 I'm just delighted to welcome you to our meeting today to hear Dr. Peter Angelos present a talk on the role of surgical ethics in the history of surgery. Let me say a few words about Peter. Peter Angelos is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics. The Vice Chair for Ethics and Professional Development and Wellness in the Department of Surgery, the Chief of Endocrine Surgery, and the Associate Director of the McLean Center for Clinical Medical Ethics all here at the University of Chicago. A native of Platsburg, New York, where his father was a community general surgeon, Dr. Angelos completed his undergraduate degrees, medical school, and PhD in philosophy at Boston University. He then completed his residency in general surgery at Northwestern University and went on to complete fellowship in clinical medical ethics here at the University in 1991-92 and in endocrine surgery at the University of Michigan in Ann Arbor. Dr. Angelos, as you can imagine, is an intense and busy endocrine surgeon who's written widely on improving outcomes of thyroid and parathyroid surgery about minimally invasive endocrine surgery and ethical aspects in the care of surgical patients. Dr. Angelos has now written more than 250 peer-reviewed publications and is authored or co-authored over 50 book chapters. He edited two editions of a book called Ethical Issues in Cancer Patient Care. He's the co-editor of the American College of Surgeons textbook entitled Ethical Issues in Surgical Care and is the co-editor of a very recent book, a textbook called Ethical Issues in Surgical Care, 750 pages long that came out about a month or so ago. It's called Difficult Decisions in Surgical Ethics. Dr. Angelos was also a regular contributor to the American College of Surgeons surgery news where he wrote a column on surgical ethics from 2011 through 2019. He's the governor of the American College of Surgeons, a member of the Academy of Master Surgeon Educators of the American College of Surgeons, past president of the American Association of Endocrine Surgeons and in June of 2019 Dr. Angelos began a six-year term as a counselor of the American Board of Surgery. So we're very excited to hear his talk today entitled The Role of Surgical Ethics in the History of Surgery. Peter, please. It's all yours. Thank you, Mark, very much. You're always very kind in your introductions and I really appreciate it. So I am hoping that you are all able to see my slides okay and if that is not the case then hopefully someone will tell me but you know it really is a pleasure for me to be part of this series. I have to say I've really enjoyed it. I think it's been one of the best series that the center has had in the 15 years that I've been at the University of Chicago. So let me just see if I can advance. So you know I have no financial disclosures but I do have just a few disclaimers and I want to do I do want to get them out of the way in the outset. You know I really love history but I am certainly not a historian and I say that with the knowledge that there have been some absolutely fantastic scholars of history who have given really erudite talks in this series. And so in that sense I think mine is going to be a little bit different because this is not really a you know it's not an intensive historical study of a specific area but rather I would say it's a little bit of a it's a little bit of a personal journey that I'll share with you and I think it's related to obviously my interest in surgery and my interest in surgical ethics but also I have to admit that I love old books and over the years have collected a large number of antique surgical books and medical books and so in an answer to the repeated question why do you buy these books I started reading them and you know found some very interesting things and so you know hopefully that will be a little bit of a justification for one of my many bad habits. So by way of outline I will share a little bit of personal history because I think it definitely reflects on how I look at the world. I'll tell you some of my initial perspective on surgical ethics a little bit about what the literature shows and then I do want to spend a little bit of time talking about how surgical ethics and decision-making in surgery has been impacted by changes in surgical care and those are things that I think it's easy to lose track of how how different things are now and I'll spend a little bit of time talking about informed consent for thyroidectomy because that kind of brings together surgical ethics and what I do clinically which is endocrine surgery and then talk a little bit about the central question of surgical care. So again I hope that you'll indulge me just for a couple minutes to give you a little bit of personal history. This is a map of you know the northeast of the U.S. and what you see here the red dot is Plattsburgh New York. So I have a I did want to put that on a map because most people don't know where Plattsburgh New York is and Plattsburgh New York is where I grew up and that's a picture of my grandfather in front of Angelos Restaurant and Bakery. So my grandfather who I was named after Peter Angelos he actually moved from New York City to Plattsburgh because he was an illegal immigrant and figured no one would find him there and so it actually worked out and he became a U.S. citizen. This is actually a matchbook cover from Angelos Bakery and Restaurant that I found on eBay a couple months ago and just couldn't resist buying. It's amazing what you can find if you waste time like I do looking for antiques. So you know my my parents were Mina Angelos and S. Peter Angelos and my father grew up in Plattsburgh. My mother grew up in Montreal. They got married in Montreal and and my father finishes residency military service obligations and returned to Plattsburgh to go into practice. This is what you know this is my parents and shortly after that they moved back to Plattsburgh and when they moved back to Plattsburgh a small town there were in fact two hospitals in this small town. There was the Champlain Valley Hospital which was a Catholic institution and then there was the Physicians Hospital which had a really beautiful lawn and ponds with swans and that sort of thing and so those were the two hospitals at which my father practiced community general surgeon and eventually the two hospitals merged. It became CVPH Medical Center Champlain Valley Physicians Hospital and then now it's actually been acquired by the University of Vermont so things do have a way of evolving. Now my father as I said general surgeon community practice he grew up in Plattsburgh. He came back to Plattsburgh. He spent his entire career at Plattsburgh as general surgeon and he loved being a surgeon and later in his life and earlier in my career he had the chance to come to the OR and when I was operating so it was really a lot of fun and we shared a lot of discussions of cases over the years. Some of my personal experience I think Mark was mentioned that I was in medical school and then subsequently went into a PhD program and got a PhD in philosophy. At