Invited commentary: Is there a distinctively surgical ethics?

Surgery conveys power. That power is socially endorsed and may be reinforced by the surgeon's individual charisma; but, as with all power, it must be constantly renewed and re-validated. In surgery, that renewal and re-validation is derived from surgery's techne (technical capabilities), its episteme (knowledge base), and its phronesis (practical wisdom or judgment). These are the sources of the surgeon's Aesculapian power. It is not productive to see power solely as domination. Foucault writes:Power must be analyzed as something that circulates, or rather as something that only functions in the form of a chain. It is never localized here or there, never in anybody's hands, never appropriated as a commodity or piece of wealth.

Patients have no choice but to acknowledge surgical power when they consult a surgeon. Because normal people do not normally submit themselves to such domination willingly, there is always an element of surrender in the surgical relationship. But it is a surrender that presupposes rescue, not a surrender that presupposes annihilation. To understand this relationship of rescue is a first step toward a creation of an ethics of surgery. Accepting rescue as a legitimate principle privileges respect for dependence in the surgical relationship. Campbell has argued persuasively that this principle should hold for medicine at large, not just for surgery.

It is not hard for surgeons to understand the need for rescue. They confront that need in their work every day. They themselves also at times need help and rescue from colleagues when they have troubles with diagnosis, management, or operations. The category of rescue is available as a realm of shared understanding for both surgeons and their patients. It is a category that needs to be acknowledged and negotiated between patient and surgeon. It is the first pillar of a surgical ethics.

Surgery is an act of proximity like no other. To operate on another is to be within them, to be privy to the sight of the secret body, a sight denied even to the owner. This is the extremity of the “medical gaze.” Broyard, diagnosed with advanced prostate cancer, tells us what he understands by proximity in the medical relationship (p. 40):To get to my body, my doctor has to get to my character. He has to go through my soul. He doesn't only have to go through my anus.

This proximity that the patient wishes makes special ethical demands of the surgeon, of which he is frequently unaware, or if he is aware, rejects or distances as an act of self-preservation. The surgical act of operating causally connects intervention to success or failure in the most concrete way. Proximity carries with it the penalties of closeness, and particularly the pains of failure. Distancing makes failure easier to bear. Understanding the pain caused by that distancing is to understand the needs of the vulnerable patient. Understanding the risks and strains of acknowledging the intimacy is the beginning of an appropriate care of the self, but it is possible to enter into relationships of closeness that acknowledge suffering in realistic ways.

A patient looks for a particular kind of closeness in the relationship. The knowledge exchanged between patient and surgeon is intimate from the start. It achieves a unique intimacy after the operation, when the surgeon knows so much about aspects of the bodily identity of the patient that the patient can never know. But this is not the intimacy of the lover or close friend, because it is not reciprocal. That is why I call it proximity. To deny its existence is neither desirable nor possible. Understanding its nature provides a second underpinning for a distinctive surgical ethics.

Ordeals are periods of extreme experience, capable of the kind of disruption of our lives that Becker writes about in Disrupted Lives. Ordeals challenge our sense of identity and require work to restore continuity or to reconstruct identity in new ways. All medical encounters are ordeals. Patients yield autonomy, acknowledge dependence, place trust, face risk, confront embodiment and mortality, lose control over time and space, experience alienation, pain, fear, discomfort, suffering, boredom. The medical encounter takes place in someone else's system, a system with elements of the Grand Guignol, with its own culture and language of exclusion. Surgical encounters can be especially confronting. Surgery is a particular kind of ordeal. It is not usually voluntarily sought. But the structuring of the ordeal is in the hands of a surgeon and his team.

The ideal of rescue and the power of surgery balance the fear of the pain, loss of autonomy, degradation, alienation, and suffering involved. When the outcome is seen as redemptive, the ordeal is seen as tolerable, a worthwhile initiation ceremony. But the outcome is not always redemptive, or not so redemptive as was hoped. The patient who has a colostomy, for example, may wonder whether the “rescue” was worthwhile.

The immediate and obvious ordeal of the surgery itself is often not the end of the ordeal. The cancer diagnosis, in particular, is never over, even for long-term survivors. Survival brings its own difficulties, rather than mastery of other worlds. Surgeons observe and participate in the lives of patients with “deep illness” and cannot help observing and sometimes sharing their tribulations. Understanding the ordeal of the surgical episode and the sustained ordeal of adaptation to survival can help surgeons to help their patients. It is a third pillar of surgical ethics, a recognition that the surgical episode is an extreme experience and that to survive is not necessarily to survive unscathed.

Surgery leaves physical and psychic scars that may persist for life. There are other difficulties with surgical aftermath. The experience of serious illness is incommunicable because words cannot create the sufferings endured in those who listen. The fullest understanding can only come from those who have had similar experiences. There must always be at least some feeling of alienation from those who have not shared the subjective experience. Surgical ethics must accommodate and live with this creation in particular and vivid ways. And when death approaches our patients, we must remember, not deny, our own mortality.

