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First Annual Balfour Lecture
in Surgical Ethics


Donald Church Balfour
Donald Balfour

Donald Church Balfour, 1882 – 1963, received his MD from the University of Toronto, interned at Hamilton City Hospital, and studied surgery at the Mayo Clinic. His father was president of the Balfour Tool Company. Donald devised and introduced numerous instruments – an operating table, operating room mirror for teaching, an abdominal retractor. He married Carrie, Will Mayo’s daughter, and spent his distinguished career at the Mayo Clinic. He became Chief of General Surgery and President of the Mayo Foundation for Education and Research. He received many honors and awards as a surgical educator and scholar. His family endowed the annual Balfour Lecture that celebrates his memory and brings distinguished scholars in Surgical Ethics to teach in our Department.


Charles Bosk
Charles Bosk

Charles Bosk is a distinguished social scientist and a careful student of the tribal customs, values, and beliefs of surgeons. His doctoral thesis in sociology was based on 18 months of ethnographic observation as an active member of the surgical team at the University of Chicago. His publication “Forgive and Remember: Managing Medical Failure” became a classic of the sociology and surgical literature. (The following paragraphs are the Editor’s approximations of direct quotations. They are not verbatim)

Professor Bosk’s areas of specialization as a medical sociologist include professions and professionalization, deviance and social control, field methods of research, and the sociology of bioethics. He has three ongoing funded research projects: 1) how ideas about safety move from national policy-setting bodies formulate ideas about ‘safety’ that then move into administrative offices of hospitals where they are converted into policies that are then embraced or evaded on the floors where care is provided; 2) an ethnographic exploration of mandated duty hour limits on graduate medical education, especially as it impacts patient care and definitions of professionalism; and 3) an intervention to mitigate chronic fatigue in medical residents through a mandatory nap program. He is the author of “What Would You Do?: Juggling Bioethics and Ethnography”; “All God’s Mistakes: Genetic Counseling in a Pediatric Hospital”; “Forgive and Remember: Managing Medical Failure”; and is currently working on a manuscript “Thirteen Ways of Looking at a Medical Error.

“Administrative rhetoric shapes and misconstructs the issue of surgical error. The analogy to airline crashes is a very poor fit that misleads our thinking. If the analogy were carried to its logical conclusion, it would help us deal with explosions of hospitals with the death of all occupants. So, let’s drop the airline analogy. It might be appropriate to think of patients as baggage of different sizes and shapes, and the challenge of medicine might be envisioned as the ability to handle these well. We do better with the management, delivery and safe-guarding of medications than the airlines do with baggage. The handling of patients is a much a larger and complex challenge.

“Quality improvement does not comport well with patient experience. System error has displaced impairment or incompetence of individuals. It is still true that ‘bad apples’ like Dr. Shipman in the UK require individual responsibility, as a focus for management. Our healthcare workers, a ‘vulnerable population’, are suffering from safety program fatigue. New interventions to deal with the challenges outlined in the Institute of Medicine Report ‘To Err is Human’ include rescue teams, electronic records for order entry, the 80 hour workweek and other innovations. Fatigue errors are rare and, interestingly, the 80 hour workweek did not improve outcomes. 80 hours is just 8 hours short of half a week, a long period of service.” In Charles’s study of the 80 hour week, he found that hospital computers were set so that they could not accept more than 80 hours. This resulted in full compliance, an imaginary accomplishment.

“Safety innovations have drained face to face interactions and therefore have drained trust. Technology is opaque, making problems difficult to identify and fix. Interns involved in night float coverage, a remarkably inefficient innovation of the 80 hour workweek, go from a panel of 10 patients during the day (3 sick, 3 safe, and 4 uncertain) to a panel of 60 patients as they cover 6 services on the night float. That means 18 sick and 12 uncertain, an impossible assignment of responsibility.

“System error tends to end the discussion of most clinical errors. No one feels responsible and there is no incentive to solve system problems, which are beyond individuals’ capability to change. Similarly, checklists encourage mindlessness.” In a gracious footnote, Charles referred to his position as an observer and commentator on the problems of surgery. Quoting Mark Siegler, he said ‘I have the counterfeit courage of the non-combatant’.

“Health is a public good that has been transformed into a marketplace good. This creates a tension between the ideal and the real. We need to correct the mistaken assumptions embedded in policy solutions. Fools are cleverer than system designers. It is difficult under current dogma to determine what counts as a mistake.


The Balfour retractor, for many years a staple of abdominal surgery

“There is a lesson to be learned. The job of residents is physically and cognitively demanding. Residents are required to make decisions under time pressure, with incomplete knowledge in the presence of uncertainty. This leads to errors and adverse outcomes, but error is an essentially contested concept. We cannot define it out of context. Residents can only use tentative reasoning in the presence of uncertainty. If A is true, then B may be the best decision in this setting. [If A cannot be known at the time a decision is required, defensible errors can follow.]

“We need to look at health policy on the street level. The IOM Report of 1999 used an unfortunate model – the body count model, where there are 44,000 or 86,000 or 98,000 deaths in the healthcare space caused by error. The goal to cut the number in half by 5 years involved technology, such as electronic order entry, the electronic record, the 80 hour week, and various other system fixes. The ‘To Err Is Human’ Report has led to ‘techno – vigilance’ in the United Kingdom, and technology solutions in the United States. The solution is not more robots, we need more discussion of surgical judgement.

“In medicine, death occurs related to the pathophysiology of disease. In surgery, it does not result from the pathophysiology of disease, because of surgical agency to interrupt the pathophysiology. In medicine, when a patient dies, colleagues ask: ‘What happened?’ In surgery, when a patient dies, colleagues ask: ‘What did you do?’ The challenge for the future is to align the experience of the patient with the experience of the surgeon, and to curb the enthusiasm of surgeons and patients for operations that defy the odds and result in miracles. The value of the ‘time-out’, even though it seems counterintuitive for each individual to say their name prior to the surgical operation, is that it enables people to speak when a later challenge occurs. We need to punish those who do not speak out.

“In the post Greenspan era, we have been taught to think differently about return on investment. Return to capital is perceived as progress. Return to labour is seen as inflation.”

Charles’ goal is “engaging people’s understanding of what they are doing”. He is an enthusiastic student of the great sociologist Elliot Freidson, author of the “Professionalism; the Third Logic”, a thought-provoking critique of the notion that the market or corporate structures like governments or institutions can provide adequate logics or conceptual frameworks for civilization to flourish. His Balfour lecture on Surgical Ethics was a highly praised demonstration of the importance of Professionalism as a guiding framework for addressing important challenges faced by surgeons.


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