 Finally, the last speaker in the session, not quite reproductive ethics, though surgical ethics very much has important implications on the fields of gynecology and obstetrics is Dr. Peter Angelos. He's the Linda Kohler Anderson Professor of Surgery and the Chief of Endocrine Surgery at the University of Chicago. Dr. Angelos is president of the American Association of Endocrine Surgeons. An accomplished author, Dr. Angelos has published many journal articles and book chapters on his research into improving outcomes of thyroid and parathyroid surgery, minimally invasive endocrine surgery, and best practices for thyroid cancer treatment. Dr. Angelos co-edited a recent book entitled Ethical Issues in Surgery. He's recognized in medical ethics and serves as associate director of the University of Chicago's McLean Center for Clinical Medical Ethics. He's regarded as one of the country's leading surgical ethicists, and in the 12 years that he's been at the university, he has promoted fellowship training for more than 60 surgeons. Today, Dr. Angelos will give a talk entitled Surgical Ethics 30 Years Later. Please give a warm welcome to Dr. Peter Angelos. Julie, thank you very much, and thank you all for letting me be part of this session, because clearly I'm not doing anything with respect to reproductive ethics, although I think it is good that ethicists reproduce. So I am very thankful for Mark for allowing my talk to be moved into this session, because I unfortunately won't be able to be here tomorrow during the surgery session. I have no financial disclosures. I do have a disclosure that Mark told me I have 20 minutes, not the 10 minutes noted in the program. So if you're looking at the program and think this is unethical, he's talking for too long, Mark said it was OK. So I just want you to know that. I want to talk about sort of where we were 30 years ago, a little bit about where I think we are now, and some thoughts about where we might go in the future. And I'm going to try to certainly end on time, because I know there's a break following me. So I want you to think back to the fall of 1988. So 30 years ago, fall of 1988, lots of people were going to see Rain Man. Die Hard was in movie theaters, as well as a fish called Wanda. And many of us who are old enough really enjoyed that movie. The first major computer virus infected computers connected to the internet. It was big news, a virus. Who knew? And there were lots of men's fashion trends that were significant. I won't share many of them with you, but this was very popular. I personally could never pull this off. So I don't have any pictures of what I looked like in the fall of 1998. But that was when I was applying for residency. And so it was a memorable time for me. And I was at Boston University. I had spent time getting a PhD in philosophy and then had come back and finished my, was in the process of finishing off my fourth year. And I went to talk to the dean of students about what I was going to go into, because you need a dean's letter to apply for residency. And when I told him that I was going to go into surgery, he burst out laughing and said, surgery, that's crazy. Why would you go into a mindless technical discipline like surgery? And so I have often thought of that and thought about whether surgery is, in fact, a mindless technical discipline. And I don't think it is. And I could give you lots of arguments for that, but I won't. Instead, let me just suggest that there are and have been challenges to teaching ethics in surgery. Some of that has to do with this notion that there's so much to learn. So that in surgery, it's not only learning about the anatomy and the physiology and the disease processes, but it's also learning the technical skills of doing an operation and doing it well, hopefully. And certainly there is this, I think for some, there was, 30 years ago, a feeling that if you spent a lot of time talking about ethics, that would take away time from learning about the technical discipline of surgery, which is critical. And I do remember as an intern, there was a lot of discussion about work hour restrictions. And the chair of my department said, absolutely, we could limit your hours to 80 a week with no problem. Your residency would just be 10 years instead of five years. And none of us thought that was a good idea. Certainly now, we've learned that we can, in fact, train surgical residents on an 80-hour work week in five years, so it's amazing. I do think that there was, for a long time, a sense that surgery demands decision-making, and soft topics like ethics were hard to put into the curriculum. And there was no question that new technology and techniques pressure surgeons to learn more. And to some extent, that idea of trying to keep up maybe led people to believe that ethics didn't really have a role in surgery. I can tell you that even though I wrote a personal statement about how I was going to integrate ethics in a surgical career, nobody asked me about it in my interviews. None of the surgeons, except one who was the chair at Northwestern where I ultimately went. So why was surgery slow to adopt ethics? Well, again, lots of potential reasons. I think that for many reasons, surgeons are often very conservative. And there was, for many people, a sense that there was no tradition for surgical ethics in the