitary tumor when Cushing started his surgical exploration. There was a very satisfactory alternative with regard to cataract surgery. The difference is important. While it was incumbent upon Cushing to indicate to his patients that the surgery he was about to perform was unproved and could result in the patient’s death, Ridley had responsibilities that went beyond that. He also needed to tell his patients that a highly successful procedure was already in existence, and that the likelihood was that the patients undergoing his procedure would not do as well as with the older surgery. But the potential benefit of intraocular lenses was enormous, and visionaries such as Ridley realized that.

Nevertheless, for such visionaries to act properly, it was essential for them to recall the primary purpose of surgery, which is to help the individual patient. The part of the surgical event that is concerned with the development of new knowledge must be subsidiary to the part that is intended to benefit the patient. When this is not the case, the surgeon is acting improperly. He or she is not performing as a physician, but rather as an investigator. If that surgeon presents himself or herself to

the patient as an investigator who is not primarily interested in the well-being of the patient, if that investigator is aware of the patient’s extreme vulnerability, then in some situations it may be appropriate to proceed with procedures that are primarily for the purpose of developing new knowledge rather than for helping the patient. However, such settings are extremely rare, if they exist at all. Having said that, however, physicians who do not participate in efforts that are designed to provide new knowledge without introducing a significant risk to the patient under consideration are as unethical as those surgeons who present themselves as physicians, and yet are acting as investigators. There is an ethical responsibility to develop new knowledge, so that all patients may benefit in the future. The physician’s primary purpose is to maintain or improve the well-being of his or her patient, but that is not the physician’s sole purpose. To ignore the subsidiary purposes of surgery and the subsidiary responsibility of being a physician is to be at least partially negligent.

4.One of the motivations for performing surgery is the desire to become famous. That is, for some surgeons, performing a surgery becomes driven by a purpose which is, to become famous, to win the Nobel Prize, to be the most revered surgeon, etc. These motivations can lead to great accomplishments. But we have to wonder what percentage of the great contributions in medical history are the result of a desire on the part of the contributor for fame in the sense just described. Nevertheless, as valuable as they are, when those contributions become the primary purpose of the action, they pervert the primary purpose of being a surgeon. In such a situation, the patient is not used as ‘teaching material’ or ‘research material’, but rather as ‘building material’, used by the surgeon to build up a reputation that he or she hopes will bring about his or her desired fame. The consequences of such actions are that developing physicians see such behavior rewarded and therefore may wish to emulate it. Additionally, such behavior rarely results in patients obtaining the best care they can. Again, as with the discovery of new knowledge, such behavior can only be justified if the patient is fully aware of the primary purpose of the surgeon.

Performing surgery in order to win an award has its ‘good’ side, as does performing surgery in order to teach and to discover new knowledge. However, that good side does not justify the bad side of it. The good side of it can coexist with the primary purpose, which is to help individual patients, so long as that primary purpose is kept primary in the surgeon’s mind.

5.Surgery is challenging. It is exciting. For some surgeons, it is fun. It can become a game. And the seductive power of games has become especially apparent with the development of computer games.

Millions of individuals across the world now spend millions of hours playing games that will bring them no reward other than the fun involved in the playing of the game itself. The value of having fun is great. Play is one of the wonderful aspects of existence, whether that play be squirrels cumbering on the lawn, seagulls soaring, or computer nerds figuring out the details of a new game. Fun is conducive to health. One of the characteristics of Mozart’s music that makes it one of the towering accomplishments of mankind is the great delight that the music evokes in listeners. It is appropriate for surgeons to enjoy themselves while performing surgery. It is not appropriate for surgeons to enjoy themselves at the expense of those on whom they are performing that surgery. If the fun part of surgery results in the diminishment of the surgeon’s ability to accomplish the primary goal, i.e., helping individual patients, then the fun part is inappropriate. However, as with the other purposes discussed, this need not be the case. It is a matter of remaining clear in one’s mind and actions as to what is a primary and what is a subsidiary purpose.

6.For some individuals, surgery becomes a way to amass wealth. It is easy to say that the desire to become hugely rich is less worthy than the desire to ‘make a living’. However, this is probably not a defensible position. Becoming vastly wealthy allows the vastly wealthy individual to do things that are not possible for an individual who has less means at his or her disposal. A significant portion of the great contributions to human society has been made by individuals who amassed great wealth. Universities have been founded, churches built, centers for the homeless established, great works of art commissioned, students supported, and on and on, by wealthy people. Creation of wealth is one of the essential components of a successful society. There is, then, nothing inherently wrong in wanting to become rich by performing surgery, although the initial response of most to such a purpose will be that, becoming rich at the expense of the sick, is wrong to the point of being obscene. But this is not so, as long as the primary purpose continues to be primary. If a surgeon is able to provide care which is superb and to make a great deal of money at the same time, that surgeon should be congratulated and encouraged by the medical profession and society at large.

7.The final purpose for performing surgery includes a miscellany of purposes. For example, a surgeon may want to discover a better way to perform cataract extraction, because his parents became blind from cataract surgery. Or a surgeon may want to improve the technique of treating compound fractures of the femur because his brother was incapacitated by such a fracture. These purposes, too, are appropriate, because they may motivate, encourage, and sustain surgeons through

difficult times. However, when these purposes become all-consuming, so that what the surgeon does is done at the cost of individual patients, then the purpose is improper. But, as with all the other purposes discussed in this chapter, they are inappropriate only to the extent that they interfere with the effort of the surgeon to provide the best care possible for the patients under his or her care within the context in which he or she finds himor herself.

Conclusions

Medical ethics is an essential part of medical actions, and is a subgroup of bioethics, which is de-

rived from applied ethics and philosophical ethics. Applied ethics is based on the principle that each allows the other the same amount of freedom that he requests for himself. When this is not the case, but when a person acts according to the principle, “most for me, what’s left over for the others”, justice has been violated (or: a problem regarding justice arises). A number of purposes are included in the aims of surgery, i.e., surgery is undertaken: (1) for the purpose of repairing; (2) to teach others how to perform surgery; (3) to discover new knowledge; (4) to allow the surgeon to become famous;

(5) to have fun; (6) for the purpose of becoming rich; and (7) to achieve a specific goal, perhaps not directly related to improving the health of the patient.