Surgical ethics: a framework for surgeons, patients, and society

Surgery can be defined as the action of man upon man. It can be conceived as both a passionate art, where the matter worked with is living flesh, and a science, where knowledge is dominated by the power of action. The French poet Paul Valery states in his Address to the College of Surgeons in 1938 “All of the science in the world cannot make an accomplished surgeon. It is the Doing that consecrates it1.” In 1529, in “surgical” lessons at the Parisian Hospital l’Hôtel Dieu, the surgeon Ambroise Paré states: “Leafing through books and chatting or prattling about the operating room means nothing if the hands do not put into practice that which reason dictates2”. Since then, it has been recognized that for surgeons, the main goal is not knowledge (episteme), but action (techne). During a surgery, there is always an action by one person, the surgeon, upon another person, the patient. The surgeons are thus required to complete surgical procedures differing greatly from other medical specialties where once a medical treatment is defined, it can continue without the direct involvement of the physician3. Consequently, for surgery there’s primacy of action over knowledge, and thus the definition of an ethics of action (i.e. surgical ethics) is necessary. Ethics is a branch of philosophy that aims to conduct an intellectual analysis of the moral human dimension in all of its complexity. Ethics is concerned with the principles that allow us to make decisions about what is morally right and wrong4. Medical ethics deal with the principles that guide behavior and decisions that concern patients in the clinical field. A specific form of medical ethics that some authors define as a branch of medical ethics has emerged to deal with specific ethical issues and dilemmas specific to surgeons. In fact, surgery embodies several unique characteristics that justify the need for its own ethical approach. For example, surgery hurts before it heals, it is invasive and penetrates the patient’s body and surgical decision-making is generally done under uncertain circumstances5. Moreover, the field of surgery evolves rapidly (i.e. innovation, robotics,) making the surgeon face new and ever more challenging ethical issues. The aim of this paper is to reflect upon surgical ethics and their role in the practice of surgery today. Bioethics in Surgery

Ethics is a branch of philosophy that aims to conduct an intellectual analysis of the moral human dimension in all of its complexity. Ethics is concerned with the principles that allow us to make decisions about what is morally right and wrong 4 . Medical ethics deal with the principles that guide behavior and decisions that concern patients in the clinical field. A specific form of medical ethics -that some authors define as a branch of medical ethics -has emerged to deal with specific ethical issues and dilemmas specific to surgeons. In fact, surgery embodies several unique characteristics that justify the need for its own ethical approach. For example, surgery hurts before it heals, it is invasive and penetrates the patient's body and surgical decision-making is generally done under uncertain circumstances 5 . Moreover, the field of surgery evolves rapidly (i.e. innovation, robotics,) making the surgeon face new and ever more challenging ethical issues. The aim of this paper is to reflect upon surgical ethics and their role in the practice of surgery today.

Surgical ethics: a framework for surgeons, patients, and society
Diana CarDenas, MD, PhD. 1 The practice of surgery is based on the technical capabilities of the surgeon (techne), their knowledge (episteme) and their capacity of judgment (phronesis). Surgeons face situations that call into question moral choices and face ethical difficulties in their daily practice. In fact, innovation is increasing, and as operations become more complex and the risks become greater, the tools necessary to approach an ethically challenging surgical case become more important. Surgical ethics can be distinguished from other medical ethics fields because of its unique characteristics and goals. Ethics lie at the core of professionalism: a proficient surgeon is considered to be not only competent to perform the art and science of surgery as traditionally understood, but also to be ethically and morally reliable. The principlism and the four-box model approaches to clinical ethics could serve as a guide to the surgical ethics discussion. There are five categories of experience and relationships that are especially important in surgery-rescue, proximity, ordeal, aftermath and presence. Ethical reasoning should help surgeons to gives answers to the questions: What should be done? Has the right decision in this situation been made? Cir 47:e20202519   Thus, I will first define the scope of this particular   form of ethics, then present the main ethical issues   faced by surgeons and how surgeons deal with them. Finally, I will show how ethics could impact the development of the discipline of surgery.

