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4
Manipal Manual of Surgery
Key Box 1.1
Principle of Ethics
Beneficence
Non-maleficence
Autonomy
Justice
More details in
Chapter 3
BENEVOLENT
A doctor should be gentle while receiving the patient
and then examining the patient. He should have
empathy and understanding toward the patient. That
does not mean that he should shed tears. The doctor
should be kindhearted, gracious, considerate, and
compassionate. While suturing the wounds and while
removing sutures or while applying large dressings for
leg wounds or such other procedures, extreme care and
empathy should be shown. Very often, these are done
by junior surgeons/residents who have to be clearly told
about these aspects.
COMMUNICATION, CONTINUED LEARNING,
COMPETENCY
, COUNSELLING, CONSENT
The doctor–patient relationship starts from the first visit
of the patient to the doctor. Develop a good rapport
with the patient. The first impression is the best
impression. Good communication skills impress. Do not
negate patient’s views even after you convince
effectively. If we look back to 20–30 years ago, our family
physicians did not even have MBBS degree, leave alone
specialization and super specialization. They were ready
to listen to the patient, do home visits, attend midnight
calls and accept whatever money that was given to
them. Doctors were looked upon as Gods and patients
accepted both success and failure. Their success was
largely because of good communication skills. The
world is changing at a great speed and moving ahead.
Communication alone does not heal, and good
medical care is needed. Medicine is changing. We cannot
sit idle without updating our knowledge. With conti-
nuous medical education (CME), theoretical knowledge
can be updated. One can improve skills by attending
conferences, attending workshops and thus attain
competency. Patients also feel happy that the doctor has
attended many conferences all over the world and has
improved his knowledge.
Always explain to the patient what you are doing, why
you are doing and what possible complications can
happen. These have to be told in a language that the
patient understands and get his signature. This is called
informed consent. At surgery, do what is required for
the patient. Do not do an additional procedure for an
Section I • Basic Principles of Surgery
incidental finding for which you have not taken consent
Key Box 1.2
5Cs for Doctor–Patient Relationship
Communication
Continued learning
Competency
Consent
Counselling
(Key Box 1.2). Every major surgery can have complications/morbidity and mortality. The patient must be
counselled before surgery (Figs 1.1. and 1.2). Counselling
and consent are given in more detail in the next chapter.
Fig. 1.1: The patient is being briefed about her illness, why and
what type of surgery will be done, possible alternatives for surgery
and complications related to surgery
Look at the 1st picture explaining
easy cholecystectomy–no adhesions–
more than 95% success of laparoscopic method and discharge within
2 days. However, 2nd picture shows
gallbladder adhered to liver due to
chronic cholecystitis–so may have to
do open method–in about 5%
patients. Hospital stay of 5 days may
be required.
Fig. 1.2: Illustration of how simple sketches can be used to explain
procedures to patients
Doctor–Patient Relationship
5
DIGNITY AND DIVERSITY
India is a country with multiple languages and many
cultures. Diversity is our strength. The doctor should
be sensitive to these cultural differences while treating
the patients. Appreciate and respect their culture. Do
not discourage discussions. Maintain their dignity. Our
deeds should not have any deleterious effect on the body
or mind. Understand the patient behaviour in the
background of their culture, occupation, habits and
family circumstances. Often, in India, the disease may
trigger problems at home or a fight between family
members. Doctors should not just treat the disease but
also help alleviate family issues caused by the disease.
This is possible because patients still hold doctors in
high regard even today.
EVIDENCE-BASED PRACTICE AND ETHICS
Every doctor should appreciate the need to update and
be familiar with different therapeutic modalities,
administration of “essential drugs” and their common
side effects. The latest available information should be
passed on to the patient with scientific data so that he is
aware of what is the best solution for the present
problem. Knowledge is strength and that gives us confi-
dence while talking to the patient or while attending
the courts. While making the patient comfortable, it is
not just enough to tell him what disease he has and what
can be done. Convey the various options available and
the cost of the treatment. Most often, problem arises
because of inadequate information and options. Often
the patient says, “Doctor, you do it”. I still do open
hernia repair, but I tell my patients about laparoscopic
hernia repair. Vast majority of patients agree to what
you say. We must know and accept our limitations.
