[Sent 22 June 2020 to the Surgical Ethics Education working group]
Greetings from St. Louis and WashU. For ‘Surgical Ethics Education Resources #34’, I am sharing with you (inserted below and also attached) a way to frame surgical ethics with ‘trust’ as the linchpin (i.e., the peg or pin that holds a wheel on an axle, that keeps a wheel from slipping off an axle). This explanation is the third of seven brief ‘Ethics 101’ promptings I prepared for our surgery clerkship students. We circulate a prompting every couple of weeks during their 12-week surgery clerkship. I welcome your feedback about this way to position ‘trust’ in framing the ethical dimension of surgical care. Doug
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What do we invite patients and their families to trust about us?
Douglas Brown, PhD
Trust is counter-intuitive . . . involves risk . . . is necessary to work . . . requires courage . . . .
‘Fiduciary’ in ancient Roman law denoted the transfer of a right from one person to another person with the recipient’s obligation to return the right either at some future time or on the fulfillment of some condition. The fiduciary held this right as a trustee with the responsibility to exercise the right on another person’s behalf. In modern surgery, ‘fiduciary obligation’ refers to the trust patients place in their surgeons to act in their best interests. The surgeon receives the patient’s trust because the surgeon possesses the special authoritative knowledge and technical skills to which the patient seeks access. Such knowledge and skills prompt the patient to seek out the surgeon in the first place. The vulnerability acknowledged by the trusting patient creates a fiduciary obligation for the surgeon who accepts responsibility for the patient’s care.
A relationship this special must be rigorously safeguarded. Surgeons who prioritize their fiduciary obligation to patients seriously consider conflicts of interest. Surgeons are among a large and diverse work force that brings to the hospital numerous potentially conflicting priorities. Many surgeons are engaged in clinical research and in training/education healthcare learners, both being responsibilities that use patients as means to accomplish interests other than the patients’ best interests. And surgeons have to navigate the availability of commercially-driven surgical innovations that far too often result in eventual injury to surgical patients and even skew professional organization’s technical bulletin guidelines.
Accordingly, the ethical dimensions of patient care can be effectively framed by asking -- “What are we inviting patients and families to trust about their caregivers?”
Each response to this centering question puts into clinically familiar language one of the four basic intentions that are foundational to surgical ethics -- i.e., to avoid adding to the patient’s pain/suffering (non-maleficence), to make a desired difference in the patient’s well-being (beneficence), to align management plans with the patient’s values and goals (self-determination), and to be fair in the use of limited resources (justice). When surgeons are able to follow through on these four intentions in an integrated way, the ethical dimension of their patients’ care is sound, balanced, in harmony and the surgeons experience what brought them into a surgical career. For cases in which the ethical dimension of care is shaken or broken, the centering question – “What do we invite patients and families to trust?” -- can be an effective starting point for determining which one or combination of the four intentions has failed to such a degree that respect has given way to loss of confidence, suspicion, adversarial defensiveness.
The trust upon which safe and beneficial care depends is a partnership/collaboration between surgical teams and patients (with their families and friends). In order for surgeons to follow through on what they invite patients and families to trust, surgeons need their cooperation, their participation, their assistance. Thus the companion question – “What do surgeons need/expect from patients and families in order to follow through on what they invite patients and families to trust?”
As surgeons work to avoid harm, they need patients and families to provide complete and reliable information. As surgeons seek to deliver desired beneficial outcomes, they need patients and families to make a determined effort to adhere to the management plan. As surgeons establish goals of care that align with patients’ values and preferences, they need patients and families to realize there are limits to what can be achieved. As surgeons strive to be fair in the utilization of limited resources, they need patients and families to consider the interests of other patients and families. These clarifications highlight the accountability patients and families bear for following through on the four basic intentions that are foundational to surgical ethics.