the point when I was finishing and was applying for surgical residencies that was winter spring 1989. I found out that when you write a personal statement for a surgical residency about the importance of integrating ethics into an academic surgical practice not many people ask you questions about it and it was one of those things where it was almost as though I had written about something that was unrelated to surgery and there was truly an overwhelming lack of interest. I think I interviewed at about 10 residencies and nobody asked me about this interest. Nobody asked me about my PhD in philosophy except for Dr. David Narwald who was the chair of surgery at Northwestern and it is perhaps because of his interest that I ultimately did my residency at Northwestern. So in the 1980s I would say it seemed that very few surgeons were interested in ethics and I can give you lots of anecdotes about that but you know suffice it to say there just wasn't an overwhelming degree of enthusiasm. Now in the contrary there was a lot about medical ethics in the news and you know there were Time Magazine articles about it and you know there were cover stories in Life Magazine and you know there was a lot of excitement about things like the artificial heart and all kinds of new medical technologies and how that was impacting ethics and so you know there was a tremendous amount of enthusiasm. It's interesting to me and you know again in reflecting on some of the books that I've read over the years about ethics let me just read this to you. I thought this was a very fascinating suggestion that said ethics is beginning to be fashionable. Almost everybody now has a notion that he knows what it means. Among American people this is dangerous for we are very prone to get and then get over our fashionable crazes that which yesterday everybody was talking about is tomorrow what no one ever heard of but whether or not the word ethics becomes popular or not. I believe that any group of people who once began to look at things from an ethical point of view cannot easily break the habit and that this habit has come to stay whether the word ever dies out or not. So I was really struck by this that ethics is beginning to be fashionable and what was particularly interesting to me about this is that it's from a book by Richard Cabot MD called Adventures on the Borderlands of Ethics and what you'll note here and those of you who aren't you know quick in your Roman numerals this was published in 1926 so I thought it was fascinating that Dr. Cabot from Harvard thought that ethics was beginning to be fashionable but he was worried that it would be a trend that came and went rapidly and fortunately he was not correct in that assessment. Now there was a period of time when I thought that you know the way to explore some of the historical aspects of medical ethics and surgical ethics was to you know do a PubMed review and so you know I did that for medical ethics and I looked at medical ethics in titles and abstracts of articles and found that there through 2021 there were 6431 results so lots of results and and in fact you know you'll see this is how many articles each year so the numbers going up so that's impressive but it actually goes all the way back to 1830 that was the first mention of medical ethics in a title or abstract within PubMed and there are now you know a maximum of 432 references in a single year that first article I thought was interesting this is from the medical surgical review of 1830 and and I'll just read it again because I think it's so nicely stated medical ethics in the modern sense again this is 1830 must be considered the most important branch of our professional studies because it involves the science of life a knowledge of human nature and the art of turning that knowledge to the greatest possible advantage now it is very remarkable that although this notable science of life is useful art has been cultivated with great success during the last 20 years and is now brought to the highest degree of perfection not a line has been written on the subject or any code of instructions put on record for the benefit of rising or falling generation now you know really it's impressive how far that the authors felt they had come in 1830 now I thought it was really interesting at the time when I found this article I thought well gosh you know that's so interesting I wonder how far back surgical ethics goes and so so I did a similar review of surgical ethics and found that the first mention of surgical ethics and literature that I could find was 1975 and that there were a total of 49 results and so really a much you know shorter history much smaller number of articles maximum of eight references in a single year now I have to tell you that my error in doing this review and and the comparison of these areas is that I think I was misguided in exploring for the origins of surgical ethics by searching the literature for surgical ethics because surgical ethics was not a term that was widely used rather the history of surgical ethics I think is much better seen in the exploration of the history of surgical decision-making and how that has occurred over you know the last 150 plus years now certainly the theoretical concept of surgical ethics did not exist separate from the activities of surgeons and patients and so in that sense I think that any any attempt to find to find some discussion of surgical ethics is going to be missed if you do what I did which was look for surgical ethics in the literature because that's not the way it was discussed so so I do think that in this context it's really important to correctly place surgical ethics within the realm of clinical practice and clinical medical ethics so clinical medical ethics as you know many of you who were who heard Dr. Siegler's talk a few weeks ago clinical medical ethics as established and cultivated by Mark is a practical endeavor between patients and physicians focused on benefiting the patient so it derives from this clinical encounter and I would say that clinical medical ethics is thus very clearly to be distinguished from theoretical bioethics it is not a theoretical activity certainly one can have hypothetical discussions but clinical medical ethics at its essence I think is very much related to that clinical encounter now surgical ethics by definition I would argue is clinical surgical ethics because one cannot in fact have theoretical surgical ethics because again surgical ethics is very much embedded in the activities of surgeons and patients in their interactions and so I would argue that just as operating is essential to the practice of surgery surgical ethics cannot be separated from surgical practice and for that reason I think it's valuable to think a little bit more about surgical practice and how decisions were made in surgical practice in order to better understand some things about surgical ethics so for that reason I think you know it's essential to to look back at some history and you know we won't go back too far but again some of the issues that I think are relevant when it comes to surgical