When you cannot do it or do not have facilities, it is
better to refer to higher centers rather than provide
substandard initial treatment.
FAMILY PHYSICIAN
In the present times, a surgeon or a physician cannot
truly become a family physician because of specialization. However, we can have all the characteristics of a
family physician. To name a few: Patient listening,
maintaining a smile even at the late-night clinic,
enquiring about the patient’s professional life, family
life adds a personal touch to the practice of medicine.
The aim of a medical college teacher is to help the
student do the MBBS degree course, i.e. to become
competent to practice preventive, promotive, curative
and rehabilitative medicine with respect to the
commonly encountered health problems in a patient
and in community. Most of the doctors achieve this and
become successful in practice.
GET HELP
‘Call for help’ is an important step in today’s practice,
especially when a complicated surgical procedure is
planned. It is better to inform the patient when you are
taking or have taken a colleague’s help. It is vital to
obtain a proper informed consent after explaining all
possible complications to the patient. ‘Call for help’ also
refers to taking another opinion to arrive at a diagnosis,
to order for appropriate investigations, to take decision
or help at surgery and also to manage some unexpected
serious complications such as bleeding, anastomotic
leaks or any such events.
CONCLUSION
We strongly believe that if you follow these simple
guidelines of doctor–patient relationship of ABCDEFG
(Key Box 1.3), you will not only achieve higher goals in
your profession and be successful, but will also be able
to avoid frictions, abuses and attacks by the patient or
his relatives.
Key Box 1.3
ABCDEFG of Doctor–Patient Relationship
A: Attitude
B: Benevolent
C: Communication, continued learning, competency,
informed consent
D: Dignity and diversity
E: Evidence-based science
F: Family physician
G: Get help
Wish you all the best, my dear students! I wish you a
bright future.
Section I • Basic Principles of Surgery
2
Communication and Counselling
Changing scenario
Counselling
Medical details
Methods of counselling
CHANGING SCENARIO AND
THE NEED FOR COUNSELLING
Health care has been witnessing phenomenal changes
in the recent years. In the past, the doctors planned and
administered the treatment, the outcome of which was
willingly accepted by the patients; a paternalistic
attitude was prevalent among the doctors. In choosing
the doctors and the hospitals, the patients had very few
options. Illiteracy was rampant and patients were
generally ignorant about the diseases.
This scenario has been progressively changing in the
last few decades. People have become more educated;
the media has played its role in mass health education;
the common man has some general knowledge about
common diseases. Doctors, corporate hospitals and
nursing homes have proliferated and patients have the
option of selecting the doctors and hospitals of their
choice. Doctors have retracted from the paternalistic
roles; patients have to participate in the decision-making
process. The phenomenal growth of medical science,
astounding technological advances, increasing health
care costs, improving awareness, rising expectations of
the patients, and most importantly the Consumer
Protection Act have brought into sharp focus the
importance of communication and counselling in the
medical practice.
Counselling means exchange of ideas to reach a
conclusion (Webster). There is hardly any place for
counselling while eliciting patients’ history; a formal
consent is required for physical examination, especially
the internal examination, viz. digital rectal examination
and per vaginal examination. It is at the end of physical
examination that the counselling skills become
Factors influencing counselling
Patients’ rights
Quality of counselling
Steps of informed consent
Key Box 2.1
Aims of Counselling
Explain medical details of the disease
– Diagnostic dilemma
– Lab reports and their accuracy
– Treatment options
– Complications
– Outcome
– Cost
Address psychosocial, emotional and spiritual issues
Obtain consent
increasingly important in explaining the diagnostic
dilemma, accuracy of lab reports, treatment options,
outcome, complications and costs (Key Box 2.1).
