Editor's Column:
Giving Life from Death Row and Other Issues in Surgical Ethics
Martin McKneally
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"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.
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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.
M.M.
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