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DE LA SALLE HEALTH SCIENCES CAMPUS – COLLEGE OF MEDICINE

Detoxicol
SDLS 2008
Medicine for the intoxicated
Subject: Bioethics Lecture Date: November 11, 2005
Topic: Moral Aspects of Surgery Transcriber(s): Jaime Aherrera
Lecturer: Dr. Renato Ocampo No. of pages: 6

MORAL ASPECTS OF SURGERY

INTRODUCTION
• It is important to understand Informed Consent, especially in Surgery
• FOUR MAIN PRINCIPLES OF TRADIOTIONAL ETHICS
o Stewardship
o Totality **Stewardship & Totality are concerned with Surgery
o Double Effect
o Cooperation

I. STEWARDSHIP
• Humans beings are Custodians of their Own Lives and of the World – We should always take care of our own
body (anything we do to destroy our bodies is Morally Wrong or Immoral)
• Genesis 1:25 – “Go for and Multiply” = we are the Stewards of our lives
• Humans are the Proprietor of everything in this world starting with our bodies
• Informed Consent is NEEDED in the Principle of Stewardship

❖ Four Dimensions of Stewardship:


o Personal
o Social
o Biomedical
o Ecological

A. Personal Dimension
o We are the Custodians of ourselves
o We are supposed to take care of the body given to us
o DONT harm the Human Body (don’t smoke, drugs, etc)

B. Social Dimension
o We are supposed to provide the well-being of our patients
o Stewardship extends to other Human Beings – we should also take care of the Well-Being of others

C. Biomedical Dimension
o We are the Stewards of our Patients and Everyone in the Health Service Community
o Health Providers = Prioritize HEALTH and NOT the Wealth of the Patient

D. Ecological
o We are Custodians of the Environment - We must preserve God’s Creations (includes Natural Envrionment)

II. TOTALITY
• In the Human Person, the Parts exist for the Whole; and therefore; the Good of the Part is Subordinated to
the Good of the Whole
• Ex) The eyes are there because they help the Human Body – they are for the good of the whole

**NOTE: In Surgery, when we remove something from the Human Body:


o The Appendix is there because it contributes to the Good of the Whole (Lymph Organs)
o When the Appendix is Inflamed, it threatens the Human Body (it becomes a THREAT) – therefore, it is
Moral and Natural to remove the Appendix for the good of the whole
o Removal of Appendix (if Inflamed) is MORAL based on the Principle of Totality

**Points Emphasized in Prenotes:


o When the part becomes a Subordinate to the Good of the Whole, then it CAN be removed
o Each individual organ in the Human Body exists for the Good of the Whole Organism
o If one organ becomes Detrimental to the good of the Whole, it is Moral and Ethical to Sacrifice it
o Ex) Breast Cancer in Females – we can remove the Breasts
ASPECTS IN SURGERY

I. DEFINITION OF TERMS:

A. Mutilation
o It is the Act of depriving a Limb, a Member or Important Part, Deprival of an Organ
o “Mutilare” – Maim or Distort, Amputate, Diminish or Lessen
o In General, Mutilation is UNACCEPTABLE  HOWEVER, Stewardship & Totality Justify Mutilation
o Ex) Removal of a Limb, or even a Small Mole

**NOTE: The Principles of Stewardship and Totality Justifies an Operation or Surgery

B. Surgery
o Entails a Positive Invasion of the Body’s Integrity
o There is a Physical Evil = because there is an act of Injury
o Is there a Moral Evil?
o When we Break into the Integrity of the Human Body, there must be an ETHICAL Justification
o Informed Consent is still IMPORTANT

**EXAMPLE: Inflamed Appendix: Based on Stewardship & Totality:


 Stewardship = as the owner of my body, I will consent to Removal of Appendix
 Totality = the Appendix does not do good for me
 Based on Stewardship and Totality, we come up with an Act WITHOUT Moral Evil!!!