Explain Medical Details of the Disease
Diagnostic dilemma: The patients often expect that
every disease should be accurately diagnosed in the first
visit; in simple disease it is possible, but not in complicated ones and if this is made known to them, their mind
is prepared to accept subsequent changes in the
diagnosis. When the final diagnosis is less serious than
the first, the patients are happy to accept it; but if it is
more serious, the patients are unhappy and tend to lose
faith in the doctor. The intensity of these undesirable
effects of change in the diagnosis can be minimized by
proper counselling, e.g. benign-looking breast lump
turns out to be malignant in the histopathological report.
Accuracy of investigation and their complications:
Many patients believe that it is possible to prove the
6
Communication and Counselling
7
diagnosis by lab tests and that more expensive tests are
more accurate; counselling should remove this mis-
conception; lab tests are not 100% sensitive and specific.
Patients with simple curable diseases do not pose much
problem, but those with serious and life-threatening or
incurable diseases often demand foolproof lab diagnosis
and such a proof is not always possible to secure. In the
absence of such a proof and when the lab test reports
are conflicting, counselling becomes increasingly
difficult, e.g. disagreement between the pathologists
about the presence or absence of cancer in the specimen.
Counselling should also include a brief mention about
the anticipated complications of investigations, e.g.
allergic reaction to IV contrast agent.
Treatment options and their complications: That the
patient has to participate in the planning and execution
of the treatment has become an accepted norm. The
doctor has to offer treatment options, discuss the merits
and demerits of each of them and then decide to
administer it. Possible complications and their approximate incidence should be discussed, e.g. recurrent
laryngeal nerve palsy in thyroid surgery.
Outcome: It is a fond desire of many patients that every
disease is completely curable. Many diseases, disabilities
and deaths are not totally preventable by the most
modern medicine. Discussion about the outcome of
treatment is especially important in surgical patients
because operation is an event which has no parallel in
non-surgical branches of medicine; and any adverse
postoperative outcome is almost always attributed to
surgery. In search of cure for incurable diseases, the
patients keep changing doctors and hospitals spending
their resources until they are told and convinced that the
cure is unachievable. Patients’ ability to cope with the
disease and accept the outcome of treatment improves if
it is told to them before executing the treatment what is
the anticipated outcome—palliation or cure.
Cost: It is better to overestimate the cost than to under-
estimate it and to express it as a range than as a finite
figure, unless it is a package.
Key Box 2.2
Patient issues that may need attention
Psychosocial, emotional and spiritual issues: Anxiety,
illness, ability to function/earn, lifespan, social status
Fear: Pain, disability, deformity, disfigurement, death
Worry: Cost, family
Shy: Genital/sexual problem
Embarrassment: Previous treatment by some other
doctor, ask for the second opinion
Patients’ preferences, e.g. CPR in case of cardiac arrest
Address psychosocial, emotional and spiritual issues:
Anxiety, fear, worry, shyness, embarrassment, religious
and cultural issues, and patients’ preferences are
addressed on individual basis (Key Box 2.2). Patients’
mental make-up and will power have significant bearing
on the management of the patients.
Methods of Counselling
There is no single best method suitable for all patients
on all occasions. Counselling is individualized and
personalized. Verbal counselling is the most common
method. Showing charts and diagrams is an easy and
effective way of convincing. Giving patient education
material for reading or showing videos are other
methods. Showing other patients being treated for
similar disease is quite helpful. The patients’ family
physician can be used for counselling because he has a
better rapport with the patient than the specialist. If
there are a number of patients with the same/similar
condition/disease (e.g. maternity hospitals or cancer
hospitals), group counselling is useful. Complex
situations (e.g. living donor liver transplantations) need
the services of counselling experts. Speaking the
patients’ language and having good vocabulary and
communication skills makes the job easier (Key Box 2.3).
Key Box 2.3
Methods of Counselling
Verbal counselling
Diagrams, charts, illustrations
Printed literature for patient education
Patient education video
Show similar patients treated/being treated
Using the patient’s family doctor for counselling
Group counselling
Counselling experts
Factors Influencing Counselling
There are many factors influencing the counselling.
