 So, the penultimate speaker, I've been wanting to say that for days, is my good friend and colleague Dr. Alberto Ferreres. Alberto is Professor of Surgery and Chair of the Department of General Surgery at the University of Buenos Aires. He's a GI and Minimally Invasive Surgeon. He's the President of the Argentine Chapter of the American College of Surgeons, the President-Elect of the International Society of Digestive Surgery, and the President of the Argentine Society of Medical Humanism. Alberto has not only a medical degree and a Ph.D., but also a law degree, and his talk today is on the ethical care of surgical patients. Alberto. Thank you. Thank you, Peter, for your kindness. First of all, I am really honored to be standing in front of all of you, and I particularly want to thank Dr. Max Iglo, all the Associate Directors of the McLean Center, as well as the McLean family, for the insight and support. I would also like to state that being a fellow, a 2009 fellow, an ethics fellow, made me not only a better surgeon, a better physician, but also a better person. So, thank you, all of you. So, let's move on, nothing too disclose, and this is the overview of my lecture. A couple of characteristics that make surgery unique is that we have to harm every time we operate on a patient before we can achieve healing. In the second place, it's fallible, and there has been a public awareness about the fallibility of the surgeon, who are not gods, but just humans after the IOM report in 2000, 1999 as well. Uncertainty. Many of our decision-making processes under conditions of uncertainty, and one of the issues that we have to discuss is if we can convey this sense of uncertainty to our patients, because many of them will run out of our practice. And last, but not the least, surgery is prone to risk, two errors, anti-complications. We have to deal with complications on an everyday basis. Having said this, also not to forget, we penetrate every time we operate, we can do the scalpel, we introduce a minimally invasive trochan, we are penetrating the patient body, and as Judge Benjamin Cantor also stated a long time ago, the surgeon who performs an operation without the patient's consent commits an assault. So, as Dr. Pellegrini mentioned in his presidential address, surgery is a moral practice. The surgeon should be considered a moral agent, and a moral compass is a tool which is required for everyday practice. So, ethics remains at the core, at the center of the competency of professionalism. So, it's not enough to be an ethical surgeon. We need to be diligent, and what do we mean by achieving surgical diligence? We need to be competent enough to practice surgery, and be ethically and morally reliable. Otherwise, with ethics, it's not enough to take care of our patients. So, the three tenets of a supper surgeon or a master surgeon should be good surgical habits. That means technical skills, 30% according to the research. Supper decision-making skills, 70%, but we have to review these with humanistic and ethical feelings towards the patients, towards our colleagues, and also towards society. Otherwise, you are not going to achieve an excellent performance. Ethical practice means that we have to respect the dignity of our patients, we have to be tolerant of their beliefs, and we have to respect their decisions, whether for approval of our proposal regarding surgery or their refusal. So, we have to do unto others as you will have them do unto you. The patients, we have to remember they have seven basic rights, two or three of them are negative, and four of them, they are really positive. The last one is to decide whether to accept treatment, to be on his or her body to accept treatment or surgery. The goal of this research was to examine, we prospectively performed the incidents on the cause of ethical conflicts during the process of surgical care of patients at our institution, which was approved by the IRB, and we analyzed ethical conflicts which required either an ethics consultation or the surgical residents of the faculty requested some support in the decision-making process or in the relationship with the patient. So, we were really broad and we first of all redefined what meant to have an ethical conflict or an ethical dilemma, and the initial results, as you can see in this slide, were rising ethical conflicts every year from 2009 to 2013, and you can better view this in this diagram. Regarding the causes, most of them close to 50% were issues related to surgical informed consent and through telling, and I will approach the issue of through telling later in my talk. The implementation of palliative care, advanced directive, we covered change in our legislation. The involvement of surgical residents in surgical care, futility, DNR orders, some challenges to address for social patient relationship, and according to our population, advice about alternative treatments or medical keywords. Here in this graphic, you can have a better idea about the incidents of issues related to the surgical informed consent or through telling. Let's go with some reflections. Surgical ethics is related to the recognition of the rights of patients who are requiring our surgical care. So, we have to give answer to two questions. One is the character of the surgeon that has nothing to do with our activity unless the impairment of the surgeon affects its relationship and his or her clinical practice. The second question we have to address, which ought to be the conduct of the surgeon, and this is about right and wrong issues regarding surgical care. The four ethical principles can give a good framework as described by Boshamber Childress in 1979 for the first time, but they were not originally developed based on Sir William David Rose, who had defined the prima facie duties, which included, as you see, non-maleficence, justice and beneficence, and his book, The Good and the Right, was published in 1930. What support gives literature? This is one of the first papers published in 1980 about the ethical conflicts, especially regarding the surgical arena. According to Lockwood, clinical trials were in the first place, surgery for the age and resuscitation measures, informed consent. The barefoot doctor applying to economies of places in the world with scarce resources or lack of appropriate resources, an organ for transplantation was just a concern at that time. More recently, Maccahill published in the Journal of American Colleges of Surgeons, and some of the issues confronted with, surgeons confronted, providing honest information with a strange hope, and I think this is a main issue for us. The uncertainty about the patient's prognosis, many times, which is challenged by the patients are kids of her family, preserving the patient choice, sometimes