ethics and surgical decision making I think it's impossible to think about the history of surgical ethics without understanding the challenges of surgery prior to anesthesia and antisepsis so you know this is a you know it's a somewhat cartoon view of an amputation this is from Rawlinson the amputation around 1800 and now what's impressive is of course that the patient is awake now for surgeons you know that you can't actually amputate a leg with a saw like that because the saw works on the bone but not so good on the soft tissue so you've got to get to the bone before you use the soft tissue but think about it this is all done with an awake patient now surgery prior to anesthesia was an absolutely harrowing experience for the patient I would argue also for the surgeon and often for the medical students who paid to be in the galleries and so you know operations were they weren't public spectacles but they were very much viewed by by students who paid tickets to actually be admitted into the gallery to observe now it is also true that surgeons often downplay the horrors of the operation to protect the patient from worry now you know with this in mind I think it's valuable to think about how our current concepts of informed consent could actually be manifested when the patient's going to go through such an absolutely horrific experience and so you know most surgeons by report really downplayed the the the sheer pain associated with operations there is a story of a 12-year-old boy who recalled asking his surgeon if his upcoming leg amputation for tubercular swelling of the knee would hurt and the surgeon's response was no more than having a tooth out and the boy was brought to the operating theater blindfolded pinned down by the surgeon's assistants and then by the patient's own account 60 years later when he relayed this to medical students the boy counted six strokes of the saw before his leg dropped off so you know think about that experience and what that must have done not only to the patient but also you know everyone who witnessed it including the surgeon now some of you know about the history of Mr Robert Liston because he was in London surgeons were not doctors this is Mr Robert Liston and he was London's most renowned surgeon in 1846 he operated at University College Hospital he had a very successful practice and in addition he was able to you know since he did a lot of surgery and medical students needed to see operations he was very popular professor now he was reportedly eight inches taller than the average London man in the 1800s and he used that height and reportedly tremendous strength to his advantage and he was known as the fastest knife in the west end because of the speed with which he was able to operate and many of the operations in those days were in fact amputations so Liston built his reputation on brute force and speed and you know speed was essential to patient survival because you know he described taking off a leg doing a leg amputation and he talked about how one had to grip the leg tightly and then sort of clamp down on the vessels as rapidly as possible to prevent exsanguination so you had to get the leg off so you could clamp those vessels and tie them and reportedly the gleam of his knife was followed so instantaneously by the sound of sawing as to make the two actions appear to be almost simultaneous and so again he would rapidly cut through the soft tissue to get to the bone and cut through the bone very quickly and you'll see a couple references to this book the butchering art by Lindsay Fitz Harris I think it's an excellent book I totally enjoyed it and I would recommend it to you this is you know a portrait of Liston about to do an amputation his reportedly most famous case was a leg amputation in 2.5 minutes which you know anyone who's been in the OR today that's very impressive because we have to wait three minutes just for our prep solution to dry and we time it on the clock so the amount of time we're waiting for the prep to dry he was done with his operation unfortunately the assistant was holding the patient's leg lost three fingers while switching blades a spectator who was a little too close his coat was slashed the patient subsequently died of gangrene the assistant unfortunately also died of gangrene and the spectator was so shocked by the ordeal that he reportedly expired on the spot so one operation in 300 percent mortality now clearly that would not go over well today but I think you know maybe this is a true story maybe it's not but it was you know indicative of the speed and the danger associated with the operation so in the 1840s surgery was by no means for the faint of heart patients were at risk of severe pain and even if they survived that surgical ordeal the pain of the operation they were at risk of dying of infection now in addition surgeons were also at risk of dying of infection so you know when before we had the germ theory nobody wore gloves why would you wear gloves gloves are a recent invention by holstead who wanted to keep his scrub nurses hands from being irritated by the antiseptic solution due to the risks many surgeons completely refuse to operate on patients and focus their practice on the treatment of external ailments like skin conditions and superficial wounds rather than taking on things like removing tumors or doing amputations in fact operations were relatively uncommon events due to the risks that the surgeon and the patient both had to assume and in fact records say that in 1840 there were only 120 operations performed at Glasgow's Royal Infirmary you know one of the largest hospitals in the city so it was a very unusual thing and it is partly because it was so unusual that students flocked to surgical operations to you know gain that education because it just didn't happen that often and surgery was always thought of as a last resort and I actually think that this concept of surgery as a last resort has had some reverberations throughout history and so even today when it's obviously much safer frequently in the mind of surgeon in the mind of patients at least surgery is a last resort now without question anesthesia created a revolution in surgical care and as many of you know the first public demonstration of medical ether was in 1846 by Dr. William Morton the patient Edward Gilbert Abbott had a neck tumor reportedly and had surgery at the amphitheater at Massachusetts General Hospital now still preserved as the ether dome this is the the representation of that event the first operation under general anesthesia in that was reported in the U.S. now there's some controversy there are other people who did it before Morton but they they didn't publish about it until after the fact so it's controversial but certainly this created a of revolution and ether as a general anesthetic was widely accepted pretty rapidly Liston in fact performed the first leg amputation under general anesthesia in December of 1846 in London so the same year that Morton performed surgery that fall you know Liston did an amputation in London the same year and so certainly a major