history of surgery. And I thought that this was a fascinating idea. One of my senior colleagues, we were talking about how there's so much more attention to ethics now in surgery. And he joked, and he said he had trained in surgery before there was ethics. And I tried to correct him and say, I don't think that's what you meant. I think perhaps you meant before there was formal teaching in ethics. But nevertheless, I think that there was ethics in surgery and has been for years and would hate for anyone to think that I thought otherwise. But I do think that there is a bit of a tradition that has, for various reasons, kind of been lost. And one of my weaknesses is old books. And my wife will attest to the fact that I spend way too much time and money buying old books. But I did find this book that I thought was really fascinating. It's very short, The Ethics of Operative Surgery by Sir William Stokes from 1894. And I was absolutely astounded by this, and I couldn't wait to buy it, of course. And Dr. Stokes wrote, it might be that in the minds of some zealous operators, it may have had a tendency to beget an overweening confidence in the powers of our art. The result has been that the ethical principles, which should always guide us in our operative work, have, at times, I think, been neglected. And operations undertaken that in the present state of our knowledge have, I fear, overleaped the pale of legitimate surgery. Now, that's perhaps not the way we would say it today. But I think that this sentiment is very much captured in the M&M discussions today, because surgeons often have to temper their enthusiasm for an innovative operation in the context of potential complications for which the patient will be at risk. And so surgeons often feel, you know, it's just a great new technique, it's so cool, it would be great, and yet it's the patients who are the ones that may be at risk. So let me suggest a few contemporary strategies for teaching surgical ethics that we have used here and now in lots of other institutions are being used. Ethics M&M discussions, I think it's a great time to get the department together to talk about things. Certainly, conferences devoted to cases in surgical ethics are important. And the McLean Center Surgical Ethics Fellowship has been, I think, a great way to offer some surgical residence fellows and faculty the opportunity to gain this greater depth in clinical medical ethics. And I did count, there's a few errors in the listings, but I corrected them. So 69 surgeons have been McLean Center Ethics Fellows, including the current cohort. Prior to 2007, it was 5%, so 12 surgeons. And since 2007, 69 surgeons, or 24% of the fellows have, I'm sorry, 24% of the ethics fellows have been surgeons. Why the increasing numbers? Well, I think possibly several reasons. I think that there's this increasing realization of the importance of ethics in the practice of surgery. I think that there's been role modeling from faculty who have done the fellowship. I think most importantly, surgical residents and fellows who have done the fellowship recruit others. They are better at recruiting fellows than I am because they trust each other more than they trust me. I think that the enthusiastic support of department leadership has been critical. And perhaps it is this idea, if you build it, they will come. So it has become, to some extent, a point of distinction for our residency that people who have an interest in ethics, who are going into surgery, know that we have such a program here and they tend to wanna come. And so it becomes this self-fulfilling prophecy. Certainly, organized surgery in the American College of Surgeons has been much more supportive of surgical ethics than in years past. There's been a long-standing ethics colloquium which continues and lots of former fellows and people in this room have participated. There is every year a John Jay Connolly Ethics and Philosophy lecture, which we've had good representation from the McLean Center at Giving. There's increasing surgical ethics elsewhere in the program. Town Hall meetings meet the expert lunches, panel discussions all related to ethical issues in surgery. And I do just wanna highlight there's been a scientific forum session on ethics where we present empirical research related to ethics and end-of-life care. This past year was the fifth year of such a dedicated session. And it was truly a full room. There was standing room only during that session. And for those of you who are thinking, well, maybe I'll submit something. October 2019, the meeting is and the abstract deadline is March 1st. So get working on your abstracts. I think that the ACS, McLean Center Surgical Ethics Fellowship, this has been a joint program with the American College of Surgeons started in 2015 and we've had a national selection process and partial support for surgeons to come and be ethics fellows. And I think this has been a really valuable program in getting the word out about the importance of surgical ethics. There is an organization that is known as the Consortium for Surgical Ethics. Initially started through support of WASHU and the McLean Center. And it was initially this informal networking dinner of surgeons at the Clinical Congress, 30 to 50 attendees for each of the last six years where we've had discussion of challenging