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A Surgical Ethics Course, and A Sad Footnote on the VA

Martin McKneally
Martin McKneally

The Surgery Department organized a one day intensive Surgical Ethics course this spring at the Toronto Convention Centre. It was co-sponsored and managed with the American Association for Thoracic Surgery at its annual meeting. The course used the Teach the Teachers technique that has worked well for teaching bioethics to residents at the University of Toronto for the past 15 years. Instead of importing ethics scholars, we helped expert surgical teachers prepare short talks about ethical issues in their field of specialization.

Cardiac surgeon Vivek Rao discussed the ethics of rationing mechanical support for failing hearts. “There is a natural limit on the supply of transplants, but only an economic limit on the availability of manufactured LVADs.” Nurse Practitioner-ethicist Jane MacIver explained the ethics of surgical decision making, based on her studies of how patients make choices between transplants and LVADs for advanced heart failure. Surgeonethicist Karen Devon challenged caregivers to become involved in the electronic and social media that are becoming a major source of patient information and disinformation. Karen described how former Playboy bunny Jenny McCarthy continues to lead her internet followers to oppose vaccination, based on the disproven myth of a link to autism. Her campaign has resulted in outbreaks of measles, whooping cough and mumps where these diseases had disappeared. Karen challenged us to engage and improve the media by refuting false claims.

Cardiac resident Bobby Yanagawa clarified the evolving and contentious issue of organ donation after cardiac death. “The dignitary rights of dying donors and their families are as important as the legal and neurophysiologic data about the hands-off period. The definition of death is socially constructed and somewhat variable.”

Peter, Rutka and photo of Janes

Donation after Cardiac Death criteria vary.

Harvard thoracic surgeon and Chair of the Society of Thoracic Surgeons Ethics Committee Richard Whyte presented “Explaining our mistakes to patients”, coached by our senior surgeon-ethicist Mark Bernstein who was away during the course. Your editor presented our study of preoperative discussions of life sustaining treatment (describedin Spotlight Fall 2013). Surgeons from Syracuse, Wake Forest, Duke, Ohio State, Cleveland Clinic, Nicaragua, Medical University of South Carolina, Baylor, and Calgary spoke on topics ranging from “When is the resident competent to operate independently” to the “ethics of the learning curve” and “managing the declining competence of aging surgeons”. Our Department will offer another Surgical Ethics Intensive Course next spring.

Course co-director and Medical University of South Carolina cardiac surgeon Bob Sade recently made my day by sending references to two publications championing the fist bump as a safer form of greeting than the handshake (1, 2). I’ll write more about this in the next issue, and give a friendly bump to all who have doubted the wisdom of switching to this cool and safer greeting.

I asked Ken Kizer, our Bigelow Lecturer, whose management transformed the VA health care system, for a comment on the disturbing current headlines about waiting lists, suffering, and deaths of neglected military veterans in the US. Ken has been out of the VAHS for the past 15 years. His description of the current situation is printed nearby. In my view, his remarkable contributions have been undermined by imposition of a command and control regime. Militarizing a health care system under former generals, setting unrealizable standards with inadequate resources, and reluctance to accept unfavorable information inevitably led to falsifying waiting list reports without attending to waiting patients. There is an excellent Perspective commentary by Kizer & Jha in the June 4, 2014, NEJM that has relevant lessons for all health care systems (3).

Finally, after 10 years as editor of the Spotlight, I am searching for an associate editor to work with and then succeed me. I can promise a stimulating experience - interviewing the fascinating people who are guests and members of our surgical family, and learning more than you ever could imagine about the Department that binds us together. Writing about all this is illuminating, because writing requires a level of reflection and justification that exceeds the requirements of conversational discourse. This can sometimes be frustrating but is immeasurably rewarding.


1. Sklansky M et al. Banning the handshake from the health care setting. JAMA online May 15, 2014.

2. Ghareeb PA et al. Reducing pathogen transmission in a hospital setting: Handshake versus fist bump – a pilot study. J Hosp Infect. 2013;85(4):321-323.

3. Kizer & Jha, Restoring trust in VA health care. NEJM.org June 4, 2014.



“The recent allegations that some VA medical centers may have falsified wait time lists to cover up treatment delays for veterans are deeply disturbing. Multiple investigations are underway to determine the validity of the allegations and the extent to which any veterans may have been harmed. It will be some time before the findings of these investigations are known, but I am certain that they will find that the genesis of the organizational malfunction in this case is multidimensional. Skyrocketing demand for services, and especially mental health service, for veterans returning from the wars in Iraq and Afghanistan is certainly a factor. Shortages of some types of health care workers, insufficient funding or budget flexibility, information technology and staff training shortcomings, and possible bad behavior of some administrators also are likely to emerge as contributing factors.

“However, the fact that more than 20 VA medical centers are under investigation for possible improper behavior on the same issue speaks to deeper, more systemic problems. VA leadership has turned over multiple times in the past decade with, unfortunately, a gradual return to the command and control style of management that predominated prior to the organization’s transformation in the late 1990s.

“Concomitant with the changes of leadership has been successive erosion of the principles of quality improvement that were integral to the VA’s turnaround. Hospital managers and clinicians have been less engaged in the development of policies and programs that they would have to implement, and the environment has become less open, or safe, for them to express criticism or dissenting views about the directives. Likewise, while many of the same performance improvement tools, and especially performance measurement, have continued to be employed, these tools are now being used in an increasingly compliance-focused (instead of improvement-focused) environment. These dynamics have been further complicated by the implementation of a pay-for-performance-like incentive program that ties personal financial gain to performance measure results.

“Additionally, it has been known for several years that the information technology and other infrastructure being used to monitor and track patient wait times is inadequate for what it is being used for, although it appears that little has been done to fix the problems. Given all these circumstances, when VA’s leadership changed the wait times performance measure standard from 30 days to 14 days a couple years ago, it became, in essence, a prescription for driving administrators to find workarounds. Predictably, not all of the workarounds would be acceptable.

“On a more positive note, the VA’s current wait times problems are fixable, and there are thousands of hardworking, dedicated VA staff who are anxious to fix them so they can get on with providing high quality care to veterans.”

Ken Kizer

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