change in surgical care resulted and you know this is indicative of that change so now this is the Agnew Clinic by Eakins 1889 oil painting and so Agnew is here you know able to not rush through an operation but in fact spend time lecture to the gathered students that are in the gallery the patient is presumably getting dropped ether anesthetic and so you know the operation can take as long as necessary and I mean if you're an anesthesiologist then longer than necessary so certainly there were big changes but unfortunately anesthesia did not solve all the problems because again without antisepsis and a germ theory of infection surgical patients and surgeons themselves were still at significant risk of infection and so at that time surgeons believe that pus was a natural part of the healing process and most deaths post-operative deaths were due to post-operative infections now as I mentioned not only did many patients die of infection but surgeons as well died and operative surgery was really a very very filthy business Thomas Percival who in ethics people you know look to as an important historical figure Percival advised surgeons to change their aprons and clean the table between procedures to avoid everything that might incite terror but few surgeons actually heeded this advice it was almost like you know it was a point of pride that one had you know a bloody apron and bloody instruments now Joseph Lister who's pictured here a very austere gentleman he was a British surgeon who was known as the father of modern surgery and through an really incredible series of experiments and collaboration with Pasteur Lister developed a method of cleaning surgical instruments and dressing wounds with carbolic acid that really dramatically reduced the risks of infection and so this is a illustration so again it's a it's a totally clean environment you know with the white you know white cloths and this carbolic acid that was sprayed in the air even to kill airborne pathogens so by the late 1800s general anesthesia was widely adopted antisepsis and this what was known as the Listerian approach to operating room cleanliness was gaining acceptance however challenges did remain that continued to make surgery the last resort for many patients and you know just to just to share a few words about something again that clinically I deal with all the time and that is let me just share with you some of the historical issues with thyroidectomy because I think it's it's sort of illustrative Samuel Gross was a very was a very influential surgeon in the mid 1800s in the U.S. and so this is Gross this is also a portrait by Eacons and this is an earlier portrait but and so you know this is before there was all of the antisepsis but there was general anesthesia so the patients actually asleep but Gross you know wrote a textbook of surgery and that was very influential in the 1860s in the U.S. and this is what he said about thyroid surgery thus whether we view the operation in relation to the difficulties which much necessarily attend its execution or with reference to the severity of the subsequent inflammation it is equally deserving of rebuke and condemnation no honest insensible surgeon it seems to me would ever engage in it you know he goes on to say a couple paragraphs later that you know that anyone who tries to do this is going to be faced with torrents of blood and lucky will it be for him if his victims survive his this horrid butchery so that was his view of thyroid surgery which you know it's a fairly strong view and obviously things changed over time now theater koker who's pictured here was a major force in the history of thyroid surgery he was born in burn switzerland supposed to spend most of his career there and was the professor of surgery and director of the the the university clinic early in his experience the mortality risk so the risk of dying of a thyroidectomy was approximately 12 percent and later later series that mortality risk had declined to one percent and koker was such a meticulous surgeon that he was known to actually preserve the parathyroid glands even before the parathyroid glands had been described as a separate organ and so it's fascinating there were sort of two schools of surgical approach koker was the very meticulous operation where he tried to remove the whole thyroid and leave the parathyroids and his patients died of mixidimicoma when he took out most of the thyroid because they had so little thyroid now bill roth was another famous surgeon in europe bill roth was known as being a very fast surgeon who operated extremely fast sort of more along the listin approach but he did lots of thyroid operations and so his patients he left enough thyroid tissue that most of them didn't have problems with hypothyroidism but they did have problems with tetany because the parathyroids were removed so you had to sort of pick which way you wanted to go koker was the one who was ultimately more successful in that his approach was widely emulated and he won the Nobel prize in medicine in 1909 now surgery for graves disease even beyond koker's Nobel prize remained challenging and and i would say it's it was particularly challenging prior to safe antithyroid drugs so graves disease which was also known as exothalmic goiter is you know it's especially before antithyroid drugs it was challenging there were certainly challenges in preoperative management because if one did not have a good way of making a patient you thyroid getting their thyroid hormone level down to normal it was challenging the thyroid gland is very vascular and i would say even today removal of a large graves thyroid gland continues to be challenging but thyroid storm is a particular risk so if a patient is hyper thyroid and we take them to the operating room even today we're at risk of them having a huge release of thyroid hormone and going into thyroid storm and that's a you know real medical issue so george cryl was a surgeon who came up with an innovative approach to solve what he thought was the problem of operating on patients with graves disease cryl was interestingly enough the founder of the cleveland clinic and so if you look at the history of surgical clinics the male clinic the cleveland clinic that cryl started the lehi clinic that was founded by dr lehi in boston all of these much of their early volume was taken up by doing thyroid surgery well cryl was very influential and he described a new approach to the challenge of operating on graves disease patients so this is his article from jamma generally the american medical association in uh 1911 so it was a new principle of operating based on a study of 352 operations so cryl wrote in several desperate cases in which the margin of safety of patients was tested by anesthetizing without the patient's knowledge with ether or with nitrous oxide there was a moderate though short exacerbation of graves symptoms and so daily inhalations which are presumably for some medicinal purpose so essentially you bring a patient to the hospital you tell them we're going to have you inhale this every day but those that's actually