379teaching ethics becomes an opportunity to address “difficult to teach” Accreditation
Council for Graduate Medical Education (ACGME) core competencies including
professionalism, communication skills, and systems-based practice, allowing resi-
dency programs to fulfill ongoing milestone-based assessments that are required
according to the Next Accreditation System [ 22 ]. While surgical ethics is still a
developing field, there are numerous exciting prospects for scholarship and dis-
course related to its role as an applied philosophy exploring ever-expanding techni-
cal advances and their impact on clinicians and patients.
Prior Inquiry
A small body of literature serves as the basis for guidance in the development of
future ethics curricula. Most of the empiric studies on surgical ethics education have
been summarized in a systematic review [ 13 ], which synthesized overarching educa-
tional goals related to (1) cultivating virtuous physicians and (2) teaching skills for
the recognition and management of ethical dilemmas that develop in the ordinary
course of patient care. While cultivating virtuous physicians is challenging to mea-
sure, an Aristotelian virtue-ethics-based framework has been suggested as an ideal
way to discuss, evaluate, and remediate the six ACGME core competencies through
exploration of associated virtues and vices [ 18 ]. Recently, interviews and focus
groups have shown that ethics issues are naturally dealt with in the “hidden curricu-
lum” of surgical training, yet when they are presented formally, they gain signifi-
cance and become identifiable to the learner for discussion [ 15 ]. Further integration
of ethics into objective standardized clinical exams (OSCEs) for assessment and
evaluation was found to add greatly to the educational process for learners [ 13 , 15 ].
From the perspective of both program directors and learners, surveys suggest
that the ideal method for ethics education is by case-based learning, which can be
reasonably implemented in traditional surgical teaching conferences [ 9 , 12 ]. Expert
opinion suggests that ethics curricula can be designed with a focus on different
learner levels [ 17 ], as well as by covering different topics using a modular approach,
as done in the ACS textbook [ 21 ]. An interventional study on teaching informed
consent to surgical residents that used pre- and posttest evaluations demonstrated
that psychomotor processes of ethics can be taught using mixed methods and result
in an improvement in a resident’s level of confidence over time [ 2 ].
While many of the aforementioned studies demonstrate enthusiasm for design-
ing and implementing curricula, there are few studies in which there is rigorous
evaluation of the process of teaching ethics other than pre- and posttest surveys.
Brewster and colleagues utilized standardized patients to simulate three aspects of a
complex case: informed consent for resection of a retroperitoneal sarcoma, an inani-
mate team-based simulation of their handling of an intraoperative catastrophe dur-
ing caval dissection, and a videotaped review of the resident disclosing the adverse
outcome to the patient’s (simulated) wife [ 5 ]. Residents found this to be a valuable
learning experience, with particular value gained from debriefing their emotions
and performance. Another study showed that implementation of elements of the
21 Teaching Surgical Ethics