difficult, and as was said before, withholding or withdrawing life-sustaining support, which is very difficult, especially in huge surgery or major surgery. In 2001, Wagner Meyer from Canada related all these ethical conflicts related also to surgery, and she introduced the issue of making mistakes and concealing information from a patient, not only about his or her prognosis, but about the disclosure of surgical error. This is a paper from Norway about the ethical conflicts, and all are related with starting withholding or withdrawing treatment, but also they include overtreatment and meeting patients' expectations. As has been said, I will not... It depends on this issue about the components of the surgical consent, but regards that the second point, information, we do not only have to give information, but we should give some recommendation, and that's a surgical complication, a surgical consultation concludes with the recommendation, what you should do in my place, or what you should do to my children. But why do ethical conflicts arise in surgery? Well, I have a couple of reasons. There is a team approach versus the Augusta director approach. When I started training in surgery more than 30 years ago, the surgeon was the owner of the patients. Accountability or responsibility was mandatory. We, as residents, were like the owners of the patients of our attendants, and this sense of appropriateness has been fading along the time, and now we are performing a team approach. Hospitalists also in Argentina are developed and many surgeons do not take care on their own of the post-operative course. Communication breakdowns. Young people communicate quite different from all surgeons or expert surgeons, and besides health literacies and other issues, especially in most countries in Latin America, in state-run hospitals. The lack of time, many times young physicians, young surgeons do not have enough time. The lack of trust and the empowering relationship within the physician and his or her patients. This opposition between fiduciarism, as was described a long time ago, versus a contract. Always the fear of malpractice litigation is surrounding the arena of surgical complications and surgical disclosures, not only of errors but about information. We are in mind that in Argentina, as in some other countries in Latin America, we do not only undergo civil litigation, but also we have criminal litigation. A physician can go to jail, and there is also a difference between the behavior of the young versus the old, some grown-ups, the faculty. When a patient comes looking for surgical assistance, he's also asking for help, for support, for advice, and for guidance. So we have been to address all these issues, and many times the path are not that defined, and sometimes we have encountered difficulties when we have to give a patient information about the linear pancreatectomy. Some will try to have as much information as possible, but sometimes we know that we are harming the patients. We can give what the data is, what our institutional data is, or even the surgeon's personal rate of complications on this and that, but we know that sometimes the patients will not be in the best condition to make his decision. So, as Mark Siegler and Johnson told, we have the four issues, the problem of solving tools, medical indications, patient preference, quality of life, and contextual factors. I will not extend on this. The issue of the classics, we could go to John Gregory, start stating about the fiduciary commitment and the role of honesty in the patient-physician relationship, as well as trust, as stated by Marshal Bay-Mai Modines, who was born in Cordova, Spain, and died in Egypt. And then the issue we have to address is how to treat, which is a matter of knowledge and medical science, but the way to treat, and there we are, that's related to medical ethics. The surgeon develops a role as an authority due to whose expertise, training, and knowledge, but the patient is the one who is in a position, in authority to consent, that something is going to be performed under his or her body. As Plato, here we can see the first term of informed consent, and regarding truthfulness, don't be consistent, simply be true, tell Oliver Wonder Holmes. When the event of neurosurgery cashing, and he's one of his colleagues, the Walter Dandy, they have a lot of discussion about how to inform the public, but the son, the Baltimore son published his failures in 1905. Then this, the writer followed by a story announcing that the patient had died. They have a huge approach to this issue in the literature as well as in the media, in the newspaper, and now this has been in the last century. Stetson and Moran, in the paper in the New England Journal of Medicine, offered the council to keep a cautious tongue, which is a moral rule, and that was a safeguard against a malpractice suit, 1934. It's not present time. And so we have to address the issue of truthfulness, whether a way to tell the truth is not the issue, but what is the truth, and when and how to disclose it. There's another truth telling when we have to tell about the truth. But there are different approaches, as you can see in this slide, there are two sides of the coin. One anticipates the need for trust and the other directly points to the necessary life decision making, which is the best. I do not have the advice or the possibility to say one is better than the other. You have to adjust this to each patient. But defining the truth can be difficult because many times we do not know the real facts about the truth. The assumption that the faulty process necessarily leads to the poor outcome can turn this issue. The assumption that the poor outcome requires a faulty process can also make some difficulty to know which is the truth. And the members of the team may have different motivations for disclosure of information. And last but not the least, the different reports of families and patients with their caregivers and surgeons. So the information we give a patient should be tempered by who the patient is and what he or she is ready to hear. Take home messages. Ethical guidance, excellent expertise are needed in the management of surgical diseases to achieve adequate and patient-oriented decision making. Ethical conflicts will probably increase in the future and their surgical ethics will be at the core of surgical training. We have to change our paradigm from the curative model with the goal of curing to the palliative model with the concern to relieve suffering. And the training and education of a modern surgeon should be scientific, evidence-based, up-to-date, humanistic, social, but above all ethical. Thank you very much. Alberto, thank you very much. Thank you. Okay. That was wonderful.