a practice rehearsal for your aether anesthesia and so so the idea was to sneak up on the patient and do their operation without them knowing that it was coming and so really interesting that was referred to an approach that was referred to as stealing the thyroid patients knew that they were to have surgery at some point but they were misled about when it would occur um now just to reflect on you know was this something that was um you know was this problematic what was the view of informed consent at that time so this is um from a textbook called uh american practice of surgery by bryant and buck um in 1911 um they wrote the fact that the surgeon can never foretell the complications which may arise in the progress of an operation nor the limitations of the disease renders it imperative for his own protection from censure that he should obtain the full and specific consent of the patient or other person who may be responsible for his care before undertaking the operation so certainly the concept of telling a patient about an operation obtaining informed consent um was you know widely accepted within surgical practice at the time but there was an ambivalence toward the informed consent for uh operating on graves patients um so this is uh from a interesting book called surgical errors and safeguards by uh max thorac um some of you are familiar with thorac hospital which still exists in chicago started by dr thorac um so he wrote this book in 1936 um and he wrote in patients with exothalmic goiter morphine should be administered to the patient in bed before he's taken to the operating room and nothing should suggest to him any reason for fear or anxiety i usually withhold from the patient the date of the approaching ordeal so i thought that was really fascinating so here he's you know he's written a book about errors and safeguards and he's saying you know maybe don't really tell your patient about this um and in fact as late as 1962 the description of the thyroid steel for graves disease was noted so this is from an article of 2016 but one of the authors reported on his experience as an anesthesiologist he said the patient was unable to take antithyroid medication beta blockers were not available at that time and radiodine was not deemed appropriate the patient was told that the treatment with thyroid calming medicine given rectally was needed during four days prior to the thyroid ectomy but on the third day the patient was given a barbiturate enumen was then taken to the operating theater and a successful thyroid ectomy was undertaken so it's fascinating to me so 1962 i mean that's not that long ago but still this is a situation in which the details of when the operation was going to happen were certainly not shared with the patient and the patient was in fact deliberately misled about why the doctors were doing what they were doing now obviously that's i've been focusing on you know one particular surgical operation but i do think that it's interesting to turn from informed consent for that one operation to what i think is the greater central question of surgical care and i do think that much of the history of surgery has been focused on the question what can be done for this patient so so early on when there wasn't a lot of options you know that was what surgeons everyone all physicians asked what can we do what can be done for this patient i do think that increasingly this is an inadequate question and the more important question is what should be done for this patient now i had for a long time thought that this question was a relatively contemporary question um and i thought in fact that this is a new question for surgery that you know 100 years ago people were not asking this question they were back to the basic what can we do but in fact i think i may be wrong about my assessment so sir william stokes um this is a picture of uh mr stokes um he was a prominent surgeon he was described as the surgeon in ordinary to her majesty queen elizabeth now i don't know what that means but that was his title and he was past president of the royal college of surgeons and of the pathological society of ireland so again very prominent guy and he actually wrote a monograph entitled the ethics of operative surgery that was published in 1894 um so this is from the dublin journal of medical sciences november 1894 um and it was a an address uh by um sir william stokes to the medical students of the neath hospital and county dublin infirmary um and i just you know i i when i found this i had to buy it of course you know i have a weakness for buying these antique books um and i think this may be the first use of surgical ethics in the literature even though i could never find it in a pub med um stokes actually stated a consideration of medical ethics that frequently exercises the mind of the operating surgeon is the question of the principles that should guide him in dealing with cancerous growths the question as to what constitutes justification in dealing with them in an operative way is ever present and surrounded with difficulty as the result of such interference must end in wheel or will satisfaction or regret to the patient as to the operator now um the the same central question that stokes referred to in this monograph i think remains in the care of every patient with cancer or any other surgical problems even today and that is to the risk of the operation outweigh the potential benefits for the patient and again one cannot answer this in a general fashion but only with a better understanding of what are in fact the patient's goals and what are the potential benefits for the patient now um i think that uh there have been um you know certainly uh emphasis on practical ethical guidelines that i found in some of the earlier surgical texts and i'll just share a couple of these with you again this is from max thorax book um he wrote how can it be possible that a surgeon would do an unnecessary operation or attempt to do an operation which he was not competent to perform such infractions result from three causes ignorance dishonesty and bad judgment uh so so i was thinking about this this morning at our m&m conference but i don't think that there was ignorance or dishonesty or even bad judgment there but this is something that again it's sort of a refrain in the in the text thorax said he should never do an operation on a patient which he would not want to have done in himself under the same circumstances now to me this is a central ethical tenant so this is a central uh foundation of surgical ethics um but you're not going to find this as a this is part of surgical care and so in essence i do think that my early uh search for you know where's the surgical ethics and surgical care well it's part of surgical practice and so it's not something that could be separated out from surgical practice and in fact it was identified by these authors and others um i would say that i am very optimistic after having looked back at some of the history of surgical ethics i'm optimistic for the future i think that we're seeing more than a realization of the