Patients’ background, literacy, level of understanding
and trust in the doctor are the most important factors.
Suspicious and indecisive mind of the patient is an
obstacle. Patients’ perceptions of doctor’s honesty,
trustworthiness, dependability and intentions have their
own measure of impact on counselling. Nature of illness,
whether simple to diagnose and treat with assured
successful outcome, or a complex disease, difficult to
diagnose and treat with a guarded prognosis, or a fatal,
incurable disease have an important bearing on
counselling (Key Box 2.4).
Section I • Basic Principles of Surgery
8
Manipal Manual of Surgery
Key Box 2.4
Factors Influencing Counselling
Diseases: Curable, incurable, fatal
Patients’ perception about the doctors
– Knowledge, competence and attitudes
– Ethical, honest, trustworthy
– Compassionate, empathetic
– Cheating, exploiting, indifferent
Patients and relatives
– Trusting and faithful
– Illiterate, ignorant
– Educated, knowledgeable
– Suspicious and doubting
– Indecisive and procrastinating
PATIENTS’ RIGHTS
Patients’ rights are supreme and should be respected;
right to refuse the plan of treatment, right to information, to have second opinion, to change the doctor and
the hospital in the middle of treatment. The doctor need
not feel embarrassed. The Consumer Protection Act has
given another right—right to file a suit in the consumer
forum. Many consumer cases against doctors are
avoidable, if every patient is counselled properly and
more importantly the counselling notes are documented
and authenticated by the doctor, patient/patient’s
relative and a witness. Some hospitals have adopted
video recording of the counselling as a foolproof method
of documenting (Key Box 2.5).
Counselling and the percentage: In medicine, nothing
is 100%. This should be used liberally while counselling,
e.g. 10% conversion rate in laparoscopic cholecystectomy;
50–60% 5-year survival in cancer patient; 90–95% cure
rate in hernia repair; 5–10% recurrence rate after
fistulectomy; 50–60% chance of saving a diabetic foot.
Key Box 2.5
Patients’ Rights and Counselling
Right to
Refuse treatment
Have second opinion
Change the doctor/hospital in the middle of the
treatment
Respect their rights
Do not embarrass/insult the patient
Document
Section I • Basic Principles of Surgery
Truth and counselling: In a hurry/enthusiasm to
convince the patient, one is often tempted to overstep
and overstate the positives and understate the negatives.
It is always better to tell the truth, because truth is
constant, consistent and durable, and hence truth need
not be remembered (Key Box 2.6).
Key Box 2.6
Truth and Counselling
Tell the truth, the whole truth, nothing but the truth
Truth is constant, consistent and durable
Truth need not be remembered
Bitter truth can be made more palatable
When the whole truth is not known, tell what is known
for sure
Do’s and don’ts: Do repeat, reinforce counselling at the
appropriate time.
Don’t argue, confront, quarrel, give false assurances,
guarantee 100% results, make adverse remarks about
other doctors, give opinions or sensitive information on
phone.
Quality of counselling and its effects: Patients are in a
state of physical, psychological, financial and emotional
distress. Counselling should more or less address all
these issues; it should be cautious, careful, convincing,
re-assuring and consoling. It strengthens the faith and
improves reputation of the doctors and hospitals;
establishes rapport, builds relationship, reduces complaints, consumer cases, assaults and vandalism. Substandard counselling is done carelessly, is indifferent,
confusing and intimidating; it results in loss of faith and
reputation of the doctors and hospitals, suspicion in
doctor’s intentions, arguments and quarrels, assaults,
ransacking, complaints and consumer cases (Fig. 2.1).
Counselling triangle: While counselling, the doctor
should be acutely aware of the presence of others and
place himself in three different places—his own place,
in the patient’s place and the place of the relatives and
look and listen to himself.
