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Deficiencies have been noted in the formal education of surgical residents in
processes of moral reasoning [ 6 , 9 , 12 ]. While 98% of surgical program directors
agreed that an ethics education could improve one’s ability to handle ethically chal-
lenging situations, 47% reported that limited faculty with ethics expertise was an
impediment to this process [ 12 ]. While an excellent case-based curriculum is cur-
rently available through an American College of Surgeons (ACS) textbook [ 21 ],
with a new edition forthcoming, textbooks alone may be considered time- consuming
and onerous for busy surgical residents who need to prioritize their learning objec-
tives. In particular, if their ethics curriculum is informally structured, there may be
deficiencies in their ability to effectively address the spectrum of real-world sce-
narios they will see in practice. Skills including learning effective communication
and negotiation may be better facilitated in a small group setting or from a video
than from a textbook.
The reported prevalence of the six ethical issues discussed in the ACS text is
encountered at least once per rotation by surgical residents and when surveyed
ranges from 75% for competition of interests to 100% for end-of-life issues [ 25 ].
During their junior years, surgical residents are exposed to dilemmas in truth- telling,
confidentiality, professional obligations, surrogate decision-making, and end-of-life
care several times per rotation and deal with conflicts of interest several times per
year [ 6 ]. While these issues are seen in practice by surgeons, barriers to formally
teaching ethics have included (1) a preoccupation with scientific and technical
aspects of medicine, (2) time constraints, (3) a lack of support by faculty in planning
ethics sessions, and (4) a tendency of residents to view ethics as peripheral to their
learning agenda [ 9 ].
The Impact
Ethical dilemmas are ubiquitous in surgery. They impact the surgeon-patient rela-
tionship and interactions between physicians, patients, nurses, and other healthcare
providers. They influence society at large when distributive justice considerations
are made, including policy changes secondary to advocacy as exemplified by pas-
sage of the 2013 HIV Organ Policy Equity (HOPE) Act, a surgeon-led initiative that
has expanded transplantation allocation between HIV-infected donors and recipi-
ents [ 4 , 10 ]. Justice considerations related to structures, processes, and outcomes of
healthcare delivery are commonplace, including addressing disparities in access
due to socioeconomic and geographic disparities (using deontological, duty-based
frameworks) and allocation of resources for trauma and combat triage (using utili-
tarian, outcome-based frameworks). The potential impact of improper handling of
ethics in practice also includes communication breakdowns leading to distrust and
possible malpractice liability and inappropriately increased costs due to mishandled
end-of-life decision-making.
The impact of a lack of teachers (surgeons and non-surgeons educated in ethics
or interested in teaching it) has direct effects on learners by creating a void in the
process of education that may need to be filled later in their careers. Conversely,
S. Ganai and K.M. Devon