importance of surgical ethics and surgical patient care but more of a real awakening of this importance i do think that there there may have been times when surgeons have perhaps focused too much on the technology and not enough on the patient and i think we're always at risk of that we need to be sure that we don't let that happen i think that as our possible interventions have increased the question of what is best for each individual patient remains central to surgical decision making and i think that we cannot ever hope to answer the question what is best for my patient without attending to the ethical dimensions of surgical care and that means communicating with patients and understanding their values with respect to our possible interventions so i do want to leave you with a few conclusions i think surgical ethics is not a new idea but i think it's a rediscovery of a fundamental aspect of surgical practice i think that surgeons cannot ignore the ethical dimension of our surgical practice and surgical patient care i think that surgical ethics expertise is actually critical to the contemporary education of surgeons and i do think that the discipline of surgical ethics owes a debt of gratitude to dr mark c where for supporting surgeons and surgical scholarship and ethics um over many years um and you know dr sigler was very nice to mention this book that recently came out with my co-authors the seal and peggy it was really you know a tremendous experience for me to get to work with them i do want to just share with all of you that this book was dedicated to mark and anna sigler and what we wrote which we three editors felt very strongly your guidance of hundreds of clinical ethics fellows through their time at the mclean center for clinical medical ethics and your collective enthusiasm warmth and dedication to the study of clinical medical ethics have inspired this book so with that i do want to thank you all very much for your attention thank you for the honor of you know giving a talk in this series and i'm happy to answer questions well that was absolutely terrific peter and just as a person as a surgeon as a colleague you are extraordinary and that was incredible and i do want to mention that that book you mentioned the butchering art is really well written and it brings kind of lister's journey of improved surgical care and um decreasing surgical mortality really uh to light because the author is just excellent um so absolutely and the other thing just on a practical level i just want to say one thing before we get to beggy i think one of the thing that's really important is that for clinicians and clinical medicine sometimes history can become more relevant to us when it has kind of an emotional valence when either it happens to us personally professionally the lived experience makes it more real and interesting and compelling in a way that i think our historian colleagues don't necessarily get the same impact and i think it what makes clinicians more passionate once they get exposed to that but i i uh want to just um let peggy mason take the floor away thanks peter that was a great talk i i loved it i thanks for telling us about your family background in platzberg thank you for indulging me that's great um i'm just struck by one of your final points which is that uh the surgeon should never do an operation on a patient which he would not want done on himself and you know i i just completely a hundred percent do not resonate with that so i'm i'm really curious how you you get to that um i i just uh there are not always mirrors for each one of us and certainly the surgeon is not a mirror for every one of us so why would we why would we need to align the surgeon's values with the patient's values yeah so that's um you know as always pey it's a great question and it's a very thoughtful one and and i guess i would say that um the way i look at it is not that not that i would want to have the operation done on myself or that i would or that i would necessarily make the same decision to have that operation but rather that if it's if it's something that i don't think um let me give you an example i it's a little bit it's hard for me to define um but you know years ago um not that many years ago but a number of years ago there was a lot of enthusiasm about an operation called a robotic assisted trans axillary thyroidectomy right so instead of making an incision in the neck we made incisions in the axilla and you know made sort of essentially made a tunnel from here to here use a robot to get the thyroid no visible scar in the neck so i thought well that sounds like a crazy operation i'm not really interested in it but i also thought i shouldn't be overly critical without learning how to do it so i learned how to do robotic surgery i did all my training and all that stuff and so then and i did one and and i did it and you know i told the patient you're gonna be my first patient etc um and you know she was very enthusiastic i was enthusiastic i did the case it went fine it took four and a half hours so like four times as long as it should have taken if i had just done an open operation and at the end of that operation i felt like you know not only would i not choose to have this operation on me i wouldn't let anyone in my family have the operation because the risks of avoiding a visible scar were so high that in my opinion i shouldn't even offer it now it is true that i am to some extent by not offering that operation by so i don't do that operation anymore i said you know one and done i've decided i'm not going to offer it if someone wants it i'll refer them to other people who believe in it who do it um and you know that's okay um but but i guess that's sort of how i look at it is it's sort of like a it's a threshold where it's not necessarily that our values have to align but i at least have to believe enough in an operation to feel like i can do it safely and that um that it's that there's some threshold of benefit now this is problematic because i am to some extent imposing some ethical judgment much like we do when we talked a few weeks ago about saying to a patient i'm not offering surgery the risks are too high right i sometimes make that decision on behalf of my patients um and that is to some extent a paternalistic approach um but that's the aspect in which i think there has to be the sort of threshold that i'd be willing to have it done on me well yeah i mean that's that's a really interesting answer because you basically are saying that you're evaluating the surgery you're not evaluating the surgery for the patient which is not so you're saying i'm going to offer this patient patient unknown i am either going to do this or i'm not going to do this it has nothing to do with that person's values yeah in that that makes a lot of sense yes got it thanks thank you okay dr moaty you're up thanks great talk uh peter as always um so your exploration of history a little bit sort of you know it all naturally draws into comparison some of the things that have changed over the years and one thing that strikes me is as being somewhat