Consent: Consent form is an important documentary
evidence in the consumer forum. Printed consent form
which is usually signed by the patient/relative at the
time of admission, giving blanket consent for all tests
and treatment is a weak evidence. Consent taken
after counselling notes are documented is strong
evidence and can save the doctors from many consumer
cases.
Communication and Counselling
Fig. 2.1: Dr Ashok Godhi explaining and counselling with the
help of a picture
Communication and counselling skills are put to acid
test by worst situation such as when the treatment
results in a severe adverse outcome due to most unanticipated rare complication, e.g. death due to drug
reaction. A successful counselling will convince, console
and calm the agitated and aggrieved relatives who
understand the human limitations of the doctors and
the uncertainties of the medical science. Conversely,
unsuccessful counselling can result in an extremely
unhappy patient even if the treatment of a complicated
disease was successful and the team of doctors were
extremely happy about the outcome.
Counselling is an art more than science. As much a
share of success of a doctor in the practice of medicine
goes to communication and counselling skills as his
medical knowledge and technical skills.
9
SU10.2: Describe the steps of obtaining informed consent
for laparoscopic hernioplasty in a simulated environment.
For medical simulation, a healthy person is trained and
asked to act as a patient. He is trained to mention a few
symptoms and signs. In a similar manner, he will be told
about a surgical procedure and its complications, etc.
Simulation helps in educating trainees/undergraduates so
that their communication skills/performance will improve
when they see the real patient.
I have given one example of informed consent for a
patient undergoing laparoscopic hernioplasty. Every surgery
should have separate consent form. Remember that the
relevant procedure has to be explained in patient’s own
language or in a language that the patient understands. The
patient should not only sign the consent form but also
consent for HIV testing, blood transfusion and anaesthesia.
The steps of obtaining informed consent are as follows:
1. The consultant surgeon will explain about the disease,
why surgery is needed and what type of surgery is
planned (open or laparoscopic) and its complications.
2. He/she will allow the patient to ask any questions and
clarify his/her doublts, if any.
3. The patient, once satisfied, will need to sign on the
consent form for surgery. One witness will also need
to sign on the consent form.
4. The consent form is then counter-signed by the surgical
consultant and indicate his name, date and time.
5. Consultant anaesthetist explains the type of anaesthesia
(regional or general anaesthesia) and possible
complications related to anaesthesia. The patient will
then need to consent for administration of anaesthesia.
This form also needs a witness signature and the
consultant anaesthetist’s signature, name, date and time.
Section I • Basic Principles of Surgery
3
Ethics in General Surgery
Introduction
Principles of ethics
Beneficence
Non-maleficence
Autonomy
SU8.1: Describe the principles of ethics as it pertains to
general surgery.
INTRODUCTION
Ethics in surgery is not something new. It has existed
since ancient times. It existed during Hippocrates
(460–c.370 BC
period, physicians were told to follow strict discipline,
professionalism, and rigorous practice. Generally, they
are advised to not harm people and if possible, help.
Some code of conduct and morals existed even in ancient
kingdom ruled by kings all over the world. We should
know that surgery may cure a patient of his disease or
surgery may save his life but surgery can also cause
disfigurement, disability or even result in more
problems due to complications.
Definition: Ethics is the discipline concerned with what
is morally good and bad, or right and wrong. Surgery
always deals with action and it is related to the body.
Thus it is more relevant today because the field of
medicine has developed rapidly. There are wide range
of investigations available and many of them are costly
also. Developments in surgery have been rapid with
advent of new technologies. These add quality to life
and at the same time, a kind of glamour and sophistication to surgery itself. A treating surgeon often needs to
decide how much he should disclose about the nature
of the disease to the patient or his relatives. He may
also be in a dilemma as to what investigation to order,
and how long and to what extent should he provide
) period also. During Hippocrates
Informed consent
Truth telling
Justice
Life and death
Fig. 3.1: Fungating carcinoma breast with bleeding
treatment, for example, how many days to prolong life
of a patient who is terminally ill and has advanced
malignancy (Fig. 3.1). This chapter discusses in brief
about ethics pertaining to general surgery.