Such an approach takes courage and a sense of personal security. It does not suit everyone, neither patients nor surgeons. But surgeons are in a unique position to understand the existential threats that their patients experience, the sense of mortality and bodily frailty they live with, and the difficulty of explaining extreme experience to others. Surgeons tend to live with repeated extreme experience, at least vicariously. They can, if they choose, in some small part be there for their patients in their extreme experience. They can usually share some of the frustration of being unable to communicate the nature of their work and their lives to others. Patient and doctor share a knowledge of the work and commitment required for the particular rescue played out between them. Opening oneself to the mortality and boundedness of patients can be sustained without loss of objectivity, without compromising the professional relationship. It suggests that a recognition of the difficulties of the aftermath of surgical acts can be confronted and alleviated as an ethical act. This is the fourth pillar of surgical ethics.

Rescue, proximity, ordeal, and aftermath are categories of experience that patients undergo. Sensitivity to them and an understanding of them will help surgeons to be ethically attuned to the experiences of their patients. Pellegrino and Thomasma have stressed the importance of beneficence and fidelity to duty as virtues for the practice of medicine. They are clearly important for the surgeon, but there is something else required. The patient undergoing surgery, particularly major surgery, wants the surgeon to be present to him at all phases of the surgical encounter. Whenever rescue, ordeal, and aftermath are active categories of experience in the context of surgical illness and its follow-up, patients look for more than a nominal proximity. They want the surgeon's presence. That presence is at best a real, physical, cognitive, and engaged presence; at least a delegated presence in which junior doctors and nursing staff express the surgeon's engagement and concern. It is the fifth pillar of surgical ethics.

Now this is important. Not everyone has the personal attributes of charisma, confidence, energy, and empathy that draw trust from patients and staff. But most surgeons have, almost by definition, the stamina and cognitive ability to be present to their patients. The regular morning round, the resident's or staff's reassurance that the surgeon is informed and directing treatment, telephone messages to patients, words to their families—all these things stand for the surgeon's presence.

Our own work confirms these hypotheses. Perhaps surprisingly (particularly given the destructive cynicism of sociologists), patients generally respected their surgeons, but were distressed by their surgeons' absences. For several patients, the program of treatment was dictated by impending overseas trips to be undertaken by surgeons.

Presence needs to be emphasized as virtue and duty in surgical education. Those for whom relationships come easily need to be encouraged to use that ability as a virtue that will prompt their presence for their patients. Those who need to protect themselves, or who cannot easily relate to others in distress, need to cultivate the duty of presence. One of the most loved surgeons I have ever met was a man with a strong sense of duty, but a restricted ability to relate warmly to others. I have never known a person more meticulously present to his patients. None of them felt they knew him at all well, yet their affection for him and their trust in him were both immense. Another surgeon had a brusqueness that amounted at times to rudeness. Again, his regular and informed presence mattered to his patients more than his manner.

I question whether we can make people sensitive to the needs of others when they lack sensitivity. I question whether we can teach communication skills as if the performance of a protocol could stand in for personal insight and warmth. The category of presence, however, can be taught. Each surgeon will manage it in a different way. Some will scarcely manage it at all. Presence can be taught by precept and example. It is the tangible expression of a recognition of the elements of the surgical relationship, the categories of rescue, proximity, ordeal, and aftermath. The surgeon's presence is required in each.

Testing and negotiating the reality of the category of rescue, negotiating the inherent proximity of the relationship, revealing the nature of the ordeal, offering and providing support throughout its course, and being there for the other in the aftermath of the surgical encounter are ideals on which to build a distinctively surgical ethics. Undergoing major surgery is an extreme experience, which changes people's lives. Surgeons are therefore repeatedly involved in the extreme experiences of others. This in itself is also a form of extreme experience, which changes their own lives. The grounds of understanding between patient and surgeon are created by the nature and the acts of surgical practice. Surgeons are uniquely placed among health care professionals to understand the experiences of their patients. They have only to open themselves to the stories of their patients and to their own stories to develop a relevant ethics of surgical care.

Surgical ethics must therefore recognize these five particularities. Principalism may help us in our dyadic and microethical relationships with patients. Virtue ethics reminds us of beneficence and fidelity to duty. Our rights and duties are those of all our colleagues. Our macroethics remind us of the constraints that our society places upon us because of scarcity of resources. These things, however, do not really distinguish surgery as having or needing a special ethics. They are the stuff of medical ethics generally. The special relationship that exists, at least in potential, between patient and surgeon can only be understood through the stories of those who endure and deliver surgical care. The surgical history—the medical history generally—conceals the nature of experience by constraining the kind of evidence it will allow. Individual values tend to vanish in the formal structure and selective editing that distinguish the medical and surgical histories. On the other side, surgeons make a virtue of coping behaviors that do not permit the telling of personal biography in ways that allow deep values to be expressed. Given the chance to talk, however, surgeons tell stories of great complexity and moral richness. They also reveal a profound understanding and recognition of patient experience and suffering. Their proximity to patients seeking rescue, facing ordeal, and experiencing the aftermath of surgery presents them with a great challenge, which they can meet best by a determination to be present for each patient throughout the surgical encounter.