unique for surgeons at this time in history is that probably for the first time ever majority of surgeons will be employed rather than independent physicians and i wonder what you know if you think that has any impact on some of these uh domains of professionalism and surgical ethics that that we think about or you know just in broad strokes what you think the effects of that may be or what we should look at or be concerned about going forward yeah that's uh it's a good question parth i i do think that it has the potential to have an impact that is worrisome to me and so you know i i see it more along the lines of sort of practice arrangements that reward physicians for keeping the business within the practice and so so you know so so for example there are you know there are systems in which if you refer too many patients outside of the practice you get penalized or you know financially penalized or if you know if the significant percentage of your referrals are within your network you know within your particular practice maybe you get a bonus and so so in in some ways i actually think that this is potentially problematic because there's a there's an inherent then conflict of interest for a providing physician and then similarly i think you know surgeons are are as guilty of that as others that you know if we don't you know if a patient says who should i go to and we say well you know you should obviously go to someone in my group because then i reap the financial benefits as opposed to sort of going outside of my group and you know getting perhaps you know a different approach so so i think that that's a real risk what's striking to me and i and i actually think you know somebody should somebody should look at this i i you know i at one time thought it would be valuable to explore but you know years ago there's a tremendous amount of emphasis on the unethical practice of fee splitting so fee splitting for those of you who aren't so familiar with it fee splitting was essentially and i may be you know it may not always be in this fashion but if a general practitioner for example referred to a surgeon and then the surgeon said to the general practitioner now you be my surgical assistant so so essentially the surgeon's fees would then some portion of that would go to the assistant and that was almost like a kickback to getting that patient referred and so that was considered absolutely unethical and the American College of Surgeons was widely against and there was all kinds of you know stuff about how fee splitting was horrible and unethical and it does strike me that a modern version of fee splitting is keeping things within our network and you know not necessarily referring to the person who perhaps has the greatest amount of experience but you know so i so i think it's a potential risk you know it's fascinating to me the evolution of surgery because as two things from an internal medicine point the rise of you know the surge the rise of surgery in the 20th century is the rise of hospitals the rise of you know the American Hospital Association the professionalism of nursing it's all amazing you know the role of surgery i think the most fascinating thing you raised and i think this is the really interesting thing is how do you make advances in surgery knowing that there are procedures that you're going to do on patients which may not benefit them or harm them in the process i mean i think we do that less than we used to do but certainly you know in the evolution of looking for newer better techniques and you know shelly mckeller talked a little bit about that about what's the last resort and just you know on it on the flip side is think about the fact that we now go to so many surgical procedures as a first-line therapy you know or that's changing you know orthopedic surgery i mean just as i was listening to dr. moody you know the Hippocratic oath is against cutting for stone god knows that urology is now not only part of the traditional medical professionalism but it's a highly respected and valued you know colleague in a way that you know you can see the changes over time so i just think it'd be also interesting from your perspective the evolution of certain you know on a personal level the evolution of surgery in your personal and professional life yeah no i i think it's um uh thanks mindy for asking it is i do think it's a real challenge um and and you know the the the difficulty is that you know medical school is you know four years and then uh you know surgical residency is five to seven and if you do a fellowship it's maybe another year or two um so you know it seems like a really long time but then you're in practice for a very long time uh and so so there are things that you know come up and change and you know we we we start doing things on people and you know sometimes we're sometimes the challenge is that there are others with more experience than we have but we're still offering it to people and then sometimes it's that we just don't really know if it's a good idea or not but you know we think it's a good idea and so we tell patients about it and you know i i had a an attending surgeon when i was a resident once who said that um patients will always do what he recommends and i said well you know why is that and he said well because i'm going to always convince them that i'm giving them the best recommendation and i do think that that that the surgeon is in a tremendous there's a tremendous power differential in knowledge and expertise and whatnot and if a surgeon says well i got this great operation it's brand new and i think it's going to be perfect for you very few patients are going to be skeptical of that most patients are going to say great sign me up um and so i do think that it creates a tremendous it's a risk but it also creates this burden to be certain that we're not offering things that just are good for us but are also good for our patients and i want to just follow up on the chat there was a really good question from um september williams who said um where do you stand on the removal of you know the artifices or the art of history where um you have people like j mary and sims where there were standard procedures done 100 years ago that are now either they were done the procedures themselves who they were done on is really you know has gone full circle and now we look at them with um don't believe that they are the standard of practice and believe that we were not acting in patients best interests what do you think about that yeah so uh thanks september it's good to see you uh so you know i think that that is a um it's a very challenging question how to how to look back at you know these supposed giants and say you know that wasn't you know not only was it a bad idea and a bad operation but that it was you know the way you studied it the way you came about to do what you are doing and thought was a good idea was also unethical um and so so you know i think that it is uh it's imperative that we um not have a narrow view of you know sort of what's good and bad i think that so many uh historical figures in surgery