PRINCIPLES OF ETHICS
The four main ethical principles are: 1. Beneficence,
2. Non-maleficence, 3. Autonomy and 4. Justice. Some
alteration of these are not uncommon depending upon
the location, hospital practices and considering religion
and race. The first two can be traced back to the time of
Hippocrates “to help and do no harm”, while the latter
two evolved later. Let us look at each one of them with
examples.
10
Ethics in General Surgery
11
1. Beneficence: This means, as surgeons, we have an
obligation to treat patients who are suffering, possibly
due to pain or any wounds, to relieve them of the
pain or any such symptom. What will you do if a
patient presents to you with a bleeding ulcer?
Irrespective of the paying capacity of the patient, his
race or religion, it is our duty to stop that bleeding,
make him comfortable and then proceed to do what
needs to be done.
2. Non-maleficence: One should not practice evil or do
harm, often stated in Latin as Primum non nocere.
This means surgeons also have an obligation not to
harm the patient. Even though no surgeon would
intentionally harm any patient, his surgery or
investigations ordered also should not cause harm.
For example, a patient with metastatic stage 4 disease
of carcinoma rectum with secondaries in the liver and
ascites presented with intestinal obstruction. The
patient had a past history of myocardial infarction 2
months prior and was on medications. The surgeon
decided to do colostomy to relieve obstruction.
However, the patient died in the postoperative period
due to leakage of ascitic fluid from incision site, sepsis
and cardiac failure. There was an expert available in
the hospital who could have done stenting to relieve
obstruction. The surgeon did not inform him nor did
he take his suggestions. The surgeon can be held
responsible for causing harm to the patient when he
could have managed the situation without surgery.
3. Autonomy: Every adult human being in sound mind
has a right to decide what shall be done with his own
body. He or she has a right to know what disease
he/she is having. The surgeon should give all the
information about the disease, treatment plans and
complications. Without this information, trust never
develops between patient and the doctor. He has the
right to give consent for treatment or refuse treatment
even after the facts have been explained. However,
if the patient is unconscious, mentally disabled, is an
infant or a child, he/she will not be able to take
decisions. A patient with hypotension and shock with
altered sensorium due to gas gangrene has a risk of
loss of limb and loss of life. He may not be in a position
to understand. In such situations, the details, pros
and cons must be explained to the relatives, and
proceed with amputation/debridement after getting
the consent from patient’s
legal representative.
However, if the surgeon feels that a few hours of
resuscitation can improve his mental status, he can
wait for a few hours till he regains normal mental
status and get consent from the patient.
Informed consent: Informed consent is a process of
taking consent from the patient/legal guardian for
Key Box 3.1
Informed Consent
Firstly, the patient should be made comfortable during
counselling and he should be able to comprehend
what is being explained.
The doctor must explain about the condition of the
patient and the type of treatment planned, in the
presence of a witness.
This must be explained in the patient’s own language,
taking the help of a translator as necessary.
The patient’s understanding improves with the use of
simple diagrams to explain.
A written informed consent must be taken either from
the patient or legal representative, if the patient cannot
sign or is minor. The form must have details of the
patient, procedure, expected complications, date and
time of taking consent.
The patient, the doctor and the witness must sign on
the consent form acknowledging the explanation and
giving consent to the procedure.
Only the procedure documented in the consent form
should be performed. If another lesion is encountered as
a surprise finding during surgery, it should not be
excised. Example: During cholecystectomy, the surgeon
finds a 5 cm cyst in the liver. It was asymptomatic. If
prior consent is not taken, it should not be removed.
undergoing any procedure after the procedure is
explained in detail to the patient in his own language
or a language that he understands (Key Box 3.1).
Informed consent in emergency situations: Example:
A patient is unconscious due to head injury following
road traffic accident but has life-threatening bleeding
from a ruptured spleen. In this situation, the treating
surgeon should apply the first two ethical principles:
Beneficence and non-maleficence, and operate. Who
can give consent in this situation? The patient’s legal
representative (spouse, son, guardian, etc.) can give
consent. On some occasions, no relative is present
and the patient is brought in by police personnel. In
this situation, the Medical Superintendent of the
hospital can give his consent to do surgery in order
to stop the haemorrhage by splenectomy/
splenorrhaphy.
