Ethical Challenges in the Operating Room

These responsibilities, with regard to a patient in surgery, cannot be discharged while simultaneous or concurrent procedures are underway, because the primary attending surgeon should not place herself/himself in a position where physical presence is required for key portions of the surgeries at the same time. For this reason, concurrent or simultaneous surgical procedures are discouraged on the basis of our ethical responsibilities to both patients.

Some surgeons may pose the argument that the immediate availability of a “backup” surgeon who can perform certain key or critical elements on one patient while the primary attending surgeon is performing or teaching key and critical elements in another room, makes this is an acceptable practice. Ethically speaking, this is an example of “co-management” of a patient, which would require preoperative disclosure to the patient, along with explanation, resulting in the patient’s consent. The patient may not agree to such an arrangement, and the primary attending surgeon will need to acquiesce to the patient’s wishes, rearranging the surgeries so they are not concurrent. Even if the patient agrees to the possibility of a backup surgeon—or co-management—the second surgeon must then become adequately familiar with the patient’s medical history and medical data, along with the scope of the procedure, and must meet the patient for an examination and discussion, just as if she/he were the primary attending surgeon. With so many risks, it just doesn’t make ethical sense, so the best course of action is not to schedule concurrent or simultaneous surgical procedures.

On the matter of overlapping or sequenced operations, the ethical implications are slightly less worrisome but still depend on the ability of the primary attending surgeon to do the following:

• Adequately plan the surgical procedures, taking into account that the procedures may not follow the “plan”;
• Completely disclose the potential risks (no substantial “benefits” to the patients are likely) to both patients when overlapping or sequenced operations are planned;
• Ensure that a backup attending surgeon will be immediately available for either patient’s procedures;
• Provide an honest disclosure of who will be taking part in each operation, as well as their roles, training, and capabilities; and
• Finally, explain why such scheduling is warranted.

Patients should also be introduced to the planned “backup” surgeon, as previously noted.

Level of Training

Although this will likely change in the near future, experience indicates that many patients agree to surgery—particularly in an academic setting—without being fully aware of the levels of training of otolaryngology residents (and perhaps medical students, as well), or the invasive procedures these trainees might be performing on them. Many primary attending surgeons do a fine job of explaining to patients how each member of the surgical team plays a role in the performance of the operation and teaching them about the importance of “learning by doing” in a medical education setting. And, most patients agree to be a part of this education process, after they understand how residents learn to be capable and safe surgeons under the guidance of a senior surgeon.