**Is it a Moral Evil or NOT?


 The actual Ethical Decision is based on the Bioethical Principles
 Actual Ethical Decision depends NOT merely upon Abstract reasoning, but upon Prudence in which
Several other Factors are involved

C. Elective Surgery
o The Operation of Procedure is performed on a Non-Urgent Basis
o The Situation DOES NOT pose an Immediate Danger – NOT Life Threatening

II. ELECTIVE SURGERY (GUIDELINES)


• Elective Surgery = those procedures that act on a NON-EMERGENCY Basis
• It is NOT an EMERGENCY (NOT Life Threatening)
• Ex) Breast Tumor – it may be urgent, but NOT an emergency (It is not life threatening at that moment)

A. Elective Surgery May Be Done:


1. If the Risk is LOW (Minimized)
 We DON’T Rush in doing Breast Surgery
 We do the surgery at a time when the Risk is LOWEST
 Ex) Gallstones in a Pregnant Woman – do surgery in the 2nd Trimester (Safest Time)
2. If the Functional Integrity is Maintained
 The patient should live a life like a Normal Human Being (Intact Function)
 A Patient can survive with One Kidney
 We CANNOT Take out the WHOLE Liver for a Tumor
 Ex) Renal Tumors, Kidneys

3. Even if the other Organs that are affected by the removal are rendered Functionless Secondary to
a more Important Surger
 Part of the treatment of Breast Cancer is Ovarectomy (they become Functionless)
 Ex) Removal of Ovaries is an Adjunct for Treatment of Cancer

B. Elective Surgery may NOT Be Done:


1. If the Risk is HIGH
 If the patient is in Poor Condition

2. If it DOES NOT Benefit the Patient


 When the Cancer has already Metastasized to the whole body, will the Removal of the Primary
Tumor Benefit the Patient?

3. If there is NO Medical Usefulness


 Cosmetic Surgery – is there a Medical Usefulness to it?

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**Issue on Circumcision:
• If it is done as Routine Procedure by a Hospital, then it is WRONG!
• There is no actual medical need for it at Birth, it is more of a Cultural Thing

III. THERAPEUTIC SURGERY


• Primary Objective = to Cure the Patient (Necessary Surgery because it is Curativ)
• Stewardship = What it think is good for my patient (removal of an inflamed appendix) – Appendectomy should be
done (the Intent is Curative)
• Totality

A. IMPORTANT Notes:
o Since it is a Necessary Surgery, because it is Curative, then it SHOULD be Done
o Informed Consent is Necessary

B. Four Elements of Informed Consent:


o Comprehensive of Information
o Effective Reasoning
o Reflective Deliberation
o Voluntariness

1. Comprehensive of Information
 We must give all information to the patient
 Options, treatment, side effects, etc

2. Effective Reasoning
 The Decision comes from a Competent Patient (ability to come up or reach a decision based on the
Relative Issue – Patient should be competent)
 It is not necessarily common sense

3. Reflective Deliberation
 Patient should be Competent

4. Voluntariness
 There should be NO Coercion
 Unethical = “If you don’t take this surgery, you will die!”

IV. PALLIATIVE SURGERY


• Palliative Surgery is NOT designed to CURE the patient – but to RELIEVE the Patients from Symptoms
• Objective = to make the patient’s life more Comfortable
• Usually done for the Terminal Ill Patients
• It is an OPTIONAL Surgery

A. IMPORTANT Notes:
o Since it is NOT designed to Prolong Life but make the patient more Comfortable (the Condition cannot be
cured), it is an OPTIONAL Surgery
o Informed Consent is Necessary
o If proper disclosure of information has been made and the patient still requests it, it may be done but always
weighing the Benefits and the Risks

B. Examples:
1. In a Colon Cancer Patient
 There is usually an Obstruction in the Colon – Increasing the chances of Death
 Will I remove the Obstruction? Depends on the patient

2. Metastasis
 (+) Metastasis to Liver and Lungs (Stage-4) – CANNOT be cured anymore!
 Option = Excise the Tumor to relieve the Abdomen’s Distention – however, it is NOT a Cure. It is
only a Relief of the Symptoms

C. Informed Consent is NECESSARY


o Physician should tell patient the Real Status of the Disease
o Physician should Inform and make it clear that the Procedure WILL NOT Cure the Disease
o There is NO Significant Difference in the Surfival Rate

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D. If Proper Disclosure of Information has been made and Patient Still Requests it, It may be done:
o ALWAYS weight the Benefits and Risks
o Ask Patient what he wants, provided that proper Disclosure of Information was done
o Palliative Surgery should NOT be Done to Poor Risk Patients
o This is Exclusive to Patients with End-Stage Diseases

V. UNNECESSARY SURGERY
• It is UNETHICAL to Perform Surgery with no real Medical Indication but which might be Undertaken for
some unworthy Motive such as financial gain or face-saving
• A Surgeon is culpable when, because of Inability of Lack of Knowledge to preserve or repair an Injury, performs an
Amputation / Mutilation rather than ask for assistance or make a referral (Surgery becomes Unnecessary /
Unethical if the Surgeon was NOT Trained to do the Surgery – not qualified)
• Although it would be easier to Amputate, the Surgeon is Bound to Conserve as much as possible part or all of a part
of the Body that is Injured

A. IMPORTANT Notes (from Prenotes)


o When it is beyond our capabilities, call for Help – Admitting Limitations is a VIRTUE
o There should be recognition of LIMITS!