Truth telling: A valuable bond develops between the
patient and the doctor when the truth has been
conveyed to the patient. For example, the patient has
gallstone disease with symptoms. The surgeon must
not only explain to the patient about the disease and
the need for surgery but also the type of surgery,
complications and difficulties that can be expected
in the given patient. Any other alternate treatment
options available as per guidelines issued by the
Section I • Basic Principles of Surgery
12
Manipal Manual of Surgery
speciality societies—such as Association of Surgeons
of India or American Society of Surgeons, etc. must
also be mentioned. For example, laparoscopic
cholecystectomy is the surgery of choice but laparoscopic facilities are not available in a rural set-up, the
patient must be informed about advantages of the
laparoscopic procedure, non-availability of those
facilities in that rural set-up and about the facilities
available at a nearby place.
In a few countries including India, when a patient is
diagnosed to have cancer or some serious disease,
the son or daughters often request that the treating
doctors not reveal the facts about the disease or
chances of survival to the patient directly. Culturally,
this is acceptable in a society where a senior member
takes the decision. However, legally this is not. To
get around the problem, the patient can be asked
whether it is acceptable to him, if further treatment
plans are discussed with his son, daughter or brother,
who will take decisions on his behalf. This is
acceptable, if the patient agrees to it.
Confidentiality: Surgeons must not discuss the disease
or patient condition to anyone without permission
from the patient. However, other health care
professionals who may be required to treat such
patients for various medical reasons or for scientific
studies, can be informed. Such situations are also
implied that the patient has been told about this.
However, when there is any doubt regarding presence
of communicable diseases such as HIV or hepatitis B,
or even
who are connected with the patient to protect others
from acquiring infection from the patient.
4. Justice: It is a fair, equitable and appropriate
treatment of persons. Several issues govern this. It
depends upon hospital resources and the time we
give each patient. Is it the same for patients with and
without insurance, paying and nonpaying patients?
Another example is when a physician prescribes an
expensive drug, it may benefit him and there may be
another drug which is equally good and cheap but
does not benefit him.
LIFE AND DEATH
• As of now, euthanasia, intentional killing of a person,
is rejected as unlawful malpractice. The patient may
be terminally ill but conscious and well-oriented. The
use of analgesic medications to the point of causing
death may be considered as an intention to kill. Here,
the surgeon or palliative medicine experts may have
to prove their innocence.
• Patients who are brain-dead or have seriously
Section I • Basic Principles of Surgery
damaged brain, once certified by concerned specia-
COVID infections, one must inform people
lists, are taken off ventilatory support and are allowed
to die. However, the patient’s family or relatives have
to be briefed about his condition and have to be
informed that the decision is taken by a group of
specialists.
Examples
1. A patient with cirrhosis of liver with encephalopathy
is slowly recovering but has a massive variceal
bleeding. The patient is not consenting for banding
therapy when explained by the doctors. If the varices
are not banded, he may die or have serious consequences but the patient does not consent. How does
one proceed in this situation? Beneficence and
autonomy have conflicts. If you follow the rules of
autonomy, you should not proceed. If you follow the
rules of beneficence, you should proceed with
banding. Now look at his mental status. He is a bit
drowsy and has encephalopathy. He is not capable
of understanding what the doctors are explaining.
So now beneficence takes precedence. The specialist
should go ahead with banding after explaining the
procedure, advantages and risks involved to the
patient’s relatives.
. A 65-year-old retired banker was diagnosed to have
2
a 6 cm tumor in the liver, a hepatocellular carcinoma
and a big and suspicious nodule in the lung probably
metastasis. He was advised to undergo surgery for
the liver tumor followed by other modalities of
treatment including chemotherapy and removal of
lung lesion, etc. The patient said he does not want to
undergo surgery as he is scared that he may die of
complications and that he would resort to alternative
medicines. What should be done now? It is his
autonomy, he has taken this decision in spite of
knowing about the disease and probable survival. So,
we should not force him to undergo surgery.
