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Editor's Column:
Giving Life from Death Row and Other Issues in Surgical Ethics

Martin McKneally
Martin McKneally

"Eight years ago I was sentenced to death for murder. There is no way to atone for my crimes, but I believe that a profound benefit to society can come from my circumstances. I have asked to end my remaining appeals and then donate my organs after my execution to those who need them. There is no law barring inmates condemned to death in the United States from donating their organs, but I haven't found any prisons that allow it." (Christian Longo, Op-Ed., The New York Times, March 6, 2011).

Prisoner Longo raises one of the many interesting and challenging issues in surgical ethics. Linda Wright, Mark Bernstein and I brought a small sample of other surgical ethics issues to Surgical Grand Rounds at UHN in February. We discussed deception, anonymous altruistic organ donation, and surgical ethics education.

Several of our surgeons will soon begin a multi-institutional research project to evaluate the covenant forged between surgeons and their patients when high risk operations are performed. Their mutual commitment is a variant of informed consent unique to the specialty and undescribed in textbooks of ethics or law. Surgeons commit to the postoperative care of these patients at a level of intensity and duration that is startling to some outside the specialty, and conflicts arise in Intensive Care Units around this issue.

The ethical issues related to deep brain stimulation to alter the mind in psychiatric patients are being explored by Nir Lipsman and Andres Lozano. Jane MacIver, Vivek Rao and Heather Ross are studying ethical issues facing patients with terminal congestive heart failure, as they make choices about artificial support and listing for heart transplant. In this issue of the Spotlight, Alex Mihailovic describes the complex international surgical quandaries related to training programs that send their residents to developing countries in order to acquire skills in open surgery.

These are only a few of the challenges in surgical ethics, a field as old as surgery, but only recently developing a formal program of study. Karen Devon, recent valedictorian of our General Surgery program, will study surgical ethics next year at the University of Chicago before returning to the University of Toronto. Orthopaedic resident Mark Camp and Otolaryngology resident Jennifer Guillemaud are currently completing Masters Degrees in Ethics here.

Surgeons from Canada, the United States, Nigeria, India, Pakistan and Kenya have studied at The Joint Centre for Bioethics to strengthen their skills in surgical ethics. Encouraged by these developments, my hope is that one day the University of Toronto Surgery program will be identified with expert training in surgical ethics. When surgeons think of Stanford, they think of heart transplantation. When they think of Toronto, they think of lung transplantation among other strengths. Some day our brand will include an identification with surgical ethics if all goes as we hope. We have received encouragement from Dean Cathy Whiteside to develop a program to complement the Surgeon Scientist Program, enabling surgeons to study surgical ethics formally. Meanwhile, all of our surgical residency programs have ethics coordinators with varying levels of training through the Teaching the Teachers Program, the Executive MHSc program and their own formal and informal self education. Mark Bernstein's impact on the neurosurgery division is an outstanding example of the effect of formal ethics training.

A recent survey of surgical residents and ethics coordinators to be published in a forthcoming issue of the American Journal of Surgery describes the views of residents and coordinators. The responses to this qualitative inquiry were encouraging. Graduating chief residents from 22 programs, including but not limited to surgery, told the researcher that "my ethics training was as important as my formal medical training." Senior surgical residents had a much more positive view of ethics training than junior residents whose experience with ethical issues is limited. There is a tendency for senior residents and staff to conduct conversations about complex ethical issues (like intraoperative or impending death) with families and patients while junior residents are dispatched to set up the next operative case or manage problems on the floor. Including junior residents in these conversations more frequently will provide powerful lessons from their role models.

When I described our program at a recent Surgical Grand Rounds in the United States, the surgeons in attendance expressed enthusiasm and admiration for ethics education in its present form in Toronto. There is much to accomplish to strengthen this program. I encourage trainees and faculty to become engaged in the next iteration of surgical ethics in the Department of Surgery. For more information, contact martin.mckneally@utoronto.ca. Our surgical chairs have been very supportive of this program and look forward to its flourishing.


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