B. Examples:
1. A Patient with a Skin Tag want to go Overseas – he is required to have Surgery for the Skin Tag
 There is NO Medical Indication for the Removal of the Skin Tag – it is actually not needed
 It is an Unnecessary Surgery – not really needed

**NOTE: Remember Principle of Stewardship = we have to preserve as much Tissue

2. A General Practitioner does Heart-Surgeries


 The General Practitioner is NOT Trained for this!
 Therefore, this Surgery becomes Unnecessary

VI. INCIDENTAL SURGERY


• Incidental Surgery = Procedures done in the Course of Some other Procedure
• Ex) A Caesarian was done, however, during the operation, the Surgeon sees an Inflamed Appendix – is it Moral to
Remove the Appendix?
• Informed Consent is IMPORTANT – If the consent says “Caesarian Section” – DON’T do anything else!

A. When is Incidental Surgery Approved (When can it be Done?)?


1. The removal of the part of the Body DOES NOT Pose a Serious Threat to the Patient’s Live
 The procedure could be done w/ Expertise & Probability of Developing Complications are LOW
 If there is a reasonable Risk but generally Safe Procedure and will NOT cause a Danger to the Life
of the Patient, then it becomes an Acceptable Procedure

2. It is done during the Course of a Main Surgery

3. The part removed has NO Integral Function in the Body


 Once an Organ is taken, you should maintain the Functional Integrity of your patients
 Appendectomy DOES NOT cause any change in the Functional Integrity of the Patients

4. The Part removed Enhances Physical Appearance


 This may sometimes depend on the Outlook of your patients
 The Patients are Custodians of themselves
 Always remember that the Removal of a Part DOES NOT pause an Integral Dysfunction and in
some extent, perhaps Improve their Appearance

B. Clinical Cases
1. Incidental Appendectomy
 Incidental Surgery is when, during the Major Surgical Procedure, the Surgeon decides to remove
the Appendix – although the Appendix is Normal, so as to prevent Future Appendicitis

2. Strictly Elective Appendectomy


 You CANNOT take out the Appendix just because you want to take it out to prevent Future
Appendicitis without any Symptoms and Major Surgical Procedures – this is NOT Acceptable

3. Elective Tonsillectomy
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 This is Acceptable in Patients with Chronic Tonsilitis

4. Circumcision of the Newborn


 This is an Unnecessary Surgery
 If it becomes a Routine Procedure in a Hospital, then it is a Money-Making Venture because it is an
Additional Expense for the Patient – HOWEVER, if it is requested by the Patient, it is allowed

C. Suppression or Excision of a Healthy Organ


o It is JUSTIFIABLE if the Normal Organ exercises an Influence on Another Diseased Organ

VII. PLASTIC SURGERY


• May be Reconstructive + Cosmetic
• Is it moral for the patient and the doctor to undergo Plastic Surgery?
• It exercises the Principle of Stewardship = Beauty and Wellbeing of the Human Body
• The desire to be Beautiful is NOT a Moral Failt

A. Reconstructive Surgery
o It is a Surgery, Plastic in a Sense and Reconstructive
o It enhances / restores the Anatomic Integrity of Patients who have other Injuries (ex. Trauma, Burns)
o With Extensive Malignancies where you “Chop Off” the Significant Portions of the Body and left a very Huge
Defect (the Defect is Closed and do some Reconstruction)
o There are NO Problems in Strictly Reconstructive Procedures because it is part of the Therapeutic
Management

B. Cosmetic Surgery
o There must be due Proportion between the Risk and Benefits
o These are Procedures that DO NOT have Medical Benefits (Ex. Face Lifts)

1. There must be Due Proportion between Risks and Benefits:


 Benefits = Enhancing the Physical Appearance of the Patient
 Risk = If there is a Cardiac Problem, Asthma