However, if he comes with pain/discomfort/any
other complications later, it is our duty to give him
the best palliation. We can also suggest that he seek
a second opinion. Jehovah’s witness patients refuse
blood transfusion even when they know that their
life could be in danger. This group is a sect of
Christianity. Here autonomy comes into the picture,
not justice.
3. A 70-year-old man undergoes total gastrectomy
followed by esophagojejunostomy for carcinoma
stomach. He was a smoker with COPD, diabetes, also
had myocardial infarction a few months back and was
on treatment. He developed multiorgan failure on
day 6 due to pneumonia and deteriorated very fast.
He was intubated and he went into coma by day 14
and no improvement was seen till day 21. How to
Ethics in General Surgery
proceed in such cases? This is the time to discuss
patient’s condition with his family and explain to
them about his condition, whether his lung condition
is reversible, take them into confidence and
discontinue the treatment.
4. A 75-year-old lady was brought with bleeding per
rectum of 8 months duration and jaundice of 1 month
duration. It was treated as hemorrhoids for a few
months. Rectal examination, biopsy and later MRI
revealed advanced carcinoma rectum infiltrating the
anal sphincter. She also had multiple metastasis in
both lobes of liver. Relatives of many patients insist
that diagnosis should not be told to the patient. How
do we proceed? Call the patient and ask her whether
her disease and best plan of action can be explained
to her son/representative and whether she would
consent for that.
5. A 35-year-old lady underwent hysterectomy for
excessive bleeding. She was discharged after 5 days.
However, she returned after 4 weeks with abdominal
pain, distension and high-grade fever. CECT scan
revealed foreign body—a left-over mop in the peritoneal cavity. The patient underwent exploration and
the mop was removed. She did well and was discharged. What should the surgeon tell the patient?
He has to tell the truth. That mop was left behind by
mistake. One can also apologise to the patient. The
expenses of the second operation or surgeon’s fees
can also be waived off by the hospital authorities and
some amount of compensation can be given to the
patient. Here is a situation of harm caused to the
patient inadvertently by not following certain
guidelines/check lists to prevent them.
6. During COVID-19, an 85-year-old, otherwise fit patient
in Nagpur whose saturation was 60%, who required
an oxygen bed told the doctors in the hospital to give
that oxygen bed to a 35-year-old patient who was
also having 60% saturation since there was only one
oxygen bed available. It was a great sacrifice.
However, if you face this situation in real life in
emergency department, what should be your
decision? Decision cannot be based on wealth of the
patient, influence from the authorities or influence
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Fig. 3.2: Tense ascites with obstructed umbilical hernia
from politicians. A 35-year-old patient has a longer
life. He may be the only bread-earning member of
his family. He may have the responsibility of looking
after his parents. So, he has a definite edge over the
85-year-old man/woman. So, this is fair decision and
justice to resuscitate the 35-year-old man.
7. An advanced case of liver cell failure, portal hypertension, uncontrolled ascites (Fig. 3.2), with large
obstructed ulcerated irreducible hernia with sepsis
for surgery—surgery was done to relieve pain,
fungation and ulceration—only as palliation. All the
details about the risks were explained to the patient.
Surgery was done after consent was obtained. He
died on the 3rd postoperative day of sepsis,
hypotension and shock.
CONCLUSIONS
If you follow guidelines of ABCDEFG of doctor–patient
relationship which is given in Chapter 1 and principles
of ethics given in this chapter, it is a great service to the
humanity. You will give your best to your patients. You
will also uphold the virtues and values of medical
education and ethics.
FURTHER READING
Rev Col Bras Cir-. 2020 Jun 15; 47: 2020. Surgical ethics: a framework for
surgeons, patients, and society.
Section I • Basic Principles of Surgery