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ACS-sponsored textbook on surgical ethics [ 21 ] in the form of four faculty-
facilitated seminars improved the confidence of residents [ 25 ].
An assessment of a formal bioethics curriculum across 67 residency programs
within an academic center demonstrated that (1) bioethics teaching was considered
valuable by teachers and trainees, (2) there appeared to be mismatch between educa-
tional agendas of the staff and ethical issues faced by residents, and (3) staff and stu-
dents indicated that they felt that ethics teaching had a positive impact, but there was
a lack of formal evaluation to confirm the impression [ 19 ]. The global impact of ethics
education is uncertain. If the ultimate intended goal of teaching ethics is to change
behavior, it is unclear whether acquisition of new ethics knowledge and skills actually
accomplishes this task or improves patient-centered outcomes. There is clearly room
for scholarship and discourse on the subject of surgical ethics education.
Approaches
Current formal approaches to ethics education for surgical residents include inde-
pendent study (e.g., providing residents the ACS textbook), didactic lectures, small
group discussions, and larger group case-based learning paradigms. Among
responding programs in 2008, 76% of surgical residency programs incorporate ele-
ments of ethics education into either their core curriculum or grand rounds, with
only 2% using standardized patients or simulated scenarios [ 11 ].
Ethics education also occurs in a variable fashion throughout residency training and
is often dependent on random encounters and patient interactions. The learning may
rely on modeling the behavior of other faculty or more senior residents, which creates
risk of promoting unprofessional conduct via the hidden curriculum [ 20 ]. Ethics
education occasionally occurs in simulation sessions and is sometimes evaluated as a
component of assessments of competency, such as informally during the American
Board of Surgery Certifying Examination, where oral exam questions occasionally
focus on ethics issues such as informed consent and the disclosure of risk associated
with a surgical procedure. Also infrequently, specific cases may be discussed with a
focus on a real or theoretical ethical dilemma during required surgical morbidity and
mortality conferences. While these can be engaging to learners, these discussions are
often time limited and without defined objectives or forms of assessment of knowledge
transfer. Such opportunities require intentionality and the initiative of an attending or
resident to bring up the discussion points and frame the ethical considerations. While
there may be an expectation of competency in surgical ethics at the completion of train-
ing, the lack of a structured educational curriculum has not guaranteed that surgical
residents will be formally trained in how to approach these issues.
Integrated Clinical Ethics
Ethics curricula that integrate with the clinical and other education experiences of
trainees and rely less on teaching theoretical aspects of ethics have been advocated
as an approach to encourage lifelong learning and teaching of bioethics [ 14 ]. Future
S. Ganai and K.M. Devon