cases, networking, we've now incorporated our 501C3 organization and so people in fact can become members more formally. There's been interest, the American College of Surgeons published this book, Ethical Issues in Surgical Care. And of the 21 chapters, 15 were written by former surgical ethics fellows of the McLean Center. I think that that is a significant thing. What about the next 30 years of surgical ethics? Well, I think that there is an absolute necessity for continued growth of scholarly work. I think that we have to really critically think about some of the topics that come up in the practice of surgery on a regular basis and perhaps don't get enough specific attention. And I think that's something that I would challenge everyone and really all of us who are interested in clinical ethics to think about scholarly work in the area. I think that in surgery, it's important to further integrate the ethical dimension into surgical education. And I think that it's great that now there are sessions devoted to ethics, whereas 30 years ago there weren't. But I think that the Holy Grail is integrating the discussions into all of the education that we have of surgeons and other specialists. I think that there are some singular topics in surgical ethics in the years to come. And I'll just suggest a few of these. And I would love to hear other people's thoughts. And the good news is when you predict the future, nobody remembers what you say, so you're never proven wrong. But a few thoughts. So I think that there are gonna be challenges for surgery to prevent diseases rather than to treat diseases. And what I mean by this is, if you can imagine, I'm an endocrine surgeon, so I treat lots of patients with thyroid cancer. If someone comes to me with thyroid cancer and I operate on them and they have a complication, that's unfortunate, nobody wants that. But patients generally feel, well, I had cancer and they treated my cancer. Increasingly now, we identify genetic predispositions to diseases. And so we operate on patients because of their genetic predisposition. So for example, a child is born who has MEN2B. We know, based on the genetic defect, that this child is 99.9% likely to get medullary thyroid cancer. And so we surgeons offer prophylactic total thyroidectomy. Well, again, when you think about the risks and benefits, if there's a complication in someone who had an operation for a disease that they never actually got, it changes the emotional ramifications of that complication. And my feeling is that, especially when it's parents making decisions for children, there's a tremendous sense of guilt if there's a complication because many patients believe that maybe they wouldn't have gotten the cancer anyway. And so even if we're not talking about kids, if we're talking about adults, increasingly now we know the genetic predispositions to diseases. And I think that this will change the way we think about informed consent in the future. I do think that we need to spend a lot more time focused on informed consent and what in fact constitutes high quality informed consent. Because if you ask patients about how good was their informed consent, how satisfied were they with their informed consent, the vast majority of them are incredibly well satisfied despite the fact that they don't remember 90% of what their surgeon told them about risk benefits and alternatives. And I had surgery this year and can tell you that my own decision making didn't really follow the paradigm that we teach about how patients make decisions. So I think we really need to rethink that and I think that's critical in surgery and as well as in other areas of medicine. And then finally, I think that we need really further attention how to integrate innovative surgery into surgical practice. And so the future of everything in medicine is innovation. And so how do you move those innovative ideas from a concept to treating patients while still putting patients at the least amount of risk? And I think this is critically important in surgery because at the time that patients are undergoing an operation, they are in the most vulnerable position possible in that they are completely at the hands of their surgeons. So I would just like to thank you all for your attention. I'm happy to answer any questions. I wanna thank the McLean Center and especially Mark for his incredible support of surgery and surgical ethics here at the McLean Center. Thank you very much. Peter, hi, Christy Kirschner. So I've been thinking about payload of surgical cardiac interventions recently. My mother-in-law died this year as a result of a cardiac intervention that I would call a Hail Mary pass. I mean, it was sort of the only option that was left. And it raised the question for me again of DNR and the ability to suspend the ability to keep a DNR for a high risk palliative procedure and how interventionist insurgents are thinking about that issue. And I wonder, that's not on your list, and I'm wondering where surgeons are at this point in terms of whether they're moving in the direction of increasing comfort of saying it's okay to draw lines. And we can have that as part of the informed consent process that we know this is a high risk procedure. And if X, Y, and Z happens, this is where I would draw my line. Sure. What would you say about that? Yeah, I think that that's