Ethics In Severe Surgical Cases

Peter Johannes Manoppo

Bioethicist, General Surgeon

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science is gold mine, ethics is mine field
__________________________________________
science is gold mine, ethics is mine field
 References
 Beauchamp, Childress. Principles of Biomedical
Ethics, 5th Ed, Oxford Univ Press, 2001, pp 57-187.
 Christian J. Vierkleur et al. The Surgical Decision-
Making Process: Different Ethical Approaches.
Surgical Ethics Principles and Practice, Springer
2019, pp 193-201.
 Joan C. Tronto et al. An Ethic of Care. Ethics in
Community Based Care, 2001, pp 60-68.
 Pengurus Besar Ikatan Dokter Indonesia. Kode Etik
Kedokteran Indonesia, 2012, pp 31-51.
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science is gold mine, ethics is mine field
 Background
 Severe surgical cases have many challenges: high
morbidity & mortality, bad prognosis, difficult surgical
procedures, anesthetic problem, complications of illness
& surgical/anesthetic procedures, ethical concerns.
 Other burdens: resistant surrogates, golden hour rule for
damage-control & life-saving, unilateral decision making,
high recovery-expectation of patient/family, surgical-buy-
in effect, pre-op preparation, post-op care.
 Ethically appropriate surgeries should always be done in
any circumstances, with among-others points: autonomy,
beneficence, non-maleficence, justice, care ethics, dignity,
informed-consent, paternalism, RDE, deliberation.
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science is gold mine, ethics is mine field
 Objectives
 To know: what & how are the proper ethical ground of
the surgical procedures on severe surgical cases.
 To understand: the ethically appropriate those surgical
procedures, so that would be able to avoid futile
treatment, to decide withholding & withdrawing
procedure, based on ethics & patient best-preference
(quality of life, patient safety).
 To do: ethical surgical procedures on any
circumstances, even based on paternalism, RDE,
coercion.
 To be: ethical clinician & surgeon.
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science is gold mine, ethics is mine field
 Methodology
 Students: lectures, ethical dilemmas discussions,
ethics-inserted problem based learning.

 Surgical residents: lectures, bed-side ethical

deliberation, ethics-inserted case report, hospital-
ethics-committee attendance.

 Surgeons: lectures, benchmarking, hospital-ethics-

committee attendance.
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science is gold mine, ethics is mine field
 Problem Statement
 Severe illness.

 Surgical challenges.

 Anesthetic burden.

 Bad prognosis.

 Ethical concerns.
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science is gold mine, ethics is mine field
 Ethical Deliberation
 Autonomy.
 Non-maleficence.
 Beneficence.
 Justice.
 Paternalism.
 Rule of double effect.
 Utilitarianism.
 Care ethics.
 Dignity.
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science is gold mine, ethics is mine field
 Case Study 1
Surgery in infancy.

 Physical state ?
 Autonomy ?
 Surrogacy ?
 Informed-consent ?
 Surgical buy-in ?

Picture source: Jimmy Kimmel, ABC.

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science is gold mine, ethics is mine field
 Case Study 2

Surgery in multiple trauma.

 Golden hour rule ?

 Autonomy ?
 RDE ?
 Withdrawing ?
 Withholding ?

Picture source: Google search.

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science is gold mine, ethics is mine field
 Case Study 3
Surgery with
complication.

 Clinical burden ?
 Autonomy ?
 Non-maleficence?
 Patient safety ?
 Truth-telling?

Picture source: Google search.

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science is gold mine, ethics is mine field
 Case Study 4

Surgery in elderly.

 Autonomy ?
 End-of-life care ?
 Prolonging life ?
 Do nothing ?
 Quality of life ?
Picture source: Google search.
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Science is gold mine, ethics is mine field
 Conclusions
 Unexpected clinical situation might inflict ethical
dilemmas.
 Surgeons ought to perform ethically appropriate
on any circumstances.
 Focus not merely to clinical context but more
important to act on proper ethical ground.
 The more treatment modalities & surgical-team
members, the more ethical concerns arise.
 Further research on this issue is needed, based on
higher expectation for better ethical surgical
performance in the future.
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science is gold mine, ethics is mine field
 Thank You

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science is gold mine, ethics is mine field