Ethics in the Practice of Surgery
The exponential availability of surgical technology and innovation 6 , its use of resources and the need to limit conflict of interest foster the development of surgical ethics today. However, the history of surgical ethics is as old as surgery itself.
According to Namm et al., it dates back to ancient Mesopotamia and Egypt, but its peak can be placed during the eighteenth to the twenty-first centuries, when surgery emerged as the profession it is today 7 .
Surgical ethics are defined as the application of ethics to situations specific to surgical practice 8 .
It is essential to supporting this discipline. Surgical  sutures and cauterizations appears to disrespect the patient's integrity and to contradict the Hippocratic principle "primum non nocere". However, in order to heel the patient, this aggressive penetration into the patient's body by the surgeon is necessary, and for that reason, surgeons must separate the soul and the body, considering the body to be an "object". This object can be disrupted to be healed, and the spiritual part can be respected and sheltered to avoid damaging 11 .
Any disproportionate or futile surgery must be avoided and caregivers should not fall into therapeutic obstinacy. The latter is defined as acts that appear unnecessary, disproportionate or having no effect other than the mere artificial maintenance of life 14  The key to favoring phronesis is to have direct and honest discussions with patients and families regarding the goals of care. This can help avoid futility conflicts and improve surgical outcomes.

Ethical issues in surgery
Surgical decision-making can be viewed as a two-part process. First, there is the 'is it possible to treat' or 'how to treat' aspect, which is a matter of knowledge and technique (i.e. surgical science).
This is translated into an evidence-based practice. Respondents expressed a fairly prudent stance when judging hypothetical innovative scenarios 21 .
In a qualitative study, Zarzavadjian Le Bian et al., described that ethical conflicts were related to risk assessment and doubts regarding methodology, and most participants described ethical dilemma as being irrelevant 22 .  Table 2   • How is the safety of a new technology or technique ensured?
• What is the timing and process by which a new technology or technique is implemented at a hospital?
• How are patients informed before undergoing a new technology or technique?
• How are surgeons trained and credentialed in a new technology or technique?
• How are the outcomes of a new technology or technique tracked and evaluated?
• How are the responsibilities to individual patients and society at large balanced?
Rev Col Bras Cir 47:e20202519 -Patients with diminished autonomy are entitled to protection.
-Autonomy does not mean that a patient has the right to obtain any treatment he or she wishes or requests if this particular treatment is not medically indicated.
-Autonomy can only be exercised after having obtained full and appropriate information as well as having understood it. The decision has to be taken without any undue coercion or pressure.

Statements
The patient must be adequately informed about the benefits and risks of the proposed surgical treatment.
The patient has the right to decide whether or not to accept treatment.
A competent patient has the right to refuse a treatment after adequate information, even when this refusal would lead to his or her death.

Informed consent
Informed consent plays a highly significant role in the patient-surgeon relationship. For patients waiting to undergo surgery, obtaining informed consent is the surgeon's final step in the information process, and giving informed consent is an important decision that the patient must make freely and independently 25 .
For informed consent in surgery, the legal principle emphasizes that the patient is an independent adult who has the capacity and the competence to authorize that which is going to be done to their body and mind. Therefore, any operation that may infringe upon this principle is not only considered to be illegal and liable to result in lawsuits for unlawful injury caused to the patient, it is also ethically unacceptable 26 .

Principle: Beneficence Definition
The principle of beneficence imposes an obligation to act for the benefit of the patient.
Surgeons have to follow professional obligations and standards.
Surgeons should provide appropriate surgical intervention in response to a medical indication and following the consent of the patient.
Each decision must be taken on an individual level.

Statements
Surgeons have the obligation to maximize potential benefits for their patients while at the same time minimizing potential harm for them The patient must not be deceived.

Principle: Non-maleficence Definition
The principle of nonmaleficence imposes an obligation not to inflict harm on others. Surgery should minimize possible harm.
Surgeons must assess the nature and scope of the risks and benefits.

Statements
If the risks and burdens of a given surgery for a specific patient outweigh the potential benefits, then the surgeon has an obligation not to operate. continue...

Principle: Justice
The principle of justice refers to equal access to health care for all. Limited resources including the time surgeons and other health personnel and caregivers devote to their patients must be evenly distributed to achieve a true benefit for the patient.
Resources should be distributed fairly without any discrimination.
With regard to limited resources, there must be proper use of ethically appropriate and transparent criteria.   25 . This way, surgery will not be conceived merely as a practice of applied technology, but as the humanistic art of healing.