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EDITOR'S COLUMN

Surgeon Ethicists

Martin McKneally
Martin McKneally

Chairman Jim Rutka’s column celebrates the approval of new pathways to academic promotion in our department. The Global Surgery path has been recently described (see 2016 Surgical Spotlight article) and will receive more attention in the spring. I will describe here some of the work of our surgeon-ethicists, to give readers a sense of where this new path leads.

Mark Bernstein, our first executive MHSc bioethics scholar, completed his Bioethics Master’s degree while serving simultaneously as UHN Division Chief of Neurosurgery. His energetic teaching and research has brought neurosurgical residents, fellows and faculty into surgical ethics, and enriched the education of a broad range of graduate and undergraduate students.

Senior Neurosurgery resident Nir Lipsman, Division Chair Andres Lozano, and Mark Bernstein are charting the unfathomed ocean of ethical issues in deep brain stimulation for an expanding range of conditions – including anorexia nervosa, memory loss, and intractable depression. For example, in a seminal article in the journal Bioethics, the question is examined whether the device or the patient is the source of volition. Nir writes: “The stimulation device releases constraints imposed [by depression] and restores [the] experience of being in control of... behaviour…. It is thus compatible with distinct philosophical conceptions of free will…if one’s desires to act are too weak to develop into plans of action, then DBS may be able to enhance these desires and thereby facilitate the performance of actions one wants to perform. In this respect, the stimulation device can enable one to be an agent in the fullest sense.” [Lipsman N, Glannon W. Brain, Mind and Machine. Bioethics 2013; 27:465-470.]

Senior General Surgery resident Megha Suri’s moral reasoning about truth-telling in the setting of a poor prognosis provided surgeons with a nuanced and more realistic account of the spectral nature of truth-the ‘objective’ truth revealed by brain imaging of metastases, the subjective versions of the truth – one known by the family that mother shouldn’t be told for various reasons known best by them, and another known by the patient -that she is dying, and doesn’t want or need punitive disclosure of technical details learned through tests. [Suri M, McKneally M, Devon K. Tragic Knowledge. World J Surg 2014;38:1626- 1630.] Working with endocrine surgeon Karen Devon, Megha underlined the importance of maintaining hope while harboring tragic knowledge, and taught us that the half-life of surgical truth is 45 years.

Colorectal surgeon Ryan Snelgrove, working with Karen, is evaluating the effectiveness of “Ethics M&M” as a technique of integrating ethics teaching and learning into the experience of surgeons in their familiar and trusted conference venue- instead of a separate event like an ethics lecture.

Pediatric orthopedic surgeon-ethicist Mark Camp studies patients’ views about conflicts of interest that arise when surgeons work with industry.[Camp MW, et al. Patients’ views on surgeons’ financial conflicts of interest. J Bone Joint Surg AM 2013;95:e9(1-8)] With colleagues at the Hospital for Sick Children, he is also developing web-based decision aids to help anxious parents better understand the operations their children require in the frightening setting of traumatic injury.

Mark, Ryan, and Karen have organized three Surgical Ethics courses in the Department. The 2017 version is advertised nearby. It will include analyses of interesting ethical questions such as “What is the Global Surgeon’s moral responsibility for the management of post-operative complications that arise long after leaving the patient in Africa?” “Can Medical Assistance in Dying provide a source of organs for transplantation? Will altruism confuse the motivation of patients seeking to end their lives? Will trust in the reliability of anesthesia in the Operating Room enhance the attractiveness of donation as a way to terminate unbearable suffering?”

Congratulations to our Chair and the advisory group of surgeons who are advancing the programs of Surgical Ethics and Global Surgery by formal recognition, as the Department has done so well with Surgeon Scientist and Surgeon Educator programs. They have established the reputation of the Department, recognized by our recent enthusiastic external review, as one of the leading academic surgical centres in the world.

MM




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