2. The Motive is Morally Acceptable:


a. Acceptability in one’s Social Milieu
• Ex1) When a criminal wants to change appearance to escape the law
• Ex2) Facelift, Liposuction is Morally Acceptable as long as Principle of Stewardship
(Preserve & Enhance Human Body) is observed

b. Enhancement of one’s Business Opportunities


• Ex) Bold Stars having Breast Augmentations for Business Opportunities

3. To Improve one’s Physical Appearance is NOT Necessarily a Moral Fault


 The desire to look Beautiful, Acceptable and Desirable is NOT a Moral Fault

4. It is Subordinate to many other Human Goods (Limitations of Cosmetic Surgery)


 Hard to Judge Patients in these conditions
 These are t he people who spend money on Parlors – despite the Fact that they have no Money for
the Children’s Tuition Fees

VIII. GHOST SURGERY


• Surgery in which the Patient is NOT Informed of, or is Misled as to the Identity of the Operating Surgeon
• The IMMORALITY of Ghost Surgery is Based on the Following:

A. Patient has a RIGHT to Know and Select the Surgeon to whom he is to Entrust his Life

B. The Moral Evil is the Attendant in Justice which is Likely to Befall the Patient
o Justice = giving someone what is due
o When the patient seeks for your service and there is an Implied Physician-Patient Contract that you are
going to treat him and that he is going to pay – that’s the REALITY!

C. Professional Fee
o The Referring Surgeon has NO Right to it
o The “Ghost Surgeon” has NO Total Right to it because he is an Accomplice
o As a Moral Guideline = even if you are the Attending Surgeon, if you are NOT the one who did the
Procedure, you have NO right to the Professional Fee

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D. The “Ghost Surgeon” is Likely to be Excluded from the Pre-Operative Examination & Post-Operative
Care
o This is Likely to be Detrimental to the Patient
o There is a Lapse in the Total Care because there is NO Continuity in the Preoperative, Operative, and Post-
Operative Care

E. It Seriously Militates Against the Common Good


o By the term that there is Injustice, then it is AGAINST the Common Good

IX. SURGERY & RESIDENCY TRAINING


• An Operating Surgeon is the Performing Surgeon – as such, his duties and responsibilities go beyond mere
direction, supervision, guidance, or minor participation
• The Operating Surgeon may be assisted by Residents or other Surgeons
• With the consent of the patient, the Operating Surgeon may delegate the Performance of Certain Aspects of the
Operation to his assistants – provided this is done under Participatory Supervision (ie. he must scrub)
• Full Disclosure to the Patient is necessary if the Resident of other Physician is to perform the Operation under Non-
Participatory Supervision

**The Surgeon’s Obligation to the Patient Requires him to Perform the Operation:
o Within the Scope of Authority Granted by the Consent to Operation
o In accordance with the Terms of the Contractual Relationship
o With Complete Disclosure of Facts, relevant to the Need and the Performance of the Operation
o Utilizing his Best Skills

X. SEXUAL RE-ASSIGNMENT

A. Hermaphrodism
o Also known as Ambiguous Genitalia = meaning, there is some Genetic Problem (Confusion as to the Sex
arises)
o Remember that the Penis is the Homologue of the Clitoris; and the Scrotal Sac is the Homologue of the
Labia Minora – any change may bring about the Confusion

1. Medical & Scientific Tests should be Done to Determine which is the Predominant Determined Sex:
 External Genital Morphology
 Internal Genital Morphology
 Chromosomal Sex
 Gender Role

2. In Cases where there is a Total Equivocal Sex Identification:


 Approach may be either Towards Either Sex
 Choice of Sex depends on the Individual
 In case on Infants / Minors (to a Certain Age), parents determine after consultations w/ Specialists

B. Sex-Change
o Sex Change is AGAINST the Law of Nature – if you are created to be a Man, then DON’T insist that you
are a Woman Locked up in a Man’s Body
o The Problem is NOT Physical but EXISTENTIAL
o It is a Total Disregard to the Principal of Stewardship because you are the Guardian of Yourself and you are
Morally Obliged to Preserve your Well-Being and NOT to Destroy what was given to you by Nature

**It is Morally UNACCEPTABLE Because:


 Since it is NOT definitely established that Problem is Biological, the Procedure is NOT a Cure
 Procedure is an Attempted Palliation which is Drastic, Destructive, and Irreversible
 Surgical Sex Change does NOT Solve the Persons’s Existential Problem – it is Primarily a Case of
Psychotherapy
 There is NO Solid Agreement that such procedures does much good and help to the Individual
 There can be an Ambiguity about really wanting it

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