true. That is a very good, it's a great question and certainly the issue of limitations and things like DNR orders in the operating room or in the interventional suite. I think that it is important. I think that there's been a lot of work probably 15 years ago about writing policies. And so now lots of institutions have policies that allow things like what is known as required reconsideration where the surgeon and the patient and the anesthesiologist have a conversation about what are the limits of their advance directives and some agreement is drawn as to what we're gonna say is resuscitation as opposed to general anesthesia, for example. I think that the interesting fact, I would say at least based on my observation is despite these great policies, almost every place in fact requires patients not by virtue of a policy, but just says, well of course we have to just suspend your DNR order. And so I would agree with you. I think that that is something that needs continuing attention and I'll add a fourth bullet point. I think that's a good one. I would also say the concern about surgeons and interventionists being judged by their statistics needs to be resolved because when there's such high risk palliative procedures, I think we should say thank you. Thank you for using your skills to try to help and improve the quality of life of this individual and you shouldn't be punished for it. So that's something else I'd put on your list. Good point, thank you, yes. Hi Peter, I'm Alexia Torquay from Indiana. Thank you for this talk and just for all the work you've done in this field. It's just really amazing the growth of it. I had a question actually about teaching, particularly at the resident level. And the thing you said about, I mean, residents, surgery residents of course work incredibly hard, incredibly long hours. Even for me, when I was a tired medicine resident, I was most interested in something that would help me save my patient that night on call. And every time something touchy-feely came up, I thought it was a good idea for a nap. And so I do wonder, even I loved ethics. So what strategies do you find are the best ones to engage very busy, very hardworking residents who are worried about the nuts and bolts of learning to be a surgeon, to get them engaged in these important issues? Yes, thank you for asking that. What I would say we have found here is that it is very much focused on the actual patient care. And so for example, I talked about M&M. So once a month, we'll designate a case for the ethics discussion. And so the residents know, or fellows, know that they're assigned for the ethics case. So that's coming up. And by presenting a case where it's really not clear what the right answer is and putting people in the position of thinking about, well, what would you do if you were the one trying to make that decision? That's what I think engages people. If you can push people to the point where they have a certain level of discomfort, that's when they want to know, well, how am I going to get rid of this discomfort? I think that even to see faculty disagreeing about what the right answer is, is valuable because in some ways it reinforces the fact that these are hard things often to discuss and to deal with. So I would say making it real and case-based and engaging surgeons to model the fact that these are important topics. I think that that's critical. Thank you very much. Maggie Moon from Johns Hopkins. And I always love to hear you speak. It's wise and it's calm. And it makes me feel like we're heading in the right direction. And then this week there was a really interesting essay published in the New England Journal. I don't know if you saw it. It was a resident in ENT in Boston, I think, sort of crowing about comparing her residency to this doomed North Pole expedition and sort of crowing about fainting in the OR and lying about duty hours. This sort of the thing that I thought we had walked away from in surgery. And if you haven't read it, you ought to read it. It's sort of fascinating and completely distressing. And I just wondered about what it meant, what that sort of language means about the hidden curriculum. I mean, it was published in the New England Journal, which really surprised me too, because it just feels like it's time to get past some of this. But I just wondered how it feels for the trainees. I mean, are they hearing the same thing that you're hearing? And what does this mean? Sure, yeah. I mean, I must say I have not read that piece, but I'm going to go look for it right away. To me, that's very troubling, because I do think that there is clearly a hidden curriculum. I would hope that one aspect of that hidden curriculum is a sense of professionalism about what we're doing and why we're doing it. And I fully believe that there is a challenge when it comes to work hours and even reporting work hours, and there are tensions. But I do think that we should, as a profession, have gotten beyond that. So I am quite curious to read it, because it seems like that's not the message that we really want to be sending. And certainly not what I think should be what is most attractive to people who think about going into surgery or surgical subspecialties. Yeah, once you read it, I'd love to talk to you about it. Absolutely. Thank you. Thank you. Thank you very much. Thank you.