and throughout life have both positive and negative aspects of their their you know their lives their careers and whatnot and i think that we are not put people on this high pedestal as though they were you know they were the epitome of everything great i think that there's a that it is a it's a troubled and nuanced history and i think that we do need to acknowledge that and i think that that's um that if we don't do that then i think we in essence we cheapen all of the things that we say we value now about informed consent and about you know the ability for pay for patients to participate decisions etc. Dr. Heckmach did you want to say something? Unmute yourself my friend. About what Peggy said uh want to follow that uh some years ago when i was younger i had a patient who had the paraplegia on in a machine and couldn't talk and it was it was so frightening to me what would happen if i would have been in his place and you have seen a paraplegic patient so the family asked me what would you do doctor and i said well i would prefer to die and then about a few years later the patient was rehabilitated family came to me and criticized me that you said you wanted to die and he is doing very well now then i told the truth to the patient i really wanted but if today you were asking me that question i would have liked to have the all the treatment so the question is we really need to know the patient far more than what the patient is before we say what would we do on us or our own family the situation we need to know so some about a year ago i were to have an operation i know that there is always a risk when we choose a doctor or we choose a lawyer so i told my doctor i will never criticize you i will promise never sue you but just tell me what the effect of this operation is as a whole and let me choose it i am interested in ethical issue but don't think of any other situation if this happened you don't tell me what would you do on your just tell me what was the effect would that be a better answer to tell the person that these are the issues and not just in one word or two words perhaps requires that they were to and then tell you tell me what to do and if i find that what the patient was bizarre selection then i withdraw i say i would not do it but if i see it's reasonable despite the fact that i wouldn't want it on myself do it on the page yeah um thanks javad that's you know i think it's a good question um i do i think that this this issue what would you do if you were me or what would you do if you know you were my you know insert you know whatever the relationship mother father sister brother um increasingly it's you know what would you do if i were your your child you know as i'm getting older that's what i keep getting asked so anyway i i think that what's hard about that and and i'm i'm very sensitive to the fact that patients i think appropriately are seeking advice and i think that it's a bit of a pet peeve of mine that we so frequently talk about what we offered a patient so i'll hear you know surgeons say well i offered them this operation um and and it seems to me that there are situations in which there are you know legitimately multiple choices that are both that are all medically appropriate and in those circumstances i think that in order to answer the question what would you do if you were me or you know my relative um i do think that we've got to pause and explore a little bit more as you said um and i also think that um i actually think we have a responsibility to give a patient a recommendation when they ask for it i think that that's something that we should do i think we should be you know if you go to an expensive restaurant um you get a recommendation from the waiter if you go to you know an inexpensive restaurant they just give you the menu and you got to pick yourself so i think we at least ought to be as good as you know the expensive restaurant make a recommendation um but that being said i think that it is it's not enough to just say well i would do x i think that we ought to say well because i value these things i would choose this but if i valued some other things it more i might choose something different and so so i do think that putting our recommendation in the context of you know why we're making that recommendation i think is also part of our responsibility and i don't think that we do that as much as we should excellent i was going to let ed kaplan who's on the line here um speak peter that was a wonderful talk can you hear me yes we can thanks ed it was wonderful i i finished my residency in 1967 at the university of pennsylvania i saw dr ravd and do a thyroid steal on one occasion where he injected i don't remember if it was barbiturates or what we would go in and inject something in the patient's arm every every day and then finally without telling him we went to the operating room and and treated his graves disease things have changed when i started my internship there were no oral diuretics for example for heart failure and people gave uh mercurial diuretics at that time just as one example and and uh i just one other thing that is profoundly different that in the city of philadelphia not one surgeon or internist would tell anyone that they had cancer there was one surgeon at graduate hospital which is one of the hospitals in philadelphia name his name was ferguson and he was the only doctor in every in philadelphia that would tell the patient that they had cancer everybody would tell the family but no one would tell the patient the professor of medicine francis wood when i was a medical student gave us a talk about how his grandmother had a mass in her lung that they saw in chest x-ray and to the day that she died he told her that it was tuberculosis and wouldn't tell her that it was a cancer so things have really changed and there are many i mean that's just a few examples of profound changes that have occurred i enjoyed your talk immensely it was wonderful peter thank you thanks so much ed i really appreciate it's amazing that you actually saw a patient have the stealing the thyroid procedure very impressed anyway so there was a lot of interesting comments in the chat but i think peter you deserve at least 15 minutes before i do the afternoon session that's our new thing is we've got to give our um our speakers a little break to get up and stretch their legs and just on behalf of the mclean center it's always a pleasure to welcome one of our colleagues and our friends to give us a talk and the personal stuff is really huge because um you know where you come it's it's like that show um finding our roots i love that thing is because history really can be very personal you know if you find that your grandfather was like a slave owner or that some of your relatives did something either heroic or terrible it affects you personally eons down the line so those things where you can you know really hook into your history i think have a resonance for all of us so thanks for sharing that and every time i see you now i'm going to think about upstate new york and flag so thank you so much thank you bye